Clinical Judgements

by Claire Rayner

  ‘As for being a do-gooder, perhaps that’s a better label than the reverse,’ Levy murmured. ‘And I have to say I take exception to the suggestion that I and — what was it? — these people like me to whom you refer so vaguely, have had anything to do with the appearance of the human immune deficiency virus in this country. But let that pass. The crux of the matter is this man has a sub-acute strangulation of an inguinal hernia. He is not coming to us like some sort of humble supplicant for relief, but because he has a right to do so, as does every citizen coming to an NHS hospital like this one. We do him no favour in responding — we are simply fulfilling our contractual obligations. But let that pass too, and consider the man’s health, shall we? As doctors. Now, I gather there is a possibility the hernia can be reduced by conservative methods, but it’s clear that ultimately surgery will be the answer. You are refusing to operate — or to allow any other surgeon on your firm to operate, unless he has a blood test for HIV, so —-’

  ‘As I have every right, and indeed the duty to do so,’ Lemon flared. ‘What sort of surgeon would I be if I had so little concern for my own and my immediate staff’s wellbeing that I’d expose myself and them to this loathsome disease and thereby expose future patients? Don’t forget that chap in the West Country who picked this up somewhere when he was operating and then died of it and they had to go seeking out his patients to see who he’d infected and —’

  ‘Rubbish,’ Levy said crisply. ‘If you use a halfway professional aseptic technique you should neither give nor get any infection any more than that poor chap did. You shouldn’t believe all you read in cheap newspapers! None of his patients, as I recall, in fact suffered at his hands. I do agree, mind you, that you’ve had a poor record in that area — rather more infected wounds on your wards than in most other surgical wards last year, weren’t there?’

  Lemon’s face mottled with an ugly colour. ‘That is an outrageous suggestion! How dare you imply that —’

  ‘I imply nothing,’ Levy said wearily. ‘I am just pointing out that the basis of good surgery surely is to use properly constructed barriers between patient and staff to ensure no passage of infection, either way. Actually, from all I know about the virus — and I have made some small study of it, unlike so many that I know — I can assure you that the patient, should his immunity be in any way compromised, will be at far greater risk from you than you will from him. But that is beside the point. He is not, as far as we know, HIV positive. So there is no reason why —’

  ‘The man refuses to be tested!’ Lemon shouted. ‘So of course he’s positive, and he damned well knows it! That’s why he refused. That should be clear to the meanest intelligence.’

  Levy raised his brows. ‘I fail to see how you can draw such a conclusion from the evidence. He is, I gather, in a permanent faithful relationship and has been for many years. Therefore he is in a low risk group and —’

  ‘Relationship! Relationship — faugh! To use such words for the sort of disgusting practices these scum get up to — you make me sick, Levy. You and all your kind! I will not tolerate this sort of practice in this hospital and so I tell you! Dean you may be, but I am not a negligible person here! Either that man accepts a blood test and agrees to abide by our decision about surgery on the basis of the results, and goes elsewhere if necessary, or —’ and he stopped and glared at Levy.

  ‘Or what?’ Levy said softly. ‘Are you suggesting this is a resignation matter?’

  Lemon was silent for a long moment and then snapped, ‘No, I am not. I’m not going to be driven out of my own hospital by you subversives and —’

  ‘One of these days you’ll use this ridiculous language in front of witnesses, Lemon,’ Levy said and smiled sweetly at him. ‘And then I’ll be forced to take you to law, you know. You really shouldn’t indulge yourself this way. You’ll find it becomes ever harder to control your tongue, you see, when there are other people about. Now, just you listen to me. I am no subversive — though why I bother to argue with someone who is certainly not fully accessible to reason I’m not sure — but as I say, I am not subversive. But I am concerned about the welfare of every patient who comes to this hospital, and who needs treatment. This man needs treatment. I am also concerned for the rights of every patient who comes here. This man has the right to refuse a blood test which could compromise him in other areas, outside the hospital. He has financial arrangements to make, and since the world of money is littered with people who are just as bigoted as you are, Lemon, there is no doubt that he will be refused the mortgage he needs for his business if he has a test and it is in fact positive. Also, if he is by any remote chance positive, his life will become a great deal more stressful than it is at present. He has made the perfectly valid choice not to be tested. I support his right to do so, and assure you that you are not at risk, as long as you practise safe and good surgery. If you can’t accept that, then we will transfer the patient to another surgical team and —’

  ‘Oh, no you don’t!’ Lemon said. ‘It would be the easy way out, wouldn’t it? The way you people use to slide your revolting methods and ideas in. That man was admitted on my take-in from A and E and he is therefore my patient. You will not transfer him for devious reasons of your own —’

  ‘Ah! Excellent! You accept the responsibility for his care then? You will operate, since that is his need, and —’

  ‘No, I will not!’ howled Lemon. ‘Not till he’s tested. I’ve made myself as clear as crystal on this —’

  ‘What you are making very clear is your wish either to see this man die for want of adequate treatment, or his discharge untreated from this hospital. Either way that doesn’t seem to me to be the sort of care I would give to someone I designated as my patient. You’re making it difficult for me not to take this matter further, Lemon.’

  ‘You’ve already made the point that we have no witnesses to this conversation, Levy,’ Lemon said and suddenly grinned. It was a distorting grimace, but Levy kept his eyes courteously on him. ‘So it’s your word against mine. And everyone knows what a subversive you are —’

  ‘Such an odd word,’ Levy said. ‘I’m not sure you’re using it in quite its proper context. I might as well call you a fascist, mightn’t I? Or a closet homosexual who hasn’t the insight to understand that his hatred of this group of people is based on —’

  ‘Oh, very clever,’ Lemon said and marched to the door. ‘Very clever! I’ve heard you on this sort of line before. Whenever anyone objects to anything you say it’s because he has a hidden desire for it. When I tried to get that Rosen woman’s ghastly clinic out of here you were just the same — you and her together. Yes, well, it isn’t surprising, is it? Believe me, Levy, you won’t have much more time to carry on this way. I’ll see to it you start running this hospital as a decent place should be run, or get out. The latter for choice. Meanwhile, I’m telling you, I and my staff won’t operate on a man like this until he’s HIV tested. And nor will I stand by while anyone else in this hospital is coerced into doing so.’ And he slammed out of the room and left Levy sitting at his desk staring after him.

  After a long moment he sighed and pulled his list of internal phone numbers towards him. Lemon was getting worse. He’d always had a tendency to rigidity, even twenty years ago when they’d both been senior registrars at St Kitts. Levy had thought then that he had some deep-seated anxiety, for he never showed any signs of interest in anyone of either sex, devoting himself entirely to his work and to his church, and there was no doubt that he’d made himself into a superb surgeon as a result of that hard work. He had no distractions, no friends, no wife, no children to worry about (and Levy let his mind slide on to the matter of his son Joel and the way he had only yesterday wrecked the family’s second car for the second time in two years, and immediately, with a strong effort of will, slid it off again) so why shouldn’t he be superb? What else was there to fill his life? But now his rigidity and idées fixes were approaching paranoia. It might be time to talk to Barbara Rosen ab
out him and consider what they should do. It was always hell to have to cope with a colleague with psychiatric illness; it had been dreadful three years ago when Bragg the anaesthetist had finally tipped over into total drug dependency and they had to get him into care and out of the place before a disaster happened. Lemon was far more of a problem because he still had enough control to avoid spouting off too much, or too obviously, in a group. It was only when he had just one listener that he really allowed himself free rein.

  And, in all fairness, there were people who would not see this latest anxiety of his as anything but reasonable. The BMA meetings he’d been to recently had been starred with discussions on the matter of HIV testing of surgical patients; there would be people right here at Old East who would defend Lemon’s stance and go ahead and test a man such as Slattery without his consent anyway, getting the blood ostensibly for other purposes. Thank God Monsarrat had been able to resist his chief’s demands and had come to him (though, Levy thought wryly, I wouldn’t like to be in his shoes in the future when he has to deal with Lemon) so at least there was time to do something about the situation. But what? That was the problem.

  He ran his finger down the list of phone numbers and then stopped. And after a moment picked up his phone and dialled.

  ‘Who?’ Kate said and slipped off her mask, glad to get the wet folds away from her mouth. The bacteriology people from the path lab were testing a new design of mask to see just how much infection was stopped by a layer of water-impermeable film between the fabric folds, and this one was clearly very efficient. The inner side was sodden and her face was sore and reddened from the constant wetness left there by her own breath. It had made the operation even harder than it should have been, that personal discomfort, and now she grimaced with relief as she peeled off her gloves and then her gown and dropped them all into the skip to be dealt with by the theatre orderly. ‘Who did you say?’

  ‘Professor Levy,’ the staff nurse said. ‘He rang down just after you’d started and said would you come and see him. Or he’d come down here if you’d rather.’

  Kate peered up at the theatre wall to see the time. ‘It’s after five,’ she said slowly. ‘And I want to see Hynes back into the ward … Ask the Professor if he wouldn’t mind coming over. I’d rather not change and then have to change back again. I’m sure he’ll understand. Did he say what he wanted?’

  ‘No, Miss Sayers. Just that he needed a word. I’ll ring him, then —’

  After she’d gone Kate stood for a moment looking round. The theatre itself always seemed to her so exciting a place: the glint of chrome and polished white tiles and glass; the smell of it, ferociously clean and disinfected; the smooth perfection of the design of the walls, all curves at top and bottom to prevent the harbouring of dust and with flowing lines to every door and fitting. Before a list it looked rather intimidating, with its neat rows of bowls and trolleys covered to protect their collection of shining sterile instruments, the gloves and gowns set ready, the emptiness of the smooth table under the great eye of the lamp; but afterwards, as now, it was a comfortable sort of place, rumpled and messy like, she thought suddenly, a woman after sex. And then grinned at her own silliness. As though the clutter of bloody swabs still hanging from their counting board, the tangle of soiled green linen on the table and the puddles of blood and water on the floor looked in the least sexy: of course they didn’t. Yet still there was that violated feeling to it all; and she liked it.

  And just what does that say about my own attitude to sex? she wondered briefly as she turned to the door. Do I see it as dirty and messy, a violation and a spoiling? Well, maybe I do. It sure as hell isn’t rosebuds and singing birds. And she frowned at the memory of last night and Oliver’s urgency that had been so unlike the way it had used to be between them. Where was the peace and the time and the, well, contemplation, they had once shared? Now it was all rush and — no, she wouldn’t think about it. And she pushed open the big double swing doors and went padding out in her soft white theatre sneakers, pulling her close-fitting cap from her head at last to let her hair fall free and to feel the bliss of cool air on the back of her neck.

  It had been a dreadful case, simply dreadful. The outcome was good enough, she was sure of that; her registrar, who had been decidedly white about the lips as he had watched her knife slide round the penis and down into the groin to encircle the scrotum, had volunteered that at the end.

  ‘Hell look like — well, as normal as it’s possible to look, won’t he?’ he’d said. ‘Never mind the function, just take a look.’

  And she had lifted her brows and said, ‘Well, that’s what he — dammit, she — wants. Only the look of it. Doesn’t care about the function at all.’

  ‘Well,’ the registrar had said, looking down on the exposed crotch area now that the towels had been removed. ‘If I didn’t know, I’d say this was a woman. Slightly flat about the mons perhaps, and not too lavish about the labia, but a woman all the same. I’ll be interested to see how it settles down once the stitches are out. How long will he — she need the catheter?’

  ‘Hard to say,’ Kate said. ‘We have to make sure the urethral stump remains patent, of course. Don’t want any granulation there. I’ll try her without it after twenty-four hours, and if necessary recatheterise. Look, will you see him to the ICU —’

  ‘Her,’ the registrar murmured and Kate flashed a grin at him.

  ‘Hell yes. It won’t be so difficult now, though. Yes, will you see her to ICU and make sure the nurses know the level of fluid input we want? And write up the rest of the post-op drugs, will you? And the antibiotic too. I want a wide umbrella here. That area of the bladder wall behind the prostrate gave me a nasty time.’

  ‘More blood too?’

  ‘Oh, yes. A good deal. My God, that one did blow, didn’t it?’

  ‘Didn’t it just,’ he said appreciatively. ‘I can remember learning the internal pudendal arterial branches and the perineal and so forth, but I never thought to see what they could do when you nipped them —’

  ‘I had to,’ Kate said, needing to justify herself to this young man. ‘How else could I get the tissue of the penis away without interrupting the artery? And I could hardly clamp it too soon — not till I knew how much tissue I needed to save. Exsanguinate it too long and I’d have had no leeway for the vaginisation, would I?’

  ‘I was fascinated,’ the registrar said. ‘But I’m glad it was you and not me —’ and he had gone and left her standing there to worry about whether Hynes had lost so much when that dramatic burst of pulsating bright blood had flooded her operating area that he would suffer undue aftereffects. But then she took a deep breath and shook her head at herself. If the anaesthetist had been worried she’d have cause to be, but he’d been serene about the whole thing.

  ‘A healthy chap,’ he’d said. ‘He’ll survive the operation well enough, that’s for sure. Whether he’ll survive the effects after that — well, that’s another thing. Can’t say I approve of this, and that’s a fact.’ And he too had gone stumping off to leave her alone in the theatre with the detritus of her operation. And she’d been grateful. She had needed time for herself.

  But, it seemed, couldn’t have it. What on earth did the Professor want? She had few dealings with him, since he was a physician, but those she’d had had been amiable enough, so she had no reason to fear this summons, but all the same a prickle of apprehension made itself felt beneath her ribs and she thought — It’s like being at school. Just hearing the Head wants to see you makes you feel like some sort of criminal.

  She put her head round the door of Sister’s small office where she was sitting over her post-list cuppa, gossiping with one of the junior housemen.

  ‘Sister I’ll take the notes with me to ICU and write them up there. I believe Professor Levy will be looking for me Will you tell him that’s where I am if he comes here?’ And she nodded at the houseman, who was a little embarrassed at being caught with Sister who was famous for her cheerfu
l disposition and sexual generosity towards good-looking young men, and went on her way. She’d be late home tonight; there was no way she’d leave Old East until she was sure Kim Hynes was fully conscious and there was no unwonted bleeding.

  And just as well, she thought then. To see Oliver tonight after last night’s discussion — well it hadn’t been quite a row, had it? — about Sonia would be little pleasure. Home at midnight and straight to bed was the likely pattern of the evening and it was just as well.

  The Intensive Care Unit was as usual very busy and, as she walked into the hubbub, the beeping of the monitors and the hissing of oxygen and the general sense of urgency, she felt her muscles tighten. This was really where the patients’ wellbeing was made or lost. The doings in the theatre were dramatic and important, of course, but the emphasis there was on drama. Here it was long painstaking watchfulness over the bodies brought tubed, wrapped, strapped and empty, it often seemed, of any human spirit, to be protected and tended and slowly brought back together. Not till her patient left this extraordinary place could Kate feel her job was even halfway done. The operation didn’t end until the patient was back in bed in the ward.

  Professor Levy was waiting for her, looking a Little odd in a cap and mask and with a gown over his neat dark suit. There was no real reason why all visitors should be shrouded so, but Sister ICU liked to express her authority by demanding such a ritual, so everyone obediently swathed themselves; and Kate wanted to laugh as she looked at the dapper little figure of the Dean standing there meekly waiting for her. But all she did was smile and say, ‘Good afternoon, Professor. I’m sorry I couldn’t come over to the Medical School —’

  ‘I was grateful to get out of it for a while,’ Levy said. ‘I always am. Hate offices. Not too keen on these ICUs, mind you, though they’ve done wonders for a couple of my more extremis patients in their time. My dear, I need your help.’