Clinical Judgements

by Claire Rayner

  ‘If I can, of course. May I just see my patient first?’

  He followed her across to the high bed on which Hynes lay, her head still shrouded in a helmet of fabric and with tubes running from her nose and mouth to the oxygen tap beside the bed and to the suction machines. At the other end of her, people were busy checking her blood drip and the drainage from her bladder and her wound, and Kate took up her charts and read the last collection of information obtained from the various monitors and then took her pen from her pocket and wrote steadily for some time, while Levy stood quietly watching the patient and showing no restlessness at all. And Kate was aware of his quietness and was glad of it. A comfortable man to have around.

  When she had set the chart back in its slot at the foot of the bed and leaned over Kim to see if she was ready to talk yet (and she wasn’t) Levy said quietly, ‘That your patient for Dr Rosen?’

  Kate nodded. ‘How do you feel about that?’ she asked, watching him sideways.

  He smiled, and though she couldn’t see his mouth behind his mask, his eyes narrowed agreeably and she thought — I like people who smile with their eyes. Even more comfortable to have around. ‘If Barbara said she agrees, then I do. We’ve talked interminably, she and I, half the night sometimes, about her work. Any arguments I’ve ever had on the matter have long since been demolished. And you?’

  She shook her head. ‘I have to admit I still get doubts. I did this afternoon when I started. It was —’ She stopped and saw it again in her mind’s eye; her own hand so smooth and brown in its thin glove that it looked robotic and detached from her body, and the knife, neat and small and so seemingly innocuous between her first finger and thumb, watched it in her memory as it hovered over the shaven skin and then descended to make the first long curving incision. She saw the golden-painted skin part and the edges curl back to show the bubbles of subcutaneous fat, creamy and sweetly pretty in the glare of the lights and watched it become starred with little flowers of bleeding points. She saw the penis and scrotum again, so aggressively male and yet so helpless in their stillness and watched her knife curl round to circle them with that red-starred fat; and then took a sharp little breath in and turned and looked at Levy. ‘It was difficult,’ she said. ‘Not the sort of surgery I enjoy. Somewhat — destructive.’

  ‘Most surgery is an insult,’ Levy said and again his eyes narrowed agreeably. ‘And now I need you to insult someone else for me. This time not only the patient.’

  ‘Oh?’ She was wary. Levy had a well-earned reputation for being manipulative. Whatever Levy wanted, usually, Levy got; he charmed his way into people’s good books and once he had what he wanted smiled his way gratefully on to the next person. Was it her turn now to be involved in some of his politicking?’

  ‘I’m being political,’ he said disarmingly and she blinked at his perceptiveness and then blushed a little beneath her mask. Wretched man!

  ‘Well?’ she said carefully. ‘I don’t step outside my speciality much yet, Professor. I haven’t been in it long enough to do that.’ And it was her turn to smile disarmingly.

  ‘I came to see you because you are competent and sensible but, I think above all, brave. You do what you think the patient needs, rather than what you want.’

  She creased her forehead. ‘But that’s what it’s all about,’ she said after a moment. ‘The patient’s needs —’

  ‘Ah, but there are many surgeons who say the patients only know what they want. It is the surgeons who know what they need.’

  Her face cleared. ‘I see what you mean. Well, I’m not that arrogant. I hope.’ And then she laughed. ‘What do you want me to do? I’m happy to listen.’

  ‘You’re very sensible,’ he said. ‘But then, it’s a function of youth to be sensible. Listen, Kate —’ And she felt a moment of pleasure as he used her first name. They’d always been on pleasant acquaintanceship terms but this was suddenly intimate. And she liked it. ‘Listen Kate, I’ve got the very devil of a problem. It involves Goodman Lemon — yes, well may you look alarmed! There will be ructions. But the patient, you see, is the one I’m concerned about. I’m sure we can find good reasons for a man of fifty-seven to need a genito-urinary consultation. And if he then needs urgent surgery? Let me explain what the problem is. And I hope you’ll be the one who can solve it for me. And, of course, for the patient.’

  And he took her by the elbow and led her to the little office Sister had at the far side of the ICU and began to explain it all to her.

  Chapter Thirteen

  At half past six Sister Sheward gave up all hope of getting to her concert at the Barbican. She should have gone off duty at half past four but she’d been willing to stay until seven at the latest, to see Mr Holliday settled after his physio and the late appointment in X-ray. But what with all the fuss over Audrey Slater and the Minister as well as that silly first year getting his trousers into such a twist over Joe’s attack of breathlessness, it had been one hell of an afternoon; and when at six-thirty Laurence Bulpitt had arrived and told her he had to go through a long appraisal examination with Holliday that she and only she could assist him with, she admitted defeat. She sent her staff nurse from the second shift to phone and leave a message on David’s machine to the effect that she was involved in an emergency and couldn’t get away, and pulled the curtains round Holliday’s bed with as quiet a hand as she could. No need to display her irritation with loud clattering behaviour. It helped no one, after all.

  ‘I do hope I’m not causing problems coming at this time,’ Bulpitt said and flashed her a wide smile. ‘But I’ve been hectic today and tomorrow will be worse, so this really is the only time I can. And I have to admit that my wife’s dinner party doesn’t really attract me that much. Now, Mr Holliday —’ And he transferred his wide smile to the patient.

  ‘Not at all, Mr Bulpitt,’ Sister Sheward said, trying not to speak through clenched teeth. Convenient for him of course; was there ever any consultant, even the best of them, who didn’t put his own convenience first? Even Neville Carr was famous for coming in to do his round before breakfast, on the grounds that he found it so much easier to get in through the traffic early, and never mind the havoc it created on a busy ward. Why should Bulpitt be expected to be any different?

  But; Bulpitt hadn’t waited for her rejoinder. He was bending over Mr Holliday with an ophthalmoscope in his hand and peering at the old man’s eyes while he murmured at him and she stood and watched him and straightened her tired shoulders. This shouldn’t take too long; maybe she could just make it? Was it worth phoning David again?

  But it was after seven when at last Bulpitt let her pull the covers back over Holliday’s skinny old legs and led the way down the ward back to the nurses’ station, and by then she had forgotten her irritation and her ruined evening, for there was no doubt that what she’d learned had been fascinating.

  ‘I must say the change in the tremor’s very marked,’ she said and Bulpitt nodded, not taking his eyes from the charts on which he was writing.

  ‘That was the most obvious change,’ he said. ‘I agree. A little coarse tremor when I tired him, but otherwise, much better. Hardly any pill-rolling movement, and he managed that glass of water as elegantly as you like. Had to be fed all the time before, you know.’

  ‘Yes,’ Sister said. ‘His wife told me.’ She grinned then, suddenly cheerful. ‘And heaven help me but I’ve got a fair brace of determined wives on the ward at the moment. What with Joe Slater’s missus stirring up the Minister, and then Mrs Holliday laying down the law on what we have to do for her husband —’

  ‘The Minister? What happened?’ He was all ears now and humped himself up to sit on the edge of the desk and stare at her. ‘Do tell.’

  Sister laughed now, seeing the whole episode in her memory. ‘Marched into him pushing the tea trolley, didn’t she? I’d let her take the teas round as a bit of therapy really, because she was so low, and she simply went up to his bed like an avenging fury and made him put down the pho
ne he was using and stood there and harangued him for five minutes flat out about the awfulness of his being there and three beds being thrown out of the section to accommodate him and she having to take her sick husband home with not enough help to look after him when his chemo was finished. Oh, she laid into him, well and truly!’

  ‘And where were you at the time? Not stopping her, I take it?’

  She opened her eyes wide. ‘How could I? I was busy hanging on to the secretary who was there with him, telling him all about it, so that he couldn’t go and interrupt her. I mean, I was too busy and so was he. There was no sign of his private nurse, of course, and the detective as it happened had gone off to pee — oh, she did very well in the time she had. I was proud of her —’

  ‘But you’re not usually backward in coming forward with your praise, Vera,’ he said and she glowed a little at the use of her first name. Everyone was supposed to be so egalitarian these days and often they were, but the consultants generally used the ‘Sister’ label out of extra politeness; yet politeness was the last thing Vera She-ward ever wanted from her consultants. ‘If you felt that strongly about having him on the ward, why didn’t you say so and stop him coming in? And now he is here why didn’t you —’

  ‘He’s a patient of Agnew Byford,’ she said and after a moment he made a small grimace and nodded.

  ‘I take your point. That does make it … So you let Mrs Whatshername do it for you.’

  ‘Why not? She’s a capable lady with a tongue in her head. And her complaints would carry more weight than mine. She’s a patient, you see, a voter. To Saffron I’m just an employee of his NHS. He oozes charm at me till I feel sick, but he pays me no real attention. But Audrey Slater — that’s different. The voice of the voter, you see? It certainly seemed to be like that anyway.’

  ‘How?’

  ‘Mr Saffron asked me to arrange for another bed for Joe. Not to send him home.’

  ‘Just like that!’ Bulpitt said. ‘Oh, isn’t life grand! The noble Minister for Health, comfortably getting over his bit of angina in a showy NHS bed when he’s perfectly well able to get himself tucked up out of the way at a glossy place, like the Wellington or wherever, has only to ask for a bed to be made available and it is —’

  ‘Who said so?’ Vera said sharply. ‘I didn’t!’

  Slowly he grinned again. ‘You refused?’

  ‘Didn’t refuse — of course not! I just told him the truth. That I just don’t have that sort of clout. I ought to but I haven’t. Told him that when people come to me and say they have to use my beds and move out three patients to make room for an important one I have no way of objecting —’

  ‘You’re a bloody marvellous liar! You reign over this ward like a duchess and well you know it. You let me bring my patient here — and Carr, too. Dammit, the Slater man wouldn’t be here at all if you hadn’t agreed to —’

  ‘But Saffron doesn’t know that, does he? I told him I couldn’t do anything about it — that it was up to him really. That with all the cuts there’d been in the area and the fuss over the rumours about closing the hospital altogether people were very miserable. I pointed out the marchers outside in the courtyard with their banners — not that he could have missed them — and took Mrs Slater away and left him to stew in his own juice.’ Again she looked reminiscent. ‘Dreadful way to treat a cardiac patient, isn’t it?’

  ‘Dreadful,’ Bulpitt said cheerfully. ‘Quite dreadful.’

  ‘Except that he’s really getting on very well. If he were anyone else it’s my guess he’d have been out on his ear two days ago. But Agnew Byford won’t let him go in a hurry. He’s worth his weight in —’

  ‘— knighthoods.’ Bulpitt murmured and they both laughed. Byford’s hunger for public recognition was one of Old East’s most enduring pieces of folklore. ‘But we could do without too much fuss, frankly. If Saffron starts a drama over the bed availability and finds out how we poach Byford’s beds — has he told Byford yet?’

  She shook her head. ‘He’s away — operating in a private hospital in Swindon or somewhere. I heard him telling Saffron all about it before he went. Life saving isn’t in it, believe me. You can see Saffron thinks he’s being looked after by the Angel Gabriel crossed with a reincarnation of Aesculapius at the very least. Oh, he’ll tell Byford fast enough when he gets back —’

  ‘That’s a pity,’ Bulpitt said. ‘Because I was hoping to use your services again, Vera.’

  She frowned. ‘Mr Bulpitt, you told me this was a one-off! Just this case, you said, because you had some suitable foetal material —’

  ‘That was fully my intention. But when we got the foetus and had a look at it, we found there was a sizeable amount of available tissue. It was a twenty-six-week infant remember, so the substantia nigra was excellent.’

  ‘Substantia nigra —’ Sister said, struggling to remember her neurology lectures, and angry with herself that she had to make such an effort. ‘Is that all you can use?’

  ‘Well, yes, but there was a good deal there, as I say. And Fay Buckland made sure the uterus was removed intact so the foetal head was protected even more. A really good specimen, and I was delighted to get it. And now we find we can store it too. I used what we needed for Holliday and the rest is in a tissue medium with antibiotic waiting to be disaggregated and made into a cell suspension. We can’t do that till just before we inject it but of course I have every confidence we’ve got enough of the material there to use on at least three more patients. So I was going to ask you, once we transfer this chap back to my wards — and going by his immediate reaction to his operation, which was excellent, indeed remarkable, he’ll be able to bloody well walk back — if I could bring down a couple more? I wouldn’t bother you, Vera, really I wouldn’t, if I had any nurses halfway as good as you to rely on, but my ward staff are a dead loss.’

  ‘You ought to go and see them in the office about that,’ Vera said reprovingly but basking in his praise. ‘You can’t just pinch Byford’s beds —’

  ‘Carr does,’ Bulpitt said and she burst into laughter.

  ‘Honestly, you’re all the same, you men,’ she said. ‘Like kids — ’s’not fair, ’s’not fair — he did it first — he did it first —’

  ‘And why not, if it works?’ Bulpitt slid to his feet. ‘Dear dear Vera, let me do it, hmm? It seems a great pity when we’ve got such good results from the one we’ve done not to have another go. The Birmingham lot are beavering away as well, in spite of all the silly headlines.’

  ‘Headlines? I read about this in the Lancet. Have there been headlines elsewhere?’

  ‘Here and there,’ he said dryly. ‘A hell of a lot of silly comment one way and another. You’d think we were transplanting whole brains the way some of the papers and TV programmes went on. Like mad scientists in the movies, making monsters. Such stuff! Yes, there’s been a good deal of fuss, and that’s one of the reasons I want to replicate the Birmingham work. We’ve all got reputations to make, you know, every one of us —’

  She sighed and looked at her watch. ‘I’ve put in three hours overtime today, do you know that?’ she said conversationally. ‘And I was supposed to be hearing Stephane Grappelli at the Barbican tonight. Ah, well, there it is. Send your patients down, Mr Bulpitt. But whatever you do don’t get me involved with the politics of it all. Bad enough Byford will be going potty when he gets back and Saffron tells him about Audrey Slater. Just let me go home now, will you?’

  ‘Of course!’ he said and reached out and patted her arm. ‘I’m a selfish devil — you should have said —’

  ‘And it wouldn’t have made the slightest difference if I had,’ she said tartly. ‘Would it? Not with your wife’s dinner party to dodge.’ She couldn’t resist that. The patting of her arm had been so damned patronising and not at all what she would have preferred from him.

  He laughed, a little awkwardly this time. ‘That really had nothing to do with it,’ he said. ‘I’ll have to put in an appearance anyway. I really did
have to go through that check-up with Holliday. And surely you were interested?’

  ‘Oh, of course.’ She walked round the desk to the other side to check her records were all ready to leave. ‘Um — you — er, David.’ She peered at the first year who was standing on the far side collecting the temperature charts to be filled in by the senior nurse on duty. ‘Pass me my bag, will you? Thanks. Of course it was interesting, Mr Bulpitt. To see that sort of progress in a Parkinson’s — nil tremor, able to hold his own glass, much reduced rigidity, it’s all great. But really I am very tired now, I want to go off duty.’

  ‘On your way then!’ he said and reached out one hand as though to pat her again and then seemed to think better of it. ‘I’ll see you tomorrow then, and arrange to swop Holliday for one or two of the other old Alzheimer’s we have. It won’t be so easy to measure any change with that but it’ll still be useful, I think — good night, Sister!’

  David went to supper at eight, already tired, and irritated that he’d been sent to first supper. That meant he’d have to go back to the ward for another half-hour before going off duty at nine, instead of being allowed to go to second supper and straight off. That would have been much nicer — time to get a drink at the pub over the road and a sandwich. Much nicer than the eternity of spaghetti that was all there seemed to be on offer in the dining room tonight.

  Gloomily he piled his plate high with the despised spaghetti and found a corner table. He was dying for a cigarette, but it was now practically a week since he’d had one; well, almost. You couldn’t count the couple he’d slipped in when other people had given him them. Certainly he hadn’t bought any since that afternoon Joe Slater had been admitted and Dr Carr had said — and he slid away into thinking of Neville Carr as he pushed the spaghetti into his mouth; and managed to forget all about his yearning for a cigarette.