Sisters of Mercy

by Andrew Puckett

  ‘I wish I could reciprocate that sentiment,’ I said pointedly. I did go with him, though.

  When we got to Pathology, his secretary led us past an array of spotless — almost fairground — machinery that emitted hums, buzzes and clicks and was tended by two white-coated figures, to Dr Cannock’s office.

  ‘Come in, Mr Jones. Oh, hello, Sister,’ he added as he noticed me.

  ‘Sister Farewell’s helping me to compile my report,’ Jones explained.

  ‘Oh. Well, do sit down, both of you.’

  We sat down.

  ‘Now, you wanted to know about the relationship between Pathology and ITU, I believe?’

  ‘That’s right.’

  ‘Well, I’m not sure I can be very much help to you there. As I imagine Sister has already told you, the relationship is not as cordial as it might be.’

  ‘No, she hasn’t told me that,’ Jones said with a glance at me. I looked down at my hands, surprised, and a little embarrassed that Dr Cannock should have chosen to bring it up.

  ‘Doubtless she will,’ he said. ‘We do, of course, perform a considerable number of laboratory tests for them.’

  Jones took out his notebook. ‘How many is considerable?’

  He thought for a moment. ‘Say, fifteen to twenty a day for ITU, although if you include the Coronary Care and Medical wards, that increases to fifty or more.’

  ‘What kind of tests would those be?’

  ‘Clotting tests and electrolytes on the cardiac cases. Some blood counts. Some microbiology.’

  ‘What would they represent as a proportion of your workload?’

  ‘Approximately a fifth.’

  Jones looked up from his notebook. ‘So you do a thousand tests a day here?’

  ‘It’s not so many. Like most pathology departments, we’re geared for testing large numbers.’

  ‘Yes, I noticed all the automated equipment when we were shown through.’

  Cannock smiled. ‘As a chemical pathologist, I’ve worked with automated equipment for a great many years. More recently, the problem has been in processing the large numbers of test results generated by the automation.’ For the first time, his dark brown eyes gleamed with some kind of enthusiasm. ‘And the answer to that problem lies in the complete computerization of the reporting system throughout the hospital.’

  ‘I’d certainly agree with you there,’ Jones commented. ‘You obviously know something about computers then, Dr Cannock?’

  He gave a short laugh. ‘You could say that, since I’m on the working party that designed the hospital system.’

  ‘Really? That can have been no mean task. How did you manage to fit that in with running Pathology?’

  ‘The two aren’t as incompatible as you might think. You know about the Medicines Control Agency and the Accreditation of Pathology Departments?’

  ‘Some, yes.’

  ‘Well, what the MCA is demanding for path labs today, they’ll be demanding for hospitals tomorrow. A totally comprehensive and secure computer system. We decided to begin work on it before being ordered to.’

  ‘I see. So what was your part in it?’

  ‘The formulation of standard operating procedures, especially with regard to the use, and abuse, of passwords.’

  Jones chuckled briefly. ‘In my experience, that’s virtually impossible to prevent.’

  ‘Oh, there are ways.’

  ‘For instance?’

  ‘Well, if a member of staff uses the password of another who is on leave, then the system can flag this up.’

  ‘That is comprehensive. And you’ve got that working here?’

  ‘On a pilot basis only.’ He glanced up at the clock as he spoke. ‘I’m sorry, I don’t want to be rude, Mr Jones, but I did say this would have to be brief, and I do have another appointment shortly.’

  ‘Of course.’ Jones closed his notebook and stood up. ‘Well, thank you for giving us your time at such short notice.’

  ‘I’m only sorry I couldn’t be more help.’

  ‘No, that was just the sort of information I was looking for.’

  When we were back in the corridor, I said, ‘Were you really interested in all that stuff about computers?’

  ‘Certainly.’

  ‘Why? It all seemed a bit creepy to me. Big Brotherish.’

  ‘It was rather, but that could be useful to us.’

  ‘How?’

  ‘You’d be amazed at the amount of information you can extract from a computer, especially a nosey one.’

  ‘I don’t doubt it,’ I said drily. ‘But it scares me … it’s not what hospitals and medicine ought to be about.’

  ‘Perhaps not.’ He paused. ‘What did Cannock mean about the relationship between ITU and Pathology not being a cordial one?’

  By now, we were back at ITU, so I said, ‘I’ll tell you in the office.’

  Viv was on the phone in the Duty Room, which was otherwise empty.

  ‘I was surprised he brought it up,’ I said, when I’d shut the office door. ‘It came about because a lot of ITUs have their own mini-labs with a lab worker to do the urgent tests. Mr Chorley wanted one here, but Dr Cannock wouldn’t have it.’

  ‘Why not?’

  ‘He said he wanted all laboratory tests to be carried out under one roof — for purposes of quality control. He arranged for us to have exclusive use of a phlebotomist instead, so that urgent samples could be taken straight back to the lab. It still left a lot of bad feeling, though.’

  ‘So the girl who takes the blood samples is part of Pathology?’

  ‘Yes, either Susan or Pat are with us or in Coronary Care or the Medical ward most of the time. Usually Susan.’

  ‘Is there really enough work to keep them busy all day?’

  ‘In all the three wards, yes. Some patients need testing several times a day.’

  He said slowly, ‘What’s to stop them putting something in rather than taking it out?’

  ‘I suppose that might have been possible,’ I replied after a pause, ‘when we still used conventional syringes. But we don’t, not any more.’

  ‘Oh? What do you use?’

  ‘Vacutainers. They’re sample bottles that are manufactured with a vacuum in them, so they take the exact amount of blood required. There’s absolutely no way anyone could use them to inject anything. I’ll show you, if you like.’

  I went into the Duty Room, and was looking for a set in Susan’s cupboard when she came in.

  ‘Can I help you, Sister?’ she asked.

  ‘Yes, I think you can,’ I said, standing up. ‘Were you about to take a sample?’

  ‘I think so.’ She picked up a couple of request forms from the tray. ‘Yes.’

  ‘Would you mind if we watched you? Mr Jones and myself?’

  ‘Of course not.’

  ‘Mr Jones,’ I called, and he came to the door. ‘Susan’s about to take a blood sample, so you can see how it’s done.’ He stopped short. ‘What, now?’

  ‘Yes. Is that a problem?’

  ‘No. No, not at all.’

  I didn’t notice how pale he was until we’d gowned up and were at the bedside. Susan set out three tubes in a rack, then screwed one end of the double-ended needle into the plastic barrel of the set. Then she applied a tourniquet to the patient’s arm.

  ‘Could you clench your fist for me please, Mr Hughes?’ she said, and Mr Hughes duly obliged.

  She felt his arm until she found a vein, then unsheathed the second needle of the set and quickly punctured the vein with it.

  I glanced at Jones — he was deathly pale and actually trembling slightly, and a frisson of Schadenfreude rippled through me as I remembered something from the previous night. So the great Mr Jones had a weakness — he was needle-shy!

  Susan took a tube from the rack and pushed it into the open end of the barrel. The rubber cap of the tube was penetrated by the needle inside the barrel and the vacuum drew in the required amount of blood. She slotted the tube in the rack and t
hen filled the other tubes in the same way.

  ‘Have you seen enough, Mr Jones?’ I inquired sweetly.

  ‘Yes, thank you,’ he replied thickly. I thanked Susan and we left.

  ‘You should have told me you were needle-shy,’ I said as we de-gowned.

  ‘It wasn’t the needle, it was the blood,’ he said, after a pause. I didn’t say anything, just looked at him, and he went on, ‘If you must know, my brother was a haemophiliac and the sight of blood always made me feel ill. Can we leave it at that, please?’

  ‘Surely. I’m sorry.’

  By the time we’d returned to my office, he was almost back to normal.

  ‘Are conventional syringes ever used for blood-taking?’ he asked.

  ‘Very rarely — I can’t remember the last time. Besides, a lot of patients watch when their blood’s taken, and they’d notice if something were being put in with a syringe rather than taken out.’

  ‘All right, it was just an idea,’ he said after a pause. ‘What other paramedics come on to the ward?’

  ‘Jacqui, the ECG technician. The physiotherapists — they come quite a lot.’ I thought. ‘That’s about it.’

  ‘Would either of them ever use an invasive procedure?’

  ‘No. Jacqui sticks on electrodes. The physiotherapist lays on hands.’

  ‘So it comes down to a doctor or a nurse, doesn’t it?’ He paused. ‘And of the two, a nurse has to be the more likely, wouldn’t you think, Sister?’

  ‘Would that be another example of your unfortunate manner?’

  14

  I sorted out the nursing rotas for him so that he could go back to my house and study them while I looked up the action times of insulin and digoxin. For the benefit of the staff, he bade me an ostentatious goodbye, saying he would see me later at Miss Shenstone’s lecture.

  I left for home about half an hour after that and found him immersed in paper in my living-room.

  ‘You look as though you could do with some coffee,’ I said.

  ‘Please. This is going to be more complicated than I’d hoped,’ he continued gloomily. ‘Assuming, that is, that insulin is still our favourite for the method.’

  ‘I think it must be,’ I said, ‘considering its availability and ranges of times it takes to act.’

  ‘What did you find?’

  I’d discovered that soluble insulin could act in anything up to four hours, insulin zinc in anything up to six hours, and PZI in a maximum of eight to fourteen. With digoxin, the times were two hours for the injectable form and six hours for the oral.

  ‘Let’s take Mrs Sutton for example,’ he said, after I’d made the coffee. ‘She died at about half-past twelve in the morning. Only if she’d been given potassium chloride could it have been someone on that midnight shift.’

  ‘That’s very unlikely,’ I said. ‘I was on the ward myself from midnight.’

  ‘All right. If she’d been given soluble or zinc insulin,’ he continued, ‘it would have been someone on the previous shift, 1600 to midnight. And if it was PZI, it could have been on the 0800 to 1600 shift.’

  ‘More likely to have been 1600 to midnight, though.’

  ‘More likely, yes, but not certain.’

  ‘Unless it was in a drip as you suggested,’ I said. ‘Although I don’t think she was on a drip …’ I found her notes. ‘No, she wasn’t.’

  ‘Just because Mrs Sutton wasn’t poisoned via a drip doesn’t mean that the others weren’t.’

  ‘But I thought you said yesterday that the killings were either planned or random. That would mean both.’

  ‘If it’s a psycho, as you seem to think, they might take the chance to kill whenever it occurred. Let’s see how many of them were on drips when they died.’

  In fact, only two out of the eight were, which is about what I’d have expected under normal circumstances.

  ‘Which suggests to me that the killings were planned,’ he said. ‘We’ll still have to consider the possibility of both, though.’

  ‘But that’ll make it impossible,’ I protested.

  ‘Tedious, perhaps, but not impossible.’ He looked up. ‘Why don’t you make us something to eat, Jo, while I think about it?’

  If, at that moment, I’d had some potassium chloride and a syringe on me, I think I might have used them. I gave him a filthy look which he didn’t even notice, then went through to the kitchen and made an omelette so that I could take it out on the eggs.

  He ate quickly and absent-mindedly, asking sporadic questions.

  ‘What happens when a nurse is sick?’

  ‘Either the shift does without, or someone else has to step in, like I did on Tuesday.’

  ‘D’you keep records of that?’

  ‘Yes — in that book by your elbow marked “Out of hours working”.’ A thought struck me. ‘But wouldn’t that suggest unplanned killings, just when we’d decided they’re probably planned?’

  ‘It might give the killer the opportunity they’d been waiting for, especially if it was at night. I assume there are less of you there then?’

  ‘Less, but in an ITU, that’s still a lot. That’s why it’s called intensive therapy.’

  But sarcasm was wasted on him.

  ‘You know what we’re going to have to do, Jo?’

  ‘I can’t wait to hear.’

  ‘We’re going to have to make a chart — a list for each dead patient — of the staff who fit into the time-frame, then see which names come up on all of them.’

  ‘I still think you’ll end up with a hell of a lot of names.’

  ‘We can worry about that later. The thing is, the accuracy of these rotas is critical. I notice in places — here for instance — that names have been crossed out and others pencilled in.’

  ‘That’s when two people have agreed to swap duties.’

  ‘Does it have to be a swap? I mean, couldn’t one simply take over the duties of another?’

  ‘That can happen, although not often. Too tiring, for one thing. It screws up their time sheets, for another.’

  ‘Are all such changes marked here on the rota sheet?’

  ‘They certainly should be. It has been known for people to forget, although I give them hell if I find out.’

  ‘Is there any way these rotas can be checked?’

  ‘No, not really.’

  ‘You mentioned time sheets just now. Do the staff fill them in themselves?’

  ‘Yes.’

  ‘Who signs them?’

  ‘I do, but —’

  ‘D’you keep copies?’

  ‘Yes …’

  ‘Well, that’s how you can check these rotas.’

  ‘But what’s to stop the killer simply leaving out the times they actually killed someone?’

  ‘The person they swapped with — they’ll have put the right times.’

  ‘But it’ll take hours …’ I protested.

  ‘Another thing — these rotas only cover the nurses. What about the others — the doctors?’

  ‘We keep a logbook which covers the doctors and all the paramedics.’

  ‘We’ll need that as well, then.’

  ‘Oh, my God!’

  ‘Beautiful omelette, Jo.’

  ‘Oh, get lost, Jones …’

  *

  ‘We stand helpless in the face of the suffering and deaths of our fellow human beings. To somehow intervene in this inexorable process, however briefly, is the best expression of our humanity.’

  I sat up. That had to be the most riveting start to any talk I’d ever heard, and Miss Shenstone’s voice, with its dark Celtic overtones, was the best medium to convey it. Jones had left the house before me and saved me a seat near the front of the packed lecture hall.

  ‘That statement, made by a fellow physician many years ago, is as true today as when it was first uttered.’ Miss Shenstone looked around the hall. ‘It was with that statement in mind that the transplant policy of this hospital was formulated.’

  Dr Cannock, who as ch
airman of the meeting had introduced Miss Shenstone, was now sitting to one side of her on the platform, busily taking notes.

  ‘It is our policy in this hospital to attempt to recover every single organ that becomes available, so that it may be targeted as soon as possible to the most suitable recipient, wherever they may happen to be in the country. To that end, we have a standard procedure, the first step of which is to ascertain the tissue type of every patient who is admitted to St Chad’s.’

  She turned, seemingly taking in every member of the audience. ‘We do not want patients to die — that would defeat our purpose. But when they do, our policy is to immediately put them on life support and actively seek permission for transplant from the relatives. As soon as this is obtained, we send details of the organs available, together with the donor’s tissue type, to the British Transplant Headquarters in London. They have on computer details of all the patients in the country who require transplants and can decide which of them should be the recipient. Then the donor can be sent to whichever transplant unit is to be used.’ She paused again to look round.

  ‘The successful working of this policy depends on you, ladies and gentlemen. Yes, every one of you is involved; every one of you has his, or her, part to play.’

  She does have this tendency to go slightly manic sometimes when giving a talk. Not in the operating theatre, though. I remember seeing her there once when I was training, and she was utterly confident, completely in control.

  ‘The medical and nursing staff,’ she continued, ‘who have the unpleasant, and at times traumatic, task of approaching the relatives of the deceased for permission for transplant. Who then place and keep the donors on life support. The medical and scientific staff who perform the tissue typing and other laboratory tests. The clerks who type the results. The porters who carry the samples. All of you.’

  Having given us a large slice of the credit, she now went on to describe, with slides, case reports of recent successful transplants carried out in the unit. Not surprisingly, her audience wanted to hear about their altruism and gave her their complete attention.

  When the slides were finished and the lights went up, she said, ‘There has been a certain amount of … disquiet in the media over the last few years concerning organ transplant. The phrase Spare Parts has been bandied about. We have been given images of wealthy ghouls prolonging their perhaps useless lives by a form of cannibalism. Not nice at all.