A Mistake Read online

  ALSO BY CARL SHUKER

  Anti Lebanon

  The Lazy Boys

  The Method Actors

  Three Novellas for a Novel

  A Mistake

  Copyright © 2019 by Carl Shuker

  First Counterpoint hardcover edition: 2019

  All rights reserved under International and Pan-American Copyright Conventions. No part of this book may be used or reproduced in any manner whatsoever without written permission from the publisher, except in the case of brief quotations embodied in critical articles and reviews.

  This book is a work of fiction. Names, characters, places, and incidents are the product of the author’s imagination or are used fictitiously. Any resemblance to actual events is unintended and entirely coincidental.

  Library of Congress Cataloging-in-Publication Data

  Names: Shuker, R. Carl, 1974– author.

  Title: A mistake / Carl Shuker.

  Description: First Counterpoint hardcover edition. | Berkeley, California : Counterpoint, 2019.

  Identifiers: LCCN 2019004433 | ISBN 9781640092495

  Classification: LCC PR9639.4.S56 M57 2019 | DDC 823/.92—dc23

  LC record available at https://lccn.loc.gov/2019004433

  Jacket design by Sarah Brody

  COUNTERPOINT

  2560 Ninth Street, Suite 318

  Berkeley, CA 94710

  www.counterpointpress.com

  Printed in the United States of America

  Distributed by Publishers Group West

  13579108642

  For Carl James Patton

  Flight controllers here are looking very carefully at the situation.

  Obviously a major malfunction.

  —Space Shuttle Challenger launch commentary

  Contents

  A glass of milk with Voltaren and Panadeine

  Meeting the parents

  Jessica

  Teaching

  Conference, Queenstown

  The M&M

  High winds aloft

  To the butcher’s

  It is bitter—data

  The flaw

  Going private

  Nature cannot be fooled

  Cumulative sum of failure

  Cumulative sum of failure 2

  Cumulative sum of failure 3

  Publication day

  The astronauts

  Two memories

  In the ICU

  Acknowledgements

  A glass of milk with Voltaren and Panadeine

  ‘Hello there,’ Elizabeth said, leaning over the girl, smiling. ‘Hello. Hello Lisa.’ The girl looked up at her accusingly. ‘My name is Elizabeth Taylor. Please call me Liz. I’m the consultant surgeon and this is my registrar, Richard Whitehead.’

  Elizabeth smiled wider for her.

  ‘How are you feeling?’

  The girl lay in the bed in the emergency department and she was pale and very sick and there were black bruises under her eyes. She had an IV in one arm and was in her very early twenties. A white girl, small and thin and turning in her pillows, selfish, inward in her pain.

  She looked away to the ED nurse who had been waiting with her. The nurse was a middle-aged Englishman standing with his feet together. He had a tag on his chest that read

  #HelloMyNameIs

  Awesome

  with Awesome crossed out and Matt written underneath in Biro.

  ‘Where’s the doctor—’ the girl said.

  Richard was beside Elizabeth, turning through the notes and murmuring.

  ‘She’s tachycardic,’ he said. ‘Up from an hour ago. Respiration 22 and steady, pressure is down, is why we paged.’

  The girl looked past Elizabeth to the male nurse, and she said, ‘My shoulder. My shoulder hurts.’

  Matt leaned down to her and he said, kindly, ‘Does it hurt in your shoulder now?’

  ‘Yes.’

  ‘Does it hurt when you breathe?’ said Elizabeth.

  The girl looked at her wide-eyed and she said yes, and turned to Matt again and Matt watched her eyes, half-smiling down at her.

  ‘Okay. That’s okay,’ he said.

  ‘She’s got no pain at McBurney’s point,’ Richard said. ‘Doesn’t look like appendix. She’s had a total of 10 milligrams of morphine since 9:30 for increasing pain and 10 milligrams of Maxolon for the nausea.’

  ‘Where are you from Lisa?’ said Elizabeth in a conversational voice. ‘Lisa? Where do you live?’

  ‘Rotorua,’ the girl said, like a question.

  ‘Are you on holiday in Wellington?’ said Elizabeth. ‘We’re having a lovely summer down here aren’t we. Get out of the way,’ and Matt stepped quickly sideways.

  Elizabeth pulled the gown off the girl’s stomach. She pressed gently on the right side above her appendix. The girl squinted and tensed. Then Elizabeth pressed gently on the left side of her stomach by a cluster of small moles and the girl half-squealed in a low wheezing exhalation. Her eyes outraged and wet.

  ‘Did that hurt, Lisa?’ said Elizabeth. ‘I’m sorry. You be brave now.’

  The girl had started to cry and was looking at Matt. She made a keening sound then she said, ‘Where’s the other doctor?’

  ‘GP at Adelaide Road saw her three days ago,’ Richard said to the notes. ‘One day of cramping abdominal pain. Soft and tender abdomen with guarding at left iliac. Given trimethoprim, diclofenac, paracetamol, and sent away. She came back again three days later, from some camping ground in the Hutt, in a lot of pain. No bowel motion or urine for two days, elevated pulse, and they put her on IV fluids and transferred her here. Radiology suggests necrosis to bowel and organs and notes there’s an IUCD in situ.’

  Elizabeth listened and looked down kindly at the girl.

  ‘Lisa,’ said Elizabeth. ‘Lisa. Are you pregnant, Lisa?’

  ‘No. No, I don’t think so. No? Is it a baby? Is it a baby?’ she said and she stared at Elizabeth and at Matt.

  Richard flicked through the notes.

  ‘BhCG negative. It was added to the labs.’

  ‘Who did that,’ murmured Elizabeth.

  ‘It was a locum I think,’ said Richard and looked around the ED.

  ‘Good for them,’ said Elizabeth. ‘Someone’s on the ball. Who’s with her? Do you have someone with you like a boyfriend or your parents, Lisa?’

  The girl looked left and right. Her breathing becoming more shallow, more desperate.

  ‘The boyfriend’s outside,’ said Matt.

  ‘Is your boyfriend with you Lisa?’ said Elizabeth. ‘What’s your boyfriend’s name? Is he from Rotorua too?’

  The girl looked left and right again. ‘Stuart,’ she said and as she spoke Elizabeth pushed her stomach down again above her left hipbone with three fingers and this time the girl screamed.

  ‘Okay now, we’re going to take care of you, Lisa,’ Elizabeth said. ‘You be brave now.’

  ‘Where’s the doctor,’ she said, very angry now, and Elizabeth ignored her.

  ‘Well,’ she said to Richard.

  ‘Uh,’ he said, and he looked at the chart. ‘Clearly . . . intra-abdominal catastrophe. Immediate surgery to assess for ruptured viscus, bowel or appendix. Aggressive fluids and transfer to theatre for laparoscopy.’

  Elizabeth said, ‘Well. Possibly. I think we’d rather provisionally suggest pelvic peritonitis maybe due to salpingitis. You said yourself she had no pain at McBurney’s and this was confirmed by examination right in front of you. Why add appendix to that list? Leaving yourself outs? I agree with the immediate urgent laparoscopy. Three units of packed red blood cells crossmatched and prep for theatre and page Dr Mirnov to consent her.’

  Richard was nodding and nodding and staring at the notes.

  Elizabeth turned back to the girl.
/>   She was moaning and had closed her eyes.

  In the corridors from ED to theatre Elizabeth’s sneakers slapped and squeaked. Her father’s only daughter, 42 years old, youngest and the only woman consultant general surgeon at Wellington. Sudden bursts of light as the sun went west over the valley as she walked and her sneakers slapped and squeaked on the shining linoleum. Mid-afternoon, now, clouds creeping south over Newtown. There was a black-eyed little sparrow trapped inside the hospital, testing the windows, flying from sill to sill down the corridor. As she walked she called Simon Martin to get on with a boring hernia repair she’d been about to begin when she was paged and then she called theatre to get ready for this girl.

  ‘Robin,’ she said into the phone. ‘Prep for laparoscopy and a peritoneal washout and removal of IUCD. She’s septic and will need antibiotic cover. Tell Vladimir we’re on our way. How are you, anyway?’

  Elizabeth’s voice was cheery and pleasant. She had been up for 27 hours. This was the end of her on-call. She was so constipated she had not used the toilet in two days. It was useful for operating. She hadn’t drunk any liquids but coffee all day and her bowels burned and felt dry and heavy and wooden, reliable.

  As she walked through the interrupted glares of southern sun Elizabeth had an abrupt verbatim recall of a brutal peer review comment she had received yesterday. It was a revise and resubmit on an editorial she and Andrew had sent to the Royal London Journal of Medicine, about the upcoming public reporting of surgical outcomes in New Zealand.

  These authors have conflated several very different, very important issues and failed to produce a meaningful interpretation that usefully advances our understanding of any of them.

  Andrew McGrath was head of surgery and dean of the Wellington campus of the Otago Medical School. It was her job to reply to the journal on their behalf. The Royal London Journal of Medicine was one of the Big Three, alongside The Lancet and the BMJ, most prestigious medical journals in the UK. Impact factor: intimidating. The third oldest medical journal in the world. Even to be gutted at peer review was something of a coup. Andrew would be in the corridors. Andrew would be at the upcoming conference in Queenstown. She’d better have something ready.

  Elizabeth bore down, she focused, and the solution came, as it always did for her, when she bore down.

  ‘Robin, please make a note for me,’ she said as she walked. ‘Say: we are grateful for this reviewer’s comment and upon reflection we have adjusted those paragraphs at lines 120–130. I’ll recheck that. Say: however, we regret we cannot agree with his view given his previously published partisan position on public reporting of surgeons’ outcomes in the Royal London—2013 I think it was, I’ll check that, Robin—and something something really vicious there, and delete those paragraphs and replace with a reference to Carnaby et al., 2012, that’s C-A-R-N-A-B-Y, and say this quote: “For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.” That’s Richard P. Feynman who said that. F-E-Y-N-M-A-N.’

  She saw herself moving in reflection in the hospital windows as the sun hit her. Small, straight-backed and uniformed in blue scrubs. Happy. The bird bumping against the glass inside her. Would it die in here?

  Go, she said to herself, and disappeared again in the shadow.

  ‘I’ll check it but it’s something very close to that, anyway. All good?’

  Robin was speaking.

  ‘Hold on.’

  She flicked through the notes as she walked.

  ‘Yep. Last oral intake 7:30 this morning. She had a glass of milk, Voltaren and Panadeine.’

  The girl was asleep. Her belly button all that was visible in the centre of a square of pale skin formed by the blue drapes. At her shoulders the drapes became a great blue crucifix shielding her head and Vladimir, sitting on his stool by the anaesthetic machine.

  Elizabeth, gloved and gowned, said, ‘Now.’

  Everyone, even the circulating nurse, stopped moving.

  ‘We will perform a classic Hasson open technique. Why?’

  The nurses came back to life and moved about the theatre. Elizabeth pinched a fold of fat on the girl’s stomach with gloved fingers and squeezed it to open up her belly button. Richard leaned forward and widened the navel with the Littlewoods forceps.

  ‘Let’s give it a clean first, Richard,’ she said.

  ‘Sorry.’

  ‘Inevitably you will encounter material in the umbilicus initial prep has missed.’

  The comment was directed at Josie the scrub nurse and she looked up.

  ‘It’s clean,’ Josie said.

  ‘We’ll see,’ Elizabeth said.

  ‘Do you want to do the checklist, Doctor?’ said Mei-Lynn. She was indicating the large poster of the surgical safety checklist on the theatre wall.

  ‘No, we don’t have time. Let’s get on with it. Now’—the doors flapped behind her as Richard scrubbed the girl’s belly button with a swab in forceps—‘get in there. Clean it properly.’

  The doors flapped closed. The nurses had parted. Someone new was there. Elizabeth leaned back, rolled her neck in her shoulders and leaned down again to the belly button.

  ‘Hello, Andrew,’ she said.

  ‘Hello, everyone,’ he said. He was behind her, not scrubbed, wearing his double-breasted suit. ‘Carry on. Just looking in.’

  ‘For the benefit of those new here, Andrew McGrath, head of surgery. Welcome, Andrew.’

  ‘Yes, yes,’ he said. ‘Carry on.’

  Elizabeth met eyes with Robin across the girl’s stomach. Elizabeth grinned at her but Robin didn’t let her eyes change.

  ‘Now. Why Hasson.’

  Richard glanced up at Andrew as he cleaned and back down again. ‘Um, a 2014 review,’ Richard said, ‘found major and minor complications a percentage point safer for, um, open technique versus the Veress needle?’

  ‘But that particular study was an Indian review,’ said Elizabeth. She stood over the patient, pinching the girl’s stomach. ‘Context matters. Number five blade please.’

  Andrew moved closer to the edge of the sterile field, almost standing among them to get a better view.

  ‘Andrew and I,’ Elizabeth said, ‘are working on a paper about publishing our outcomes. For a medical journal you might just have heard of called the Royal London Journal of Medicine. Aren’t we Andrew? Bit controversial. Publishing our numbers in the papers. Complications and patient deaths of named surgeons. Which for one we think ignores the stellar contribution to this girl’s care made by all of you.’

  ‘Mmm,’ Andrew said. ‘Well, quite.’

  He leaned forward to watch.

  Elizabeth took the scalpel from Robin and punctured the skin beneath the girl’s belly button and in one bloodless cut incised straight down a single centimetre.

  She said, ‘And we’ve had a peer review come back that’s been let’s say somewhat suspicious of our conclusions.’

  A couple of the nurses sniffed soft laughter. Richard flicked his eyes up to Andrew and back down again.

  ‘That peer review,’ Andrew said, ‘is from an Oxford don who’s actually Australian. He’s very partisan on the issue of publishing outcomes. And he doesn’t like me.’

  The nurses looked at nothing but the operation and the instruments.

  ‘I’ve got a few ideas,’ Elizabeth said.

  ‘Very good,’ he said.

  ‘First of all—’

  ‘We can discuss it later,’ he said.

  She stared at the incision. She felt her left eye twitch. She was tired. She made herself not look at Richard, or Robin. That sudden rage; it was interesting. She made herself find it interesting. She held it and turned it and examined it. How susceptible she was to the hand that pats the head not patting. And she used it to focus.

  She placed the scalpel back on the tray and took the forceps and reached inside the wound and grasped a piece of the tough tissue under the belly button and pulled it up through the hole she had made. R
ichard grasped it with forceps on the other side and she took up the scalpel again and sliced a line down through it. Robin reached in with her forceps and grasped another piece of the tissue and they pulled it up and Elizabeth steadily cut her way through the stiff fascia, faster than she normally might. It was wet and white even against the girl’s pale skin but there was no blood. A little white bud of meat protruding at her belly button.

  ‘Just a few fibres at a time,’ Elizabeth said. Then, as she sliced, ‘The Cochrane review covered 46 randomised controlled trials of 13 laparoscopic techniques. What did they find, Richard?’

  Richard said, ‘Um, they found with Hasson technique no events in any of 12,000 patient days, I think it was 12,000 wasn’t it, it was a lot, for mortality, gas embolism, or internal injury.’

  ‘It also found Veress needle method will score lower every time,’ she said. ‘Failed entry, vascular injury, visceral injury. Veress loses every time and if you assist a surgeon who attempts it you’re endangering the patient. It’s bullshit. Bad medicine. Now we see the peritoneum.’

  The peritoneum was visible. Inside the small hole: a taut, veined white bag. Elizabeth pinched the fat fold and lifted it, pulling at the stomach. ‘We give it some traction,’ she murmured, ‘why.’

  ‘To avoid uh, to avoid damaging the underlying structures when we um, penetrate the peritoneal sheath into the abdomen.’

  ‘Yep, Richard.’

  She leaned down with her forceps. The small hole was now held open with three pairs of forceps grasping tissue, and pressure from her pinch. She pushed the forceps into the hole and pushed it against the peritoneum until it popped through into the girl’s abdominal cavity. Behind her Andrew moved slightly to get a better view. She opened the forceps like scissors to widen the opening and then removed them and pushed her whole finger inside the hole in the girl’s belly and felt around inside for adhesions, for rips in the hole. When she removed her finger Robin leaned down and pushed a wide smooth retractor like a shoehorn inside the hole. The girl’s belly joggled and shifted and a clear fluid tinged with yellow was filling the hole but Robin held the retractor steady as Elizabeth leaned her forceps into it for leverage to sew a purse-string stitch, left and right. It was like a dance, but there was less pleasure in it now, being good, because it was a performance before him.