A Mistake Read online

  Elizabeth picked up the trocar from the tray. This one had no blade. It was a short blue pipe with taps around a handle like a thick screwdriver and she took the retractor from Robin and used the retractor like a plank to ease the pipe into the hole in the girl’s belly on a diagonal, screwing it left and right, drawing the leaking fluid to help it in.

  ‘Hasson,’ she said as she screwed it in, ‘has a small incision which leaves little or no scarring enhancing postoperative recovery. Hasson allows access under vision. Hasson won’t puncture the bowel.’

  ‘Thank you all,’ said Andrew. ‘Carry on.’

  ‘Thanks, Andrew,’ she said. ‘Get what you needed?’

  ‘Just checking in,’ he said.

  ‘Checking in.’

  ‘Yes.’

  ‘Cheers, then,’ she said.

  ‘Yes, yes,’ he said.

  ‘Cheers, cheers,’ Elizabeth said and grinned at Robin and the doors flapped closed.

  There was a momentary pause and she blinked and breathed out through her nose.

  ‘Right,’ she said. ‘Let’s get on with helping this girl. We will be inserting three trocars into Lisa today. Trocar, from the French trois, meaning three and carre, or edge. The three edges of the blade opening a portal into the abdomen into which we now have access—12-millimetre for camera, light and gas to blow up her abdomen thus creating a pneumoperitoneum for us to work within, and 5- and 8-millimetre for other instruments as needed, and for drainage. We’re inserting three ports today, including camera, at the risk of repeating myself. Now. Maestro?’

  They were smiling behind their masks as she made her small speech.

  ‘Yes?’ said Mei-Lynn.

  ‘Can you for crying out loud put the Slayer on, please. The 30-minute one.’

  Robin audibly exhaled.

  ‘No,’ someone breathed.

  ‘Oh, come on,’ said Vladimir from behind the anaesthetic machine.

  ‘Do it,’ she said, and laughed at them. ‘Did you know, Richard, a recent study out of the US showed women physicians have measurably better outcomes than the men? Journal of the American Medical Association this year. Huge sample size too. Something to think about for all of us. And our dear leaders.’ The nurses were smiling and the atmosphere had changed again. ‘Did you also know,’ she said, leaning down, ‘first recorded use of the trocar was in 30 AD? Aulus Cornelius Celsus in the De Medicina. Originally used to drain fluids and gas from the abdomen. And that, my dears, is more or less what we’ll be doing today, 2000 years on.’

  The two surgeons stood across from each other, their hands raised as if blessing the girl’s body before them, frozen for a moment. Robin screwed the gas pipe to the side of the trocar in the girl’s belly.

  ‘Gas, please,’ said Elizabeth.

  The music began. Slayer’s Angel of Death, a thrash metal song that had been remixed until it was 30 minutes long. She liked to play it on repeat. It was hypnotic and repetitive and it helped her concentrate. The single metal riff that opened the song repeated and repeated and a German voice murmured above it. The girl’s abdomen rose as the gas inflated it like a pregnancy.

  ‘That’s the stuff,’ whispered Elizabeth, to the music, and to the pneumoperitoneum.

  Robin took up the pipe of the camera and slid it into the end of the trocar and inside the girl’s body.

  Above them on the screens shifting veils of flesh emerged from darkness.

  ‘Well, look at that,’ Elizabeth said. On the screen the tissues were red and inflamed. There were brown pits of abscesses along her fallopian tubes.

  ‘Extensive pus,’ Richard said.

  ‘Yep. Second trocar, please,’ Elizabeth said.

  She made a small press cut at the lower left of the girl’s belly with her scalpel and took up the second smaller trocar.

  ‘Left lower quadrant, direct vision please, Richard,’ she said and he rotated the camera. ‘We insert the trocar under direct vision to ensure no damage to the underlying structures,’ she said. She pushed the trocar against the cut and the skin dimpled gently. The trocar’s sleeve, its blade extending at the pressure, cut and sank into the girl. Above them on screen the blue plastic tube emerged huge into the frame inside her, and the blade vanished away.

  Then the girl’s abdomen sank slightly. The song’s riff repeated and repeated and the German voice murmured on.

  ‘Can we check gas flow please, Mei-Lynn,’ Elizabeth said.

  Mei-Lynn went to the gas tower.

  ‘Extensive pus, indicating what do you think, Richard?’ Elizabeth said up to the screens. She pressed with her fingers on the girl’s tummy. Then to Mei-Lynn—‘I want ten mercury. What’s wrong with the gas? Richard, do you want to insert the last port?’

  ‘Yep, sure.’

  Richard took up the last trocar from the tray like a dagger, the wrong way around, then inverted it so it rose from his fist. He looked up and saw she was watching.

  ‘How’s that pressure please,’ Elizabeth said, looking at him. ‘Extensive pus, indicating—?’

  Mei-Lynn was at the tower and said, ‘Um, pressure is set to ten and flow rate is six but we’re not at ten yet.’

  ‘Have you changed the gas for Christ’s sake,’ Elizabeth said to the screen. ‘Go and get a new bottle.’

  The Slayer droned on and on and it was very quiet otherwise after Mei-Lynn had left the room.

  Robin went to the tower.

  Richard hovered for a moment above the pale skin and Elizabeth looked down from the screen at him.

  ‘What’s up, Doctor?’

  ‘No problem—’

  Elizabeth touched the skin in the very corner of the visible square of her stomach. ‘Is that the 5-millimetre?’

  ‘Uh—’ He checked it. ‘Yes.’

  ‘Well let’s get on with it. What’s wrong with that gas, Robin?’

  Robin said, ‘The bottle’s full.’

  ‘Well, increase the flow. Come on.’

  Richard took up a scalpel and made a small incision at the top right of her abdomen where she’d touched the skin and put the scalpel back down again. He placed the tip of the trocar against the small slit.

  Robin pressed a button on the tower. ‘That’s six point five,’ she said and they watched the abdomen rise again.

  ‘Come on then,’ Elizabeth said. ‘This young woman is very sick and may be dying in front of us.’

  Richard pushed the trocar hard into the girl and it sank slightly and stopped.

  Elizabeth stared up at the screen with the camera handle in one hand. ‘You’re not through,’ she said. ‘Hurry up. Give it some welly. Indicating what, Richard?’

  ‘Indicating—’ he said, and he pushed the trocar into the girl.

  On screen sudden bright blood rose in the seams of the red geography of the inflamed tissues. They watched as the blood filled the cavity. It rose and it rose and it did not stop, and so close on the tiny camera, lapping gently as if in a breeze.

  ‘—cut the mesenteric,’ Elizabeth said normally. She stepped back from the girl on the bed and raised her hands before her chest. Normally, she said, ‘Quick, we have to open.’

  The Slayer was now playing the first riff with drums. Every change was elaborated at length because it was a remix of a three-minute song into a version 30 minutes long. The blood was filling her abdomen completely. Richard stood and looked at the screen. Like its meaning defeated him. Every change went forever until it collapsed into noise and resolved into the new change and everyone knew it was an Elizabeth Taylor favourite. The nurses were stopped and they were looking around.

  Robin said, ‘—are we converting?’

  ‘Can someone please call fucking Mei-Lynn back in here?’ Elizabeth said normally. ‘How’s she doing, anaesthesia?’

  ‘Uh,’ Vladimir said, ‘systolic 90. Pressure is falling now.’

  ‘Robin, remove all the laparoscopic gear. B tray for urgent laparotomy and arterial instruments. Music off, get all this gear out of the way now.’


  Robin stepped forward and grasped the camera handle. On the screen above them the image of the curved organs and the abdominal wall and the pools and bubbles of dark blood they lay within lapped and wobbled and then shot away, it all collapsed upon itself and disappeared down a tube and flew about the room, capturing their masked faces in single blurred frames as Robin pulled the camera from the port and dumped the apparatus on a trolley. She pulled the ports and trocars from the girl’s abdomen one by one, reaching in front of Richard to take the last one out, the hollow dagger that had stabbed the sleeping girl inside.

  Mei-Lynn came back into the OR carrying the CO2 cylinder hanging heavy from one hand. She stopped when she saw the two surgeons motionless and Robin piling the tubes and instruments on the trolley.

  Mei-Lynn looked around her. Then she leaned the CO2 cylinder down against the wall and came forward.

  Robin hissed, ‘B tray quick, we’re opening.’

  Elizabeth said, ‘Hurry up you silly cunt.’

  Mei-Lynn turned and went quickly back out for the instruments.

  The CO2 cylinder she’d left behind her slid slow then fast down the wall. It hit the ground and bounced and rolled away under the trolleys with brassy thunder.

  ‘Christ,’ said Elizabeth.

  Before them the visible square of the girl’s stomach was still. The small holes bloodless and waiting and under them the chaos gathered.

  Josie came forward to adjust the drapes.

  ‘Get out of it,’ said Elizabeth, and she stepped back again. ‘Robin. The B tray and the arterial instruments. How long will we have to wait.’

  Robin came forward with a fresh trolley and adjusted the drapes.

  ‘Vladi?’ said Elizabeth.

  ‘Pressure is still falling. She is becoming difficult to ventilate.’

  Elizabeth stared up at the clock.

  ‘I called for three units of red blood cells pre-op, can you please ask Betty to get the blood.’

  ‘Yes Doctor.’

  ‘Where are the fucking instruments please.’

  Robin turned to the doors but Mei-Lynn had returned with the tray and laid it out, peeling back the sterile parcels. Elizabeth reached out and pushed them aside and took up the scalpel. In one stroke she made a foot-long cut the length of the girl’s belly between the leaking hole at her belly button and the hole for the port above her left hip. The skin dropped open and dark blood rose in spots in the white fat.

  ‘Diathermy,’ Robin said to Mei-Lynn.

  ‘No, we don’t have time,’ Elizabeth said. ‘I’ll do it myself.’

  Around her the theatre staff stopped to watch what she was going to do. Elizabeth placed her gloved index finger against the side of the blade to control the depth of the incision and sliced in one long cut down again through the subcutaneous fat and sheaths of muscle and the peritoneum all at once and the girl’s bowel opened up and it was full of bright dark blood and the blood shone and moved freely about the organs so their colours and shapes were indistinguishable.

  ‘Vladi,’ Elizabeth said calmly.

  ‘Heart rate is 140.’

  She leaned in and began to separate and divide the small intestines with her hands. Richard had not moved since he had inserted the trocar. Robin placed the suction tube at the side of the wound and the blood sank quickly. The only sound in the room was its sound, the gurgling inhalation and the grind of the machine. Elizabeth used both hands to lift and separate the heavy organs. She lifted them and looked and replaced them and moved them to one side.

  ‘There,’ she said. ‘There. And there. Suction. Put your finger on it.’ Robin reached in. ‘Not you,’ Elizabeth said. ‘Richard. You cut her.’

  Robin swabbed the cavity with a piece of gauze and for a moment they saw the small dark slit in the back of the abdominal wall pumping blood. Richard pressed his finger against it before it disappeared. Their white gloves were up to their wrists in red. Elizabeth moved on and lifted the loops of small intestine, the slab of liver, the inflamed uterus, parting the organs, pushing the sick fallopians aside as the well filled with blood again.

  ‘There. There’s a cut in the IVC here and we need to extend the incision to clamp it,’ Elizabeth said.

  She took up the scalpel again and extended the opening in the girl’s belly high and low in small tugging cuts. Robin added another retractor to pull back the skin and fascia of her stomach then leaned in. Elizabeth teased up the thick, leaking vein and held it with one finger over the cut. Robin clamped it above and below with steel clamps then suctioned out the blood and reached in to mop up with a wad of gauze and yet more bright blood filled the seams. There were five hands and four clamps inside the girl’s abdomen.

  ‘Careful with the ureter. Stay where you are. Govern these ventages with your fingers and thumb,’ she murmured, and sniffed a soft laugh.

  She lifted her finger from the rent in the vena cava and it did not bleed any more. They were all paused and watching. Mei-Lynn finally turned the music off and there was silence. ‘Give us some Bach, please,’ Elizabeth said. ‘Sonatas and Partitas. Monica Huggett on violin.’ The girl’s organs moved with her breathing. Richard had his finger on the other cut. The music began, and they watched and then the blood in her rose again. She was still bleeding and it was then they saw the bright overflow pumping from nothing in the wide, strong ribbon of the psoas muscle.

  ‘That’s not the IVC, that’s the lumbar artery bleeding.’

  Elizabeth took up the needle and sutures and she held the muscle in one hand. She examined it. She leaned back and selected forceps from the tray and leaned in. She began to suture the lumbar vessel deep within the muscle by feel.

  It was all very quiet as they watched her work. There was the gurgle and grind of suction, then quiet, and she spoke normally and taught them.

  ‘This is a controlled emergency and not a chaotic emergency. The torrential bleeding from the vena cava is controlled with clamps and we can move in order of urgency. Richard has control of the posterior tear with his finger. The bleeding lumbar vessel is the most urgent due to the volume of bleeding and I am going to focus all my energy on that right now. Anaesthesia are you caught up?’

  ‘I’m not sure.’

  ‘We have a cut in the posterior abdominal wall from an uncontrolled trocar insertion that is controlled with digital pressure. We have a rent in the IVC which is clamped, and we have severe lumbar bleeding in the psoas that is posterior and deep I’m currently sewing with five-oh prolene,’ she said.

  ‘Thank you.’

  As she sutured the others watched. Josie gathered the unused equipment. As she sutured Elizabeth whistled and hummed along with the Bach, little progressions that interested her, that moved her, and she murmured, who, quietly, now and again. As she pulled it off. As she nailed it, as she killed it.

  ‘Who.’

  When she finished sewing the lumbar bleed she sewed the cut in the vena cava closed in seconds, and Robin unclamped it and as the blood flowed again the vessel swelled full and did not leak, and then she sewed the hole that Richard had been holding with his fingertip for 20 minutes. They hardly spoke during this part of the procedure apart from once, when Elizabeth said, ‘How much blood,’ and Robin checked the bottle on the suction machine and said, ‘About 1400 mills’ and held the big red bottle up. Vladimir said, ‘A lot.’ Elizabeth told Mei-Lynn to call and cancel the stump revision she had been scheduled to do and then she removed the IUCD and then she removed the girl’s appendix for good measure. Then they went on with the original operation. They mopped out the pus and washed the girl’s abdomen out with 5 litres of sterile saline. They closed up the wound with surgical staples and Elizabeth left Richard to sew up the port holes like a med student. They were finished at 5 p.m. with time for Elizabeth to have a cup of coffee and make her next operation at 6 and write up her notes afterwards. She visited the girl in ICU about 11 p.m. that night before she went home and the girl was awake and taking oxygen through a CPAP mask
she didn’t like and then she died at 4 a.m. the next morning.

  The US Space Shuttle Challenger, like all the space shuttles of the late 1980s and early 90s, was comprised at launch of three main parts known in the business collectively as ‘the stack’.

  These three main parts are the shuttle itself, known as the orbiter, mounted at launch on top of a gigantic tank of fuel for the shuttle’s engines, in turn flanked by two solid rocket boosters, or SRBs, to propel the stack into space.

  Two minutes after launch those solid rocket boosters jettison, at 45 kilometres in the sky, and they descend by parachute to the ocean, where they are retrieved, refurbished and re-used, like sterilised surgical instruments.

  The SRBs look like pencils and they are 45 metres long and weigh nearly 600 tonnes. Most of that weight is their fuel, a rubbery solid material made of ammonium perchlorate and atomised aluminium powder called APCP.

  Because of the weight of the SRBs they are built off-site in four sections by a contractor named Morton Thiokol, huge drums moved by truck and rail to be assembled near the launch pad. Each section of rocket is joined to the other using a simple joint, known as a tang and clevis. A U-shaped joint, running around the perimeter of the rocket, which receives a tongue—the tang—from the section beneath. There are, necessarily, minute gaps between that U and that tongue.

  APCP burning at over 3000 degrees Celsius finds that gap.

  So at two points thin rubber O-rings circle the rocket. These two O-rings are just 6.4 millimetres thick and they sit inside a groove in the joint that is under 8 millimetres wide, greased and protected by flame-retardant putty. When the booster fires, the heat and pressure forces the O-rings into the gap between the tongue and the clevis. This is called pressure actuation. The rubber changes shape; it is forced to, and the forcing creates the seal necessary for the rocket to function properly. The launch thrust shoves the tongue up into the U and the O-rings into their grooves and the rocket seals up tight under pressure of a thousand pounds per square inch. It’s all designed to move dynamically. To change as it plays. To adapt to the pressures it will face in a dynamic and predictable way. The stress is necessary for success.