by Carl Shuker
When rubber is cold it is less flexible. Cold changes materials from a flexible, supple state to a hard and brittle state. The polymers are not moving. On the day of the launch of Challenger, January 28, 1986, it was 2 degrees Celsius. Part of the right-hand SRB faced away from the sun and there was a 6-degree Celsius difference between that side and the light. Each O-ring sits in a groove under 8 millimetres wide. They need to bounce back to seal that gap.
At just 0.678 seconds into the launch cycle there was already evidence of black smoke appearing above the O-ring joint on Challenger’s right solid rocket booster.
Meeting the parents
Elizabeth entered Wellington Hospital again at five the next morning through the great glass doors from the roar of windy darkness to lit calm.
The children of a young Māori family were climbing over the couches outside the elevators and the parents watched her as she came and when she grinned and said mōrena loudly the woman visibly frighted and Elizabeth punched the up button.
On the third floor she changed into scrubs and talked to Vladimir who had seen and consented the first patient already. In the wards it was very quiet with the ward lights still dimmed and the hospital still felt quite new, the wide surfaces and bare off-green walls. Here and there the orphaned posters telling everyone to observe the five moments of hand hygiene.
The glassed nurses’ booth was half empty and uncluttered and Richard was waiting inside. He was smiling with the nurses and hunched over a clipboard. One of whom must have said his name or her name because his smile disappeared and he looked up sharply—his big new sideburns, his premature balding, his red and wide and vulnerable eyes. Richard was from Otago and his father was a senior surgeon at Dunedin and he used, she knew, carmellose sodium to hide the tiredness, his pockets full of the little plastic vials, leaving the bathrooms with tears in his eyes. Richard was 26 years old.
‘Ready?’ she said when he came out.
‘Yes, of course.’
He held the notes to his chest and stared at the floor and she waited and she raised her eyebrows. ‘Sorry,’ he started. ‘Sorry—13,’ and he indicated the way like a maître d’ and she said she knew where it was and he dropped his hand and followed her a step behind until she said, ‘Walk beside me, Richard.’
‘Yep.’
‘How are you doing?’
‘I’m all right.’
‘You sure?’
‘Yep, yep.’
‘Good. How did you hear?’
‘Hear what?’
She looked at him.
‘Richard, we lost the sepsis this morning. I was texted on the way in.’
Richard went grey. She could see him thinking. See him ageing, see him recede and age. The pattern baldness would progress. The wrinkles that would deepen and dry. He wasn’t cut out for this yet and needed to change.
‘Oh,’ he said. ‘Oh. No, I didn’t know.’
‘It’s very disappointing. It’s a bad outcome,’ she said.
He thought and she watched him muster his response.
‘She . . . oh. That’s . . . in ICU?’
‘In ICU, yes. The sepsis was too advanced. She was likely never going to make it.’ She watched his face. ‘You okay?’
‘Yep, of course. Yes.’
‘What do you think?’
‘The . . . trocar though—’
How much mercy do you need? She thought what to say. How to let him hang from the hook and still function. How to learn to love the hook.
‘This was advanced sepsis, wasn’t it,’ she said. ‘We can’t know to what degree if any the extra time in surgery contributed.’
‘But I suppose the complication—’
‘—the complication contributed. We can’t know how much. It certainly didn’t help.’
He flinched then and she regretted it. She looked at him.
‘We can’t know, Richard,’ she said, softer.
‘No, I suppose we can’t but—’
‘We will learn from it. We will be better. Let’s get on.’
‘Yes. Okay.’
The morning’s first patient was a double amputee, right and left legs, a white woman, 69, and she was sat up in bed with her prostheses off and her husband in the other chair under the window by her right side.
They were retirees from the South Island, following their grown children north. Living in an apartment on the flat in Petone. She had, at half past five in the morning before her procedure, done her hair. She was pale and a bit frightened and Elizabeth looked at them and chose a tone for their frankness, for their Southern hard.
‘How are you this morning, Mrs McLean?’ she said. ‘Not too nervous?’ She tilted her head like a caring and compassionate person would.
‘Oh, no, no,’ the woman said, and she smiled and pursed her lips ironically at Richard. Involving the junior, bringing him in.
The husband was apart from them and he grinned and straightened his back for the doctor and already he looked disappointed. Elizabeth could see from his posture he was hearing impaired. He was eager to speak and control the conversation but he didn’t.
‘My name is Elizabeth Taylor, Mrs McLean,’ she said louder, ‘and I am the surgical consultant and this is my registrar Richard Whitehead. We’ll be performing your operation today.’
‘Hello.’ The woman looked at the husband and feigned a look of fright. Then she smiled and the man grinned and grinned the pained grin of the deaf.
‘How did you sleep?’ Elizabeth said. ‘Did you sleep well?’
‘Oh, yes.’
‘No, you didn’t,’ the husband said to her.
Elizabeth felt Richard look over at the man but she didn’t look away from the woman.
‘Well, you look very well this morning, Mrs McLean,’ Elizabeth said. ‘Did Eimear help you with your hair?’
It was unexpected and the room seemed to change. They stood apart and came into themselves. More than they had allowed themselves. And the husband looked at his wife and Richard came up into his skin again.
The woman smiled a bit, and touched her hair ironically, and she said, yes, she had, actually, and that it was a dry chemical shampoo in a cap, and wasn’t it funny.
Elizabeth said, ‘Eimear knows the tricks all right. Pay attention to what she says.’
As she said this she stepped around in front of the husband and extended her hand to take the woman’s other hand, the one that was not cannulated, to begin the examination.
The woman lifted her hand and it was offered and Elizabeth took it as if they were to be married.
Richard’s face was still and calm and his body was at ease and still and she liked this. The patient will judge you, her consultant John Atelier told her in her FY2 year in London, not by the diplomas and certificates on your wall but by the manner and ease with which you perform the least manoeuvre. Elizabeth slid her left hand to the woman’s inner wrist to take the pulse rate, rhythm and volume. A history of hypertension and aspirin to thin the blood that she’d not taken for 48 hours now pre-op. Elizabeth’s hands were as dry as the woman’s skin and they were the same warmth. She held the woman’s fingers lightly in her palm. The pulse was light thunder, father in boots in the hall upstairs. The woman was to undergo a stump revision on both left above-knee and right below-knee amputations, performed seven years ago after a car accident. She had bony spurs rubbing through the repaired skin flaps, causing pain in her prostheses. They were going to cut the stumps open, file down the bone spurs and sew it all up again. The woman had requested pictures be taken. She was scared but knew what to expect. Elizabeth turned her hand over and drew her own wrist up alongside the woman’s fingers as if to check her watch but it was to look for any signs of cyanosis along the flanks of her fingertips against the colour of her own skin. She turned the woman’s hand again, looking for islands of redness on the pale palm: palmar erythema. An old working-class white woman with soft hands, elevated somehow. Too gentle for her world. Elizabeth rubbed her thumb under
the knuckles and said, in a voice, ‘What am I looking for?’
‘Dupuytren’s contracture,’ Richard said hoarsely, and cleared his throat.
‘Curse of the Vikings, they call it, Mrs McLean,’ she said, ‘who took it to Scotland where we find it among those poor bagpipers of the 15th century,’ and laughed loudly looking the woman right in the eyes and the woman laughed back. ‘Then it’s very natural to extend the hand up to the epitrochlear node,’ Elizabeth said, and she slid her hand along the woman’s forearm to the elbow and though the woman was now quite calm the husband was looking increasingly alarmed.
Through the blue halls from patient to patient, on industrial lino in the blue dim before the lights came up, they continued their rounds. When they got back to the nurses’ station the unit manager was waiting in his third-best suit.
‘Morning, Liz,’ he said. ‘Good morning, Richard.’
‘Morning, Alastair,’ she said.
‘Morning,’ said Richard.
‘Ha ha. What did you think of the new staff photo on the website?’
‘Looks like a line-up from Nuremberg in their prison fatigues,’ said Elizabeth. ‘About to be taken out and shot.’
‘Oh. Well, perhaps it was the black and white. We thought it might be nice to have everyone in a straight line. No hierarchies.’
‘What can I do for you, Alastair?’
‘Can we have a word, Liz?’
‘What’s this about?’
‘Thanks Richard,’ Alastair said.
‘Thanks, Richard,’ she said, and smiled at him.
‘Sure,’ he said, and he looked at Alastair before he left them.
‘Can we go on in—’ Alastair said, and he pointed away down the corridor.
The nurses watched them go from behind the glass.
‘Are you headed to Queenstown for the conference, Liz?’ he said in his office. ‘Bit of a jaunt?’
‘I’ll go, Alastair. I’ll take that one for the team.’
‘Ha ha. I’d like for Richard to go along at least for the weekend and take someone from nursing.’
‘Robin,’ she said.
‘Ah. Certainly.’
‘Well.’
‘Well it should be very interesting shouldn’t it?’
‘What should?’ She grinned, just her mouth.
‘The, uh, talk by the big Texan what’s his name. In Queenstown. About publishing our results.’
‘Publishing my results.’
‘Well, absolutely. Yours. You’re responsible, ultimately, under this proposition. The minister’s mistake, they’re calling it.’
There was a pause and they smiled at each other.
In three months the Minister of Health, a retired doctor himself, was to launch a system of open public reporting of the ‘results’ of New Zealand doctors and surgeons with a ceremony at Te Papa. These results were the fates of their patients, or ‘outcomes’. This public reporting was to be of the outcomes of each surgeon alone, and the plan was to name those surgeons, like they’d done in the UK, in New York state. This year this surgeon killed seven patients. His name is John Smith. For example. No one knew yet how it would look or where it would appear, despite the ceremony, the dinners—what paper, pdf, what url.
They all knew that in six months the minister would face re-election with the fallout from this scheme yet to settle upon the hospitals, but on campaign he’d have this claim to trot out, this claim that he had opened New Zealand healthcare to those who use it. That he had dragged New Zealand into 21st-century public service transparency. It was a bomb he’d dropped and a claim intended to win over patients and their votes, over the protests of their doctors—thin-skinned, he called them live on TV3—the thin-skinned versus those they had inadvertently skinned.
‘It’s the effects on training I think about, Alastair,’ she said. ‘For the young surgeons we’re trying to teach.’
‘The effects on training are potentially important.’
‘What incentive is there for me to let my registrar try anything challenging if it turns to custard and goes on my stats?’
‘Well, absolutely.’
‘Absolutely meaning none at all.’
‘Well, yes. Yep. You can certainly see it like that.’
They smiled and smiled at each other.
‘Anyway, Alastair?’
‘Well, look, Liz, the parents of the girl who died this morning have asked to see you. They’re here now.’
‘Oh?’
‘Look I warn you they’re very distraught.’
‘I’m sure they are.’
‘They were under the impression that when she was admitted yes it was an emergency but appendix or something like that. They’ve been caught very off-guard and they say they weren’t satisfied with the explanation ICU gave them.’
‘Who spoke to them from ICU?’
‘Ben Matthews. Ben was her intensivist.’
‘Well.’
‘Well I hate to ask, but.’
‘Why? She was my patient. I’m happy to talk to them, Alastair.’
‘Your contribution to the running of this unit is invaluable, Liz. Your contribution to this hospital. What you bring to the table. You are integral,’ he said.
‘Oh shut up. I’m happy to talk to them.’
‘Of course. Well.’
‘Well?’
‘So. Well—what are you going to tell them?’
‘I’m going to tell them what happened in surgery. I wasn’t there for anything important in ICU.’
‘What really happened, Liz?’
‘You’ve read the notes. You know what happened.’
‘Uncontrolled insertion of a trocar leading to . . . some internal damage.’
‘Unrelated to the galloping infection that led to her fatal deterioration in ICU.’
‘Unrelated,’ Alastair said, and watched her.
‘That’s what I said.’
There was nothing else in the room but a desk and a PC beside a round table with two chairs, some tissues and a yellow sharps box. On the wall was a clock and a calendar showing the wrong month and a print of a painting of a boatshed. The parents were sitting on the lip of a small sofa.
‘Hello,’ Elizabeth said. ‘My name is Elizabeth Taylor. I was your daughter’s surgeon yesterday afternoon.’
The woman’s lips were heavily swollen and she was still crying and pale and not much older than Elizabeth herself. The man sat erect with his right arm around her. Her hand at her knee was shaking and her head wobbled and the man stared and moved his stare and stared.
‘Owen Williams,’ he said. ‘This is my wife, Tessa.’
‘May I sit down?’ Elizabeth said and they didn’t say anything and she pulled one of the vinyl chairs out from the table and turned it around and sat facing them. She was conscious she was higher than they were but there was nowhere else to sit.
‘I am very sorry for your loss,’ Elizabeth said.
They looked at her and waited. When she didn’t say anything else they looked away. She could see the girl’s blond hair in her mother. She remembered the father’s wiriness in the girl’s body under her hands.
‘Thank you,’ the father finally said, shaking his head slightly.
‘Who has spoken to you?’
‘Everyone but you,’ the father said. ‘The intensive care doctor, and a nurse and a counsellor who was bloody useless and that chappy I don’t know who was from the DHB.’
‘Here’s what happened to Lisa,’ Elizabeth said. They looked up at her. ‘Lisa was very sick when she came to hospital. Some of her reproductive organs were infected and we think this was because of her IUCD. That stands for intrauterine contraceptive device. She had developed what we call sepsis, which is a very severe and life-threatening infection. We needed to do what is called a laparoscopy. That’s a kind of keyhole surgery where we use a small camera to look inside Lisa and see what was wrong with her. During this operation we could see she was very sick. Many of her abdominal o
rgans were infected—’
Their faces were changing as she spoke. She could feel her own face emptying as she confronted their destruction.
‘—and during this laparoscopy it became clear that Lisa needed a proper operation to help her get better. I can tell you the details of that if you want.’
The man was clenching his teeth and blinking deliberately and controlling his face. The woman was building to something. Something mounting visibly in her that kept finding new levels and falling and rising again. They weren’t saying anything and she had no idea if anything was being communicated.
‘There was a complication in the surgery,’ she said, ‘and we needed to make a larger incision—’
She knew she had gone wrong then. The father sat taller and his eyes began to move quickly left and right, his blinking faster.
‘—we were asked to sit outside the door,’ the woman suddenly said.
‘Okay,’ said Elizabeth. ‘I think that might have been in the intensive care unit. I’ve been talking about Lisa’s surgery before her time in intensive care.’
The parents just stared at her.
‘Let me try and explain. After I performed the operation to clean out the abscesses—’
‘They said she had a heart attack,’ the mother said. ‘She’s twenty-four.’
‘Lisa had a very serious infection—’
‘Why did it do that? Why did her ICD do that?’ the man said.
She bore down.
‘As I said, her IUCD had become infected. We don’t know exactly why at this stage. There are many reasons this could have happened. Lisa was really sick. After her operation she was moved to the intensive care unit. I wasn’t directly involved in her care there. Did the intensivist explain to you what happened there? Did Dr Matthews explain some of that?’
They were just looking at her in frank horror now.
‘We thought oh her appendix must have burst for it to be that serious,’ the mother said. ‘They made us go sit outside. Jeany’s driving down from Rotorua.’