by Carl Shuker
Elizabeth watched him, his quick clean hands, smooth and white from the scrubbing. His wattled chin and cowboy lean.
‘Now all of a sudden under this new disposition you surgeons and your teams are going to tell them some very dangerous and risky material for their sense of what you are and what you are going to do to them when they go under your knife. First that this is not magic and this is not religion. They’re gonna find that out when you publish these results. They’re gonna find out that within 30 days of this impending operation of theirs they’re already het up about that they have a 2 percent—or 12 percent, or 20 percent—chance of dying, and an X percent chance of getting some serious complication. That’s okay. Your patient is not gonna have little or any sense of what that means. And it’s not that relevant to them. There’s a risk and they’re already at risk. Please just be compassionate with me Doctor. Please just be a little bit kind and understanding. Take me by the hand and look me in the eye. Speak to me simply and clearly.’
‘Why don’t you speak to us simply and clearly?’ Elizabeth said loudly.
Some in the crowd laughed. Robin looked down at the table.
The Texan laughed, and continued.
‘But what they’re also all of a sudden going to find out—whether they look it up or see it on a blog or in the paper or their kid who’s up on big data tells them—is that this figure is not a blanket figure. Up the road is another man who can give them better odds: a 1 percent, or 10 percent, or 15 percent chance of dying.
‘And that they cannot go to that surgeon. They cannot. That less risky bet is off limits because your system ain’t built that way. You’re not choosing a mechanic. Sorry about that.’
He was very confident and the folksiness had all but ebbed. They weren’t laughing as he was speaking to the surgeons directly now, and their staff knew it.
‘And you can sit there all serious and explain to your patient that the surgeon up the road the data say is hot shit is a young buck qualified for six whole months who’s operated on a grand total of seven young white patients handsome and strong who never smoked a day in their life while you’ve been down in the trenches mopping up frequent fliers and the morbidly obese and the diabetic elderly brown folk with the DVT risks and the histories of gout and falls and respiratory disease. You can tell them that till you are blue in the face. It won’t fly. They are not going to be interested in the intricacies of risk adjustment. They are just not.’
The Queenstown sun was a pale gold thing, almost solid, an oblong hanging in the hotel air from the concourse windows through the double doors of the conference hall open against the heat. Elizabeth watched herself feeling that familiar uptick of fear. She called it watchfulness but she knew it for herself to be fear. Empty stomach, tick of her heart, chemical stench of peppermint, a huge calm. She tapped her pen tip against the table.
‘So what can you do? The genie’s out of the bottle. There’s no going back. You’re going to be ranked and you’re going to be compared and it’s going to happen publicly and in print and all your dirty laundry is going to be out there for the public display. Everyone who’s died under your scalpel. Every surgical site infection. Every nicked aorta. Every dead dad.’
It was quiet.
‘Some of you may be forced to leave practice or will leave of your own accord. This is not a bad thing.’
A dead silence.
‘So I say what 2014 Democratic primary candidate for governor of Massachusetts, Don—21 percent of the vote, go Don!—Dr Don Berwick said after the big old Mid-Staffs scandal in the UK.’
Half the reference was lost on the room and there was no laughter apart from one horsey, inappropriate splutter at the vote.
‘He said don’t be afraid of being measured. He said don’t be afraid of the light. He said get over the hump. He said all teach. All learn.’
Silence. Elizabeth was staring at the Texan as if she could see inside him.
‘It’s gonna get better cos you’re gonna get better. You’re gonna want to.’
He looked about and smiled.
‘You’re gonna have to.’
A blowfly wandered buzzing into the room.
‘Hello?’ Elizabeth said loudly.
Several in the audience turned her way.
‘Excuse me?’ the Texan said, and he shaded his eyes.
‘Hello?’
‘Yes?’
‘Yes, hello,’ she said. ‘Liz Taylor.’
‘Ah. Yes?’
‘Yes, ha ha.’ She made her face of My Name is Funny. He smiled down at her.
‘What can I do for you Ms Taylor.’
‘Mrs Taylor.’
He caught that she was a surgeon. ‘Mrs Taylor, I’m sorry.’
‘Well I gather you’re pro all this?’
‘Well’—he laughed and looked around the room—‘I’m pro-future because it seems to happen whether I like it or not.’
The room laughed. The New Zealanders looked this way and that as if they could fidget out of their embarrassment.
‘Well, that’s what I call resignation,’ she said brightly. ‘I’m just a bit meh on this to be honest. You’ve read the Lancet paper?’
‘The Lancet paper?’
‘Yes, the Lancet paper.’
‘I read a lot of papers—’
‘The Lancet paper puts it very clearly, Doctor. Walker and colleagues 2015. Look it up. We don’t do enough.’
‘I’m sorry, we don’t do enough to prevent harm or—’
‘We don’t do enough procedures. There’s not enough hours in the day. According to Walker et al. in the Lancet there aren’t enough people in the UK for this, and look around—there certainly aren’t enough people here.’
The group was now evenly divided between those who were staring at him and those who were staring at their tables.
‘What we’re talking about here is, I guess—’
‘Look, sorry, I just want to continue a bit here without you thinking me tendentious or a bitch or anything because this is important to us.’
Andrew’s head snapped up at the adjoining table and a senior anaesthetist at Middlemore beside him was now openly staring at her, shaking his head.
Elizabeth said, ‘Look, there are plenty of reasons why we shouldn’t be doing this and I’m not going to go through them all.’
Richard was smiling palely at her, his eyes wide.
‘But what I hope we’re all aware of are the effects this is going to have. Whether we wish it or not we will avoid sicker patients. You’ve seen this in the States. Why add this patient circling the drain to my numbers? Why take the risk? It’s called risk aversion and you’ve seen it in the US and you’ll see it here too. It will affect everything. It will affect training. Who wants to give their registrar a go in case everything turns to shambles and it goes on your numbers?’
The table around Richard froze a small second and didn’t look at him.
‘—Liz,’ said Andrew, ‘you make a good point, or points, but at Auckland they’ve been doing work with simulation and training—’
She leaned sideways to look directly at him.
‘Exactly. At Auckland.’
Robin was sitting straight up at this, as publicly outraged as she ever got.
‘If you mean resourcing—’ said Andrew, blinking rapidly.
‘Oh look,’ she said. ‘I mean numbers. We’re talking about numbers, aren’t we? So let’s talk about numbers. The Lancet paper—’
‘The Lancet paper—’ Andrew said.
‘Neoliberal data-diving is fine and dandy but we’re talking about ranking people in public and driving them out of practice with insufficient data on how good they really are.’
She was losing the room. The fear and suspense was one thing. But it was the end of a long talky session and the novelty of the famous Texan speaker helicoptered in to save the day had worn off. She had saved her speech for last and it was too late.
‘We are scientists aren’t we? Or tech
nicians? Or are we just chancers? What scientist agrees to make a judgement and publish that judgement when he knows he only has an even chance he’s right? Do you know what UK surgeons are asking themselves? When that sick patient comes in at the end of the month and they have to choose whether to operate or not, they ask themselves, do I feel lucky. They’re doing about 130 cardiac bypasses a year each and that’s a lot and it has relatively high mortality of about 1 percent. At 130 operations a year you have about an 80 percent chance of being right when you say someone has a normal number of deaths. Two times out of ten someone’s killing people and you won’t know it. This is called false complacency. Do I feel lucky.’
The Texan had been leaning on the lectern with weary determination. Andrew was signalling him somehow, because he straightened and said, ‘Well, we appear to have moved into the Q and A slightly ahead of time—’ and the room laughed, relieved.
Elizabeth breathed through her nose, and smiled horribly.
‘We can’t afford to be idiots about this and blindly follow the world. How many cardiac surgeons can we afford to lose? Do you know how many we’ve got?’
‘Liz—’
‘Twenty-nine.’
‘Okay.’
‘Not enough.’
‘Okay, Liz, thank you.’
‘Twenty-nine,’ she said, and put down her pen.
‘Okay.’
Now she was surrounded by an abundance of smiling women. They were gathered in the centre of the hotel concourse. They were perioperative nurses, infection control nurses, anaesthetic techs. They were charge nurses and ward managers, and these were the older, bigger women, dense and sizeable with responsibility and the things they’d seen.
‘I was interviewed by a journalist from the Sydney Morning Herald back in the day,’ Elizabeth was saying, ‘and I told him, I tell all my female students that if you’re approached for sex by a male colleague or a male superior you’re better off just saying yes.’
There was a little quiet and the younger nurses laughed uncertainly. They checked each other, and they watched her. They had hors d’oeuvres plates with half-circle holes moulded in the rim from which to hang a wine glass by the stem to free up their other hand, but none of them knew or thought to hang their glasses there.
‘True. You’re better off just saying yes and getting it over with.’
Robin, standing beside her with a tall glass of iced water, looked pained.
‘If you’re approached in your off-hours or in the hospital or even at a conference like this you’re better off in the long run just saying okay fine then and getting it over with.’ Elizabeth stared at them until they began to stare back. ‘Well? What do you think?’
They were quiet. The smiles were slipping, uneasy. She was matter-of-fact, maternal even. This group was dense with connection. Memories and hierarchies. Even checking someone’s face was dangerous. There was so much history they could barely move.
‘Just get it over with,’ she said. ‘In a closet. In a car. In the toilets of whatever bar or restaurant you happen to accidentally run into him. Quick as you can and none the wiser and move on, because otherwise, I’m not joking, it will follow you round the rest of your career. He will follow you round the rest of your career. This is an island. He will always be there and you will always be there and he will rise and you won’t and you won’t know why. So I’m telling you why. His power extends even to shame and his shame at being told no is worth more than yours saying yes.’
The sun poured over Ben Lomond through the concourse windows, glowing in the wine, setting the glasses to dazzle. They weren’t smiling at all anymore. Their faces had changed but Robin’s expression had not changed. Still patient, still pained.
Elizabeth said to the women, ‘So I said to him, that’s what I tell them, and I stand by it. Of course everyone took it a bit literally.’
She burst into loud laughter and laughed even louder watching them and only some of the hard charge nurses who had seen everything laughed with her.
‘Hello Liz,’ said Andrew laughingly, beside her. ‘How’s our Royal London paper coming?’
‘Oh, hello Andrew,’ she said. ‘Not bad. Peer review’s a bit good cop bad cop.’ The nurses stood by, suddenly shy. ‘You all know Andrew. Head of surgery, dean of the med school now and still in clinic a day a week. I was just talking about teamwork, Andrew.’
‘Ah, well. What did you make of the talk?’
‘I don’t know if it’s enough, is it, Andrew?’ she said. ‘“All teach, all learn.” Easy to say.’
‘No, I suppose it’s not enough at present, is it.’
‘People will be crucified.’
‘Yes, they might be.’
‘Seems like he’s pro all this.’
‘Well, as he says.’
‘And here you’re shepherding him amongst us.’
There was a silence. She liked that he came to her after the confrontation. She liked that he persisted. Andrew looked about the crowd and she saw him change his face.
‘You’re not worried about your own data?’ he said. He grinned and laughed mincingly, leaning towards her then back again.
She smiled and breathed and looked around her. Be careful. The women had merged with the crowd. Andrew. Robin. Richard over there, heading for the exit. Drifting away from land. Jocelyn Chambers, the NHS change specialist there for the conference, was talking to a young, good-looking male periop nurse, touching her hair. Flirts and sharks. They want to get inside you, transcend you. Rise above you. Burst you and be lifted. It is the real hidden curriculum.
He offered another laugh at his own comment. He pronounced it, ha ha ha.
She didn’t reply and turned away to her women. They were pairing off and receding, sharing war stories, horror stories. Eyeing the exits for a fag. She wanted to get back to the hotel, answer some emails, drink some more wine watching the mountains in the last light across the lake. Then a bath, and sleep in a big white bed.
‘Well—no, I’m not,’ she said.
‘The cardiac surgeons have seen this coming for a long time,’ he said.
And then she couldn’t control herself.
‘They’ve got a registry, Andrew,’ she said. ‘They’ve got ministry money. They’re organised. They’ve got examples and models from all over the world. They’ve got pre-defined data dictionaries and clinical buy-in and dozens of data points being collected,’ she said. ‘They’ve sat on it for years. They haven’t published anything. Knowing—’
But he had grown calmer, less solicitous in his manner. His face—blurring, pleased.
The closer to Caesar, the greater the fear. Drenched in the hatred. Don’t be passionate. Don’t be emphatic in these conversations and do not anger. Just be right.
‘The other specialties are nervous, Andrew,’ she said, calmly, as if it were something he’d overlooked. ‘If they’re collecting their data at all, they’re sitting up at night filling in Excel spreadsheets in their singlets in front of MasterChef. Politely emailing graphs to each other. We’re years behind the world on this. We’re all recording different things.’ He looked at her. ‘The generalists are nervous,’ she said.
‘Yes and to some extent rightly so. The Lancet paper—’
‘Yes, the Lancet paper puts it very plainly.’
The shortening replies were attracting attention. They were in the centre of the room and the nurses had turned and were watching them, listening.
At sunset she raised her eyes to Robin and left the conference and walked down Adelaide Street to the lakefront and there was a park bench and she stood alongside it and watched the last sun ascend The Remarkables.
Walking home to a plush hotel in warm winds in twilight after three glasses of wine and a too-public event. To be alone.
The lake had gone silver-black and the pines above were dark and above them, as the sun behind her moved between a bank of cloud and the mountain ridge, the foothills bloomed like stage lights coming up and the pines darkened
further. The great wreckage of the mountains was all impromptu lit a dirty glowing terracotta. The reflection filled the lake’s still mirror and goldened and tarnished the entire valley of the lake. Then the ridgeline’s shadow rose from the water and flowed up the gravel and the rock, a dark sarcoma blooming from the seam of lake and blackened pine, and it raced up the mountain and across the water towards her until the last light on the peaks was the only trace of colour left in a wash of white-blue suffusing everywhere as the day died.
She stood there, all stupid and overwhelmed. Weary of talk. Shear gradients, restenosis, percutaneous coronary intervention. Fuck landscape. She felt it: the hunger, the confidence of holiday: ready to get back to work. A tingling in her fingers, a pricking in her thumbs.
That night she dreamed of the operation again and woke in the big white bed in a copper stink with Lisa dead in the bed beside her bleeding from the eyes.
The astronauts and the ground crew talk on. Shuttle pilot Michael Smith shouts over the intercom, ‘Feel that mother go.’ Someone unidentified shouts Woo-hoo, someone they’ll never know. Plumes bursting from the rupturing O-ring become continuous now and internal pressure in the right solid rocket booster plummets. Flame from the fissure burns through the strut holding the rocket to the huge external fuel tank containing 550,000 litres of liquid oxygen and a million litres of liquid hydrogen as they hit Mach 1.9.
The strut burned through, the 600-tonne solid rocket booster swings wildly, attached only at the nose. The bottom of the hydrogen tank fails. The swinging rocket hits the external tank between the hydrogen and oxygen and it ruptures and the fuels mix and vaporise. This all happens in under a second. There is no shockwave. What we see in the sky isn’t a true explosion but a cloud of smoke and fire and gases and the exhaust from the SRBs, engulfing Challenger as it moves at nearly twice the speed of sound.