by Carl Shuker
Smoke, fire, gases, exhaust, and reflected sunlight.
The M&M
The monthly Morbidity and Mortality meeting was held on a Monday after hours as it always was, in the fifth-floor conference room they called Siberia—the last room on the end of the long, long corridor. The view was over the skyline of eastern Newtown to the villas, the old fever hospital up in the trees, and the mental health unit below. Closer by were the nine steel chimneys of the hospital waste disposal plant.
Siberia had a whiteboard wall but the whiteboard paint didn’t work very well and the notes from five years of deaths and accidents remained pale and some of the words and numbers were still quite clear when they wrote up the notes of the new deaths and the new complications over the top. The room was full of men of all ages in suits, who were comfortable in their bodies, men used to their bodies, used to standing still in one place for eight hours at a time.
The piecemeal conference table they stood around was crooked and they stood among articulated boardroom chairs. Everything was adjustable so no single chair looked the same or sat at the same height or on the same recline. There was a sad twilight light out there and the far-off sound of traffic and Elizabeth came in hard and fast as she always did.
She used her folder of notes to push the door open and left it open and then she dumped the notes on the table, said loudly, ‘Hello,’ and stood behind her chair examining her phone. Women surgeons usually found two ways to be: they became men or they became something else entirely.
‘Hello, Liz,’ said Andrew from the far end of the room. ‘Welcome.’ The other men stopped and turned and smiled. ‘How’s that London Journal response coming,’ he said and smirked. She looked up from her phone and she said, ‘This one’s personal.’ They liked that and the men laughed. Robin and Vladimir came in behind her. Vladimir sat down precisely between her and the gathered surgeons and Robin sat on the other side of Vladimir.
One by one, in their own time, the surgeons went to their seats.
Nathan was first. He was a 30-year-old bariatric and general surgeon and social media zealot who had recorded a version of his registrar years on Twitter where everyone was inspiring and no one swore or was disgusting or cruel. He had a Hitler Youth short back and sides, a bow tie, beard, and a moustache with twisted tips. Elizabeth stared at him for an appalled second and the whole room paused and held. Risen on the balls of their feet when the light has changed, about to cross a road.
‘Right, well, hello, a good meeting is a short meeting and I don’t think there’s a lot to get through here today,’ said Andrew. ‘I’d like to welcome everybody and thank you all for coming. I hope to have us out of here by half seven.’ He smiled the smile of someone who decides: now smile at them. ‘We’ve got nursing and anaesthetics here today as well as surgery and that’s great to see.’
‘I’d like to leave a little early m’fraid, Andrew,’ murmured Simon Martin.
‘Likewise,’ said Jason Latham, and laughed. The others made sour, smiling faces in their suits.
Elizabeth leaned forward and looked around the table exaggeratedly.
‘Hold on,’ she said. ‘Where is Dr Matthews?’
Andrew looked at his notes. ‘Uh, as some of you may or may not know, Dr Matthews was the intensivist on today’s main case. Uh, a Lisa Williams.’
The surgeons reclined in the articulated chairs. Some of them swung back and forth. Nathan sat very upright. He was smiling and he sipped his Wishbone coffee from the vintage orange china cup and saucer he always brings from home and carries down to Wishbone to get his coffee. He always holds the cup in two hands when he drinks.
‘Uh, Dr Matthews is an apology,’ Andrew said.
There are things she hates she can’t say and can’t share. Men prepared to tell people they prefer to drink their coffee from china. Who act decisively on that preference. Elaborate male facial hair. New Zealand. An anonymous man she once overheard at a fertility clinic saying, I don’t need to see that. He’d been asked to accompany his wife during the procedure to have her egg inseminated with his sperm returned to her uterus. All the female nurses and the wife herself laughing sympathetically for him. Lazy masking with two-dollar-shop masking tape. It leaves fillets of paint-soaked tape glued to the skirting boards. Two generations of New Zealand men now who think that opshop suits with flares and big lapels, fake moustaches and Elvis sunglasses, are funny, are fancy dress. How they hide to act strong and sure of themselves. The implications of that, evolutionarily speaking. Certain phrases. ‘Kids love mince.’ ‘Cultural competency.’ Baby boomer public healthers who fell into professorships in the 1980s after decades of tagging themselves on to futile, well-meant public health promotion programmes, wasting their lectures and their students’ time and money with anecdotes of boring long-past alcohol and tobacco campaigns, and adding their names to the publications of 25-year-old PhD candidates adjuncting themselves to death on a pittance with no benefits and doing all the work. Get made associate professor and make real money. Reunion concerts. Wasted time. Het men who make an elaborated point of the fact they don’t care about fashion. Het men who make an elaborated point that they do.
‘I’d like to call for this meeting to be adjourned,’ Elizabeth said.
She pushed back her chair and stood, gathered her notes, looking down at her phone.
They swivelled in their seats to look at her.
‘Uh, now, Liz,’ said Andrew.
‘Yes?’
‘What’s the story?’
‘If Dr Matthews isn’t here what’s the point?’
‘Well the point, Liz, is surgery and mortality,’ Andrew said and laughed, but no one else did.
Jason Latham was staring at her.
‘The mortality here,’ Elizabeth said, ‘is not related to the surgery. The mortality is related to the girl’s advanced sepsis and the nearly 12 hours of intensive care that failed to save her afterwards. Without an ICU representative we are pissing about in the dark and we are going to get piss all over ourselves.’
Nathan audibly laughed with a half-contained spit through his lips and Jason turned away from her, smiling down at the table.
‘Well, let’s not get excited,’ said Andrew.
‘I’m leaving unless and until ICU get their A into G and turn up.’
‘Liz.’
‘Sort it out, Andrew.’
The surgeons were all looking in different directions and were, largely, smiling. Vladimir was expressionless and Robin was staring at the table.
‘Liz, we need to address this. Look, we’re not here to apportion blame.’
‘Blame?’
‘Look, Liz,’ said Jason. ‘You’ve got a point but where’s Richard Whitehead? Why is your registrar not here?’
‘He’s caring for patients, Jason. Where’s yours?’
‘Mine’s not one of the named subjects of a complaint to the DHB, that’s where mine is,’ he said and he smiled and leaned back staring at her.
There was a silence.
Elizabeth turned to Andrew.
‘A complaint?’
‘A complaint.’
‘Is that a fact?’
‘That’s a fact.’
‘The parents.’
‘The parents and the uh, boyfriend have written to the DHB,’ Andrew said. ‘There is now an official complaint, yes.’
‘When were you going to tell me about this complaint?’
‘I’m telling you about it now.’
There was another silence.
‘Then all the more reason this should be taken offline and ICU should be involved,’ she finally said. ‘That girl was delivered to them with a ribbon on top.’
Andrew looked away and his voice was soft.
‘Liz, all the more reason for us to sit down and go through everything we can know about what went on that day and that night in a collegial fashion sooner rather than later.’
‘Oh, don’t be stupid,’ she said.
Nathan picked
up his cup and took a sip of his coffee and put his cup back down.
Jason was not smiling anymore. He was staring at her. ‘Why do you call people stupid?’ he said.
‘Question sort of answers itself doesn’t it?’ Elizabeth said. She looked at him. ‘Why aren’t you laughing?’
‘Now why would that be stupid, Liz,’ Andrew said evenly.
‘It would be stupid because we can sit here and go through my notes and talk to my team until you’re blue in the face but you can’t possibly know what went on with that girl unless you have ICU and their nurses here. From both shifts after my handover at 7 p.m. and before her death at 4 a.m. Because they took over her care and she died on their watch.’
Robin’s mouth was closed and her eyes were moving from the tabletop to the middle distance above it and back. Vladimir had not moved.
‘The complaint,’ Andrew said softly, ‘addresses the surgery. The complaint addresses the complications that occurred during that surgery. The complaint alleges certain errors by staff here, irregardless of the care she received in ICU and the contribution of that to Liz’s death.’
He laughed.
‘I mean, Lisa’s death.’
Elizabeth laughed, and some of the older surgeons laughed too.
‘Irregardless,’ Elizabeth said.
‘Regardless, rather,’ Andrew said, and he laughed again, differently.
Other things she hates.
Men from the past in Facebook photos. Standing around their barbecues in their straw hats, their Panhead IPA T-shirts, cargo shorts and black wrap-arounds. She can’t remember who they are or distinguish between them. The women in chiffon and chambray sacks and big hats and sunglasses so huge she can’t tell who they are either. The $7 folding camping chairs on the rude ragged lawns down south.
The two pictures of Kirsten Light. The only ones on her feed she has ever posted of herself without her children. All 6-foot-blonde of her. The first posted March 17, leaned back, awkward, with one arm up on a fence of concrete block. The second posted March 18, an exact copy cropped to cut off the small bulge of her belly. Half an hour fumbling with Photoshop but she’d left the original up. Her little southern vanity. She had gentle eyes and big front teeth and Elizabeth remembers buzzing around her like a fly for two years in high school. Wanting to hold her down and spread her legs and lick her from her ass to her cunt for hours. Until she emerged. Until she came out where Elizabeth was. When Kirsten Light realised what the little friendship meant she turned stone and ash and had a horsey sneer for her forever after. Went into nursing and never posts photos of her husband. Just those southern daughters with names like Neisha, Chanelle, Bianca. That thing in my face that makes your smiles go away. That thing in my face. Butter on buttered toast that melts too soon and completely. She likes those little lingering lumps of butter.
Elizabeth sat down.
‘Okay,’ said Andrew. ‘Let’s have eyes down looking.’
Elizabeth sat and looked down at the cover page of the notes and didn’t blink for a long time. On either side of her Vladimir and Robin didn’t move. The surgeons flicked through the pages. The air conditioning hummed. Outside the day died and it grew dark and the furnace dissolved in the darkness and their reflections assembled in the safety glass.
There was a knock and Alastair the unit manager came in with his notes. He shut the door behind him by holding the latch down and slowly closing the door until it was seated in its frame and then releasing the latch very slowly until it clicked. Elizabeth turned to stare at him but he met eyes with no one and sat beyond Robin where he couldn’t see her face.
Elizabeth laughed with a snort through her nose but if he heard it he did not acknowledge it. Andrew looked up idly, then back again to his notes. Time passed. Elizabeth checked three things in the notes and closed the folder again. Andrew picked up his phone and looked at it, and then he said, ‘Well, would you like to summarise or shall I.’
He had stopped using her name.
Fire burns faster on slopes of certain angles, and it burns faster when the slope is enclosed on either side. This effect was unknown until 1987 when a small fire from a dropped cigarette burning under an old escalator in King’s Cross station superheated 20 layers of the ceiling paint above. Paint that dated back to Queen Victoria. The flashover up into the ticket hall killed 31 people. It was called the trench effect. If the escalator had been shallower by 10 degrees it would have burned out.
‘Oh, by all means,’ said Elizabeth.
‘A three-day history of increasingly severe abdominal pain,’ said Andrew. ‘She was seen by GP after hours at Adelaide Road.’
He told the story again and the surgeons flicked idly through the notes.
One lax GP; on the third day another who was on the ball: anticipating surgery, he’d noted her last meal. Elizabeth corrected the blood pressure on arrival at ED by memory. Andrew named the ED nurses, noted that Richard was busy and ordered pain relief by phone.
‘We’ll skip the surgery here and circle back,’ Andrew murmured and Elizabeth made a face of disbelief and checked the clock. It was 7:30 now and he had deliberately lied about the short meeting.
He noted Vladimir’s post-surgery review of Lisa at midnight.
‘Then, at 2 a.m. it was determined more invasive measures were needed, and cardiac arrest occurred during those measures and death was at 4:03 a.m. Is that right for everyone?’
‘As I think I’ve made clear,’ Elizabeth said, ‘I visited Lisa at 11 p.m. The nurse on duty was assisting her with the CPAP mask. She wasn’t liking it. I spoke to her. She spoke to me. I wished her well and left her there. I have no idea what they did to her. Why things went south as they did.’
‘All right,’ said Andrew. ‘Let’s now turn to the surgery.’
‘Yes let’s,’ said Elizabeth, and her voice was strong.
‘The notes from anaesthesia and your notes agree that anaesthesia commenced at 1:40 p.m. and surgery commenced at 1:50 p.m. You placed the camera port in Lisa via a subumbilical incision using the open Hasson technique.’
‘That’s correct.’
‘The uh, camera and gas port was inserted into her abdomen and uh, insufflation commenced. Is that right, Robin, from your perspective in nursing?’
Robin looked up abruptly, then down at her notes. Elizabeth was looking away from her, directly at Jason Latham—a reach, a dare. He didn’t even look up.
‘Yes, that’s correct,’ said Robin.
‘And Robin you say in your notes here that Mrs Taylor verbalised there was no gas?’
‘Um,’ Robin flicked through her notes. ‘Um, yes, I’ve written here that at about 1:55 p.m. Liz, Mrs Taylor said that there was no gas flow.’
‘What did she mean?’ Andrew said. He sat back and put down the notes and the other surgeons laid down their notes and sat back.
‘Um, I took it to mean that we had not achieved a safe pneumoperitoneum due to a lack of gas.’
‘What’s a safe pneumoperitoneum for those of us who are not generalists and don’t know anything?’
‘Um, that’s a sufficient pressure of gas inside the abdomen that lifts the peritoneal sac away from internal structures that can be damaged by insertion of instruments. The um pressure of that would be a pressure of 10 millimetres mercury on the gas machine. Also it looks quite blown up.’
‘A big belly.’
‘That’s right.’
‘What happened then?’
Elizabeth breathed through her nose and Vladimir sat and stared at their reflections in the glass. Robin looked at them both and then at her notes.
‘Um, she, Mrs Taylor, asked for a new gas bottle and Ms Chambers left theatre to get one.’
‘That’s Mei-Lynn Chambers?’
‘Yes.’
‘All right. Very good.’
‘At that point I went to the gas tower and I saw that the gas hadn’t been turned on properly.’
‘And at that point the camera port had already been in
serted using a 5-millimetre trocar and—’
Elizabeth interrupted. ‘At that point we had visualisation of the abdominal cavity,’ she said. ‘We could see on the screens exactly what we were doing. We had about 8 millimetres of mercury pressure and—’
‘I’m sorry Liz, can I just get Robin to fill us in from the perspective of nursing first of all before we come back round to you?’
Jason looked up at her.
‘Of course,’ she said. She smiled. ‘Of course.’
‘Yes, please, uh Robin, can you carry on?’
Andrew’s tie was the old goldish one with paisley like ladybirds. The knot looked almost fossilised. The gap around his shirt neck was growing as he aged and shrank. Richard once told her that his father, who bought his clothes in London when he went to conferences, told him that the space between the rake of a shirt collar and the suit lapel was known in menswear as the credibility gap.
‘Um—’ Robin looked up at Elizabeth for a second and seemed to recede. ‘Sorry what was the question?’
‘Just carry on where you left off.’
‘—Um, so. So I turned the gas back on.’
‘Wait—so the gas bottle wasn’t actually, in reality, empty?’ Jason said. The room was quiet.
‘No.’
‘Oh. And what was the flow rate?’ he said.
‘It was about—I increased it but not beyond um six point five. That’s the top it goes to.’
‘Six point five, what would that be, Robin.’
‘The gas tower measures flow rate in litres per minute. There’s the flow rate and then there’s the pressure you need to get to, and that’s in millimetres of mercury.’
‘So a flow speed and a destination. Like filling a petrol tank.’
‘Yes.’
‘And what was—’
‘Hold on Jason,’ Andrew said. ‘What is the pressure required for a pneumoperitoneum again, Robin?’
‘Ten millimetres mercury,’ she said.
‘Carry on Jason,’ Andrew said to the notes.
Elizabeth was looking from one to the other smiling in disbelief but no one otherwise in the room looked at another person.