by Carl Shuker
Hatchbacks, retaining walls, dead front lawns.
The valley opening up behind her.
Round the long corners the wheel slid in her palms, windows down, the cicadas screaming.
Under the clay cliffs of the top of Volga Street she was doing 90 kilometres an hour on the wrong side of the road and she glanced only once downhill before running the Give Way on and up Mt Albert Road without slowing down for the final climb towards Houghton Bay.
At the summit she pulled a 180 in the middle of the Buckley Road T without even looking but there was no one else looking either. And then she stopped.
Looking down at Wellington. All brown. A solitary bird on a wire. Smoke from the brush fires by the Tip Track in a red evening.
Why are you nothing to me? Why are you nothing compared to me?
She sat there for a time. Then she dropped the handbrake, stood on the pedal, rode the gears into third back down Mt Albert Road past Volga—the hardest corner because it was blind and a hairpin and there was a cliff. She was going too fast and crossed the centre line entirely to make it around but still there was no one coming. As she rounded the next corner onto the straightaway by the hockey fields she hugged the bank so close the wheels shuddered in the rough ground of the shoulder and tattered branches slapped and clawed at the windows on the passenger side.
All blind now, before the chicane that descended into Martin Luckie Park and the straightaway into Newtown. All blind on that corner but for one tiny window through the brush where she might catch a glimpse if someone was coming her way. There was nothing there unless there was a car too close and already inside the corner and she could not see them.
She breathed slowly out through her teeth.
I am the right one.
She lifted her foot from the brake and leaned her body into the door and the car dropped into the corner and she felt her stomach fall and the right front wheel lift from the asphalt.
Magpies wheeled over the park.
Villas with gingerbread trim and smug paint jobs.
The car shuddering and heaving.
There was no one.
She overcorrected on the left turn and the big car zigged and she corrected again and it zagged and then she was through. Straight onto Russell Terrace where she could see the red light above the hills over the hospital far away and where the warning sign did not read her speed but only SLOW DOWN and she slowed to maybe 70 before the Waripori Street stop sign, checking for reflections in the road signs or headlamps shining up the towers of the Mansfield Street estates and there were none and she took the chance and drove right through the intersection and only slowed down for the 40 zone at the Mansfield Road roundabout because after that there was a chance her car would be recognised, seen by someone from work.
Slowly through Newtown. Soft at the lights. Softly down Adelaide Road. Left-hand lane after the McDonald’s into the centre lane by the Basin Reserve. Onto State Highway 1 after the Arras Tunnel, changing lanes. Picking up speed after the 70 zone by the cemetery and by the port and the siloes in scattered traffic she crossed three lanes at 170 kilometres per hour in one manoeuvre, breathing steadily, the clouds above her stupid and purple and bruised and moving over the water.
She drove out to Petone, circled the roundabout and came back in at exactly 100, breathing easy, ravenous now, following the limits all the way home. That night she slept outside on a rattan chaise in the garden, the warmth still rising from the brick of the patio, and if she dreamed she didn’t remember and she woke at five, refreshed and ready for surgery.
Informed that day by paper letter the hospital had temporarily restricted her practice of laparoscopy and laparotomy in light of a public complaint and a history of comments by staff.
It is bitter—data
She lectured one afternoon a week in the Otago Medical School building, affixed to the hospital on Mein Street like a parasite. It was a guest lecture for a paper in the postgraduate diploma in public health. The students were a group of public health registrars, frustrated, ambitious pharmacists and the variously disappointed; idealists with jobs and children and not enough time, looking for a better way. In her briefcase she had pages of her handwritten data and two thumb drives.
Her presentation for PUBH 112 was on the individual clinical freedom of doctors to do as the evidence and their best instincts suggest. Versus guideline- and data-driven ‘cookbook medicine’. The growing tensions between the two. At one point she asked them directly: Japanese hospitals don’t use the same methods Toyota does. Why would you say that is? Later she descended to the basement floors of Wellington Hospital. In the elevator a young registrar from Auckland tried to ask her about an X-ray.
‘Turn it the right way round, Susan,’ she said.
The girl looked horrified and swapped it left for right. A stiff-limbed woman in a red gilet and jeans got on at 2, a patient, and Elizabeth looked at the registrar and the girl let the X-ray hang by her leg.
‘Take it up with your consultant,’ she said when the doors opened at B3. The girl just stood there in the lift after Elizabeth stepped out.
‘It’s Arthur,’ she said.
‘Please don’t follow me.’
Down the corridor, ceiling tiles were still missing from the refurbishment. There were flat slabs of concrete visible through the holes. One fluorescent tube buzzed and went out. The door read Clinical Coding and inside was a pod of desks and an older man was slid back in his seat. A younger bearded man in the corner was bent forward almost lying on his keyboard. Several younger coders were about in the other desks and one had a huge coffee mug on which was printed ‘Size Matters’. A limp poster on the wall read, ‘To increase awareness and help promote clinical coding as a career option clinical coders are profiled on a widely publicised New Zealand Careers website. Also, a clinical coding brochure is available.’
‘Hello,’ she said, as she might have done to an unattended till in a department store.
The older man didn’t budge. The younger ones didn’t even look up. The bearded one turned and he had earbuds in she hadn’t seen and she sighed.
He grasped his earbuds, sighed as well, and tugged them free.
‘Hello?’ he said.
She tapped her #HelloMyNameIs name tag with a fingertip. He leaned forward to read it. His neck was not shaven and he had hairy cheekbones.
‘Oh, are you looking for quality and risk?’
‘I’m looking for the clinical coding manager.’
‘Yes?’
She looked around. The slumped older man hadn’t moved.
‘Is that you? Got five minutes for a chat?’
He’d almost shrunk in his chair and was looking all around him too.
‘I’m sorry . . . ?’ He peered at her name tag again.
‘Liz Taylor. Mrs.’
She said it for him to hear. The tone. The ‘Mrs’. She was a surgeon. This is dangerous ground.
‘Oh. Sorry. Sorry. Yes? What can I do to help?’ The coding manager exaggeratedly cast his eyes left and right and indicated a plastic-wrapped swivel chair. ‘Pull up a pew.’
She looked at him for a long while and then looked down at the chair. She leaned down and she wiped it with the knife of her hand. She sat down and gave him her eyes.
‘Now, I’m interested in the coding of mortality and 30-day complications rates for select surgical procedures,’ she said. ‘Specifically—’
‘Ah ha ha,’ he said, and grinned. ‘Ha ha ha.’ He leaned back in his chair and laced his hands behind his head. Stale striped green shirt with bastard cufflinks and pitstains under his arms. ‘Ha ha. So. Yes. You’re here about the minister’s mistake. Just a few weeks to go now, isn’t it. Before publication day.’
He was English, stale and stank of bachelor. Always the exhaustion, the contempt. The older patients looking behind her for the doctor. Calling her ‘the lady doctor’ once they got their heads around it. Sudden memory of Atelier, who called all the Filipina nurses Betty, wrist-de
ep in the vagina of a draped 26-year-old on the trolley when Elizabeth was about the same age. She could see his hand in the girl’s abdomen, flexing inside her. His other hand gloved and waving like a conductor. I do love me a good strong uterus, the consultant said, grinning behind his mask.
She smiled another long moment. Raised her eyebrows for him.
‘What do you mean, please?’
‘This is public reporting isn’t it?’
‘I suppose it is.’
‘Let foxes report goings-on in the henhouse. Bit short-sighted.’
He nodded and grinned and waited for her.
There was an urge, wasn’t there, to just destroy him, and rebuild him in a more pleasing shape. In service. She could hear him tweaking his accent on the fly. Someone who hadn’t lived up to his education. Or a bad marriage. Living in the minutiae out here. Living in miniature.
‘I would like to learn more about how this is intended to be done at the coalface.’
‘Ah ha.’ He grinned. The sweat was dark in furrows between yellow corrugations of wild deodorant. This was his favourite shirt. He had one suit, a summer jacket and a tweed. She could see them hanging in darkness above a pile of old shoes. She hated him so much she could taste it like a Granny Smith apple.
‘And I presume as clinical coding manager you know what you’re talking about and how the ministry is planning to go ahead.’
‘They’ve got everyone scrambling haven’t they? Set the hares running down to coding to see everything’s all right.’
‘I don’t have a lot of time as I’m sure you don’t either.’
‘Not the greatest level of foresight. Let’s just apply a neo-liberal mindset to healthcare. Why not. Avedis Donabedian used to say doctors, nurses, they have a sacred cause.’
He was looking this way and that with his rehearsed disgust.
‘Who?’ she said.
She’d discovered the truth of a platitude in London, a platitude that was only more true at home. Whenever she was out of her depth or not to up to date she’d learned never to admit she did not know, had not read nor completely understood any given thing. To admit ignorance was not frank nor forthright and would not invite appreciation of her honesty. She’d learned instead to ask the smartest questions on the fly and ask them till she got her answers. To be eager. Drown them with eagerness. Say I want to understand. Please explain. No matter how much in London the answers came with a wet skim of satisfied disgust almost post-coital in its intimacy, she had her answers for next time. The knife in the ribs and the wallet in the pocket. In New Zealand it was different. In New Zealand they weren’t so suspicious. They left you convinced you were as smart and charming as they had sounded to themselves. Not knowing they were bleeding out until they met you again later, in power.
‘Explain their methodology, if you would, for me.’
‘Oh.’ He lowered his arms. ‘Well. It’s rank and spank. League tables. Name and shame.’
She stared at him.
‘Publishing data by named surgeon to enable you and your fellow surgical colleagues to be ranked in the newspapers by your performance, isn’t it? Nothing a journalist loves more than a bloodied-up surgeon. Bit of a class issue. Levels the playing field. And by performance we mean mortality and we mean the really serious complications. Death and infection and things going wrong. They intend to name you and shame you for what you’ve done.’
‘I’d like to know a bit more of the technical detail’—she looked around his desk for some sign of a name, found it—‘David.’
‘Well, essentially, when we ping our data over to planning and funding, as we do monthly, Mrs Taylor, we’re also sending over your individual surgeon rates and raw numbers for the ICD codes they’re interested in. A select group of procedures. You’re a general surgeon are you? Well you no doubt do a few of these procedures and they’re counting up your mortality and complications. Death and disability for up to a month after the op. I’m guessing they’ve decided they have enough data and they’ll dump rates and 95 percent confidence intervals for the performance of every single surgeon in the country on their website and call it job done. The Herald and the Dom Post and Mike Hosking and every armchair analyst is going to compare those rates, make a list and the first story in the morning will be the worst performing surgeon in the country is here at your local DHB and his name’s now mud and his career both public and private is probably for all intents and purposes over.’
There were certain words where the way a person said them revealed the way they felt about them. Jew, was one. Gay. Black. Nurse. Mrs.
‘You sound like you think it’s bullshit.’
‘Oh I’m all for it if it’s done right.’ He laughed. ‘Do I think we were sold a pup? Yeah, well, perhaps. But once we survive the first storm we’ll have everyone arguing the toss over worthy things like risk adjustment and case mix and a lot of people like you will be tramping down here—’
He was excited and losing control. She recognised the same rhythms in herself.
‘—clutching their case notes asking us shouldn’t the codes for this or that dead patient not be palliative rather than this myocardial infarct you’ve got marked here? Telling us they weren’t doing anything interventional they were just easing the old girl out.’
‘Uh huh?’
‘Heard of Z51.5?’
‘Sorry?’
‘You will. The code for palliative care. No chemo, no scalpels, no more interventions, just morphine and flowers. A Z51.5 doesn’t go on anyone’s stats because they were already dying when they came in. Z51.5s went from 400 to 1800 a month inside five years once people realised the NHS was measuring. Everyone started going out quietly. I don’t think secular trends quite explain a 350 percent jump.’
‘Uh huh.’
‘But ultimately once the bullshit and the bodies clear it’s better for the patients.’
‘Better for patients.’
‘Yep.’
‘And you know what’s better for patients, do you. Sitting down here in front of your screens.’
He paused. Looked at her.
‘Well, no offence but the colleges hide all this don’t they? Retraining on the quiet. Patients never know anything went wrong. Staff learn to hide things. It’s a bit of a closed shop, wouldn’t you say. And why shouldn’t a surgeon be held to the same standards as an Air New Zealand pilot?’
She gave him silence. He dropped his eyes.
‘Of course we’d do it differently but what are we. We’re just lowly coders for one DHB.’
‘How would you do it then, David. And how does one get started, please.’
He looked up then. ‘I’m sorry, are you Elizabeth Taylor?’
Standing in scrubs in the slowest queue in the world for Wishbone in the great atrium of the hospital concourse. Holding a pottle of muesli and yoghurt. Tapping the cellophane lid of the pottle with her fingers and pulsing on her feet. Sayzed Hussein, the neurosurgery consultant, passing her by with an Italian meatball wrap in his hand and gumboots on over his scrubs and he didn’t give a shit. Didn’t make eye contact and headed for the lifts. Elizabeth raised her eyebrows. Fine, then. The queue was staff and patients and families and it went right around the fridges. There were some DHB in suits at one of the tables. Two interns ahead of her. Tap tap tap, ta-tap tap tap. She sighed. The two interns were looking at one of their phones and they didn’t stop or look up when they ordered their food. She waited for her coffee and the DHB men were looking at her. She gave them her eyes and they looked away. When she got her coffee she looked around for a table and saw the two interns were seated and looking at her, too.
Around her the hospital hummed. In the tiny office her hospital desk had nothing else on it but a phone, a hospital PC and a sharps box. The DHB had a news collation service called Spoonfeed that filtered content on words like healthcare, DHB, surgery, mental health. It sent out a daily email to all staff from the laundries to the boardroom with all domestic media stories to do
with health.
The story five down from the top was from a website she didn’t recognise. ‘Angel of Death surgeon played death metal in botched op that killed our Lisa’. There were half a dozen blatant factual errors and five photographs threaded through the story. She came upon them as she scrolled down. The first was of the parents and the boyfriend, not the sister, she’d been spared, and the mother was holding a framed photograph of Lisa and they were sitting in a sofa in a picture window that looked out on a garden at their home. The next photo was a close-up of Lisa from the same framed photo. Then there were the two photographs of Elizabeth. One in black and white, cropped from the staff photo on the website, and the other was the one the father had taken. Ill-framed and blurry, she was in blue scrubs looking down at the camera and she had pale bags riddled with wrinkles beneath her eyes, wild, angry. The last photo was of her house. No one had forwarded her the story.
She’d been in one physical fight in her life in high school and the feeling was familiar. Another layer under the skin of her face. Racing heavily, wet and cold. Skin of her cheeks working, flinching, moving over it but it had no sensation and was distant and she had no control of how she looked. A giggly feeling, a light feeling. Girls in Rangi uniforms sneering. All the blue and tartan. Like a cage. So many cunts she couldn’t beat them all. There in their midst, silent and watching her, her face pale, doing nothing: Jessica. It passed fairly quickly.
Patients under general call out and flail and dream and kick. They never know and no one tells them later. Theatre teams stand around and watch them with surprised smiles, waiting for their dreams to slow down, waiting for it to stop.
She closed the tab and she sat there.
Around her the hospital hummed.
Five minutes later she opened up the 125 KB Excel template from the thumb drive David had given her. The file was called ‘cumulative_sum_failure_analysis.xlsb’ and her heart beat lightly.
The Excel file had two workbooks. Named ‘Personal’ and ‘National’.