The Hollow Men: A Novel

by Rob McCarthy

  ‘That’s sixty,’ Harry said once the second hand was back around.

  ‘Thanks,’ said Traubert, stooping over and looking down into Idris’s mouth. There was silence in the resus bay now, all eyes on the blood pressure and saturations monitor. Given that they’d just paralysed him, Idris could no longer breathe on his own, and they had perhaps five minutes to intubate him before his brain became starved of oxygen. After thirty seconds adjusting the position of the laryngoscope, Traubert asked for the tube and Harry gave it to him.

  ‘Dammit,’ Traubert said. ‘Give me a bougie.’

  Someone passed him a thin plastic stylet, and Traubert tried again, poking it forward, trying to find Idris’s trachea. Harry looked across at the saturations monitor, and down at his watch. They’d been trying for a minute and a half.

  ‘Ninety seconds,’ he said out loud, hoping Traubert would realise, pull out, and let Harry squeeze some more oxygen into Idris’s system.

  ‘Hang on, I’ve almost got it,’ Traubert said. The silence was oppressive now, beads of sweat forming on Traubert’s forehead. Harry hadn’t taken a look himself, but anatomically, Idris shouldn’t have been a particularly difficult intubation. Traubert might be a bloody good teacher and researcher, he thought, but his rustiness was beginning to show. Harry set two minutes as a cut-off in his mind. If it took him longer than that, he would step in. They’d worked too hard to save him to let it all be lost by an out-of-practice administrator.

  He never got the chance to interrupt, because Dr Kinirons did it first.

  ‘George, it’s been too long, withdraw and bag.’

  Harry was there in an instant, fixing the mask over Idris’s face, squeezing the oxygen bag. The saturations were down in the mid-eighties, and Idris was still paralysed. In an elective case, they’d wake him up and try another method, but without surgery to stop the bleeding, he would die.

  ‘Can we get the fibre-optic scope down from theatre?’ Traubert suggested, wiping his brow with his sleeve.

  ‘That’ll take ten minutes,’ Kinirons said, ‘Do you want to try, Dr Kent?’

  Harry nodded. In a minute or so of bagging, the sats had climbed slowly, eighty-nine now. He crouched down, pulled the tongue back with the scope, could see the apex of the vocal cords, not all of them, but he got a better view by lowering his back a bit. Fucking Traubert, he thought as he passed the bougie in, then slid the tube down, inflating the cuff that would keep it in place: he’d heard rumours of how useless the consultant was around the hospital, but this was the first time he had witnessed it first-hand. A nurse connected the tube to the oxygen supply and began squeezing the bag that had now become Solomon Idris’s ventilator.

  ‘We in?’ said Kinirons.

  ‘Excellent work!’ Traubert said, patting Harry on the back with a sweaty palm.

  ‘Check the capno.’

  Harry looked up at the monitor, read the vital signs: low blood pressure, but higher than it had been, fast pulse, a good waveform on capnography. Solomon Idris was probably as stable as he would ever be with a hole in his abdomen. Harry looked across at Lahiri, who wore a familiar expression, one of pained exhaustion. He’d done everything he could for Idris, but now his patient’s life was in the hands of someone else, or worse, pure insentient luck. Harry knew how that felt. Gunther had already run ahead to prepare theatre.

  ‘Everyone happy to go?’ Kinirons said.

  A chorus of yeses spilt from the group. Traubert turned to Harry and said, ‘I want you with me in theatre, if you can?’

  Harry nodded furiously. He wasn’t about to let Idris out of his sight.

  ‘So let’s go,’ Kinirons said, and the brakes came off the trolley, the blood bags transferred from drip-stands onto extendable arms attached to the bed. They rushed out of the bay, everyone grabbing a bit of the trolley, Lahiri sprinting ahead to hold the doors.

  As they went through, Harry brushed past Lahiri, who whispered low enough so Harry could hear him but no one else, ‘Don’t you fuck this up, Harry. You owe me that.’

  Harry ignored him. None of that shit mattered now. It mattered outside, and maybe eventually they’d get around to sorting it out, but right now, only one thing mattered. And, just as Harry had decided that, they were in the anaesthetic room, and sliding their patient across, and Harry was running into the scrub room to get changed.

  Just as quickly as chaos had arrived in A&E, it left. Resus Six was a mess: empty packaging and syringes strewn all over the floor, the shadows of the team who’d just inhabited it. Slowly it faded again to quiet noise, another episode added to the horrors that the cubicle had witnessed. A nurse counted the empty blood bags, scrawling them into the records. Bernie Kinirons hunched over the central desk, scrawling down a log of all the efforts they had undertaken. The nurses knelt down on the floor, picking up scalpel blades, opened packages, used needles, sliding them into sharps bins.

  Minutes later, a cleaner arrived, her mop slowly reducing Solomon Idris’s blood to pink foam.

  It took Gunther thirty minutes to find the bullet. During that time, Solomon Idris had come closer to the grave than most people ever recovered from, blissfully unaware. Seventeen years old, and for the second time the Ruskin’s doctors and nurses had saved his life.

  ‘Lucky guy,’ Gunther said as they wheeled Idris out of theatre, towards the CT scanner.

  ‘How so?’ said Harry. Only a surgeon like Gunther, who’d cut his teeth in the trauma theatres of Cape Town, could ever refer to someone in Idris’s situation as lucky.

  ‘Two inches higher and that bullet would have hit his heart,’ came the reply. ‘Three inches to the right his aorta. Either of them he’d be dead for sure.’

  The operation had been an exploratory laparotomy, slicing the belly north to south, retracting the skin and the rectus muscles to find the blood and plug the leak. When Gunther had opened it, there had been a lot, and thankfully the surgical registrar had been there to assist him in suctioning it out so they could see what was going on. The bullet had nicked one of the gastrosplenic arteries on its way in, which they’d been able to clip with relative ease, but the main issue was Idris’s spleen. In the end, Gunther had taken the shotgun approach and clipped every artery he could find in the tight network around the spleen, before unclamping them one-by-one until he found the bleeders. The tap was off. The bleeding had stopped.

  At Harry’s end, it had been plain sailing. They’d managed to establish a trauma line, a long, wide-bore tube, in one of Idris’s neck veins, and after that keeping him under sedation was second nature, and now he was at least stable. As Harry looked down at the anaesthetised teenager, he considered the irony. The likely reason that Idris had survived an injury which would kill most people was his youth, the ability of his body to compensate for devastating blood loss, shut down the periphery and protect his vital organs. Idris had been saved by his innate desire to live, even though he might have walked into that Chicken Hut wishing only to die.

  Gunther had already left when they got through the scanner, to try to get some sleep in case another emergency case arrived. Idris had been on the table for just over an hour, and was far from fixed: there was a rectangle of transparent film over his abdomen, instead of a closed scar. Surgery at this point was about damage control, stopping the bleeding so they could get the patient into Harry’s realm: the intensive care unit. They would send him back to theatre once he was fully stabilised, probably in the next twenty-four hours, to have the damaged arteries repaired and the incisions sewn up. Harry looked up at the vital signs monitor. He was happy with everything apart from the oxygen saturations, which were still hovering around ninety-one.

  The damn oxygen, he thought. That chest infection. It could well kill Idris anyway. The bacteria Harry suspected were colonising his patient’s lungs didn’t care that he’d been shot that evening.

  Traubert had left them as they finished up with the CT scan, satisfied that Harry could manage the transfer to the ICU without any help. Not t
hat the consultant had been much help in A&E, Harry thought but didn’t say.

  ‘Good job, Harry,’ Traubert had said as he left, muttering something about not getting home until late now, and missing a dinner reservation.

  Upstairs in the ICU, Harry looked at Solomon Idris’s CT scan, ran one hand through his hair and swore under his breath. The nurses were transferring Idris over to the life support machines by his bed, and a Trojan officer had arrived to guard him through the night: standard protocol in shooting cases, even when it was the police who had done the shooting. Marek Rashid, the duty ICU consultant, arrived. They both stood at the central computer station in the unit, looking at the images coming onto the system in real time.

  The good news was that the bleeding had stopped.

  The bad news was that Idris’s chest looked like shit.

  ‘You say you thought this young man had a fairly advanced pneumonia, yes?’ Dr Rashid was thinking out loud. ‘I’d say you were right about that.’

  The radiologist’s report stated ‘widespread pulmonary infiltrates’, which in layman’s terms meant that there were large cysts and collections of thick, infected tissue throughout the lower zones of Solomon Idris’s chest. On the chest X-ray that had been taken – merely to help confirm the placement of the tubes Harry had inserted – the severity of Idris’s illness was obvious. There was more white than black across the lung fields. But it was diffuse, all over the chest, rather than concentrated in one lobe like a normal pneumonia would be. The most obvious diagnosis jumped out at Harry, and he looked up at Rashid, waiting for him to say it.

  ‘Pneumocystis,’ Rashid said. ‘We’ll confirm it with cultures, but I’ll bet you ten quid that’s PCP. Remind me why you didn’t get a chest X-ray done down in Casualty?’

  Rashid was fairly strict for a consultant, but he didn’t bullshit you and didn’t expect any back, so Harry liked him. The consultants were on call for three days at a time, and not all of them would have come in when the night registrar could see the patient for them. Marek was one of the good ones.

  ‘Because he was bleeding to death,’ Harry said.

  Rashid briefly regarded Harry from behind his glasses, before nodding acceptance at this excuse and turning back to the computer screen.

  ‘The question is, what does it mean?’

  Harry knew that the question was rhetorical. Pneumocystis was an organism too weak to cause disease in otherwise healthy people – it was an opportunist, jumping in to attack a vulnerable immune system. Idris hadn’t had chemotherapy recently, nor was he on long-term steroids. That left only one other reason a seemingly healthy young man would get infected with a pneumocystis pneumonia. It was commonly seen as the first presentation of AIDS.

  ‘I didn’t think about that. He’s young for it, bloody young. I’ll order an HIV test now,’ Harry said. ‘And an urgent CD4 and differential white count. And I’ll arrange a bronch for sputum cultures.’

  ‘You put him on antibiotics?’ Rashid said.

  Harry took a few breaths of the sterile air of the ICU and felt his heart rate drop somewhat. He’d changed into the maroon scrubs that everyone on the unit wore, from the top doctors like Rashid to the physiotherapists. The ward had a restless quiet about it. Even at night, the nurses moved around performing their duties in solemn silence, punching codes through doors, pushing out their right hands like automatons to receive a dollop of disinfectant gel.

  ‘Sorry,’ he said. ‘He’s penicillin allergic, so he got doxy and gent.’

  ‘OK,’ said Rashid. ‘We’ll prescribe him some anti-fungals to cover the pneumocystis. I’ll get on the phone and wake up the microbiologists, let them earn that on-call money.’

  ‘I can do it,’ Harry offered.

  ‘No way, my friend,’ said Rashid. ‘You look awful. I heard what happened to you tonight. You should get yourself to bed. I’ll go see what the situation with relatives is like.’

  Harry yawned. At night, the ICU had its lights dimmed, an attempt to maintain a relatively normal circadian cycle for the patients, most of whom were in medically induced comas. It meant Harry was struggling to stay awake. He could hear whimpers and groans from one end of the unit and shivered: some patients, driven mad by the simultaneous sensory deprivation and stimulation, entered a state called intensive care psychosis, where even the hardiest of sedative drugs couldn’t drive the demons away.

  ‘Make sure you follow this one up, Harry,’ Rashid said. ‘He’ll be good for your portfolio. Not that you wouldn’t, mind you.’

  The reminder was worthless, as Rashid clearly knew. To Harry’s mind, there were two sub-species of medics. There were doctors that went home at closing time, played golf, went to the pub, watched TV with their families and forgot everything that had happened that day. They were somehow able to roll everything they’d seen into a vault deep inside their consciences and forget about it until their next shift. Others went home, but rang wards and texted colleagues and didn’t rest until they knew the outcome of that one patient they’d seen that day who’d troubled them. Those in the first camp, like Marek Rashid and George Traubert, were for the most part stable, happy people. Doctors like Harry and James Lahiri were firmly in the second.

  He headed over to Idris’s bed, where the nurses were finishing the handover. The kid looked dead, a tube in his mouth, one in his chest, a line in his neck, and the lines Harry had drilled into his arms in A&E all still in place. A bag of blood up with fluid and antibiotics either side, a catheter collecting urine, a monitoring line in his radial artery. Clinging to life, both physically and metaphorically.

  Harry heard someone clear their throat behind him, thought it sounded familiar, and put it together in his head just before he finished turning and saw the face.

  James Lahiri looked like shit, too. Bloodshot eyes, one half of his pale blue shirt untucked, a small stain, probably blood, over the left-side pocket, where the eartubes of the stethoscope hung around his neck rested. A paper bag from the hospital’s twenty-four-hour coffee shop was crumpled in one hand.

  ‘Lunch break,’ he explained. ‘You got five minutes?’

  Harry grinned. ‘I’m not working, remember?’

  Lahiri looked like he was trying to smile and said, ‘You always manage to get into trouble.’

  ‘Come on, then,’ said Harry. They headed into the doctors’ office at one end of the ward. Harry folded his arms and stood with his back against the wall, briefly thought about his locker in the room opposite and the bottle of amphetamines inside it, and then remembered he wasn’t actually at work and he didn’t need to stay awake all night. Lahiri shut the door behind him and collapsed into a swivel chair. It was the first time they’d been alone in a room together for almost a year. Harry tried to stop himself from breathing too loudly, and then decided just to speak.

  ‘How are you doing?’ he said. ‘Still enjoy spending your Sunday nights in A&E?’

  Lahiri pulled a can of Coke from the bag, opened it and took a big gulp.

  ‘Look, Harry. You don’t give a toss how I am and I don’t give a toss how you are, so let’s not play friends, OK? I’m here cause one of my patients got shot, and I want to know if he’s going to live, and I reckon you might be one of the only people in this hospital who’ll give me a straight answer.’

  Harry tried his best not to bite. The resuscitation of a young, male gunshot victim, with Harry there in front of him, would have brought back uncomfortable associations for Lahiri, just as Lahiri’s presence had done for him. He tried to keep that in mind. Of course, that wasn’t the reason for the venom, but Harry liked to pretend that it was.

  ‘He’s been admitted for five minutes,’ he said. ‘He’s still alive now. He might not be tomorrow morning. Christ, James, you know how this works.’

  Lahiri shook his head and sighed. He knew that Harry couldn’t even begin to guess how Idris would do, and he knew that Harry knew that, too.

  Harry looked at his old friend and decided to try and get somet
hing other than an awkward silence out of the conversation.

  ‘When you say he was your patient, do you mean you were his GP? Or was he just enrolled in your pilot scheme thing?’

  Lahiri’s GP surgery ran a unique scheme for former gang members. The ethos was a modern one, treating gang violence like a disease and managing it as you would any other. Reducing the risk factors, focusing on prevention. The high-risk cases were identified by youth workers in A&E, referred to Lahiri and the team for follow-up appointments. Most of them got therapy, some got medication to calm them down. As Harry understood it, right now nobody had a clue whether it reduced reoffending or not. All he knew was that it evidently hadn’t done much good for Solomon Idris.

  ‘He was my patient,’ Lahiri repeated. ‘I was his GP.’

  ‘When was the last time you saw him?’ Harry said.

  ‘Last year. December, I think.’

  ‘Was he OK?’

  ‘Physically, you mean?’

  Harry nodded.

  ‘Yeah,’ said Lahiri. ‘He was fine.’

  ‘Is he HIV-positive?’ said Harry.

  Lahiri pulled a sandwich from the paper bag but stopped before taking a bite. ‘Not to my knowledge. What makes you say that?’

  ‘He was sick before he got shot,’ said Harry. ‘Really sick. It looked like pneumonia, and I thought it would be community-acquired. But the radiology came back, and it looks a hell of a lot like PCP.’

  ‘Jesus,’ said Lahiri, chewing on his sandwich and apparently concentrating hard on staring at the ceiling. ‘At seventeen?’

  Seventeen was young for the disease to have progressed so far, unless he’d been infected in childhood, which ought to have showed up on his medical records, or he was one of the individuals particularly susceptible to the virus. It seemed Solomon Idris had been unlucky: a recurring theme.