‘No,’ Sister Whelan said with all the insulting patience she would use to a particularly stupid child. ‘Why do you want to use a no-touch technique? For a hernia? It’s not like a bone job, is it? Just a gut —’
There was a little silence as Kate contemplated the dreadful hole she had so carefully dug so very deeply for herself. To tell Sister Whelan why would mean explaining about the possible risk of cross infection, and to someone who was as fiercely protective of her staff as was Sister Whelan, that could be a disaster. Even as she stood and stared at the slit of face and eyes that was all that was visible of the doughy face in front of her she could see the whole scenario as it flickered on its inevitable progress: Sister Whelan horrified to hear one of the patients coming to her precious theatres might be carrying HIV; Sister Whelan realising the fact that this case must belong to another surgeon by rights, since it was outside Kate’s own usual speciality; Sister Whelan either refusing to allow Gerald Slattery over her portals or sweeping all her staff out — oh, damn and blast it all to hell, Kate cursed silently. What had she done in speaking to her? She should have managed with the egregious Trevor, useless ham-handed ass though he was. She would simply have to thread all her own needles and prepare all her own gut sutures and just manage — if Whelan hadn’t already realised there was more here than she knew, and persisted, it could be — Oh, damn, damn, damn —
‘No special reason,’ she said quickly then, after what seemed an eternity but was little more than a few moments. ‘I just don’t want to lose my technique, you see. It took me a long time to learn it — and —’
‘Well, another day, perhaps, Miss Sayers,’ Sister said sharply, obviously deeply irritated. ‘I really can’t be expected to cope with such a — with things like that when we’re so very busy. Next week possibly. If Nurse Brandon is on duty, of course.’ And she swept away, her little feet twinkling busily and seeming to slap out their message on the terrazzo floor, ‘And off duty she’ll be, you can depend on it. Off duty she’ll be —’ And Kate once more cursed under her breath and went, to get her coffee before starting on her next case. At least she’d managed to stop the damage in time, she told herself. Be grateful for that.
Chapter Twenty-Two
The second TUR went a little less well. The man bled a good deal and that obscured her vision and as she became a little more tetchy, so did Trevor Cantor become a little less capable. She knew at some deep level that if she handled the boy right, he’d be fine; he was one of those who slowed down under pressure. Only when he felt really secure in what he was doing could he cope with the speed that was necessary, and if she had had enough patience for him she could have brought him along nicely. But as her operating field blurred over and over again with blood she became very irritable and snapped and that made the anaesthetist, a cheerful Maltese, become ever more flippant, for that was his way of dealing with stress.
‘Thank you, Dr Azzopardi,’ she said at length, when once again he had distracted Trevor’s attention with one of his sallies. ‘I’d be grateful if you could let this man concentrate. He’s not showing a great deal of it at the moment.’ At which comment the runner — Sister Whelan’s second in command, who was shaping up nicely to be as despotic as Bridie herself — showed distinct signs of annoyance and Kate sighed and doggedly worked on, biting her lip beneath her mask, determined not to say another word.
When at last the case was finished and she could dispatch him on his way, they ran into more trouble. Byford’s case, which had clearly taken longer than anyone had expected, was just finished and her own patient emerged into the concourse just as Saffron’s trolley was pushed out of Theatre One, fluttering with drips and mobile monitors, and well escorted by no fewer than two nurses and two porters as well as the security man, as burly and imperturbable as ever. Kate stood at the door as her own runner tried to get their trolley past all the confusion, and as she saw that no one was in the least interested in anything but Byford, Byford’s patient and Byford’s needs, her irritation boiled over and she pushed herself forwards determinedly past the other trolley and with one hand on her runner’s back propelled her firmly onward.
‘This patient needs to be in the recovery suite now,’ she said loudly and crisply and looked pointedly at Byford, who ignored her with lofty disdain. ‘So if you don’t mind —’ and then went back into the theatre to push the nurses there to work faster at getting ready for her next case, the suprapubic repair. It was already past eleven-thirty and time was running tight; there would be new lists this afternoon to be dealt with, and Sister Whelan was as edgy as a cat as she tried to get rid of Kate so that she could bustle about on her own account. But Kate was now far too irritable to be sensible and instead of retiring out of the way to leave Bridie Whelan to calm down, she stayed stubbornly put, watching them get ready with a stare of grim determination on what could be seen of her face, and feeling more and more tense as the time ticked on.
Outside there was more hubbub as the next case was brought in for Byford, and she listened, sneering a little inside her head as Byford’s plump tones filled the air with his importance.
‘I want a five-minute BP — yes, every five minutes. Just keep a very close watch. If necessary I’ll have him back in here but I hope it won’t be required. Azzopardi, are you anaesthetising this one for me? No? Then keep out of the way, will you? I really can’t cope with all this hubbub —’ And he went striding into his own theatre with a great deal of hubbub, leaving Kate seething and even Azzopardi looking put out.
The next case came in then and Kate looked down at the area, once it had been sheeted and the skin prepared, and said over her shoulder to the runner, ‘Staff Nurse, get my next patient up now, will you? This won’t take me long at all, and I really do want to get on —’
She didn’t really know why she was fussing so; there was no panic after all. If she wasn’t finished before the nurses’ lunches became a matter of paramount importance, too bad. They’d just have to wait and there was an end to it. Sister Whelan herself might fuss and flurry but she wouldn’t jeopardise a case for such a reason, surely, and Kate knew that she’d get her list finished without undue difficulty. And yet she was now so edgy she almost felt as though she had to increase the pressure she was under, had to get Slattery up soon, get him into the anaesthetic room, hurry, hurry, hurry — and she started to clean the edges of the messy wound that lay before her in the bright eye of the great theatre lamp, very aware of the sweat that was trickling down between her breasts.
The stitching took much longer than she had hoped. The wound had been big to start with, the remains of an operation performed by another rather elderly surgeon at another hospital two years earlier, and his technique had been a very old-fashioned one. Kate had agreed to try to help the poor man who ever since he’d had it done had leaked urine from his perforated bladder on to the surface of his belly; a miserable existence. And Kate had been sure she could relieve it very easily.
And easy it was in a sense, but laborious and slow. By the time the last stiches were in, fine silk and close-set nylon, and the special impermeable dressings set in place, the clock was shouting one o’clock at her and Sister was glaring.
‘I have to do the next case now, Sister,’ Kate said loudly, anticipating her complaints and demands for rescheduling. ‘Mr Slattery’s up here and he’s premedded. I’m not putting him through a delay. So, I’m sorry about lunch —’
‘I’ll stay, Sister,’ Trevor Cantor volunteered at once. ‘I’ll grab a quick sandwich while someone else sets up, but I don’t mind not going up to the dining room, really I don’t. I’ll be glad to help out.’
Kate at once felt wretched, for she had been snapping at the boy mercilessly and he was now wet with sweat and pallid with anxiety; but she had to give him his due. He was a stayer. And she flicked a glance at him and managed a smile. ‘It really isn’t all that —’
‘There’s no one else to do it,’ Sister Whelan said sharply. ‘So thank you, Trevor. Th
e others have already gone to lunch except Cassie Brandon. She has to stay here for Mr Byford. He has got to get Mr Saffron in again — he’s not too well and the ballooning didn’t — Well, no need for fuss. But he’s coming back. So get cleared up here as fast as you can.’ She flicked a glare at her runner and the two juniors with her. ‘And then go to lunch. I’ll be back by one-thirty and I can run next door, while you take over here if I’m not finished. It’s only a hernia so I hope we won’t waste too much time in here, and I can get back to Theatre One —’ And once more she glared at Kate and went padding away to eat her own lunch.
‘I’m sorry,’ Kate said drearily to the three nurses now cleaning up at a great rate, hurling towels and swabs into skips and sweeping soiled instruments away to be scrubbed and sterilised. ‘That last one was trickier than I thought —’
But none of them said anything and she went dispiritedly away to the surgeons’ room to find a few curled sandwiches which were all that Byford had left after his own coffee break, and some half-cold coffee. And was marginally comforted to find that Fay was still beavering away in her own small theatre, the least convenient to work in, yet showing no signs of any fatigue or bad temper. Good for Fay, she thought, and stretched her shoulders. Good for Fay. I’m bushed. And she sat down and put her head back on the wall and let herself doze as she waited for the theatre staff to tell her they were ready for her, and prayed behind her closed eyes that Trevor Cantor would sweat less and move faster during the hernia repair. Because she’d need all the support she could get, she now realised. It was all getting to be a much less comfortable list than she’d expected.
By a quarter to two, as Byford went on and on with his efforts over his last case in Theatre One, and Fay was still wheeling her Ds and Cs in and out of Three, Sister Whelan was in a white-hot rage. She had spent only fifteen minutes over her lunch and then come back to realise she would have to warn Orthopaedics, ENT and Paediatrics that they couldn’t operate until after four at the earliest, rather than from three o’clock. The theatres had no hope of being ready till then, the way the morning lists were going, and she marched around Theatre Two as Kate set to work on Slattery, bristling with annoyance and clearly furious with Kate for insisting, as she was, on using her no-touch technique. It could add as much as fifteen minutes or more to the total operating time, and, as far as Sister Whelan was concerned, that was a personal affront and deliberate malice on Kate’s part.
I nevitably Trevor picked up his senior’s mood and became slower still, and by the time Kate had cut down through the skin and fat and reached the fascia, laboriously diathermying each tiny bleeding point — somewhat to Azzopardi’s surprise, for who worried that much about little bleeders? — the whole theatre was buzzing with tension. And Azzopardi didn’t help when he craned forwards over the head of the table and said conversationally, ‘I never saw such a lily-white job! What’s the matter, Kate? This one a private patient who’d have to pay for a unit of blood? You’re saving every teaspoonful —’
‘I prefer to operate in a clean area,’ Kate said sharply and didn’t take her eyes away from the wound, looking for every little bead of blood so that she could occlude even the smallest of veins. She would have closed off capillary oozing too if she could.
‘I hardly think it’s all that vital for a simple inguinal,’ Sister said, stopping to look over Trevor’s shoulder. ‘Hold that clamp more upright, Cantor, for heaven’s sake! You’ve been shown that often enough!’
‘Yes, Sister,’ Trevor said and immediately tipped the clamp so acutely that it slid out of position and grimly Kate seized it and put it back.
‘We’re managing fine, Sister,’ she said. ‘I’d prefer a little quietness here if you don’t mind.’ It was the nearest she could dare come to telling Sister to shut up, and Sister was well aware of it and made a sharp little sound behind her teeth and began to collect used swabs with ostentatious efficiency.
Outside, beyond the thick door, the sounds of the theatre block came muffled to her ears and as Kate went doggedly on freeing the loop of gut, mobilising it, looking for adhesions and checking for the position and state of the testicle on that side, she listened as much to relax her tension as because of any interest. The rattle of wheels again: Fay’s last case, could it be? Kate hoped not — it would be agreeable to be able to speak to Fay when she finished in here. It would help bring her back into a pleasant frame of mind. Fay was always in a good mood, no matter what happened. But the wheels sounded again and she heard the door of her own theatre shift and sigh as the next-door theatre opened yet again to admit another patient. Ah, that would be Fay’s last one. So maybe they could meet up after all —
She had managed to push the loop of gut back safely into position now. It hadn’t been nearly as oedematous as she had feared it would be, after being held so long in the ring of muscle that had tethered it into the wrong place. Now all she had to do was repair the weakened wall to make sure there was no recurrence of the hernia and sew up the layers of abdomen, and she would be able to send Slattery back to his bed safe and sound with the minimum of blood loss. Whether he was HIV positive or not really didn’t matter; no one had touched his blood so far and there was no reason to suppose anyone would.
She became aware again of sound from outside, and lifted her head briefly to listen, for it was so unexpected. Raised voices, someone shouting and then someone else speaking loudly and firmly and Sister Whelan heard too and went hurrying self-importantly over to the door to push it open.
Kate went on working even as she listened, not taking her eyes from her working hands. They moved there in front of her in the pool of clean shadowless light thrown by the great lamp over her head, smooth and brown and featureless, crawling over the pinkish-grey membranes and rich yellow fat globules like busy snakes. A pleasing image, she thought, and felt as she sometimes did when she reached this stage of a long list, a little separated from her physical self, as though she were just an operating machine, while the real Kate stood to one side and watched, amused and remote and considering.
Facing her, Trevor Cantor became aware of the noise outside too, and that made him even jerkier than usual and the finely pointed scissors he had been holding ready to snip off the ends of the sutures she was tying moved convulsively in his hand.
The separate Kate watched, aghast, seeing what was coming and unable to do anything about it. The points of the scissors jerked forwards and went into the other side of the wound where Kate’s brown hands were moving, and buried themselves in the tissue. And Kate stood and stared, her hands no longer moving, for a fraction of a second that felt like a year, and saw the blood begin to ooze round the glinting chrome.
Trevor was still holding the scissors by their loops and again the watching Kate realised what he was going to do and was horrified, and again the brown hands that were Kate’s could not move fast enough to stop him.
Trevor gasped, and jerked his hand back, pulling the scissors out, and at once the blood stopped oozing but began to pulse, bright red and glistening, into little rhythmic bubbles which became heavier and richer, and even as Kate grabbed for a swab stopped being bubbles and became a spurting series of high jets.
By the time she had managed to get a swab over the punctured artery her own gown was streaked with blood and so was Trevor’s. His glasses had been affected too, and he stared at her over his blood-streaked mask, peered through the little rivulets trickling down the lenses and muttered dully, ‘Ooh, Miss Sayers — ever so sorry, Miss Sayers —’
‘Panic you not,’ Azzopardi said comfortably. ‘Our Kate’ll get that dealt with in a flash, eh Kate? So much for your nice lily-white operating field though, eh Kate? Oh, well, no harm done —’
‘Oh, Christ,’ Kate said and pushed harder against the wall of the wound with her swab, which was rapidly becoming a sodden crimson rag. ‘Give me another swab fast —’
Trevor reached awkwardly behind him for his instrument trolley, as he stood with his head turned sidew
ays to allow the junior nurse gingerly to remove his glasses to clean them and Kate saw in a brief glance that the girl had managed to get blood all over her hand while she was doing it, and felt sicker than ever. Now two of them affected; and although Slattery had said it had been seventeen years since he’d had any partner other than his own, and although she was reasonably confident he wasn’t HIV positive, still and all, maybe — and she realised she was breathing hard and fast as she scrabbled in the wound with her bloody hands and pushed with her artery forceps, snapping eagerly in a search for the source of the danger.
She found it of course. The operating Kate was too experienced and well trained to fail, and the watching Kate made a conscious effort to calm down, to breathe less rapidly and to sweat less hard as at last the bleeding stopped.
Gingerly the brown hands moved again, swabbing out the wound, and slowly the tissue reappeared underneath the folds of the stained fabric: the greyish-pink fascia, the deep crimson muscle and the yellow fat, and she took the swab away and set it carefully in the bowl at her side.
‘No one is to touch that,’ she said sharply as the junior came trotting round the table to take it all away in the usual manner. ‘Do you hear me? I want nothing touched here. I’ll deal with it — Now, Trevor, go away. I’ll manage on my own now.’
The boy stared at her, his face wet over his mask and his weak eyes blinking without his glasses.
‘I can manage, Miss Sayers, honestly I can. I’m ever so sorry I let my hand slip, but it was all that shouting —’
And indeed the shouting was still going on as Sister Whelan’s voice joined in. The whole episode had lasted less than minutes, Kate suddenly realised and she took a deep breath, deliberate and slow, and managed to crinkle her eyes reassuringly at the boy now looking at her so miserably.
Clinical Judgements Page 25