The Patient (21 page)

When Jonathan was physically well enough, he was transferred to the Urology ward, where it was back to low nursing numbers, fewer resources and the consequent patient griping. His eyes met with those of the man opposite, whose arm was heavily bandaged and in a sling.

‘What's the matter with your arm?' asked Jonathan.

‘Well … nothing was the matter with this arm. It was actually my left arm that had a nerve trapped in the wrist. They had some mix-up and cut open my right arm instead. Then the bloody thing got infected, and now I'm stuck here with my good arm in a sling and my other arm still needing an operation. They're a bunch of shonks here. The nurses don't know what they're doing. I've been given the wrong dose of antibiotics twice in the last week. The place is filthy. The food tastes like shit. And wait till you see the way they treat the poor bugger next door,' he said, nodding in the direction of the man in the bed beside his, who was motionless and had a tube coming out of his chest.

Just then, a nurse came up to the man with the sling and looked at his chart. ‘Have you been given your antibiotics yet?' she asked.

‘Yes, they gave me them at twelve,' he said, through gritted teeth.

‘The morning staff haven't recorded it in your chart. So you're not due again till four, is that right?' she asked.

He just nodded. As she walked away, he muttered, ‘I hate this place. They don't even know whether I was given antibiotics or not.'

A doctor and young nurse walked up to the bed of the man with the tube in his chest.

‘Mr Jenkins, the oxygen in your blood is a bit low,' said the doctor. ‘I think we need to turn up the oxygen for you and also increase the suction on your chest tube.' Mr Jenkins didn't move or say a word. The doctor looked at the nurse and said, ‘I think we need to turn up the oxygen and suction.' Then the pair walked from the room.

‘What's his story?' Jonathan asked the man with his arm in a sling.

‘Bad car accident – tore one of his lungs,' said the man, wincing. ‘He's got that tube sucking air out from around the lung while it heals. At least, that's what I heard the doc say the night they brought him in, but, in this place, who knows what the hell they're doing?'

About half an hour later, the young nurse returned to the lung patient's bed and drew the curtains around him. Jonathan heard fiddling and clattering. Then he heard the man gurgling.

‘I can't breathe! I can't breathe … help!' the man shouted breathlessly.

The nurse must have pressed an emergency button, Jonathan figured, because a loud siren started sounding and within seconds a more senior-looking nurse and the doctor who had been there earlier came running towards the bed.

‘What the hell are you doing?' Jonathan heard the
doctor shout from behind the curtain. ‘Why is the oxygen connected to the chest tube?' Jonathan heard more cluttering. ‘It's OK now. Are you all right, Mr Jenkins?'

Finally, the doctor and the two nurses came out from behind the curtain and stepped into the corridor. Jonathan couldn't quite make out what the senior nurse was saying, but then he heard the doctor, loud and clear.

‘I
did not
tell her to put oxygen down the chest tube. That is one way to kill this man. There are lots of others. God Almighty. How could she have done that?'

More whispering and talking.

‘Sister, I did
not
! Look, you know that your staff member has stuffed up here. Why are you trying to blame it on me?'

Jonathan strained to hear the more senior nurse, whose face was red with anger, but she was still whispering.

‘My order was
not
confusing,' retorted the doctor. ‘And even if it had been, the physiology is absolutely clear. If you pump oxygen into the space around a man's lungs, the pressure on his heart will kill him in a minute or so. Any nurse should know that. I'll take this up with the boss, and I'll be writing an incident form.'

He was walking away as the young nurse said something that Jonathan couldn't quite catch. The doctor replied, ‘Fine! You do that, then.'

On my morning ward round the next day, I lamented the shell of a man who was lying in the bed before me. We talked for a while, and it became clear that Jonathan was depressed.

Having been through my own cancer experience not so long ago, I felt a great sense of affinity with him. I could not help but feel his pain, his anguish. The picture of his children next to the bed made my heart ache, and I was no longer impartial. Once upon a time, I could go home and forget about the sea of troubles at the hospital. Now I knew how each needle, stitch and drain felt. I also knew that the incisions into the bodies of my patients were nothing compared to the deeper incisions into each person's soul, their dreams, their imagined futures, that unexpected illness or trauma makes.

There was a time when I would have been oblivious to his broader needs. I would have regarded Jonathan as a man with a disease that needed curing. Like most surgeons, I would not have stopped to imagine that he needed more than a cure; he needed healing. If there was one good thing that had come out of my cancer, it was that I recognised he needed help. Perhaps I was the one who should have sat with him and helped him through
his psychic groans. However, I was not yet emotionally strong enough to be able to do that, and he could not wait for me to recover from my experiences, my own staring contest eyeball-to-eyeball with the Angel of Death. I arranged for a social worker to help him through it.

The next day, she came to see him while I happened to be doing my rounds. Sadly, she was inexperienced and spouted the usual social-worker questions such as ‘How do you feel?' and ‘Body image is important to you?'. I could tell immediately that Jonathan was turned off by it. She must have sat down for a long while afterwards to write up her notes about Jonathan's mental state, because several very detailed pages made their way into his file. But she didn't come back.

Physically, at least, he gradually got better, and he was able to leave hospital six weeks after having his cystectomy.

My life had settled back into a busy routine after my bout with cancer. In fact, it was easier to be busy. I yearned to be busy. I yearned to get back to work. The only thing that punctuated work was my family and the occasional check-up. As a result, my research was progressing well. Using my background in both education and surgery, I was helping to rewrite a medical curriculum at the university. Each week, I also spent some time supervising a masters student, trying to get my PhD written up and, finally, seeing my patients.

For those patients who could not afford to pay to see me in the rooms that I had to have at an exorbitant cost, the hospital provided a weekly Urology Clinic. It was a memorable experience to run the clinic, which resembled a MASH unit. Each afternoon, there would be upwards of 50 patients booked in. The whole Urology team contributed. The residents and registrars saw follow-up cases and talked with a consultant specialist when
they needed to check on a course of treatment. The consultant specialists, of which I was one, saw all the new patients, and we used the consultations as an opportunity to teach the registrars.

‘So what do you think of this X-ray?' I asked a registrar one day. The patient was sitting right there – as they often were when my colleagues and I put registrars through their paces.

‘There is calcification around the bladder … ummm … I have never seen anything like it … ummm.'

I usually led the first-or second-year registrars to an answer, but I was not about to show mercy to this, or any other, third-year registrar. These were doctors just about to sit their specialist examinations.

‘Just describe it then, doctor,' I said to the hapless third-year. ‘It is doctor, isn't it? You aren't just pretending? You actually
do
have a medical degree, don't you?'

‘Yes, sir. I have a medical degree,' he said, looking uncomfortable. ‘This is an intravenous pyelogram showing a bizarre pattern of calcification around the bladder. The appearance could be consistent with bladder cancer.'

Here was my big chance to humiliate. The other consultant specialists and I had all been through this and had sworn never to treat our registrars in the same way. But the temptation was too strong; the sport of humiliating registrars is too much fun to resist. It was a drug that all of us could become addicted to. In anticipation, I had already briefed the patient on what his condition was – reassuring him that it wasn't, in fact, a cancer – and tipped him off to the fun I was about to have with this registrar.

‘So, Mr Thompson, this
could
be a bladder cancer, but it
could
be a possum in your bladder or it
could
be a stone … You would
be happy with a surgeon who felt he
could
have a diagnosis, wouldn't you?' Patients loved getting a rare glimpse of the life behind the mask.

Turning back to the registrar now, I said, ‘It
could
be anything, doctor. What do
you
think it is? Perhaps you might like to ask Mr Thompson a question. You are allowed one.' I was enjoying the barbecue so much.

‘Do you have a family history of cancer?' the registrar asked.

‘No. Not the question you should ask. Do not bother answering that, Mr Thompson.'

‘Do you smoke?'

‘No! Wrong question.' After several more attempts, I gave the registrar a clue. ‘Ask Mr Thompson if he has travelled recently.'

When Mr Thompson volunteered to the registrar that he had been on a missionary trip to Southern Africa, I asked the registrar, ‘Does that help you, doctor?'

‘It could be some sort of infection?' The penny still had not dropped.

‘What type of infection? Where in Southern Africa was he? Did he swim in any
lakes
, for example?' Despite my obvious clues, the registrar was still not getting it, so it was finally time to let him off the hook.

‘Have you ever heard of bilharzia? Schistosomiasis?' I asked with a demeanour like Rumpole of the Bailey expounding wisdom and virtue. The patient had a classical case of bilharzia, an infection of the bladder caused by a parasite known as a schistosome, with calcification, which gave the bladder an eggshell appearance on X-ray.

‘Please present this case to the department meeting next week with a presentation on the life cycle of the
Schistosoma
and its relationship to swimming in Lake Malawi, in Africa.' Registrar
dismissed. It was a hard way to learn, but lessons learnt this way were learnt for life.

The clinic was a funnel through which passed some of the most interesting cases in Urology, but to save costs many hospitals have phased out this valuable learning opportunity. For patients who didn't have a lot of money, the clinic was a great opportunity to receive good medical care, while contributing to the future of medical education. Of course, not every patient was willing to have their medical diagnosis and treatment used for teaching, and we respected their right to refuse.

After I had seen out Mr Thompson with the prescription he needed to clear up his infection, I picked up the next set of notes from the nurses' desk. They were Jonathan Brewster's. Unable to afford to see me in my private rooms, he had been coming to the clinic for follow-ups. I had not seen him for months, as his last couple of appointments had been with one of the registrars. I was seeing him myself this time because the registrar had told me his back pain had returned, and I was concerned. I called his name. Out of the throng of patients in the waiting room, one head started to rise slowly upwards. His back was so bad that he was struggling to stand. I went over and helped him to walk towards my room. This was one patient I wasn't going to ask to act as a teaching prop.

There was obviously something going on in his back. His bone scan had been clear, but perhaps we were missing something. I was suspicious that he could have some metastases (secondary cancers, which have migrated from the original site of the disease) that were affecting his spine, and a CT scan could show the early stages. I booked one for him and then arranged to see him again in the clinic in a week.

My suspicions were confirmed. He had metastatic cancer in lymph nodes in his abdomen, which were eroding into his vertebral column bone. There must have been microscopic cancer deposits in his lymph nodes that had been missed at his first operation. Even if they had been picked up, the cards had been dealt already. It would not have influenced the course of his disease. I related the news to him and Tracy.

‘What are my options, doctor?'

Chemotherapy was the only available option. He looked resigned and impassive, numb. Tracy made all the arrangements. She had taken to carrying a large organiser with her in which she noted all his appointments and filed his results.

‘We've been trying so hard to get our life in order outside of the hospital visits, clinics, stoma-nurse appointments to help him with the urine bags and then all the treatments,' she said as she flipped pages. Tracy was always the organiser, the one who was practical. I felt so incredibly sorry for this couple.

Many people assume that the hardest thing about being a surgeon is the exactitude with which one must operate on a human being or the life-and-death decisions one must make in a split second. It is not. At least in the operating theatre a surgeon is doing something: alleviating suffering, intervening on behalf of the patient, fighting against the Angel of Death. It is the times when surgical intervention is not possible that haunts a surgeon most. The helplessness of being unable to intervene creates the greatest of all distress in the job of a surgeon.

I wished there was some healing I could offer this man. I could not remove his anguish or cure his cancer. He was beyond my ability to heal with steel. I now needed to sit back and watch him being tormented by the oncologists and their pharmaceutical-company backers with the myriad poisons
designed to slowly kill cancer while leaving the patient barely alive as a result.

Perhaps my agony was clear on my face.

‘You know, doctor, of all the doctors we have met here, you have shown us the most kindness,' said Tracy. ‘Jonathan has a lot of respect for your opinion and your kindness. You are truly compassionate.'

I was embarrassed and at the same time saddened to my core. My eyes were brimming over with grief. What had I done for this man, save talk with him now and then? I had offered him good care and had spent some time listening at each of our meetings. Why had he picked me out to be the representative of compassion on earth? All I could surmise was that the rest of his care must have been very lacking indeed. I reached out and placed my hand on the back of his. He grasped it and with teary eyes stood up and left. I made the arrangements for his chemotherapy and rang the Victoria's oncologist who specialised in uro-oncology (tumours of the urinary tract).

A couple of weeks later, Jonathan turned up for his first dose of chemotherapy, a gaunt and skeletal man walking slowly and deliberately. Vera greeted him with her vivacious smile. He nodded briefly and sat down in one of the recliner chairs he had previously seen – and dreaded – in the chemotherapy room. He had his blood tested and was given his first dose of the mixture of poisons that would hopefully do a better job of killing cancer cells than of killing Jonathan.

Within a few days, he was nauseated, then clumps of hair started falling from his head, chest and legs. His appearance
became increasingly frightening. In the evenings, he would go to bed early, missing dinner because he wasn't hungry. Life had fallen to a drastic low for Jonathan. He tried to read but found his concentration was poor. He could watch only a little television without feeling motion sick and needing to vomit. Gradually, he became more withdrawn, more silent.

At his chemotherapy session each week, he would silently walk into the treatment room with no expectations, no hope – a desolate human being. He would hold out his arm and hardly interact with anyone or his surroundings.

After his third dose, Vera became worried about his state of mind. The social worker who saw him previously in the ward was called again and arranged to see him the next time he came in for chemotherapy. Jonathan despised her insistence on finding out how he felt. He simply answered, ‘I feel like death.'