6

AT THE BEST OF times, and even on the most harmonious of units, specialist registrar ward rounds are a source of friction.

The root of the problem is that, except in cases where the registrar is extremely inexperienced, they’re unnecessary. With the registrar doing a round with the HO on a daily basis, and the consultant doing a round with the whole team on a weekly basis, do you really need the SR, who spends most of her time in clinics, to do a weekly round as well? The chief objective of most SRs on their rounds is to prove that the answer is soundly in the affirmative, while the chief objective of most registrars, not thinking ahead to imagine what their own futures might be like in one or two years, is to show the SRs that they’re utterly superfluous. Thus, unless the SR or the reg happen to be of exceptionally pusillanimous character, the SR round is typically a miserable, grisly round of the most gruesome and vindictive variety. The SR spends it trying desperately to think of something new to add or, better yet, to contradict the previous instructions of the reg, while the reg invariably spends it fighting back tooth and nail, each side attempting to inflict maximal ridicule on the other in front of the more junior doctors.

Yet Goldblatt didn’t resent it. It was one of many fine traditions of the profession and as such he thoroughly respected it. If Emma wanted to do her SR round by the book, naturally he was prepared to do his bit as well.

Emma did, it seemed.

Adopting a time-honoured ploy to establish supremacy from the off, she turned up a careful twenty minutes late for her first round. She rushed into the doctors’ office at ten to three that Monday afternoon with a whole list of excuses designed to show how important and busy she was. No one was there to hear them. Getting into the spirit of things, Goldblatt had responded with an equally time-honoured counter-manoeuvre: he had waited ten minutes and then taken the rest of the team and started. Apart from the manoeuvring, there wasn’t really any point in Goldblatt taking the rest of the team and starting, since he and the rest of the team had already seen the patients that morning. But then the whole exercise had no real point anyway, at least as far as the patients were concerned. And since he and the rest of the team had already seen the patients, it was turning out to be an exceptionally quick round, and if they were lucky they would finish the whole lot before Emma arrived, which would put her in the unusually fortunate position of having done her round without even having been there.

They didn’t finish before Emma arrived. She discovered them halfway around the ward. Emma immediately pushed in front of the HO and seized hold of the notes trolley with both hands.

‘Sorry I’m late,’ she said authoritatively. ‘Right, where are we up to?’

Goldblatt took a step back. It was a pleasure to welcome such a resolute captain aboard.

They went back to the start. Emma enjoyed a more leisurely pace to the round. She seemed to think she would be letting someone down if it lasted less than three hours. She wanted to know every trivial fact, read through the notes, review the result of every test, check every detail twice over, and demonstrate the thoroughness with which she examined each patient, commencing with a careful and far-reaching examination of those subtle indicators of health and disease: the fingernails.

Goldblatt got bored. A bleep came up and he used the opportunity to escape to the doctors’ office where he answered the call and then lingered. Then he decided that he might as well use the opportunity to cancel one of the admissions that was booked for the next day and wasn’t going to get in even if a cholera epidemic broke out overnight and carried off half the patients in the hospital. The cancellee cried on the phone, and Goldblatt listened sympathetically to her complaints and patiently explained the reasons for her cancellation, and then listened to her complaints again, and patiently explained once more, finding this a lot less tedious than watching Emma practise her examination technique, but finally the patient wanted to get off the phone, and although Goldblatt had been hoping to be asked to explain everything for a third time, he had no choice but to hang up. He went back to the round. They had inched their way two beds further along, and had drawn the screens around a patient who had a mild case of Fuertler’s and was in for the work-up. Emma was stabbing her finger at an open page on the patient’s notes.

‘The Prof has written that he needs a colonoscopy while he’s in,’ she was saying violently to the HO. ‘Why haven’t you booked it?’

The HO glanced at Goldblatt. ‘Because Malcolm told me not to when we went round this morning.’

‘Did you tell her not to?’ demanded Emma.

‘Yes,’ said Goldblatt. ‘I told her not to.’

Emma turned away furiously. ‘Mr Siepl, when you saw Professor Small in clinic, did she say you were going to have a colonoscopy?’

Mr Siepl hesitated. He was a chubby, bald man with a head like a cannonball, and his face had assumed a painful expression of confusion. Goldblatt felt sorry for him. They put you through such horrible ordeals in hospital. Yes or no? Which answer was he meant to give?

‘That’s the test where they put that huge long tube up your back passage to look at your bowel,’ Goldblatt explained, in case this would help Mr Siepl decide.

‘It’s not huge!’ said Emma indignantly.

‘How big is it?’ said Goldblatt.

‘I don’t know how big it is!’ retorted Emma, not even glancing at him over her shoulder.

‘It’s about a metre long. Ludo, how long is a metre? Could you show us, please?’

Ludo measured a metre in the air between her two hands. Or maybe it was a metre and a half.

‘I’d say that’s huge,’ said Goldblatt. ‘Would you say that’s huge?’ he asked the HO.

‘I’d say it’s huge,’ said the HO.

‘Mr Siepl, would you say it’s huge?’

‘It’s not huge!’ snapped Emma, rudely interrupting before Mr Siepl had a chance to have his say.

‘Well, it’s pretty big, isn’t it? Show us again, Ludo.’

Ludo showed them again. Like a fisherman telling the story about the one that got away, Ludo tended to exaggerate with repetition. She also had an impressive arm span. Mr Siepl stared at the gap between her two hands with silent terror.

‘It doesn’t matter if it is huge,’ said Emma. ‘If he needs it, he needs it.’

‘True,’ said Goldblatt. ‘Emma, we explained to Mr Siepl that Professor Small was right to think about getting it done to make sure there was nothing serious going on, and to ask us to consider it when he came in. And now that he’s here we can consider it. And that’s what we’ve done, as we explained to Mr Siepl this morning.’

‘Rubbish!’ said Emma. ‘The Prof wanted it!’

Goldblatt tried to suppress his exasperation. What more did Emma want? ‘Yes,’ he said between clenched teeth, ‘but that was five months ago in clinic, and what she wanted us to do was consider it.’

‘She did not. There’s nothing about considering it here. She wanted him to have it.’ Emma turned to the HO. ‘I’m the SR. Book it!’

The HO glanced at Goldblatt. He reached for the notes. He was happy to save Emma’s blushes in front of a patient – and the Prof’s, if it came to that – but not at the price of putting that patient through an unnecessary colonoscopy.

‘Professor Small wanted a colonoscopy to investigate altered bowel habit,’ he said, reading the Prof’s clinic entry. ‘Mr Siepl, has your bowel habit altered?’

Mr Siepl looked a little abashed and possibly felt reluctant to talk about it. Maybe the audience wasn’t big enough. There were only four doctors watching him, as well as Debbie, Sister Choy’s second in charge, who kept putting her head in and out between the screens to see if they were finished. Discussion of something as personal as bowel habits would normally justify an audience of at least eight. On the other hand, there was also the family of three who had come to visit the old man in the next bed, but they were on the other side of the screen so it wasn’t clear whether they really counted as part of the audience. They had lapsed into silence, anyway.

‘I was a bit loose,’ said Mr Siepl hesitantly.

‘When?’ asked Goldblatt.

‘A few months back.’

‘Before you saw Professor Small in clinic?’

‘Yes.’

‘And was there any reason you were a bit loose back then?’ asked Goldblatt affably, having heard the answers to the exact same series of questions on his round that morning.

‘Well, we’d been on holiday in Spain.’

‘And?’

‘Well,’ said Mr Siepl, who was obviously getting to the really embarrassing bit, ‘I ate a lot of fruit.’

‘Fruit?’

Mr Siepl nodded glumly.

‘And since then?’ asked Goldblatt.

‘Normal,’ said Mr Siepl.

‘Really?’

‘Once a day. Regular as clockwork!’

Goldblatt handed the notes back to the HO. ‘Book him a colonoscopy. Write that he had an increased frequency of bowel motions for a fortnight six months ago due to dietary factors, and that the symptoms have resolved.’

The HO pulled out a request form and began writing. ‘Won’t they query this?’ she said, looking up for a moment.

‘Yes. Better put down that it was specifically requested by Professor Small.’

The HO began to write again.

‘Don’t put that down,’ said Emma.

The HO looked up.

‘No,’ said Goldblatt. ‘Put down that it was specifically requested by Dr Burton.’

The HO looked down.

‘Don’t put that down,’ said Emma.

The HO looked up.

‘Give me the form,’ said Emma. Her face had flushed pink, but her voice was cold.

The HO gave her the form. Emma put it in her pocket.

‘I think we can afford to wait and watch how things develop,’ Emma said to Mr Siepl, and avoided Goldblatt’s gaze.

They moved on to the next patient. Once more Emma insisted on delving back into the patient’s prehistory. Goldblatt found a pretext to drift away to do something useful. Like throwing scrunched-up balls of old results at the rubbish bin in the doctors’ office. He had just about cleaned the whole place up by the time Emma, Ludo, and the HO came back from the round.

‘Sorry, Emma,’ he said, ‘I got caught up. You know. Things.’

Emma looked at him with narrowed eyes. Goldblatt wasn’t sure that she believed him.

‘Everything all right?’ he asked.

‘Fine,’ said Emma.

Goldblatt nodded. Fine. He still hadn’t worked out what Emma meant when she used that word.

Emma looked suspiciously at the rubbish bin, which was brimming with scrunched-up results balls. A couple lay on the ground under one of the desks, where Goldblatt had neglected to retrieve them after missing the target.

Suddenly her eyes went wide. ‘Who put those there?’ she shrieked.

Goldblatt almost jumped out of his chair. ‘What?’

‘These!’ cried Emma, already down on her knees and halfway under the desk. ‘Who did it?’ She backed out with the brown Manila folders that Goldblatt had tossed under there a few days previously. Emma stood up and clutched them protectively to her chest. ‘Who put them there?’

Goldblatt, for one, was reluctant to answer. He looked at the HO. The HO looked back at him and glanced at Ludo. Ludo was watching him. Her mouth was expressionless, but her blue eyes, with their low and drooping lids, were smiling. It was a cold, unpleasant smile, malicious, cruel, and knowing, with a promise of excruciating pleasures to come.

‘It must have been one of the cleaners,’ said the HO.

‘The cleaners!’ hissed Emma, as if they were a clan against which she and the rest of the Burtons had been fighting a blood feud for generations.

‘I’m sure it was a mistake,’ said Goldblatt, tearing himself away from Ludo’s gaze and the silent process of negotiation they had been conducting.

‘A mistake! We can’t have these sorts of mistakes. The Prof would go absolutely—’ Emma stopped. Her eyes narrowed. ‘Why didn’t you pick them up?’

‘Who?’

‘You.’

‘I don’t pick things up off the floor!’ retorted Goldblatt indignantly. He wrinkled his nose in disgust. ‘I’m a doctor. And so is she. And so is she. And so are you. We’re all doctors. I shouldn’t have to tell you this. Didn’t they teach you that in medical school? Things on the floor are dirty. Things on the floor give you disease.’

Goldblatt took one of the folders from Emma and held it up between two tentative fingers. ‘What are these, anyway?’ he asked, unable to keep the repugnance out of his voice.

‘The Prof’s Fuertler’s files,’ said Emma.

‘Well,’ said Goldblatt, ‘she ought to take more care of them.’

Emma snatched the folder out of Goldblatt’s hands and stormed off to her office to save the Prof the trouble.

Goldblatt glanced at Ludo, who hadn’t taken her eyes off him for a second. He didn’t know what bargain they had struck in return for her silence, but he knew she’d make him pay.

Five seconds later Emma stormed back in. ‘Every patient on the ward has to have one of these filled in!’ she announced vengefully.

‘You should have told us before,’ said Goldblatt.

‘I’m telling you now.’

‘Every patient?’

‘Every patient with Fuertler’s Syndrome!’ retorted Emma, and stormed out again.

Goldblatt thought about that. ‘She sounds serious.’

The HO nodded.

‘Every patient needs a Fuertler’s file filled,’ murmured Goldblatt, warming to the alliteration of the rule.

‘Every patient with Fuertler’s Syndrome,’ the HO corrected him.

‘Every patient with Fuertler’s Syndrome,’ said Goldblatt, grateful for the HO’s precision. ‘And how many of our patients have Fuertler’s Syndrome?’ he enquired.

‘Almost all our patients have Fuertler’s Syndrome,’ replied the HO cheerfully.

‘Then they all need a Fuertler’s file filled,’ concluded Goldblatt, and settled back to wait.

There was a long silence, broken only by the sound of consciences creaking. Finally Goldblatt heard something snap.

‘All right, I’ll do it.’

Goldblatt looked at Ludo. ‘You didn’t move your lips,’ he said in amazement. He turned to the HO. ‘She didn’t move her lips.’

‘I’ll do it,’ repeated Ludo.

Goldblatt knew what that meant. ‘Thanks anyway, Ludo. But we want someone to do the Fuertler’s files.’

‘I’ll do it, Malcolm.’

‘All of them?’ asked the HO, scarcely daring to hope.

Ludo glanced at her dismissively. She was an SHO. She had her dignity. She wasn’t about to start discussing work allocation with an HO.

‘Well, that’s...’ Goldblatt stopped. He didn’t know what it was. Surprising? Worrying? There were so many words he could have used. It was surreal, that was for sure. Ludo volunteering to do something...

‘Malcolm?’ said the HO.

Goldblatt looked around quickly, hoping the HO was going to say something to break the strange spell that seemed to have settled over the office.

‘I still don’t quite understand what we’re going to do about Simmons.’

Goldblatt stared at her. This was getting more surreal. ‘Simmons has gone,’ he said, in case the HO had developed some form of acute amnesia. ‘We don’t treat patients who have gone. We treat patients who are here.’

‘What about all those tests we were doing? What happens if one of them shows something significant?’

‘I had a professor of Ophthalmology when I was a—’

‘I know,’ said the HO. ‘If you don’t want to see it, don’t look.’

Goldblatt stared at the HO. ‘Very good. And the other thing?’

‘Beware the unilateral red eye.’

‘Congratulations. You know as much Ophthalmology as I do.’

‘I’m serious, Malcolm. What if something happens to him?’

Goldblatt shrugged regretfully. What would happen? But what could he do? Simmons had chosen to go. It was a free country.

‘Maybe we should try to find him.’

Ah, the HO. So sweet, so charming, in her state of uncorrupted HOdom.

Ludo laughed.

‘What?’ demanded the HO.

‘Nothing,’ said Ludo. ‘Coffee?’

The HO came with them to the cafeteria. Ludo started to whine as they waited for the lift to arrive. The accommodation the hospital had provided for her was a decrepit, uriniferous room in a typically pestilential hospital accommodation block. Goldblatt had already heard about it twenty times.

‘Complain,’ he said.

‘I have.’

‘And?’

Ludo gave him a sour look.

‘I moved into a new flat the week before I started work,’ said the HO. ‘It’s brilliant.’

‘Can I live there?’ asked Ludo.

‘No,’ said the HO.

Ludo turned her back on her.

The lift arrived, but Ludo’s whining didn’t stop. She had no shame. There was a patient in a wheelchair with a nasogastric tube up his nose, for heaven’s sake. He already had enough reason to be nauseated without Ludo making everyone’s stomach churn. Goldblatt wasn’t listening any more. Maybe the HO was. Or maybe some of the other people in the lift were. At least they hadn’t heard it all before.

They got coffees and sat down at a table in the cafeteria. Goldblatt had no idea what Ludo was whining about now. He watched the HO, who was nodding, or shaking her head, or just frowning as she tried to keep up with Ludo’s latest litany of victimization. The HO was small, and the white coat the hospital had provided was too big for her. She had rolled the sleeves up to her elbows.

Goldblatt was beginning to worry for the HO. She had landed in the middle of the most specialized unit he had ever seen. Pathologically specialized. If he hadn’t seen it for himself, he wouldn’t have believed such a unit could have existed.

It was full of Fuertler’s patients admitted for the Prof’s excruciating work-up of a thousand tests. While they were in, they all got a five-day infusion of a drug called Sorain, which was apparently supposed to help them. According to the product literature, Sorain had been shown to have some minimal effect on Fuertler’s skin lesions. The Prof loved it. Everyone got Sorain no matter how mild or severe their Fuertler’s was.

What kind of an introduction was this for the HO, dipping her toe for the first time into the surging seas of medicine? Wasn’t there a risk that she’d mistake the overheated little inlet in which she found herself for the entire ocean? Sheltered in the foetid, tropical lagoon that the Prof had created, how would she learn to weather the storms that awaited her beyond the doors of the ward on the seventh floor? How would she prepare for the toll those storms would take on her?

Of course, there were the three beds that the Prof had allocated to Dr Morris when he joined the unit. With his passionate fascination for medicine, he filled them with the weirdest, most complicated and least diagnosable patients ever to step out of the pages of a medical textbook. Some of them were so weird that they were waiting to step into the pages of a medical textbook, and Dr Morris, who was planning to write one, was going to put them there. But they were no good for an HO. To learn her craft, an HO needs the meat and drink of medicine, the bread and butter of the trade: pneumonias, heart failures, myocardial infarctions, strokes, asthmas, diabetics, thromboses, overdoses, dehydrations, gastrointestinal haemorrhages, and the exacerbations of any of a thousand chronic diseases. It was true that the HO would admit them when she was on call overnight, but under the arrangement Professor Small had reached in Fuertlerizing her unit, none of these patients went to her once they were admitted. The patients the HO admitted went to other consultants whose medical teams assumed responsibility for their ongoing care the following morning. If she was to learn her craft, the HO needed not just to see these patients when they came in, but to manage them on the ward over the ensuing days, learn the decision trees for their treatment, and see how these conditions evolved: their exacerbations, their complications, their resolutions. Snapshots at admission would teach her nothing.

Instead, she was going to see Fuertler’s, a disease that evolved snail-like over months, or years, it if evolved at all. She would see every nuance, variant, and subtle manifestation that she was never going to need to know about again in the entire course of her career. Thirteen beds of more or less healthy Fuertler’s patients, having the work-up, getting the wonder drug, and going out again. The only thing the HO was learning was how to get their endless tests done.

Admittedly, she was proving highly adept at this role. Goldblatt had already explained to her that the job of an HO is one part medicine, two parts blood-taking, three parts filling out forms, and forty-seven thousand, three hundred and twenty-two parts chasing other doctors and departments who promise to do things and don’t. She had plenty of native cunning, and was well on the way to working out how to make sure the patients got as many of their tests as the opposition would allow. But if most of her life as an HO was to be spent chasing tests, it needed to be spent chasing tests on more than one rare and almost irrelevant condition.

Goldblatt watched the HO over his coffee as Ludo whined. How would she learn what life was like in the real world of medicine that teemed and boiled outside the Prof’s hyper-specialized unit? How would she know what to expect when she was released into it?

‘Have you been on call yet?’ he asked suddenly.

Ludo stopped talking and looked at the HO with interest. She enjoyed whining, but nowhere near as much as she enjoyed Schadenfreude.

The HO nodded. ‘On Friday. I’m on again tonight. It wasn’t too bad. I got a couple of hours’ sleep.’

‘Let’s hear you say that after you’ve been doing it for six months,’ said Ludo. ‘How many did you admit, anyway?’

‘Eight,’ replied the HO.

Ludo laughed.

‘What?’

‘Eight!’ muttered Ludo contemptuously, as if the real work didn’t begin until you admitted twice that number.

There was some truth in that, thought Goldblatt. Eight was light. If you had only admitted eight, you would have no idea what a night on call could be.

When she was on call, the HO was part of the team that did the medical ‘Take’, admitting and providing treatment for all the patients with acute non-surgical problems who turned up on the hospital’s doorstep. She was teamed with a senior house officer and a registrar, with a strict hierarchy of personnel. The HO was ‘first-on-call’, the person to whom all the calls from the wards were directed. She fielded anything the nurses chose to throw at her, the steady stream of requests that go on all night, like the ticking heart of the hospital, to write up a drug, insert a drip, renew an intravenous order, take a blood test, review a patient, investigate a new symptom, declare a death. The senior house officer was ‘second-on-call’, taking the calls from other doctors in Casualty, and from GPs seeking advice or wanting to arrange an emergency admission, backing the HO up when she needed help, and ordering the HO off the wards and into Casualty to help with the clerking of new patients who had to be admitted. Finally, the registrar was ‘third-on-call’, the person to whom the second-on-call turned when he and the first-on couldn’t manage, and who provided overall guidance for the team.

The HO was on call one night in every four, including one in four weekends. Ludo, as a senior house officer and second-on-call, would be on call one night in five. As registrar, Goldblatt would do medical Takes one night in nine. He was also on call for Dermatology and the Prof’s unit one night in five, but this duty was carried out from home, and most queries, which were infrequent, were dealt with over the phone. When he was in the hospital for medical Takes on the weekends, he worked only one of the two nights. The HO and Ludo would both work both nights, starting Saturday morning and going through to Monday morning, following which they were expected to work a normal Monday on the Prof’s ward, so that the whole period amounted to a fifty-six-hour shift.

Common sense, or even simple humanity, might have dictated that the doctors with the highest work intensity should have had the lowest on-call frequency. That would have meant the first-on-calls, or the HOs. In fact, they had the highest frequency. There were many carefully considered and fully justifiable reasons for this. For instance, HOs were the newest, weakest, and most vulnerable members of the profession, and thus the least likely to answer back when unreasonable demands were made of them. They were the least experienced, and thus the most likely to believe the old lie that the only way to learn how to practise medicine was to do it while too sleep-deprived to remember anything you saw. They were the most idealistic members of the profession, and thus the only ones still prone to believe that self-sacrifice was an important part of their vocation. And most importantly, HOs were the youngest and fittest of the species, and therefore the least likely to collapse and die embarrassingly of overwork.

The strict grading of the on-call hierarchy often blurred during the day, but in every hospital where Goldblatt had ever worked it invariably reasserted itself with a steel grip at night, when sleep was at a premium. There were certain rules that were never broken. The most important one was that you had no right to expect a more senior person in the hierarchy to look at a patient until you had already seen that patient. You had no right to expect a more senior person to try to perform a procedure, such as siting a drip, until you had tried and failed. In blunt terms, you had no right to be asleep when a more senior person was awake.

The intensity of the work, the physical toll taken by repetitive sleep deprivation, and the sheer number of years that a doctor was expected to go through it, combined to create an irresistible downward pressure that sent responsibilities lower and lower until they came to a halt at the very bottom, piled on the people who were least capable of carrying them out. An HO, having once or twice woken a registrar, soon learned that he was expected to assess patients and make decisions at night that no one would have dreamed of allowing him to make during the day. An SHO, who would have been instructed to refer even routine GP queries to her registrar during the day, would find herself giving advice over the phone to GPs when they rang about emergencies at night. In short, after the sun went down, the system ran on the fallacious but convenient assumption that just because someone was named to do the job, the job was being done by someone who knew how to do it.

And they would do that job, all through the night, all through the weekend, to the bitter end – no matter how exhausted, confused, uncertain, overburdened, and terrified they were of the barrage of demands that faced them.

Someone had to prepare the HO for the high-speed train of exhaustion and fear that was about to slam into her. It was better for her to know the things she would inevitably experience than leave her to face them alone when they first confronted her – as Goldblatt had been left alone after his encounter with BatesorBent – too frightened or ashamed or confused to talk about it. That was Goldblatt’s reasoning, anyway, as they sat in the cafeteria.

Ludo’s motivation was much simpler. She went straight for the jugular. ‘We’ll see how long it takes before she does it,’ she said to Goldblatt, and laughed a dull, lazy, complicit laugh.

The HO glanced distrustfully at her, then turned to Goldblatt. ‘Until I do what?’

Goldblatt sighed. He knew where Ludo was headed. Why on earth had he decided to have this conversation when she was with them? He wished he could stop.

But he couldn’t. Once the lid of the box had been opened, even a fraction, it had to be opened all the way. He saw the anxiety deepening on the HO’s face. Ludo laughed again.

‘Don’t worry about it,’ said Goldblatt. ‘It happens to all of us eventually. Don’t feel guilty about it when it does, that’s all.’

‘What?’ demanded the HO.

‘Wishing your patients will die so you can sleep,’ said Ludo.

‘Malcolm!’

Goldblatt shrugged. Ludo had a certain way with words – or lack of a way – but that didn’t alter the essential truth of what she was saying.

Ludo grinned at the HO.

‘You’re disgusting!’ the HO shouted at her, jumping to her feet. Her small square face burned with outrage.

‘She is disgusting,’ said Goldblatt, ‘but she’s right.’

‘No she isn’t. She’s a sour bitch who’s pissed off because she can’t find anywhere decent to live.’

‘True again,’ said Goldblatt, ‘but she’s still right.’

Ludo smirked.

The HO slumped back in her chair and stared at Goldblatt with terror and confusion. Goldblatt felt for her. He knew she was feeling something that he too had once been capable of feeling. But like the innocence of that long-ago Goldblatt who had found himself saying a murderous goodbye to Three Hours of Work, the HO’s ability to feel it would soon utterly disappear.

Ludo watched her avariciously. This was much more fun than whining.

‘When will it happen?’ whispered the HO.

Goldblatt shrugged, selecting a scenario at random. There were so many to choose from. ‘Oh, it’ll be in the morning some time.’

‘The morning,’ emphasized Ludo, like the voiceover in a trailer for a C-grade movie.

‘Say about four o’clock. Let’s say you’re on call, and you’re just about to leave Emergency after clerking your twentieth patient for the day.’

‘You’ll probably be going to one of the vending machines to get your supper,’ Ludo added.

‘No,’ said Goldblatt. Once they had started, he thought, there was no point rose-tinting the reality. ‘Not her supper, Ludo. Be realistic. Her lunch.’

The HO stared.

‘So it’s four in the morning and you’re off to get your lunch. And you think – to the extent that you’re still capable of thinking – that if nothing else happens you might just manage to get a couple of hours’ sleep. And then some nurse who came on duty twelve hours after you started, and will go off duty twelve hours before you finish, stops you just before you can get out of the department. They’ve just had a call from the ambulance service to say some guy with a known gastric carcinoma is on the way in with a big haematemesis...’

‘That’s a bleed from his oesophagus,’ said Ludo.

‘I know that!’ snapped the HO.

‘... and he’s got a BP of fifty over unrecordable, and he’s still hosing. You hate that nurse. At that moment, you hate her like she’s just sunk a knife into your mother’s belly. This patient’s going to take two, three hours to sort out. You’re not going to get to bed. You’re probably not even going to get your lunch. So what do you do?’

The HO had gone into some kind of trance and was staring at Goldblatt without breathing. Her glasses were hanging on against gravity at the very tip of her little nose.

‘You could wait there,’ said Goldblatt. ‘The ambulance is only ten minutes away. Once that patient arrives, every second is going to count. You could wait, so you’re on the scene to get to work as soon as they wheel him in. You could just nip into the nurses’ room and steal a cup of coffee while you’re waiting, maybe a biscuit...’

Goldblatt paused. He had an awful sense of déjà vu, which wasn’t surprising because in fact the whole scene was déjà done, at least for him, over and over in countless variants, and like all moments of great drama it was nothing more than the barely veiled reconstruction of an event that had actually taken place.

‘Or you could leave, go and have your lunch, and if they still haven’t called you, go to bed, hoping...’ Goldblatt paused, and he could sense Ludo watching with monstrous enjoyment, ‘... hoping the patient dies in the ambulance so you can get some sleep.’

The HO shot up from her chair. ‘I’ll never do that! Never!’ she cried with zeal and repugnance.

Ludo laughed pitilessly

‘You will,’ said Goldblatt, as if unable to stop before he had finished painting the full Hogarthian sequence of the HO’s inexorable moral demise. ‘You’ll rush off to bed wishing the patient dies in the ambulance and lets you sleep. Not only that, but when some nurse on a ward bleeps you at seven o’clock and you realize you actually got some sleep, which means no one called you from Casualty, which means the patient must have died – you’ll be glad. You’ll be happy. You’ll punch the air.’

‘I will not!’ said the HO in disgust. ‘Only Americans punch the air.’

‘That’s true, Malcolm,’ said Ludo.

Goldblatt shrugged. ‘Everyone punches the air if they’re pushed far enough.’

‘I won’t,’ said the HO, still resisting the truth. She pulled her white coat tighter around her, as if that were going to protect her.

‘You will,’ said Ludo.

‘The reason I’m telling you,’ said Goldblatt, ‘is so you won’t feel guilty about it. Everyone does it. More than once. You don’t have to tell anyone when it happens, but if you think it would help, talk to someone. Don’t feel you have to bottle it up. You can talk to me or...’ he glanced at Ludo. ‘Anyway, you can talk to me. Or not. It’s up to you.’ He paused. This was important. ‘Everyone does it. Everyone ends up feeling like that at some point. Do you understand? It doesn’t make you a bad doctor.’ He watched to see if the HO understood. ‘It’s nothing to be ashamed of. It’s reality. Don’t repress it. Whether you tell anyone else or not, don’t blame yourself.’

‘You should tell me when it happens,’ whispered Ludo.

The HO had decided to repress whatever she could. ‘I didn’t do medicine to do that to patients.’

‘You’re not doing anything to patients,’ said Goldblatt. ‘If they die before they get to you, they die. It’s not your fault.’

‘Well, I didn’t do medicine to think about patients like that.’

‘Neither did we,’ Goldblatt pointed out.

‘I’m going,’ said the HO. ‘You’re both disgusting.’

The HO turned on her heel and walked away between the tables.

‘Six weeks,’ Ludo shouted after her. ‘I give you six weeks.’

The HO kept going without turning around.

Goldblatt shook his head. Six weeks was too long. No one lasted six weeks.

‘Four weeks,’ he said quietly, as he watched the HO walk out of the cafeteria. ‘If that.’

Ludo tossed her head dismissively. She was very conscious of the way she tossed her head, never tossing it without first pausing to visualize the effect it would achieve as her long dark hair swept romantically through the air.

Goldblatt noticed a team of doctors from another unit sitting down together at a table nearby. He thought about Emma and the round she had conducted that afternoon. He had the feeling that the round – or at least his part in it – hadn’t been a raging success. For either of them.

Ludo started whining about the Prof, whom she hadn’t even seen yet, even though she had just volunteered to fill out her Fuertler’s files. She’d have to wait until Wednesday when the Prof did her round. And what if the Prof didn’t come to her round on Wednesday, like last week? She wouldn’t see her then, either.

Goldblatt shrugged. He had seen the Prof. He didn’t think Ludo was missing much.