JUST BEFORE NINE A.M. on the fourth Sunday after he had started on the unit, Goldblatt walked into the hospital carrying a bag. He went to the doctors’ mess, bleeped the registrar who had covered the Saturday, and sat down to wait.
The mess was strewn with plates covered in coagulated gravy, soft-drink cans, coffee cups, torn newspapers, take-away pizza containers, and other debris indicative of the forced incarceration of desperate people. It had a stale smell, and Goldblatt opened a window on to the cold, grey air of a late February morning. The HO, he knew, was already somewhere in the hospital. It was her first weekend on call. Since she and Goldblatt worked different Take cycles, and since she was required to cover both days of the weekend, and he did only one, it was purely a matter of chance that he was rostered on this particular Sunday as her medical registrar.
The Saturday reg arrived in the mess with a senior house officer called Steve. They had just finished a quick round of the patients who had come in the day before. Like the HO, Steve had to cover the Takes on both days of the weekend. The HO had been with them on the round, but they had sent her straight back to the wards, hoping to get the Sunday morning bloods taken before the emergencies started coming in. On busy Sundays it wasn’t unusual for house officers still to be taking Sunday morning bloods at midnight.
‘I usually handle things myself with the house officer,’ said Steve after the other registrar had told Goldblatt about the patients who needed review, handed over the key to the on-call room, and gone. Steve soon let it drop that he had just passed the second part of the Royal College exam, and it was obvious that he felt he knew enough to do without anyone else’s advice unless he asked for it. That suited Goldblatt. There was nothing worse than an SHO who was always pestering you for confirmation of his decisions. With someone like Steve you could be sure that after midnight only a major catastrophe with casualties numbering in the hundreds would induce him to call his registrar and admit that he couldn’t cope. This was a highly desirable situation that considerably boosted Goldblatt’s chances of getting some sleep overnight, which was the main concern of just about any registrar.
‘OK,’ said Goldblatt.
‘The way we do things here is pretty standard. I take the calls from the GPs and divide the admissions between myself and the house officer. I’ll have a look at the patients she sees as well. If there’s a medical student around, I’ll see the patients he clerks too. I’ll probably be in Casualty all day. If the house officer gets into trouble on the wards I’d appreciate it if you could help her out.’
‘OK,’ said Goldblatt.
‘Can I tell her to ring you direct? Not after midnight, of course,’ added Steve quickly. ‘I didn’t mean that.’
‘OK,’ said Goldblatt.
‘And we’ll call you if the numbers start building up in Casualty. Is that all right?’
‘Sure,’ said Goldblatt.
‘Well, that’s about it, then,’ said Steve. ‘The bed numbers are pretty tight, but that’s always the way. Takes are busy here, but they’re great experience.’
Goldblatt nodded. He was sure they were, and he hoped Steve would find the experience just as great as he hoped. Personally, Goldblatt had never found that the great experience of busy Takes was enough to compensate for the fact that they were busy.
Steve finished his coffee. He had a narrow face with a sharp nose, and receding blond hair. He did everything very deliberately, as if each movement of his body was designed to give the impression that he was in control. He was wearing his white coat, and his tie was tightly knotted at the throat. Goldblatt was in jeans and an open-necked shirt, and he had no idea where his white coat was. Steve looked good for a guy starting his second day on call. It was probably the morning blush. If you got a couple of hours’ sleep you were usually all right until midday.
Steve glanced at his watch and got up. ‘I’d better go,’ he said, ‘they rang me half an hour ago about some old lady who’s been brought in with a stroke.’
‘Expecting anything else?’ asked Goldblatt.
‘A couple. There’s a known epileptic who’s been fitting all night. And a GP rang me at six about someone with severe Crohn’s disease, but he hasn’t turned up yet.’ Steve shrugged. ‘Nothing we can’t handle.’
Steve left. Goldblatt looked around the battlefield of the mess. He picked up the shreds of one of the Saturday papers and read an article about celibate priests. Priests apparently didn’t want to be celibate any more, and frankly Goldblatt couldn’t blame them. A woman arrived to clean away the detritus that had been deposited overnight. Goldblatt bleeped the HO to find out if she was still alive. The HO said she was, but there was something in her voice that made him wonder whether she was lying. During the week she had been strangely excited about her first weekend on call, but it sounded as if that was a long time ago now. She hadn’t finished the bloods, but Steve had just bleeped her to come down and help out with a man in cardiac failure who had turned up hard on the heels of the stroke.
‘OK,’ said Goldblatt, ‘let me know if you’re in trouble.’
‘I’m in trouble,’ said the HO.
‘No, you’re not,’ said Goldblatt. ‘This isn’t trouble.’
‘It feels like trouble.’
‘It isn’t trouble.’
‘Then how will I know when I am in trouble?’ said the HO.
‘I’ll tell you.’
He put the phone down. A man from the hospital shop brought the Sunday newspapers into the mess. Goldblatt picked up one of the broadsheets and started reading. He wasn’t really interested in most of the pap that padded it, but once you left and started to get involved with what was happening outside the door of the doctors’ mess, it didn’t stop.
But there was only so long you could stay there. Eventually he went to the accommodation block behind the hospital and dropped his bag off in the on-call room, and then came back to see a patient on the Coronary Care Unit the previous day’s reg had asked him to review. Then there were another couple of patients he had to see on other wards. One of them needed a blood test. Goldblatt magnanimously did it himself even though he could legitimately have demanded that the HO come up to do it. Who said he didn’t pitch in with both hands?
Once he got going, the rest of the morning passed in a grey stream of patients on the wards whom the HO kept ringing him to go and review. She was never there when he arrived, always having been called back down to Casualty, where Steve was ploughing through the growing crowd of hopeful applicants queuing for admission. At one o’clock he snatched a quick lunch, and then went down to review what Steve had done and help out.
Over the next few hours he saw a succession of patients. At around four in the afternoon there was a brief lull before the Sunday-night rush began. Goldblatt grabbed a coffee. The HO went off to the wards to take the rest of the morning bloods.
The Sunday-night rush was the last great hurdle of a weekend on call. It could start as early as midday and go on, in some cases, right through to the next morning. A rush developed when a critical mass of GPs suddenly decided they couldn’t cope any more with various patients who had been gradually deteriorating at home over the weekend. The Rushed – as the patients were technically known – weren’t necessarily all that ill. Some would be close to death and should have been admitted days before, but others would end up being sent home from Casualty after a five-hour wait. There was something about Sunday nights, maybe just the loneliness at the end of two days of house calls, that induced a collective madness in GPs and made them unable to tolerate uncertainty for one second longer.
Early in the evening a patient on the Haematology ward developed chest pain that turned out to be a full-blown myocardial infarction, and by the time Goldblatt had dealt with that, transferred the patient to the Coronary Care Unit, organized treatment, and got back down to the Casualty bear pit, it was eight o’clock and the department was awash with the Rushed. Virtually all the SHOs in the hospital were down there masquerading as gynaecologists, ophthalmologists, paediatricians, surgeons, psychiatrists, and any other specialist who happened to be required.
Goldblatt hadn’t heard from Steve since he had gone up to the Haematology ward to deal with the infarct. He wondered just how much trouble Steve was in.
Lots. Steve came out from behind the screens around one of the cubicles, glancing around apprehensively like someone who knows he’s under attack but doesn’t know where the next blow is coming from. He’d loosened his tie. His face was pale, his eyes were sunken deep into dark sockets, and he looked as if he needed intravenous rehydration a lot more urgently than the various patients lying around the department with drips in their arms. He saw Goldblatt and glanced at him grimly in recognition.
‘All right?’ said Goldblatt.
Steve managed a despairing grin.
‘What have you got?’
Steve pulled a piece of paper out of his pocket. ‘There was the haemophiliac with a haemarthrosis because he couldn’t find his factor VIII.’
‘You already told me about him. I saw him before,’ said Goldblatt. ‘What else?’
‘The stroke.’
‘Which stroke?’
‘The second stroke. The old guy.’
‘You told me about him as well. Do I need to see him?’
Steve shook his head. ‘Just a normal stroke,’ he murmured, studying his list. ‘What about the myocardial infarct? Did I mention him to you?’
‘Which one? I just saw one on the Haematology unit.’
‘No, the one who came in. Sixty-three-year-old male.’
‘No, I haven’t seen him.’
‘He’s OK. Straightforward anterior.’ Steve glanced at one of the high-dependency cubicles, which was temporarily empty. ‘Looks like they’ve just taken him up to CCU.’
‘Did you strep him?’
Steve nodded.
‘Any failure?’
‘No problems. He’s fine.’
‘I’ll look at him later,’ said Goldblatt.
‘Don’t worry about him. First MI. Smoker. Overweight. We’ll hear if anything happens.’ Steve paused to peruse the piece of paper, which was covered in hastily scribbled notes. ‘Let’s see. There’s a pyelonephritis one of the medical students is seeing, and I’ll have to see her afterwards. I’ve got an asthmatic having a nebulizer. He’ll probably go home. That bleeder we had earlier stabilized. Oh, you remember that patient with bronchial carcinoma? He died.’
‘Down here?’
Steve nodded.
‘Died in a Casualty department.’ Goldblatt shook his head. ‘Imagine doing that. Idiot GP. What the fuck did he send him in for?’
Steve looked over his list, possibly not even hearing the question. ‘There’s a thrombophlebitis. I’ve got a severe diarrhoea coming in, a swollen leg...’
‘What about the one you were seeing in there?’ asked Goldblatt. ‘Who’s that?’
‘Some old guy with Parkinson’s who’s had a fall.’
‘Bringing him in?’
‘The wife says she can’t manage. We’ve only got two male beds left in the hospital.’
‘The guy with the Parkinson’s, can he walk?’
Steve shrugged. ‘Kind of.’
‘Any acute problems?’
Steve shook his head.
‘Well, if he can walk... he can walk,’ said Goldblatt, citing an age-old adage of med regs everywhere struggling with bed shortages. ‘Get him back for an early review.’
Steve nodded.
‘All right,’ said Goldblatt. ‘Now, where’s the house officer?’
Steve looked at his list again. ‘I think she’s with the headache.’
‘Which headache?’
‘Didn’t I tell you about the headache?’
The headache was around the corner in one of the treatment rooms. Goldblatt pushed the door open quietly and saw an obese man in his forties lying curled up on his side with his spine exposed under a bright yellow light. On one side of him was a student nurse, and on the other was the HO, seated under the light with an instruments trolley at her elbow, gloves on her hands, and a long needle poised between her fingers. If Goldblatt hadn’t known any better, he would have said she was about to try a lumbar puncture.
‘I don’t think you want to do it exactly like that.’
The HO jumped. ‘Malcolm!’
‘Do you think you want to come outside for a second?’
‘Why?’ asked the HO.
‘I think you should.’
The HO told the patient she’d be back, and stepped into the corridor with Goldblatt.
‘Does Steve know what you’re doing?’ asked Goldblatt.
The HO nodded.
‘Have you ever done a lumbar puncture?’
‘I saw one yesterday.’
‘And does Steve know that?’
‘Steve did the one I saw.’
‘I see,’ said Goldblatt. ‘And you feel confident doing it by yourself?’
‘He didn’t have time to show me again. He told me to do it. “See one, do one, teach one.” Isn’t that what they say?’
‘Who? All the doctors who have been struck off for malpractice?’
Goldblatt gazed at the HO. She was on automatic. She had big black bags under her eyes and greasy smudges on her glasses. She was still holding the needle even though she had desterilized her gloves by touching the door when she followed Goldblatt out.
‘I’ve got two patients to see after him,’ pleaded the HO. ‘And I don’t know what else after that. And the wards keep calling me. Can’t I go back and get this finished? Please? Can’t I?’
‘Sure. But let’s see if we can get the needle in the right place.’
Goldblatt went back in with the HO and guided her through the procedure. As anyone who had done a lumbar puncture before would have known, the obesity of the guy with the headache made him a nightmare LP candidate. After the HO had had two tries, Goldblatt put on a pair of gloves and did the job himself. He left her labelling the specimen tubes for the lab, and went back to Casualty. The Rush was in full swing. There was no standing on ceremony now. Steve was drowning. Goldblatt plunged in. He saw a woman with inflammation of the superficial veins in one of her legs and sent her home. He saw a diabetic with raging cellulitis of the foot and welcomed him to the hospital. He dealt with another six patients, none of whom required admission, and reviewed a couple of others that Steve was bringing in. The next one he saw should have been sent in twenty-four hours earlier. He had a past history of a heart attack, and a malignancy known as a VIPoma – not a tumour reserved for celebrities, but one that secretes large amounts of a hormone called Vasoactive Intestinal Peptide, causing profuse and watery diarrhoea – and his bowel had been pouring out fluid a lot faster than he could replace it by drinking. Goldblatt examined him. He was anxious and severely dehydrated. Goldblatt took bloods and inserted a drip to start rehydrating him intravenously.
The VIPoma was a big man in his sixties, with a barrel chest and a ruddy face.
‘Will it stop?’ he said anxiously once Goldblatt had put the drip in. ‘I’ve never had the diarrhoea so bad.’
Goldblatt nodded. ‘It’ll stop. If it doesn’t, there are things we can use. The first thing is to get the fluid back into you. That’s what’s urgent. Let’s worry about that right now.’
The VIPoma nodded.
‘Where’s your wife?’
‘She went. Had to get home. I was waiting so long.’
Goldblatt smiled. ‘Sunday nights are bad.’
‘It’s all right, doc.’ The VIPoma looked down at the drip in his arm. ‘I feel better already. Can you just... Oh, can you get me a nurse? Quick!’
Goldblatt couldn’t find a nurse. He got him a bedpan and helped him on to it.
Goldblatt left the cubicle. It was after one in the morning now. The Emergency department was quieter. Some of the cubicles were vacant. The Rush was waning. Goldblatt found Steve and the HO sitting opposite each other across a desk in the doctors’ area, writing notes. Each of them still had one patient left to see. If no one else came in, and if the wards stayed quiet, there was even a chance they might get some sleep. The medical student who had been hanging around for most of the day had disappeared. Goldblatt sat down and wrote up his notes about the VIPoma. Only the blood results were missing. The potassium would probably be low as a result of the VIPoma’s diarrhoea. Goldblatt had included extra potassium on the intravenous orders, but more might have to be added. He told Steve about the patient, and Steve muttered something unhopeful about finding him a bed. Goldblatt told the HO to check the blood results and add more potassium to the VIPoma’s intravenous fluid if necessary. He wrote down the amounts she should add, depending on the blood result. The HO nodded, without looking up.
Goldblatt stood up. ‘Looks like you can handle it now,’ he said, glancing around the department.
Steve nodded.
Suddenly he was aware of his own tiredness. ‘Call me if you need me.’
‘I’m sure we’ll be OK,’ said Steve, reasserting the autonomy that made him such a great second-on-call for a registrar to work with.
Steve’s bleep went off. He called through to switchboard. ‘Medical SHO,’ he said. He waited. ‘This is the medical SHO,’ he said again, then listened for a long time. Goldblatt watched him. Suddenly the exhaustion and helplessness that Steve had managed to suppress when the Rush ended were visible again. His face collapsed. Even after all the years he had done it himself, Goldblatt still didn’t know how anyone coped with two consecutive nights on call.
He glanced at the HO. She was watching Steve anxiously.
‘OK, send him in,’ Steve said eventually in a toneless voice. ‘Let me just write down his name.’
Steve listened and wrote something on a piece of paper. He put the phone down and looked at the HO.
‘We’ve got a patient with end-stage alcoholic cirrhosis coming in. He’s got a depressed conscious state and a low BP. GP thinks he’s got pneumonia and he might be bleeding internally.’
‘Sounds like a mess,’ said Goldblatt.
The HO closed her eyes in despair. Her face screwed up until all that was left was her little button of a nose, and the glasses balancing in front of it, and her tousled red hair on top of it.
‘Call me if you need me.’ Goldblatt looked at the HO. ‘Make sure you get the results on that lumbar puncture and the potassium level on the man with the VIPoma.’
The HO’s eyes were still closed. She nodded.
Goldblatt left them.
He joined them again two hours later, the high-pitched ping ping ping of the cardiac arrest bleep ringing in his ears.
A big, pale mound of a belly was the first thing he registered as he ran into the room. And doctors and nurses all around it. Steve was pumping on a broad pink chest. The belly rolled and rippled with each of Steve’s compressions. Another doctor, presumably the anaesthetics SHO, was standing at the patient’s head, squeezing on a bag that was connected to a tube that had been put down his throat. The HO was trying to get blood from a groin. Goldblatt looked at the ECG monitor on the emergency trolley beside the bed, trying to assess the situation, still partly asleep after having been woken by the bleep three minutes before, clammy, disorientated, still breathless after running from his on-call room, his body still recalibrating from the shock of dashing out of the accommodation block into the freezing night air and then back inside.
The ECG was showing a dead flat line.
‘Have you shocked him?’ asked Goldblatt.
Steve shook his head.
‘Drugs?’
‘Adrenaline. Twice.’
‘Who is he?’ said Goldblatt as he made his way around Steve towards the patient’s head. ‘Anyone know anything about him?’
‘He’s the patient with a VIPoma you admitted before.’
Goldblatt looked down at his face. ‘What was his potassium?’ he asked as he pulled back on one of the VIPoma’s eyelids and shone a torch into his eye.
The pupil was dilated, but there was a flicker of contraction.
Goldblatt let go of the eyelid and put the torch back in his pocket. He looked around to find the HO staring at him. Frozen. Her needle was still stuck in the VIPoma’s groin.
‘What was the potassium?’ Goldblatt asked again.
‘I don’t know,’ the HO whispered.
‘Go and find out.’
The potassium was 1.6. Less than half the lower limit of normal.
They worked on the VIPoma. They poured drugs and potassium into him, and Goldblatt tried to shock his heart back into action with the electrified paddles of the defibrillator machine, progressively turning the power up and leaving big red rectangular burn marks on the VIPoma’s skin. Steve kept pumping on his chest until the sternum under his hand started to make a sickening, crunching sound with each compression. The HO stood there transfixed, watching. Eventually Goldblatt checked the VIPoma’s pupils again. Dilated and fixed.
‘OK,’ said Goldblatt. ‘That’s it. Stop.’
Steve stopped pumping and stepped back. The big pale belly lay still now, lifeless.
Goldblatt looked at the HO. ‘Do you want to call his wife?’
The HO stared at him.
‘No? Then I suppose I’ll have to do it.’