THIS WAS HOW IT happened. People didn’t realize it. When you listened to them, you just had to laugh. They missed the point. Long hours meant tired doctors, they’d say, and tired doctors made mistakes. They prescribed the wrong drugs, gave the wrong doses, made the wrong incisions – and people died.
No, tired doctors hardly ever made mistakes. No matter how tired you were, it was almost always possible to summon up enough brainpower for twenty seconds in order to check the name and dose of a drug. Your adrenaline would see to that. In his entire career, Goldblatt had seen only one serious mistake that he could attribute to simple fatigue, when one of his SHOs calculated the wrong rate for an insulin infusion at three in the morning. Even then, the monitoring regimen the SHO had scheduled ensured that the mistake was discovered before any harm ensued. The truth was different. Tired doctors didn’t make mistakes – tired doctors weren’t there. Doctors have discretion. That’s what people didn’t understand. They have discretion, and tired doctors use that discretion differently than fresh doctors.
Say you had a patient who’d been deteriorating through the night. In between seeing new emergencies in Casualty, you got him stabilized, and finally managed to get to bed at four a.m., desperate for sleep. You knew your bleeper might go off any second. On the other hand, you might just get three hours’ sleep before the full day of work that faced you. There weren’t going to be any concessions for what you’d been through overnight. Maybe a jokey ‘Two hours’ sleep, eh? Lucky you!’ from some consultant. No one cared. No one wanted to know. New day, new patients, new clinic, new life. Any sleep you got between now and then was precious. So you got to bed at four, and you had this sick patient who, you knew, should be assessed again in an hour or so. That’s what you’d do during the day – no question. After all, they taught you at medical school that you’re meant to identify problems early, not wait until they’ve had a chance to progress and develop their own complications.
So what were you going to do? Were you going to get up again in an hour and review the patient, or were you going to let the nursing staff call you if they thought he needed to be seen? If you were going to wait for a call from the nurses, were you going to give them explicit instructions about when you should be called, or were you going to leave it up to them to decide, knowing that most nurses, having been intimidated by doctors they’d woken in the past, wouldn’t call unless they judged the situation to be extreme? And if they did call you, would you get out of bed to assess the patient in person, or would you try to deal with it over the phone? And if you did go to assess the patient, and if you were an HO out of your depth, did you dare to wake a more senior colleague, or would you try to muddle through it tragicomically on your own?
Welcome to the grey realm of the doctor’s discretion. There were no right answers to these questions. Sometimes it was one, sometimes another, depending on the case. There were no rules here, no certainties. Only judgements. The chances were that no one would ever know anything about the decision you made except what you chose to write in the notes. And there weren’t any fixed standards by which to measure your decision anyway. No one was there, looking over your shoulder from the shadows of the darkened ward, when you made it. How could anyone else know how ill the patient really was when you saw him before you went to bed? How could anyone really know what your true assessment had been? No one would ever know but you.
It was all in the realm of discretion, guided by how exhausted you were, how frustrated you were, how desperate you were. Yes, people died because of tired doctors, and that was how.
But what could you do? A system that institutionalized exhaustion as a mode of operation just had to accept that sooner or later it would kill off its agents’ altruism. In its place would appear the survival strategies to which exhausted individuals resort.
Was this a good thing to do to medical practitioners? It was going to turn people who started off as carers into survivors. It was going to turn their patients into their adversaries. And at least a residue of this – so scarring, so indelible – was going to remain in the soul of each one even after the hard years were over.
But people didn’t understand – or refused to. ‘Fifty-six hours?’ they would say when Goldblatt told them. ‘That must be hard.’ No, not hard. Hard wasn’t the word for it. They didn’t have the word for it because they had never gone through it. If you have never worked more than eight or ten or fifteen or even twenty hours in a row you have no idea. You can’t understand the irresistible power of the urge to sleep, its necessity, after thirty, forty, fifty hours without it, and what you will do for just an hour’s respite. It’s not merely tiredness, but a deep dragging fatigue that eats you from the inside like a cornered beast, clawing and cleaning out your abdominal cavity as the demands come unstoppably, incessantly, uninterruptedly, until there’s nothing left inside you but the dumb, brute desire to survive. It’s one of those experiences you can’t understand unless you’ve been through it, like being a soldier under fire.
And it wasn’t just once. It was the steady grind of the nights, every third or fourth night, and every third or fourth day after, pretending still to be alive while you walked around the hospital. It was week after week, month after month, year after year. ‘But you get some sleep, don’t you?’ people would ask, and how could they know what it was finally to lie down in a strange little bed in a strange little room at three or four or five in the morning with a bleeper lying beside your head, knowing that the sleep wasn’t yours, it was borrowed, and that all over the hospital there were a hundred hands hovering over a hundred phones just waiting for oblivion to descend on you so they could dial your number and bring you sharply and sickeningly back to consciousness. You didn’t understand it yourself until you had been woken five minutes after collapsing in exhaustion and found yourself half-running, half-stumbling in a cold sweat out into cold or rain or even snow, and then through corridors to a ward where you found yourself pumping on an arrested heart and wiping away the slime of blood, mucus, and vomit coming out of the orifices of a person already dead. Then you understood. And there was nothing unusual about this, or heroic, or exciting, or even interesting. It just happened, over and over and over and over and over.
And now there was one more tombstone to be added to the tally. Because a doctor who had been a doctor for all of three weeks, burning in the flaming crucible of her first weekend on call, undergoing an intensity of exhaustion that she had never in her life experienced before, used her discretion to delay checking a test result. One result among literally hundreds that she had screened that day.
Without even knowing it, the HO had been using her discretion all night. And all of the night before. She had missed other results as well. But as it happened, those didn’t matter. And there were lots of results that she had checked which didn’t matter either. In fact, of all the results of all the tests she had to check over the course of that long day, this was the only one that would have made a meaningful difference to the treatment of any of her patients. Funny. This was the only one she really needed to know.
Bad luck. What are the odds?
Goldblatt rang the VIPoma’s wife. The HO sat nearby at the nurses’ station, watching silently, listening as he gave the news. He stood up. ‘Come on,’ he said, and left the ward. The HO followed him.
They were on the seventh floor, across the lobby from their own ward. They walked past the lifts and through the doors. They didn’t need to go there, but they went instinctively. Like going to their own territory.
The ward was dark. A patient was coughing somewhere. A couple of nurses were sitting in the subdued light of the nurses’ station. Another nurse walked down the corridor and turned into one of the rooms, carrying an injection tray.
A ward at night. Lights glowing behind screens, the sound of people sleeping, nurses murmuring, your own footsteps on the lino as you go about your work.
They went to the doctors’ office.
‘Have you been to bed?’ Goldblatt asked.
The HO perched on the edge of one of the desks in the office. She shook her head.
‘Did you get the lumbar puncture result?’
The HO nodded. She dug around in the pockets of her white coat, pulled out a piece of paper, unfolded it, and examined it. She threw it down on the desk. She pulled out another piece of paper, looked at it, and threw it down. She dug around in the pocket. More pieces of paper came out.
‘Have you thought of getting a notebook?’ asked Goldblatt.
She went on digging. Finally she found the one she wanted.
‘No organisms,’ she read. ‘Four white cells. Three hundred red cells.’
‘Good,’ said Goldblatt.
The HO didn’t look pleased. She looked crushed. She looked pulverized. She looked like a piece of pale, red-headed skin that had once had a human being inside it.
Goldblatt watched her. The HO was waiting for him to say it, he knew.
‘You didn’t check the potassium.’
‘I...’ the HO shook her head helplessly.
‘You forgot.’
‘I didn’t forget. I just didn’t... I was going to check it. I was going to! But things kept coming up. They kept ringing me. Drips and blood cultures and people with chest pain and sleeping tablets. I didn’t get around to it. I never got time to sit down at a computer.’
‘It’s not good enough,’ said Goldblatt.
‘I know it’s not good enough. But they should have rung me. They should have rung me! They’re meant to do that. They should have rung me with a result that was so low.’
‘True,’ said Goldblatt. ‘Are you sure they didn’t?’
‘I would have got the fucking result!’
‘Are you sure you answered all your bleeps?’
The HO stared at him. She had that frozen look on her face again, the one she had had when Goldblatt had shone the torch in the VIPoma’s eyes and asked what his potassium was.
‘Listen,’ said Goldblatt quietly. ‘Tests are dangerous. They give you a false sense of security. They make you think you’ve done something. A test isn’t worth anything until you know the result and you’ve acted on it. You have to get the result. You can’t rely on anyone to make sure you’re informed of it. It’s your responsibility. You have to check it yourself.’
‘What will they do to me? What’s going to happen, Malcolm?’
‘To you?’
The HO nodded.
‘Well,’ said Goldblatt. ‘I’m going to have to report you, of course. I’ll have to say that you forgot to check the potassium result despite my explicit instructions, and therefore the patient died.’
The HO stared at Goldblatt again. Her eyes were wide. They weren’t just wide, they were two enormous, pupil-pierced balls staring at him in naked terror.
Goldblatt shook his head wearily. ‘Nothing’s going to happen to you.’
‘But I just killed someone!’
‘I don’t know if I’d shout about it if I were you.’ Goldblatt paused. ‘Look, you didn’t kill him. He had a malignancy, didn’t he? And he had heart disease. Hadn’t he had an infarct in the past? It was waiting to happen. You just... helped.’
‘Malcolm, they’ll strike me off!’
‘They can’t strike you off. You’re a House Officer. They haven’t struck you on yet.’
The HO didn’t look reassured.
Goldblatt sighed. ‘Nothing will happen to you. The patient died of a cardiac arrest secondary to coronary vessel disease and hypokalemia, which was secondary to his underlying malignancy. He wouldn’t have had the hypokalemia at all if his GP hadn’t sat on him all weekend. Nothing’s going to happen to you.’
‘But we didn’t treat his hypokalemia!’
‘We did – but not vigorously enough.’
‘What about Steve. What will Steve say?’
‘I’ll talk to Steve.’
The HO frowned. Goldblatt watched her. The HO’s lips were compressed in concentration. She glanced at him furtively.
He could report her. He had given the orders. He had written them in the notes before he left the Casualty department. He had written ‘HO to check K urgently.’ He had even written the doses of potassium to be added to the VIPoma’s fluids if the levels were found to be low. And he had told her as well. Verbally. Twice. But the HO hadn’t done it. None of it.
But what good would it do? He would be reporting the wrong thing. He would be reporting the symptom and letting the disease walk scot-free. As a doctor, that was something he had been trained never to do. Right?
‘I’ll talk to Steve,’ he repeated. ‘Now, what are you going to do?’
The HO gazed at him, uncomprehendingly.
‘This isn’t trivial,’ said Goldblatt. ‘A man has died. I’ve just had to wake his wife to tell her. Learn! Learn from this. For God’s sake, tell me you’ve learned something from this.’
‘Of course I’ve learned something!’
‘Well, don’t forget it. That’s what matters now. Remember this for the rest of your life. Teach it to others. Do that, at least, and that man’s death won’t be entirely in vain.’
The HO frowned.
Goldblatt sighed. ‘If we got rid of every doctor who killed someone when they were a house officer, we’d have no one left. Everyone kills someone. You’re lucky if it’s just one.’
The HO looked at him. ‘What about you?’
‘What about me?’
‘Did you kill someone?’
Goldblatt gazed at her earnestly. ‘What do you think?’
‘When?’
Goldblatt took a deep breath. ‘There are some questions you don’t ask.’
The HO let her head drop back against the wall. She closed her eyes and took her glasses off. There were deep red marks on her nose from her glasses, and black bags under her eyes.
‘Have you still got a lot of stuff to do?’ asked Goldblatt.
The HO nodded. ‘That patient with the end-stage cirrhosis they rang Steve about still hasn’t got here.’ She took a deep breath and let it out slowly.
Her bleep went off. She picked up the phone and dialled.
Goldblatt watched her as she listened to whatever was being said to her.
Suddenly she said ‘Yes!’ and clenched her fist at her side.
Goldblatt raised an eyebrow. It wasn’t exactly punching the air, but it was close.
‘What was that?’ he asked, when she put the phone down.
‘That was Steve. The guy with the cirrhosis won’t be coming in after all. He—’
The HO stopped.
‘Died?’ said Goldblatt.
‘In the ambulance,’ she whispered.
Goldblatt nodded.
The HO stared at him. Slowly, she unfolded the fingers of her clenched fist. Her eyes were wide, uncertain, scared, shocked.
She was lost, her markers were gone. Was she sinking into corruption, or climbing out of naivety? She found herself in a new landscape, and she wanted someone to tell her what was right and what was wrong, which way was up and which way down, but she didn’t know who she could trust to tell her. Goldblatt? Something in her, perhaps just the lack of any other guide, made her want to follow him. But how could she know that Goldblatt wouldn’t lead her further into confusion, that it wasn’t because of him that she found herself here in the first place?
Goldblatt watched the HO pupating, tearing blindly at the cocoon of innocence that enshrouded her. There was only so much he could do. She had to do the rest herself.
Suddenly he felt very protective towards this slight, small person who had been given to him as his HO, with her square face and her pinched nostrils and her glasses that were always slipping halfway down her nose.
‘Listen,’ he said quietly, ‘I know I must seem like a cynical old crate to you...’
‘No, you don’t,’ said the HO.
‘Don’t I?’ asked Goldblatt, genuinely surprised.
‘You seem... I don’t know what to make of you, Malcolm. Sometimes you’re really kind... and sometimes you seem angry. Under the jokes, I mean.’
‘Are they that transparent?’
‘Only the bad ones.’
Goldblatt shrugged. Fair enough.
‘I’m not angry with you,’ he said.
‘I know you’re not. I don’t know why, but you’re not.’
Goldblatt frowned. Heart-to-hearts with colleagues at four o’clock in the doctors’ office were never a good idea. You were all too likely to say what you actually felt. About all kinds of things.
‘Well, I just wanted to say... I know it’s tough being a house officer. Even if I don’t seem to sometimes. I know what you’re going through.’
The HO nodded.
‘And if you ever need to...’ Goldblatt looked at her. He shrugged. ‘You know... talk or whatever. I’m here.’
‘Thanks,’ said the HO.
Goldblatt nodded. ‘I mean it. Don’t hesitate.’
‘Malcolm?’
‘What?’
‘You won’t tell Ludo, will you?’
‘About the man with the VIPoma?’
‘No. I mean yes, about him, but also about that... Just now.’
Goldblatt smiled. ‘No, I won’t tell Ludo.’
‘I’ll never hear the end of it, Malcolm. Honestly. Please.’
‘I won’t tell her. But remember what I told you that time in the cafeteria. Don’t blame yourself.’
The HO watched him.
‘Now do what you have to do and try to get to bed,’ he said, and he left to go back to his own on-call room.
He didn’t see the HO again until nine o’clock, when he came back up to the ward to start the day’s work with the morning round. Another medical team was starting their round on the ward as well. The HO was in the doctors’ office.
‘How was the rest of the night?’ he asked.
The HO shrugged. ‘OK.’
There was a silence between them then. It was a little awkward. But only a little.
Goldblatt opened the admissions book and counted up the cancellations he would be making. They heard footsteps outside. Ludo walked in. She observed the HO’s bedraggled appearance with satisfaction.
‘You were on this weekend, weren’t you?’ she said. ‘How many patients did you admit?’
The HO unfolded one of her crumpled pieces of paper and counted the names. ‘Thirty-two.’
‘Thirty-two!’ retorted Ludo contemptuously, hanging up her coat. Her woollen skirt strained over her behind. ‘You’re lucky. My record’s forty-six.’
Goldblatt looked at the HO to see how she was going to respond.
‘Thirty-two’s enough!’ said the HO stoutly.
Goldblatt nodded to himself in approval.
Ludo sat down. She turned to Goldblatt. ‘I had a terrible weekend.’
‘Really?’ asked Goldblatt.
‘You know I was moving into that new flat? My flatmate! Malcolm, she’s a nightmare. Just listen to this...’
A new week was beginning. All was as it should be on the ward on the seventh floor. Rounds were starting. Ludo was whining. Cancellations were waiting.
Goldblatt glanced at the HO.
The HO stared at her piece of paper, thinking.