HE PUSHED OPEN THE swinging plastic doors of the Casualty department. Immediately, Goldblatt glimpsed an incredibly ill-looking woman lying in the fourth cubicle from the entrance. He looked away. But by then it was too late, because of the infallible Law of the Glimpse, which states that any patient you glimpse out of the corner of your eye and wish you hadn’t glimpsed is inevitably... your patient.
Nonetheless, being by nature doomed to rebel against the immutable laws that governed his existence, Goldblatt didn’t go straight over to her. He stopped a passing nurse and told her who he was and asked where he could find the patient he had been called about. The nurse glanced at a whiteboard covered in the secret symbols of nursing code, looked back at him, and said: ‘Over there. Her name’s Sandra Hill.’ And she pointed, just in case there was any remaining doubt, straight at cubicle four.
There’s a look people have when they’re really, really ill – not merely off colour, or in pain, but marrow-sappingly, heart-stoppingly, breath-strugglingly, just-let-me-die-in-peacely ill. Even from the other side of the department, Sandra Hill had that look. She was easily the sickest human being in a Casualty department that was otherwise populated by old ladies with broken wrists and people wheezing with acute asthma and big men grimacing with acute gallbladder pain.
She lay with her eyes closed and her lips pursed under an oxygen mask, and her whole frail, emaciated face focused on the effort of sucking in air.
Through some miracle of efficiency that must have been a mistake, her medical notes had already turned up. Goldblatt glanced through them. Sandra Hill was one of the rare cases in which Fuertler’s turns into severe fibrosis of the lungs, laying down dense, tough tissue over the delicate membrane that lets molecules of gas waft in and out of the bloodstream, and obliterating tier upon tier of those tiny cavities where the wafting is meant to take place. According to the notes, she had had all the treatments Tom de Witte could throw at her.
Goldblatt closed the notes and went over to her.
Her eyes were still shut as she drew breaths under the oxygen mask. She was a thin black woman of about forty with the blotchy skin of Fuertler’s Syndrome. Some of her skin was thickened and puckered, and some was thinned and de-pigmented, like fallen white leaves stuck on her wrists and neck.
Goldblatt glanced at the gauge on the wall to check the concentration of oxygen flowing into the mask. Sixty per cent. Even at that concentration she was breathing in and out continuously, the muscles in her neck straining to contribute to the leverage on her ribcage. In physiology lectures at medical school, Goldblatt had been taught that the total surface area of a pair of average human lungs, if you could unravel and smooth out the microscopically thin and bulb-like membranes within them, is the size of a tennis court. That’s the absorptive surface the human organism needs in its chest to trade its carbon dioxide for oxygen at an adequate rate to breathe easily, with some to spare. Sandra Hill didn’t have a tennis court of absorptive membrane left inside her chest. She didn’t have a badminton court. Or even a squash court. He guessed that maybe she had a table tennis table.
Goldblatt closed the curtain behind him and stood beside her at the head of the trolley.
‘Hello,’ he said.
She opened her eyes.
‘I’m Dr Goldblatt, Professor Small’s registrar.’
She nodded.
‘Is your breathing always this bad?’
‘Worse... recently,’ she whispered.
‘Over how long has it been getting worse? Days? Weeks?’
‘Days.’ She paused, sucking in a couple of breaths, then shrugged slightly. ‘Weeks.’
‘You didn’t think it might have been a good idea to come in earlier?’
She gave another slight shrug, almost lost in the effort of her breathing. ‘Don’t like... hospitals,’ she whispered, and then she laughed, more with her eyes than her mouth.
Goldblatt liked her at once. It took spirit to laugh in her situation. He didn’t know if he would have been able to do it.
He proceeded to take a history from her. She gave short answers. He kept to the bare minimum and tried to ask Yes/No questions. Not exactly the open-ended interviews the textbooks recommend, but life isn’t always like a textbook. He examined her. She managed to sit up for a minute or two for him to listen to her chest.
When he had finished, Goldblatt put his stethoscope back around his neck. ‘Don’t worry, Sandra,’ he said, ‘we’ll sort you out.’
From behind her mask, Sandra looked at him with an expression he found difficult to decipher, perhaps accusing him of lying, or thanking him for lying, or ignoring the fact that he was lying in the face of what she knew was finally happening to her after all these years with Fuertler’s fibrosis of the lungs. Goldblatt didn’t know which. But he could see that she knew the truth. She smiled, as if to show that she knew it, and was far beyond caring.
She smiled again later, when Goldblatt punctured her lung.
Sandra was dehydrated, and her chest X-ray showed pneumonia on top of her underlying lung devastation. She needed intravenous fluids and antibiotics. By five o’clock she had arrived on the ward, and the HO came along to put in a drip, bringing with her a third-year medical student who had taken it into his head to attach himself to her for the afternoon. The HO poked four needles into various places in Sandra’s Fuertlerized skin, more in hope than in any real expectation of hitting a vein, and gave up. She called Goldblatt. Goldblatt examined Sandra’s arms, swapping the tourniquet from right to left and back again, and couldn’t see, feel or even imagine there was a vein he could hit.
‘They always have... trouble,’ Sandra said.
Goldblatt looked at her feet and tightened the tourniquet around her shin like a garter. There was a vein there, on the back of her foot, no thicker than a matchstick, and, once you stuck a cannula into it, it was likely to blow in a matter of hours.
Goldblatt unsnapped the tourniquet. ‘Let’s put in a central line,’ he said to the HO. He looked at Sandra. ‘Have you had a central line in before?’
Sandra nodded ruefully.
‘Neck or chest?’
‘Both,’ she whispered.
Goldblatt smiled. ‘So you know what it’ll be like?’
Sandra nodded.
A central line is a cannula that goes directly into one of the large veins of the chest or neck, and the technique for putting one in is straightforward, so straightforward that the HO clamoured to do it, and Goldblatt almost let her until she admitted, while they were loading the equipment on a trolley, that she had never done one and had seen it only twice, both times from the back of a pack of students in Emergency. Goldblatt told her to get a little closer this time and watch carefully. The medical student, who looked as if he wasn’t used to being around sick people, stared at Goldblatt with wide eyes. ‘You should come and watch as well,’ Goldblatt said to him before they went back to wheel Sandra’s bed into the treatment room.
There wasn’t a nurse free to help, apart from the one who strolled in about halfway through the procedure because she wanted to watch, so at the start it was Goldblatt and the HO and the medical student, who was apparently called Tim. Goldblatt opened a sterilized pack containing the equipment he needed and laid it out on a trolley, then washed his hands and put on a pair of gloves, instructing the HO and Tim to take Sandra’s pillows away and tilt the bed head-down in the position required for the procedure. Then the HO arranged Sandra’s nightie, baring the right side of her neck and upper chest.
Goldblatt swabbed Sandra’s skin with cotton wool soaked in iodine. The light above the bed was hot and yellow, and the iodine ran down the side of her neck, staining the sheet, and collected in a murky brown pool in the V of her throat. Goldblatt wiped it away.
The HO snapped open two ampoules of local anaesthetic, and Goldblatt drew the local up and then injected it under Sandra’s collarbone, ending with a fat bleb beneath the skin. Then right through the middle of the bleb he slid in a large-bore needle connected to an empty syringe, letting the needle ride under the lower surface of the collarbone, and drawing back on the plunger as he went so he’d know when he’d hit the subclavian vein. He talked to Sandra as he did it.
Sandra winced as he changed the angle of the needle and searched for the vein. He elevated the butt of the needle slightly to increase the angle of penetration, explaining the anatomical landmarks to Tim and the HO. The HO was standing on the other side of the bed, with her hand on Sandra’s wrist.
Sandra closed her eyes.
Suddenly a rush of dark blood flooded into the syringe.
‘The needle’s in, Sandra. That’s the worst bit.’
He detached the blood-filled syringe, using his gloved thumb to stopper the hub of the needle that was still embedded in Sandra’s chest, and handed it to the HO, who turned away to squirt the blood into a series of tubes for lab tests. With his free hand Goldblatt picked up a flexible metal guide wire that was about two feet long, taking care not to desterilize it as it waved drunkenly in his hand. He removed his thumb from the hub of the needle, inserted the end of the guide wire through the blood that began to drip as soon as he unstoppered it, and began to feed the wire down the hollow needle. Once it was two thirds of the way in he would pull out the needle, leaving the guide wire in place. Then he would slide the plastic cannula over the guide wire into the vein. Finally he would extract the wire out of the end of the cannula, leaving only the soft plastic tube in position, with its tip sited inside the superior vena cava. That was the objective of the whole procedure.
The guide wire stopped about halfway in.
Goldblatt pushed cautiously. There was resistance. That usually meant the guide wire had started going up towards the neck. Not uncommon. When the guide wire reaches the point where the jugular vein meets the subclavian, it can either go up towards the neck, or down to the chest, which is the desired direction.
Sandra writhed a little, twisting her neck.
‘Is it hurting you, Sandra?’ asked Goldblatt, pulling back on the guide wire. He rotated it between the blood-stained rubber of the glove ensheathing his fingers to see if that would make it go down towards her chest when he pushed it further in again.
Sandra didn’t say anything. She took deep breaths on the oxygen that was streaming over her face.
‘Tell us if it hurts,’ said the HO.
Goldblatt gently pushed the wire further in. It went another couple of centimetres and got stuck once more. Goldblatt was starting to feel hot under the light. He was starting to sweat. He pulled back on the wire and twirled it again, then pushed it in, feeling for the resistance to give way.
Sandra moaned. She let go of her oxygen mask and her fingers searched for the HO’s hand.
Goldblatt drew back a little on the wire and held it still. He looked over at Sandra’s face.
‘What is it, Sandra?’
Sandra shook her head from side to side.
‘Sandra, keep your head still.’
‘Sick,’ she murmured, shaking her head.
Goldblatt watched her.
Sandra was lying with her head tilted down for the procedure. Not a good position if you’re going to vomit. Things coming up from people’s stomachs have a tendency of running down into their lungs when they’re head-down on their backs.
Sandra gasped. Runny yellow fluid came out of her mouth and nostrils and bubbled in the stream of oxygen inside her mask.
‘Get her up!’ cried Goldblatt, and with one gloved hand pressing down over the needle and wire, he threw his other arm behind Sandra’s back and in a single movement dragged her up before the HO had even got a hand behind her from the other side. Sandra was coughing and gasping and the vomit poured out of her mouth and coated the inside of her mask. Goldblatt pulled her mask off and the thin acid fluid ran down her chin and on to her nightie, staining it yellow-green.
Goldblatt noticed something on the bed beside Sandra. The needle had come out. He looked under his hand and found that only the last couple of centimetres of the wire remained in Sandra’s skin. The rest of it now was non-sterile and couldn’t be reinserted. He had no choice but to pull it out, then press hard with his thumb on the puncture site under Sandra’s collarbone. He grabbed a piece of gauze off the trolley and then pressed with that. The centre of the gauze turned red.
Sandra had stopped vomiting. She was sucking in air as fast and as deep as she could. Goldblatt asked the nurse to get another mask, and when she brought it they connected it to the oxygen. In the meantime he and the HO had raised the head of the bed and packed the pillows up behind Sandra’s back. They cleaned the blood and vomit off her chest, and Goldblatt stuck down a fresh piece of gauze over the puncture wound under her collarbone. After a few minutes Sandra was breathing a little more easily. The HO looked at Goldblatt.
‘Go and organize a chest film,’ he said.
The HO left. Goldblatt picked up his stethoscope and listened. Wherever he placed the stethoscope, he heard the dry, papery crackles of lung fibrosis, which he had heard when he examined her earlier. He didn’t hear anything new, no sloshing of fluid as Sandra breathed in and out. But that was a coarse sign, and its absence didn’t mean that she hadn’t aspirated any of her vomit in the few seconds that she had been head-down on the bed.
‘It’s OK,’ said Goldblatt.
Sandra nodded.
Goldblatt turned around. The medical student was still there. Goldblatt had forgotten about him. He hadn’t said a word.
‘Ever seen a case of pulmonary fibrosis?’ Goldblatt asked.
Tim shook his head silently.
Goldblatt looked questioningly at Sandra. She nodded.
‘Come on,’ said Goldblatt. He held the diaphragm of his stethoscope against Sandra’s skin and offered the earpieces to Tim. ‘Listen. You’ll hear crackles. Very dry, like paper rustling.’ He waited as Tim listened through his stethoscope. ‘Hear it? Those dry crackles? A bit like tissue paper? That’s pulmonary fibrosis. Remember it. You’ll never hear a better example.’
They wheeled Sandra out of the treatment room and back on to the ward. Goldblatt listened to her lungs again. He made sure she was comfortable. Then he went out to the nurses’ station to wait for the radiologist. Tim sat down as well.
There was a copy of some kind of women’s magazine on the desk of the nurses’ station, and Goldblatt picked it up and leafed through it as he waited. Ads for women’s underwear. Who let nurses bring this kind of pornography into hospitals? And what was wrong with women, anyway? Why were their ads for underwear so sexy? Surely they didn’t enjoy looking at this stuff. This was stuff for men. Men enjoyed looking at this stuff. Goldblatt could vouch for that.
He could sense Tim glancing surreptitiously at him. He looked around. ‘What?’
‘Dr Goldblatt,’ said Tim, in the hushed tone that third-year medical students use when addressing a personage as exalted as a registrar, ‘was that... all right?’
‘Was what all right?’
‘That.’
‘That?’ asked Goldblatt.
Tim nodded.
‘What do you think?’
Tim glanced away nervously. Then he looked back at Goldblatt, trying to guess what he was thinking. ‘Yes?’ he said.
‘You really think that was all right?’ asked Goldblatt. ‘She was vomiting in her mask, for Christ’s sake.’
‘So it wasn’t all right?’ asked Tim.
‘It depends,’ said Goldblatt. ‘It was all right if I was trying to make her vomit. It was all right if I wanted to add an aspiration pneumonia to the bacterial pneumonia she already has.’
The whirring noise of the portable X-ray machine was coming up the corridor. A moment later it appeared around the corner, pushed by the radiographer, a red-haired woman with an ample figure in a white uniform. Goldblatt pointed towards Sandra’s bed.
‘Dr Goldblatt?’
Goldblatt looked around. Tim was still there.
‘You weren’t trying to make her vomit, were you?’
‘No,’ said Goldblatt. ‘I wasn’t trying to make her vomit.’
‘Because you could have been,’ said Tim, trying to show that he wasn’t just another dumb medical student. ‘If she had come in with an overdose or something.’
‘True,’ said Goldblatt. ‘But it wouldn’t be a very good way of making her vomit. There are better ways. Try Ipecac. That’s good. Or a stomach washout. That’s good, but messy. Just remember one thing. If you want to make someone vomit, don’t lie them head-down.’
‘All right,’ said Tim seriously. ‘I won’t lie them head-down.’
‘And another thing. You didn’t really think that was all right, did you?’
Tim looked at him guiltily.
‘You only said that because I’m a registrar.’
The guilty look got guiltier.
‘Here’s a rule. Never ever let anyone’s ranking in the hierarchy...’ Goldblatt stopped. He was sick of making up rules. To judge by the way his career was going, they were all wrong. This one more than any of the others.
‘Never let anyone’s ranking in the hierarchy what, Dr Goldblatt?’
‘Nothing. Figure it out. Think of it as a test: complete the sentence. Give me the answer next time you see me.’
Tim nodded, a look of determination in his eye. He pulled a notepad out of the pocket of his white coat and wrote down the words.
The radiographer left the ward with her machine and they waited for her to come back with the X-ray.
‘Interesting,’ she said when she returned, handing the film to Goldblatt.
‘Interesting?’ said Goldblatt, his heart sinking. ‘Is that “interesting” as in “I’m really bored tonight and even a normal chest X-ray is interesting?” Or is it “interesting” as in “I hope you live in interesting times”?’
‘“Interesting” as in “It’s interesting that this patient has a pneumothorax.”’
‘A pneumothorax?’ repeated Goldblatt mechanically.
‘I’ve got two films to take in ITU,’ she said by way of reply. ‘Give me a call when you want me to come back.’
Goldblatt watched her go. Patients with poor pulmonary function don’t thank you for giving them a pneumothorax. Some of them die just to show what they think of you.
He flicked the switch on the viewing box behind him and its white light blinked into life. He put the film up and got the one that had been taken earlier in Emergency and put it up beside the new one for comparison. He stared at them grimly. They both had the wispy, reticular pattern of lung fibrosis. There was nothing new to be seen in the lower lobe of the right lung, which is where aspirated vomit usually ends up. But something else was different. A perfectly clear rim had appeared around the edge of Sandra’s right lung on the later film. It was no wider than a centimetre on the film, except where it expanded to a small cap on the top. Not a single lung marking crossed this space. It was a pneumothorax, a pocket of air trapped between the two pleural membranes that separate the lung from the chest wall, and there was only one place that air could have come from. A hole that Goldblatt had put in Sandra’s lung. He must have nicked the top of it as he was searching for her vein with the needle.
‘What’s this?’ asked the HO, who had just come back.
‘A pneumothorax,’ said Tim. As if he knew.
The HO reached up and ran a finger down the clear crescent at the edge of the lung. ‘Is this it?’
Goldblatt nodded.
‘Wow! I’ve never seen one of those before.’
The HO had never seen anything before. Goldblatt didn’t see why she had to make such a big thing out of one little pneumothorax.
‘Neither have I,’ said Tim.
‘What?’ said a nurse, who had stopped behind them to see what was going on.
‘Pneumothorax,’ said the HO, pointing to the film. ‘See the edge of the lung?’
‘Wow!’ said the nurse.
Ludo walked past. Ludo? After five o’clock? The evening was going from difficult to surreal.
‘Malcolm just gave Sandra Hill a pneumothorax,’ said the HO.
‘Oh, Malcolm,’ said Ludo reprovingly, and clicked her tongue. ‘Who’s Sandra Hill, one of the Prof’s specials?’
‘No, she isn’t one of the Prof’s specials,’ Goldblatt retorted through clenched teeth. ‘And what difference would it make if she was?’
Ludo looked at Goldblatt haughtily. ‘Don’t take it out on me, Malcolm. I’m not the one who gave her a pneumothorax.’
‘She’s a Fuertler’s patient who’s come in with end-stage pulmonary fibrosis,’ Goldblatt said gruffly. ‘All right? I just gave her a pneumothorax trying to put in a central line.’
‘Where’s the cannula?’ asked Ludo, looking for the thin curve of the plastic tube, which is always made out of radio-opaque material so as to be visible on X-ray.
‘I didn’t get it in,’ said Goldblatt.
‘You didn’t get it in and you still gave her a pneumothorax?’
Goldblatt nodded. ‘Thanks.’
‘What are you going to do?’
Goldblatt gazed at the film and frowned. ‘I’m not sure.’
‘We could hand it over to the on-call team,’ suggested the HO, glancing at her watch.
Goldblatt stared at the HO. That wasn’t funny, even as a joke. If the HO was going to start drawing lines, she had better learn where she was allowed to draw them.
‘We stay till it’s sorted,’ he growled. ‘It’s our responsibility. Mine, anyway. I gave her the pneumothorax so I stay to deal with it. You can go.’
The HO stayed.
Goldblatt looked back at the X-ray. ‘Ludo,’ he said, half-heartedly launching a Teaching Attack, ‘give me the causes of pneumothorax.’
There was no answer. He turned around. Ludo was gone. For a moment he wondered whether she had ever been there, or if it had been some horrible, mocking apparition emanating from the culpability in his own mind.
The HO and Tim were still watching him.
He went back to Sandra Hill’s bed. Her breathing didn’t look any more laboured than when he had first seen her. Maybe it couldn’t get more laboured. Goldblatt asked her if he could listen to her chest again, and then stuck the ends of his stethoscope in his ears.
Pneumothoraces are things you hear by not hearing them, by the abnormally low volume of the breath sounds. The layer of air between the chest wall and the lung muffles the noise. He hadn’t picked it up before. It must have been small, as it appeared on the film. Even knowing it was there, he still couldn’t definitely discern it when he listened.
Sandra looked at him knowingly, waiting to hear whatever it was that he was obviously going to tell her.
‘Sandra, there’s a problem.’
Sandra shook her head expectantly, looking at him.
‘You’ve got a pneumothorax.’
Sandra frowned.
‘I punctured your lung.’
Her eyebrows rose.
‘I’m sorry, Sandra. It does happen sometimes when you put in a central line. It’s one of the risks. Looks like it happened just now.’
She nodded.
‘There’s some air around your lung now. It’s not a disaster, but it won’t help your breathing. How do you feel? Is your breathing any worse?’
‘The same,’ said Sandra. ‘Don’t tell me... can it... get worse?’
‘We’ll have to get the air out.’
She shrugged with resignation.
‘I’m sorry, Sandra. You’re really getting your money’s worth tonight.’
Sandra smiled.
‘Get some arterial blood gases,’ Goldblatt said to the HO. He turned back to Sandra. ‘I’ll be back soon.’
Goldblatt went out and stood in front of the X-ray again. He shook his head. He had never managed to give anyone a pneumothorax while putting in a central line, even though it was a recognized risk of the procedure. And of course he just had to go and do it now to someone with zero lung reserve. Less than zero.
He estimated that the area of empty space on the film occupied well under twenty per cent of the right lung field. The teaching was that you could treat a pneumothorax of that size by simply inserting a needle and aspirating the air, leaving any remaining gas to be absorbed. But not in a person with significant underlying lung disease. A person with underlying lung disease needs the works, a big chest tube introduced between the ribs and connected to a water seal for two or three days to empty out every last bit of air and keep it out. And if there was one thing that Sandra Hill had, it was underlying lung disease, as the X-ray in front of him showed.
Goldblatt sat down at the nurses’ station. The HO came out from behind the screens, waved a tube of blood packed in ice at him, and rushed away.
He didn’t want to put a chest tube in. It’s a horrible, traumatic thing to do to a person, involving an introducer as long as a skewer and as thick as your little finger that you force through the layers of muscle between the ribs. He had a bad feeling about putting one into Sandra Hill. It felt like the trigger for a sequence that could only end in tears. As mighty oaks from small acorns grow, so medical catastrophes from small complications begin. The patient who comes in for the elective hernia operation gets a local wound infection, which sets off his subclinical diabetes, which dehydrates him, which throws his kidneys into acute renal failure, which puts him into the intensive care unit, which is where he gets the antibiotic-resistant pneumonia, which is the last straw for his atherosclerotic heart, which has the cardiac arrest that kills him. Something would happen when he put the tube into Sandra’s chest. He’d hit an intercostal artery. Or the tube would block. Or it would get infected. Something. It was just a bad, bad feeling that he had about this chest tube. Irrational, he knew that. He probably just didn’t want to put Sandra through the muscle-splitting pain of the procedure. He wanted to slip a nice thin needle over a rib, suck out the air, pull the needle out, and leave her alone.
On the other hand, if she really needed the chest tube, it would be settling for the nice quick needle that would trigger the sequence of catastrophe.
‘Dr Goldblatt?’
Goldblatt looked up. Tim was sitting next to him again.
‘Giving her a pneumothorax... that wasn’t all right, was it?’
Fast learner! ‘No,’ said Goldblatt. ‘It wasn’t.’
‘Does that happen very often when you put in a central line?’
‘Pneumothorax? That’s my first.’
Tim looked at him doubtfully.
‘You don’t believe me.’
‘No, Dr Goldblatt. I do!’
‘Don’t. Never believe people who say things like that.’
Tim looked puzzled for a minute. ‘It is your first, isn’t it?’
‘Yes,’ said Goldblatt.
Tim smiled. For some reason, that seemed to make him very happy. He opened the magazine and began to look at the lingerie ads that Goldblatt had been looking at earlier.
Suddenly Goldblatt made a decision. Arbitrary, spontaneous, definitive. The best sort. When the HO came back with the arterial blood gas results, if Sandra’s arterial oxygen came in over nine, he’d aspirate the pneumothorax with a needle. If it came in under nine, he’d go for the tube.
And if it was nine exactly?
Fuck it, he thought, I’ll go for the needle.
The HO came back.
‘Well?’ said Goldblatt.
She handed him the printout. Nine point three.
Goldblatt got up. ‘Have you ever seen anyone aspirate a pneumothorax?’
The HO saw him do it. So did Tim. Goldblatt put a sweet little 16-guage needle in over the top of Sandra’s third rib, sucked out about a hundred millilitres of air, and pulled the needle out. It took less than a minute, Sandra hardly felt it, and then it was over. Then he sent the HO off to organize another X-ray. Half an hour later the X-ray came back. The pneumothorax looked a lot smaller. When he compared it with the previous film, he didn’t even have to talk himself into believing that it was.
In the meantime he had sited a drip in the one remaining vein in Sandra’s foot, hoping that it would last overnight. The HO wrote up fluids and antibiotics, while he wrote an extended account of his numerous puncturings of Sandra Hill in the notes. The HO sat beside him and watched with a gratified look while he finished. It was after seven, but this was one night she didn’t mind staying back. One of the few things that makes life as an HO worth living: watching your registrar sweat.
The HO left. The vein in Sandra’s foot still worried Goldblatt. She’d be lucky if it lasted until morning. Tomorrow, he’d get one of the anaesthetics SRs to put a central line in. But it still bugged him. He could just imagine what would happen if that vein packed up overnight. First the on-call HO, then the SHO, then the reg would come along one after the other to try to resite it. She could easily have ten or fifteen needles shoved into her arms and feet, probing for veins that weren’t there. He wasn’t going to let that happen. He called the on-call anaesthetics reg and told him about Sandra and asked him to put in a central line if the vein packed up. Then he went and found Debbie and asked her to hand over to the nurses on the night shift that they were to call the anaesthetics reg directly if that happened. Then he went back to the doctors’ office to write the instruction explicitly in the notes.
And when he looked up, Ludo was in the doorway.
This time, he wasn’t going to be fooled.
‘You’re not real,’ he said, and he went back to writing his notes.
The Ludo-vision came into the doctors’ office and sat down.
Goldblatt looked at her again. ‘I know you’re not real.’
‘What are you talking about, Malcolm?’
‘What are you doing here? You’re not on call, are you?’
‘Dr Morris offered to take a few of us who are studying for the second part through some patients.’
‘How did it go?’
Ludo sighed. She threw back her head with a toss of her hair.
‘That good?’ said Goldblatt.
‘How did you go with that pneumothorax?’
‘I aspirated it.’
‘How is she?’
‘She’s got pulmonary fibrosis.’
‘Is she sick?’
‘End-stage.’ Goldblatt shook his head. ‘End-stage, end-stage.’
He turned back to the folder and finished the last instructions in his notes. He put the folder in the notes trolley.
He thought about what he had said. End-stage end-stage. Where do you go after that?
He looked back at Ludo. She hadn’t moved.
He frowned. Ludo was watching him.
And the words just came out. ‘Do you... I don’t suppose you want to go for a drink?’