The Patient (18 page)

A week later, Jonathan Brewster sat across the desk from Derek, who was advising him once again to have his bladder removed. This time, there was no other option. And the sooner he had it done, the better his chance of survival.

The problem was getting theatre time at the public hospital. Derek had tried hard to negotiate with the hospital for time, but the earliest Jonathan's surgery could be done was in six weeks. He suggested to Jonathan and Tracy that it might be worthwhile going private, even though, of course, the costs would be huge. Anticipating all this, Tracy had already got a quote for having the surgery in the private hospital and had discussed the options with Jonathan and his father. They could pay for it if Mr Brewster mortgaged his house and lent them the money – it was only a matter of whether the bank would approve.

There was simply no other way they could afford it. Even if Jonathan had health insurance, the gap between what the insurance company would pay and what the doctor charged would have been crippling. It wasn't just the surgery; there would be pathology and radiology bills, and if he needed
an Intensive Care bed, the price would rapidly escalate. So much for equal health care for all. All men are created equal, but some are more deserving of better and more efficient health care because they can pay for it.

Jonathan stood and nodded to Tracy and Derek, then walked outside to get some air. He was no longer able to react positively or negatively to any news, as he was numb from too much suffering. What would be would be. This cancer had defeated all the suitable weapons that the medical profession could muster thus far. It had recurred after resection, BCG and radiotherapy. Chemotherapy was not an option on its own. Jonathan's only chance was for Derek to heal with steel.

Each time that surgery and the prospect of having a bag on the side of his abdomen had raised its ugly head again, Jonathan had refused to entertain the thought and had opted for more conservative, but in his case sadly ineffective, options. Jonathan now had little hope that anything other than surgery would fix things. He considered whether he should refuse treatment and let nature take its course, but he knew that Tracy needed him to be treated. She needed to feel that everything that could possibly be done was done. Jonathan weighed up the lesser of two evils and decided that it was better to subject himself to the surgery than for his wife to suffer lifelong guilt.

Four days later, Jonathan sat on his father's balcony with a cup of coffee in his hand. Tracy bounced up to him excitedly and said, ‘It's all been sorted. The bank approved the loan using your dad's house as collateral. I've spoken with
the doctor, and he has a commitment from the anaesthetist and the hospital on the total fee for your operation. You'll have the surgery tomorrow, so you'll have to drink that terrible fluid today for your bowels.'

Jonathan was very uncomfortable about his father mortgaging his house in this way. Were there no limits to the sacrifices this man would make? They had already imposed on him by living there. He was feeding them, caring for them, paying for their daughters' schooling and now he was using his own home to pay for Jonathan's treatment.

Tracy sensed his discomfort. ‘We'll pay him back, Jon. As soon as you're better, you'll be able to get out there and get a job. Life will be sorted. Now, just concentrate on getting better.'

The next day, they fronted up to the private hospital with X-rays and pyjamas in tow.

‘Mr Brewster?' The receptionist already knew his name. ‘Welcome, sir. We've been expecting you. I'll take you up to the ward so that you can settle in. I believe your surgery is scheduled for 10 am. I'll check on how they're going and let you know.'

Jonathan and Tracy followed her up to the ward, where he had a room all to himself. It was clean and inviting. The bed already had his name above it, a phone, a television and a private bathroom.

The nurse in charge of the ward greeted them and gave Jonathan some instructions about having a shower, with antiseptic cream, in readiness for his surgery. Jonathan felt important for the first time since that dreaded dawn he went to the Victoria Hospital thinking he had an infection or a stone. He felt he was being looked after.

An hour later, an orderly arrived and introduced himself, greeting them both by name. Jonathan farewelled Tracy, who was emotional to see her husband heading off for such drastic surgery.

At the entrance to the theatre complex, Jonathan was greeted by the checking nurse, who confirmed that he consented to the operation. Then he was rolled into the anaesthetic room, where the anaesthetist introduced himself and explained what he was about to do. Jonathan was almost in tears of gratitude at being treated so respectfully by everyone.

Derek came out of the theatre door. ‘Hello there. We'll soon have you under way, Jonathan. Are there any questions?' This time he actually paused, waiting for an answer. He leant over the bed looking down at Jonathan, who wanted to ask,
Why can't you do this in the public hospital? Why can't you look after me as well there?

‘No. Just do your best,' he said.

‘We will. Sit back and enjoy it now.' The anaesthetist had already placed a cannula in Jonathan's arm and was now administering a sedative. Jonathan's eyelids closed, and an orderly rolled him into the theatre.

The anaesthetist placed several more cannulas into veins in his arm and neck in case there was a lot of bleeding and he needed a transfusion. Then, he was anaesthetised and became unconscious. Jonathan was now under the total control of the anaesthetist, the surgeon and the surgeon's assistant, Gemma. His life depended entirely on their skills, abilities and knowledge. Derek was outside, scrubbing his hands in preparation. Gemma was at his side.

‘He's a bit young for bladder cancer, poor fellow,' said
Derek. He dried his hands and donned his theatre gown, and Gemma tied up the back of it. Then she scrubbed up. When she got into the theatre, a nurse did her gown up, and she and Derek settled in for the long operation.

‘Scalpel. Are you happy if we start, Gabe?' He was addressing the anaesthetist. He plunged his knife into Jonathan's abdomen before getting the answer.

‘Yeah. Go ahead,' Gabe replied.

He made a skin incision from the pubic bone to just above the navel, carved through the abdominal fat and then the connective tissue down the midline of the belly muscle. ‘Not much of a six-pack this man, has he?' Derek looked up at Gemma, who was concentrating on pulling the edges of the wound apart to give him a better view. His hands disappeared into the belly, moved upwards to check the liver, stomach and spleen, then down to feel the cancer in the bladder.

‘It is pretty stuck down with adhesions there. It's going to be a long one, Gabe.' The anaesthetist was now on the phone to his real-estate agent; he was trying to settle on an investment property, and there had been some complications. With the phone nestled between his chin and shoulder, he injected Jonathan with some additional muscle relaxant and adjusted the gas, adding a little bit more oxygen to the mixture Jonathan was breathing.

Derek extended the wound and unpicked some adhesions so that he could take out the lymph nodes in the pelvis. He sent these off to pathology so that they could determine whether there had been any microscopic spread of the cancer to the local lymph nodes. Slowly, he worked his way around the bladder, severing it from the surrounding tissues. Along the left and right sides of the bladder were large blood vessels
that supplied blood to all the other organs in the pelvis, including the rectum, and also to the penis. Impotence was a common complication of this procedure.

‘Shit! You've pulled the hypogastric artery off.' Derek had a wonderful habit of blaming his assistants for everything. He was an old-school surgeon: no apologies, no excuses. ‘Bloody hell! Pack. Suction.
Suction!
' he shouted at Gemma, who was trying to suck out the blood that now filled Jonathan's pelvis and obscured all views of his bladder. She said nothing. She had learnt a long time ago never to defend herself to Derek.

‘Clamp!' he shouted, and a nurse handed him the instrument, which he used to try to get control of the bleeding. ‘I cannot see a thing. Suction! Suction!' Derek had both hands in the wound. Several packs and sponges had been inserted. Each came out soaking and red. ‘Gabe, we're losing a lot of blood here.'

‘I'm onto it. You do your job, and I'll do mine.' Gabe had worked with Derek for years. He had made a good deal of his income by being his anaesthetist but had no respect for his surgical abilities. He put his call on hold and went over to look at the sucker receptacle. It was filling up quickly, collecting the blood that was being spilt in the operation. This operation was not going well. There was much more blood in the receptacle than he would have expected at this stage of the procedure.

‘I'll have to go. I'll ring you back,' he said and switched off his phone. Irritated, he realised that he had been forced to give this patient some attention. He rang the blood bank and called up some units of blood.

Derek was blindly clamping at where he thought the
bleeding was coming from. He clamped onto something and realised that he had put a hole in the small intestine; meanwhile, the bleeding continued.

‘I'm operating by Braille here. Please get me another sucker. I need two suckers.' He was now visibly shaken. The scrub nurse looked knowingly at Gemma, who placed another sucker into the wound.

‘OK. I think I have it now. Vascular stitch, please.' His hands were shaking.

Both Gemma and Gabe felt uncomfortable being there, but neither of them had the spine to refuse to operate with Derek. He was fine when he did simple procedures. However, he had never been very competent at the big ones. Only last week, he had tied off the artery supplying blood to the right kidney of a patient who was having his left kidney removed. Starved of blood, the patient's right kidney had failed, so then he was left with no working kidney. Plus, in the process Derek had accidentally created a huge opening that continuously drained faeces from the bowel onto the vein. The patient was probably going to end up dead. Three months previously, he had nearly killed a patient while doing a radical prostatectomy, because he had been unable to control the bleeding.

Derek would undoubtedly find some way of defending himself if either of these cases came up before the Medical Board. Anyway, it needed someone to report him, and there were few brave enough to become whistle-blowers. There were no audit meetings at the private hospital about rates of death and illness post-surgery. That sort of meeting only occurred at the public hospital. Derek had been challenged a couple of times by his colleagues in response to anonymous
complaints. His figures in the public hospital for deaths, infections and overall complications were reviewed by administration and found to be within the internationally acceptable parameters for the procedures he was doing. Gemma remembered gossiping with Gabe about it at the time. They both could not believe that the review had been conducted with any thoroughness, as Derek's figures far exceeded those of the other urologists they worked with.

The reality was that Derek was an expert at doctoring his figures. When a patient in the private hospital had a complication, he moved him or her to another private hospital where he had admitting rights, or to the public hospital. These transfers meant that it was hard for his colleagues to keep track of patterns of complications and deaths, on which they might have been able to base a case to the Medical Board. This practice was only possible because there was no reliable means of tracking the performance of a surgeon. The quality-and safety-assurance bodies the government had set up were toothless tigers in this regard. The College of Surgeons had insisted that surgeons undertake continuing medical education but had shied away from policing the requirement, leaving it up to the surgeons to self-report their continuing development. Surgeons enjoyed their conferences at golf resorts and claimed tax deductions, but there was no one to make sure they actually maintained or enhanced their surgical skills.

Derek was great in his dealings with his private patients and had a reputation with other professionals for being competent, but in reality this assessment of competence was based more on his communication skills, his bedside manner, than on the outcomes of his care.

‘That was close.' Derek breathed a sigh of relief as he handed the needle holder with the used stitch back to the scrub nurse. ‘OK. Now, where were we? We had better fix that hole in the bowel, I suppose. Bowel stitch please, sister.'

‘Are you going to do a two-layered closure, Derek?' Gemma had seen other surgeons close wounds that way. Essentially this meant that the inner lining of the bowel and the outer lining were stitched separately, giving a more robust closure, one that was less likely to leak in the postoperative course. But Derek was pressed for time now; best practice had to give way to expediency.