The Patient (5 page)

I had the Emergency doctor's notes and the man's test results in my possession. The doctor had certainly been very thorough.

‘Dr Khadra, the other doctor told me it could be a tumour or a stone. I don't get it. How would I get stones in my bladder?' Jonathan clearly wanted answers. I could see from his notes that he'd been in the Emergency department for over 12 hours now.

‘Look, I'm unsure what you have. I don't think it's a stone or an infection. It does look like it could be a growth in the bladder. We need to do some more tests. Most importantly, we need to book you into hospital to have a cystoscopy, a direct examination of your bladder.' It was always a challenge to strike the right balance between saying too much and saying too little. He had to be left in no doubt that his condition was serious and that he needed to be followed up, but there was a limit to what he – or any patient – could take in at the first consultation. My approach was to use euphemisms and skirt the topic, all the while assessing how much he could absorb.

‘I can arrange for you to see a urologist in the clinic here at
the hospital. Alternatively, you can book an appointment to visit the private urologist at her practice. Which would you prefer?' Jonathan was still stunned. I was trying to give him the choice between seeing a urologist for free in the hospital clinic, which might entail a long wait before getting an appointment, or seeing a private urologist offsite, with a potentially shorter wait but at a price.

I liked this man. I felt sorry for him too. I could see the way the rest of his life was likely to go, as clearly as though I were looking at a year planner. He could not see it yet.

‘I think I would prefer to see the urologist in her private rooms. Do I organise that?' he asked.

‘I can give you her name and address and write a letter so that she has all the information.'

He nodded with gratitude.

Jonathan got up from the bed, took his things out of a shopping bag under the trolley and got dressed. Walking through Emergency in his tracksuit and slippers made him feel ridiculous. It was somehow more acceptable at half past six that morning, when he had arrived, than it was now in the early evening. He made his way to the doctors' desk in the middle of the Emergency floor. From there, he surveyed the scene. It looked like a battlefield and reminded him of the opening sequence in the film
Saving Private Ryan
. There was a young girl getting plaster placed on her arm by a young intern. There was a young man with a bone sticking out of his lower leg, writhing in pain. The yellow man was in another cubicle, and a young intern was trying to get blood out of his arm. Jonathan suddenly felt very faint and weak again. There was an old man receiving a blood transfusion and vomiting blood back out into a bowl. Jonathan was saved from fainting again by turning away from the scene. He looked plaintively at the doctor standing next to him writing on the whiteboard.

‘I don't know how you work in a place like this. I could never cope with all this sickness.'

‘Mr Brewster, I have your letter here,' he said, putting down the whiteboard marker. ‘Dr Khadra had to go, so he asked me to give it to you. He's written the phone number for the urologist on the front. Make sure you take all your X-rays with you with this letter when you go to see her.

When you ring, say you need to be seen sooner rather than later. OK. Do you have any questions?' The young intern was keen to get rid of Jonathan, who was equally keen to escape the clutches of this hellhole.

‘No, I think it's pretty clear. Thanks.'

Jonathan found the exit and asked the woman behind the glass at reception if he could possibly use the phone to ring his wife.

‘There's a public phone there,' she said, pointing to the other side of the waiting room.

‘I'm sorry, I don't have any change. My wife took my wallet and my phone's gone dead.'

An older woman standing next to him handed him a dollar coin. ‘Here, darls, use this.'

‘Thank you so much,' said Jonathan. The words of Willy Wonka came to him: ‘So shines a good deed in a weary world.'

Tracy was there minutes later to pick him up, and Jonathan gave her an account of what the doctors had said. This account excluded the news that it was unlikely to be just a stone. He wasn't ready to face that yet, and he certainly didn't want to cause his wife any more anxiety than was necessary. Then they both fell silent in the car.

Tracy had a myriad of thoughts about practical issues racing through her mind. Whatever it was, Jonathan might well be out of action for a while having some kind of treat
ment or an operation. She might need to spend some time looking after him, so she'd probably need more help from her parents with the girls. It might affect his job. She suddenly had a cold chill as she pulled into the driveway. Looking at the house, their home, she realised that they owed an enormous amount to the bank. Her income was pitiful. She had been trying to establish an interior-design business, but she had been spending more on finding clients and setting up her office than she had been earning. His income was everything to them. She shuddered as if to shake the thought from her head.

‘You better ring Paul and tell him what happened,' she said.

‘Nothing happened. I just have a stone or … something in my bladder. How bad can that be? I'll go and get it treated, and then I'll be back right as rain,' Jonathan replied.

It was seven o'clock when they walked in the door; the girls were still awake. They ran to hug their father. Tracy's mother looked anxiously at Tracy to get the news.

‘We don't really know anything,' said Tracy. ‘But it sounds like it might be a stone in his bladder.'

‘I need to make a couple of phone calls,' said Jonathan, and he left the room to call his boss.

Jake had done a good job of the presentation – in fact, an outstanding job. The praise Paul Carter was heaping on Jake's presentation to the board was making Jonathan feel uneasy. ‘Take as much time off as you need,' Carter said. ‘Everything's under control.'

Jonathan assured him he would be there in the morning and hung up.

He then rang the office to access his voicemails. There
were a few, but his heart wasn't in answering them, and anyway it was too late. He wrote down the numbers he needed to return. There were a couple from his secretary, Dorothy. Nothing was urgent.
I'll go in early tomorrow
, he thought.

Tracy's mum had made dinner and he ate heartily, then went and lay down on the couch. The girls were watching television. His eyes were pointed in the same direction, but his mind was full of thoughts about the day's events. A deep anxiety about the future crept up on him. It had been an enormous day. What was it in his bladder? Could it be serious? Could it be a cancer? The nurses and doctors really hadn't told him anything. Did the doctor say he did or didn't think it was cancer? It was all a blur.
To be fair, they were trying to find out themselves, I suppose
, he thought.
It'll be better once I've got some answers from the urologist
. He hadn't smoked the whole day, and now he had an overwhelming need. There was half a packet of cigarettes in his pocket, so he went out on the balcony and lit up. The first inhale was always the best. He held his breath momentarily and then exhaled slowly. A sense of well-being and calm descended upon him.

‘What's going to happen to you, Jonathan, to us?' asked Tracy softly as she came out on the balcony to be with him. They gazed at the lights of the boats bobbing up and down on the harbour.

Jonathan turned to her. ‘Has your mum gone home?'

‘Yeah. Shall we go to bed?'

‘I wish the doctor had told me more today, Trace. I wish I knew what this was all about.'

‘We'll find out soon enough,' she said, rubbing his back. ‘Does it hurt now?' she asked.

‘That's the strange thing. Even when I needed to pee that bad this morning, it didn't exactly
hurt
. No pain then, no pain now,' he said and shook his head, mystified.

‘Well, no pain – that's got to be a good sign, hasn't it? Hey, what did Paul say?'

‘He said that Jake had done very well.' Jonathan was trying not to sound emotional.

Tracy didn't need to ask how he felt – she knew that now he had the job of his dreams, one of his greatest fears was someone stealing it out from under him. She tugged on his hand. They went inside to get the girls ready for bed and made their way to their own bedroom.

‘Take therefore no thought for the morrow: for the morrow shall take thought for the things of itself. Sufficient unto the day is the evil thereof,' he muttered.

‘Where is that from?' said Tracy. It sounded familiar.

‘Matthew 6, verse 34, I think.'

He knew Tracy loved it that he could remember stuff like that, but it always gave him a shudder. All through his childhood, his dad had insisted on him reading the Bible every night; he made him memorise passages and even sprang tests on him sometimes. For a long time, he had hated his dad for it.

Jonathan slept a disturbed sleep, dreaming of snakes, of being chased, of being naked in the middle of a crowd. Several times, he awoke.

Finally, in the early hours, he got up, went down to the kitchen and made coffee.

Tracy joined him, and they watched the dawn turn into sunrise together. The girls got up soon afterwards, and the day's frenzy began as usual.

I finally arrived home at eight that night, my back in searing pain. My wife was still in theatres, giving anaesthetics. I looked at the pile of work on my desk – I was working on about six research papers at once. It had been one thing to get a place as a Urology registrar in the surgical training scheme, but it was doubly difficult to take the next step: securing a consultant's, or, even better, an academic position at the Victoria Hospital. One of the senior urologists was retiring that year, which meant there could be an opening, but it wasn't going to be easy to get that job. I would have to overcome the stigma of being a migrant, and I would be vying for the position with a vast array of excellent final-year trainees. I love knowledge and being part of universities, and so my plan was to differentiate myself from all the other registrars by adding as many degrees and research papers to my CV as it was humanly possible to.

I made myself a bowl of instant noodles, with a can of corn added for substance, and started to tackle the introduction to one of the research papers. Since completing my Medicine degree, I had already done a postgraduate degree in Computing and a Masters in Education. The same year I did my masters, I did
most of the experimental work on the function of the bladder nerves for my doctorate. My idea was to write research papers about my experimental work, and then each would form a chapter of my doctoral thesis. While I had been studying for my Fellowship examinations – the final specialist exams in surgery – I had put my doctorate on hold. This year, I had returned to working on it but continuously found myself wondering whether all this effort was necessary. ‘Just do it,' I told myself. ‘Just do it.'

Did I really want to know more than I already knew about the tiny nerves that supply the bladder? No, but I really wanted an academic position. To get that, I needed to have research papers. The bladder was as good a topic as any. I envied researchers who developed a passion, a mission, for their research topic. For me, it was a means to an end.

My efforts lasted less than a minute. When my wife came home, she saw me bent over the desk, dribbling on my papers, fast asleep.

‘Let's go to bed. We're both exhausted,' she said as she placed her hand gently on my shoulder to wake me.

‘Yeah. I'll wake up early and finish this off. I can't wait to get this stupid doctorate finished.'

The next day started at four in the morning. I worked best in the early morning; I did most of my good writing then. By seven, I was back at the hospital.

Jim, the head of department, came in shortly afterwards, and we went to see the patient on whom he had performed one of the country's first laser prostate operations using the new machine, which Jim had convinced the manufacturer to provide to the Victoria Hospital on a loan basis.

If the laser operation worked, then it opened the way for prostate resections to be done in the urologist rooms rather
than patients needing to be admitted to theatres, because the laser operation produced a lot less pain than the standard resection.

Jim was very excited to see the patient. His hopes were high. However, as soon as he saw him he realised it was bad news. The urinary blockage was still in place. The patient had not been able to pass urine after the operation.

‘The Americans apparently send them home with a catheter in their bladder and then take it out after a couple of days to avoid retention of urine. I think we should do the same,' he declared.

The operation had been a circus. The company that was distributing the laser generator had sent their senior sales representatives. Three of the staff urologists, as well as my residents and a couple of registrars from another hospital, had come to see the procedure. Altogether, there were over 12 people in the operating theatre, rather than the normal three or four. The sales reps had brought in lots of cakes for morning tea. This was a mandatory part of having their product considered by the hospital. The chances of getting new technology purchased by a hospital seemed directly proportional to the quality of the catering the company provided. The boundary between bribery and enticement was thin; a product's value to patients and medical staff was only one factor in the hospital's decision-making process.

One of the starkest examples I recall was a young salesman who was going around all the hospitals selling a new brand of antibiotics. He would make appointments with the doctors, and each time they would simply cancel or throw him out before he had been able to finish his long and boring speech about the advantages of his product. The man was on the verge of losing his job.

That was until a senior surgeon came up to the young salesman in a hospital corridor as he was attempting to line up yet another appointment to sell his wares.

‘Hey, why don't you take us out to lunch?' said the surgeon, putting his arm around the man.

The salesman happily agreed and asked the surgeon for his preference of restaurant. The reply made him pale visibly: it was one of the city's leading and most expensive restaurants.

I can cope with that
, the salesman tentatively reassured himself. Taking the surgeon out to lunch would be just within the limits of his expense account.

When he turned up to lunch, the salesman couldn't believe his eyes. The surgeon had invited about 30 other surgeons, registrars, residents and nurses. This was going to cost thousands of dollars. He spent the whole lunch on the phone with his head office trying to get clearance for the expense. No, they would not reimburse him above his expense limit; he was obliged to pay the excess out of his own pocket.
I'm going to max out my credit card and lose my job
, he thought.
This is a disaster.

The surgeon kept patting him on the back. ‘Relax. I'm doing you a favour,' he said.

Sure enough, within a month, the sales of his antibiotic went through the roof. He was named salesman of the year by his company and was subsequently promoted to regional manager.

Although the patient who'd had his prostate operated on using the new laser technology was still unable to urinate, he seemed very pleased with himself at being one of the first in Australia to undergo the procedure. ‘I had my prostate done by laser,' I imagined him boasting to his friends at the bowling club.

I accompanied Jim on his rounds with all the other urology patients and then headed to theatres.

I was going to be on an all-day case: an 80-year-old man who had bladder cancer and required a cystectomy, the removal of his bladder. The surgeon was a slow, meticulous one, and I would be assisting; it would be like watching grass grow. It was a nightmare that all senior registrars dreaded. I was champing at the bit to be my own man and operate on my own patients, but for the time being I was still a registrar and had to take what I was given.

When I got to theatres, the surgeon was already there. The anaesthetist had spent an hour getting intravenous lines for the various infusions and an arterial line in to monitor the patient during the surgery. Taking a bladder out is a major operation, with the opportunity for huge blood loss. The on-table death rate was not inconsiderable. In this particular case, the operation was complicated by the fact that the patient had already been treated with radiotherapy and was now having his bladder removed because the cancer had regrown, despite the treatment.

Gomez, the anaesthetist, was in a bad mood. ‘This is a completely unnecessary operation. At 80, I certainly wouldn't like to be going through this.'

The surgeon, Jacob, said nothing. He just smiled his impenetrable smile. I scrubbed, and then I prepped the patient and got the sterile surgical drapes on him, ready for surgery.

‘How did the laser prostatectomy go yesterday?' Jacob asked as he made his incision.

‘Well, the patient is in retention. He hasn't been able to pee yet,' I said. I knew this would please Jacob, because he hated Jim. He had always held the view that
he
should have been elected the head of department.

Slowly and steadily, the operation progressed. Minutes turned into hours. It was like watching a Japanese master sword-maker
slowly working away to produce his masterpiece. It was incredibly frustrating to watch, yet it was simultaneously like poetry in motion.

There was one advantage to being in theatres this long, which was that I could turn off my beeper. It was one of the rare times I was freed of the contraption that ruled my life. The messages would simply pile up, and then in the evening I would have to respond to them all. There would be consultations for other teams in the hospital, patients waiting in Emergency, orders on the ward to write up. For the moment, though, I was deeply ensconced in the silent zone.

Some surgeons like to have music playing in the theatre. Others like to have deep discussions. Most talk about sport. Some, such as Jacob, like to have silence. So when I worked with him, I was able to go into a deep meditative state. Random thoughts came to mind: my research; my ailing bank account; my mother, who was getting more and more unwell; the fact that I had not planned our next holiday and was desperately in need of one.

‘His blood pressure is very low. Are you pressing on any major arteries there?' asked Gomez.

‘No. He hasn't bled much, either,' answered Jacob.

‘I might just transfuse him to be safe,' said Gomez.

‘What are your plans for next year?' Jacob asked me.

It was a cruel question, because he knew that I was ready for a consultancy position and ideally an academic position, but if I appeared too keen it might prejudice my chances: I might look too immature. On the other hand, if I appeared too nonchalant, it might seem that I wasn't interested.

‘What do you think I should do?' I asked.

‘Well, there might be a resignation here, and you could get a job, probably. It depends how you get on with Jim. But you
should go overseas and do some more training. I regret not going myself. It's a great opportunity to get skills in one particular area and deepen your research base.'

I already had a job lined up in Switzerland as a fellow in Urology. This was a senior position in between being a registrar and a consultant. But it wasn't my preferred next step, as in the long term I wanted to work at the Victoria Hospital, and this was a place where the saying ‘out of sight, out of mind' applied. Several of my senior colleagues had gone overseas for training and returned to find there were no jobs for them. One of the most gifted of my colleagues found himself assisting for almost a year before a job at a peripheral hospital opened up for him. My plan was to get the Victoria Hospital job first and then go overseas.

Jacob knew I wanted nothing more than to be considered for a job at this hospital. However, there was a distinct possibility that the Urology department would choose not to replace the retired surgeon, to reduce competition between surgeons. The fewer there were, the more patients for each.

‘Have the review committee interviewed Urology yet?' asked Gomez. The Victoria was one of the problem hospitals of the state's health department, so every aspect of it was now under review.

‘No, not yet. But I think it's a waste of time. I noticed the hospital being cleaned the other day. What hypocrites. Now that the minister has appointed the review committee, it seems the hospital ought to be clean. Why wasn't it clean before?'

Gomez had led protests regarding the sad state of the Victoria Hospital. Now the administration had him in their sights. Every request he made for funding for his department was rejected. His expense account was whittled to zero. His conference travel was denied. You cannot speak out against the bureaucracy and get away with it.

Finally, the operation was nearing an end.

‘Do you want to close?' Jacob asked me.

‘Yes, sure,' I answered, happy that at last I would be doing something. While I was certainly capable of doing the whole operation, this – the simplest part – was all I was given to do that day. Jacob guarded his patients jealously.

I closed and placed dressings on the wound. The patient was to be sent to Intensive Care for close monitoring overnight. If he survived the next week, he could have a good life, for what was left of it. Of course, he would have to learn to change the bags that were now a permanent fixture on his abdomen, draining the urine that would have gone to his bladder.

Not long afterwards, I was up on the wards with Jacob. A woman was smiling away at the news that he had cut all of the cancer out of her kidney. She was essentially cured. Her husband had tears of sheer joy running down his cheeks.

‘So, does this mean it hasn't spread anywhere, doctor?' he asked.

‘Yes, that's correct. The pathology's really good. Obviously, we'll have to keep a very close eye on your wife for a few years, but I am very hopeful.' Jacob was smiling at the patient and her husband.

‘Thank you, doctor. Thank you so much, to you and the whole team. You've been so wonderful. Thank you,' said the woman. The couple were overwhelmed with gratitude. They had received a get-out-of-jail-free card. The fundamental happiness at being released from an almost-certain death sentence brings with it an afterglow of altered perception of the whole hospital system, and this couple were visibly going through these emotions now:
cancer cured; the miracle of modern medicine; the nurses were lovely; the hospital was magical; it's amazing what they can do these days. This woman had indeed been cured by the system, and she may well have received great treatment, so it was heartening to stand by as Jacob gave her the good news. Unfortunately, I knew that her positive experience of the health system was not universal.