The cutting edge
University of Bristol, England
Photography by Keith Williamson
The baby was going to be fine. The tumor was now in the lab, the blood loss was minimal, and it was now time to close the chest. Closing time always introduced a change of mood; everyone relaxed, and the conversation even became light-hearted. His registrar,1 Mark, and his house officer,2 Saskia, would handle the final touches while Carl, the consultant surgeon,3 would take the opportunity to get a coffee and answer some of the phone messages that had accumulated over the three hours they had been busy in theatre.
“That went really well. I enjoyed it,” said Saskia.
“I’ll give you a tip, Saskia,” said Carl. “After all, you are here to learn. When I was at your stage in that situation, I would have said, ‘Gosh sir, you did make that look easy!’ If the boss has a sense of humor, he will laugh, and, if he is a pompous prat, he will take it seriously; either way you can’t lose.”
“Gosh sir, you do teach me lots of useful things!” said Saskia, smiling.
“And now this is a good opportunity for you to learn how to close a chest. Mark, would you like to take Saskia through it while I get a coffee?”
“No problem,” said Mark.
As he spoke, the theatre nurse who had been answering the bleeps4 approached to announce that Saskia was needed in A and E.5 “They say you have to go now because the patient is about to breach the four-hour rule.”6
Saskia sighed and looked over towards Mark. “That’s the ten-year-old I told you about. The reason he is still in A and E is because he is waiting for a CT scan. The scanner is next door to where he is now, but his ward is three corridors and two lifts away. The scan will be done within an hour, but all they are bothered about is getting him out of their department before he breaches the target.”
“I’ll go,” said Carl. “I don’t want Saskia to miss out on this.”
“Thanks, boss,” said Mark.
Carl headed for the door. “By the way there’s a new patient with what is probably a neuroblastoma. I’m looking at the scans before I start Outpatients this afternoon. I’m meeting the family after Outpatients. Come and join me if you can.”
“Okay.” Mark turned to Saskia. “Remember how many layers there are? Where we put the drains?” They settled down to the job of closing.
Having struggled to sort out the problem in A and E, Carl was running late by the time he sat down with his sandwich and took in the details of the MRI scan. It looked like a fairly typical stage 4 neuroblastoma: enormous, it displaced the organs from their accustomed positions, distorting and throttling all the major abdominal blood vessels. Outpatients took three hours, and the letters, another half hour. Carl headed for the oncology ward. Anna, the staff nurse with the friendly but rather nervous smile, led him to the bedside. He took in his new patient: thin, pale, sunken-eyed. As Carl drew closer, he saw the telltale bruising around the patient’s eyes. His parents were close by, anxiety clear in their faces. Mother sat on the bed; father stood and held a toy.
“Hello. I’m Carl Wheeler, the surgeon. This must be Freddie.”
“Andrew Hemmings, and this is my wife, Julie.”
Carl sat on the bed next to Freddie. The surgeon was pleased to note that, ill though he was, Freddie was happy to chat and allow Carl to examine him. The tumor was not only palpable, it could be seen from the end of the bed. The swelling of the boy’s left testicle resulted from compression of the veins.
Turning towards the parents, Carl asked, “Will Freddie be okay here with Anna if we go somewhere to sit and talk?”
“Yes, I think so,” the father replied. “He likes Anna. He’s really tired. He’s been through a lot today, and I think he’ll sleep.” They sat in the office. Carl explained the situation from a surgical viewpoint and answered their questions, which they had jotted down earlier in the day on a scrap of paper. Julie had to wipe tears away intermittently and comforted herself by stroking her husband’s bare forearm. Carl explained that the following day they would perform a tumor biopsy and insert a double-lumen Hickman line for chemotherapy. Freddie would receive a general anesthetic for the procedures.
Andrew and Julie signed the consent form as Carl described the events to follow. The operation to remove the tumor, Carl continued, would be planned for 100 days after the start of chemotherapy. By then maximum shrinkage of the tumor would have been achieved. The nearest date with five hours of operating time available was Wednesday, July 22.
“How many of these operations have you performed?” inquired Mr. Hemmings.
“About ten a year. There are 100 a year in the UK, and I do about ten percent of them. I have been in the business for twenty years.”
When all the questions had been answered, Carl led them back to the ward before heading for his office. Freddie was asleep. Anna stood in conversation with his parents for a while. “Yes, he’s lovely isn’t he? And he’s a fantastic surgeon. We’ve had children whose parents have been told nothing can be done for them, but he always seems to find a way. He’s great with the patients, always seems to be able to make them laugh.”
Carl, meanwhile, had reached his office and looked dispiritedly through the doorway at the piles of paperwork on his desk. After a brief internal debate, he decided—rather than closing his office door on the whole mess—to look quickly through the pile his secretary had labeled with a fluorescent Post-it as “Urgent” before checking in on the morning’s patient. He worked through the papers, scribbling instructions on most of them; “Urgent OP,”7 “File,” “Bin,” “Put in diary,” “Tell him to B Off.”8 After that, he persuaded himself without too much difficulty that he deserved a pint on the way home.
After his early ward round the next morning, Carl had timetabled a couple of hours for office work. Often called to something more urgent during such hours, he managed to trawl through the intimidating pile on his desk for a full hour and a half, discovering that some of the things in the “Urgent” pile were indeed urgent. He and his secretary, Helen, did not always see eye to eye on what was urgent and important. Furthermore, what was important and urgent to Carl—a new referral with a potential cancer for instance—was muddled up with what seemed important to some, often unknown, being in a distant managerial office. Though Helen was sensitive to Carl’s priorities, which were usually at variance with management’s, her line manager attached great importance to the endless meetings, targets, and “initiatives,” making it difficult for Helen to dismiss them as easily as Carl did.
In the end, much of it went into the recycling bin. Calling Helen into his office, Carl went through what was left in the file with her, and he concluded by holding up a memo on which he had written an oversize question mark. “What the hell is all this nonsense?”
“It’s from the new department set up to monitor the fast-track cancer target. They are routing all referrals through their office to ensure they are seen within two weeks.”
“But no child referred to me with suspected cancer waits more than two days, let alone two weeks! This just adds another four days to the process. And look at this! Why are they saying this has to be seen within two weeks? It’s a bloody hernia.”
“The girl in the office said it was because the GP’s letter mentions a lump, so it might be cancer.”
Carl’s fists clenched and his teeth closed in a grimace. “But it says ‘intermittent lump above the inguinal ligament.’ That’s a hernia.”
“Yes, I know, Carl. She’s only just started and doesn’t know anything about medicine. I think she worked for an accountant until a week ago.”
“Well, who’s her bloody boss? I’ll phone him now.”
“She’s always ‘in a meeting,’ but I did manage to speak to her eventually yesterday. She says there is to be no discussion. They have been given absolute power to control all referrals.”
“So they are going to fuck up my Outpatient system just like they have fucked up my operating diary with their bloody 18-week target.”
At this moment, Saskia walked into the cramped office and looked in vain for a surface on which to put the pile of discharge summaries in her arms. After Carl had “excused his French,” she interjected a question. “Can you please explain this new 18-week rule, Mr. Wheeler?”
“I’ve told you not to call me that. I can’t take respect; I don’t know how to handle it. But I wish some of these bloody jumped–up managers would show some. How dare some twenty-year-old ignoramus I’ve never met call me by my first name?”
Nodding apologetically to Saskia, he took a deep breath and continued, “At the risk of boring Helen, who has heard it all before, the idiot politicians thought it would make good headlines if they could show that they had reduced waiting lists. So, completely ignoring the fact that the NHS has limited facilities, they issue an edict that no one must wait more than 18 weeks from the date they are seen in Outpatients to the date of their operation. Of course, if you make a target for one group of patients, you are going to disadvantage another group. It’s like having a carpet that is too small to cover the floor; if you move it to cover the floorboards in one corner, it simply uncovers the boards in another corner. So the operating lists of every surgeon in the country are filled for the next 18 weeks with a load of mostly minor and non-urgent operations whilst patients with major and urgent problems, which should be treated within 18 hours—or 18 days—cannot be fitted onto operating lists at all. It’s like moving the carpet to the corner where the floorboards are tight and exposing the opposite corner where there are gaps.”
He paused for breath. Blinking, Saskia looked a bit stunned. “And it’s even worse than that,” he continued. “There is another rule. Any patient whose operation is cancelled has to be rebooked within 30 days. I had to cancel a non-urgent operation yesterday morning to make space for that baby who was being asphyxiated by a teratoma. So when the hell am I going to fit in the case we had to cancel? The parents were very understanding and were happy to wait months, but the managers won’t listen.”
“I suppose I’ve got all this coming to me in a few years,” said Saskia.
“You sure have, and it’s getting worse. By the way I’ve got a bit of research for you to do. Find out who the sage was who said, ‘Not everything that counts can be counted, and not everything that can be counted counts.’ I think it was Einstein. Send it to your MP with a covering letter.” Saskia left the room pensively.
Carl saw Freddie once again before his operation. He was in for the day to have his post-chemotherapy scan. The tumor was smaller, but still a formidable challenge. He chatted to Freddie about taking out his “nasty.” Freddie was quite interested in the process of cutting him open and sewing him back up again; he seemed to find it quite funny. He had brought one of his books to show Carl the evil character whom he thought looked like his tumor—it was green, spiky, and snarling. Andrew and Julie were now much more relaxed than when he had first met them. The earlier operations had gone well, and the general sense of quiet calm and gentle humor that surrounded Mr. Wheeler and his team had given them great confidence for what lay ahead.
July 22nd was a fine day. A shaft of sunlight fell across Freddie’s face as he sat up on his bed in the surgical ward. Carl walked onto the ward; they rose and greeted him as a long–lost friend. Today, though, they noticed that he was not his normal relaxed self. He seemed tense. As they were about to sign the consent form, Carl’s bleep called him to the telephone; he left them as they read the form, which included information that there was a “greater than three percent likelihood of death.” Waiting patiently, Freddie’s parents overheard snatches of conversation down the hallway.
“Bloody pen-pushers . . . how dare they . . . me that’s got responsibility for the patients.”
Carl returned to the bedside and informed them that another case had to be done prior to Freddie’s operation, pushing his operation time from noon to 1:30 or 2. Mark and Saskia were waiting for him as Carl emerged from the theatre changing room. They sensed the tension immediately.
“Bloody managers, pushed another case in before Freddie because it was going to breach the sodding wait-list target. It’s not the least bit urgent, and Freddie’s going to take at least four hours.”
Two hours into the operation things were going well. Mark and Saskia were pleased to see that Carl was now into his usual stride, cracking a few jokes. About 80 percent of the tumor had been successfully mobilized from the aorta and vena cava. After a period of intense concentration—in which Carl dissected the tumor from the renal arteries and veins—Carl redeployed his assistants to use their retractors to give him a view of the upper extent of the tumor under the diaphragm. Saskia looked up at the clock.
“Sorry, but it’s six o’clock, and I have to go now.”
“But you can’t go now; this is when I need you most,” said Carl.
“It’s the monitoring period for the new EU hours regulations. I have to log out in the management office by six.”
Carl’s mood reverted instantly.
“Mark, you’ll have to take both retractors. Pull up as hard as you can. There’s bleeding from the tumor surface. Let’s get this bloody thing out. I’m in the dark here.”
A few minutes of cursing and struggling ensued. Mark winced as he heard the sickening “whoosh, whoosh” of major arterial bleeding.
“Shit!” There were beads of sweat on Carl’s brow.
As Carl entered the side room Freddie’s parents had been ushered into, they took one look at his face and knew what he was going to say.
- Senior resident
- Junior resident/intern
- Attending physician
- Accident and Emergency, e.g. Emergency Department
- The 4-hour rule is a requirement imposed on hospitals by government that requires that all patients arriving in the ED must be discharged or admitted within 4 hours. A financial penalty is incurred if it is broken and managers police it.
- Urgent outpatient appointment
- Bugger off
RICHARD SPICER, FRCS is a retired pediatric surgeon. He is currently studying for a BA (Hons) in Humanities and lives in Bristol in the southwest of England.