Mohamed Khadra is a professor of Surgery at the University of Sydney, Australia. He has had a successful and varied career as a leader in education and medicine, internationally and in Australia. He has a degree in Medicine, a PhD and a fellowship of the Royal Australasian College of Surgeons. He also has a postgraduate degree in Computing and a Masters in Education.

His roles have included Inaugural Chair of Surgery at the Australian National University, Pro-vice Chancellor for Health, Design and Science at the University of Canberra, Professor of Surgery and Head of the School of Rural Health for the University of New South Wales. He has won several research prizes, including the Noel Newton Prize for surgical research and the Alban Gee Prize in Urology.

Mohamed is co-founder of the Institute of Technology Australia, an accredited higher-education provider that contributes to social justice by delivering accessible and affordable degrees to students in developing countries. He is also the bestselling author of Making the Cut.

All rights reserved. No part of this book may be reproduced or transmitted by any person or entity, including internet search engines or retailers, in any form or by any means, electronic or mechanical, including printing, photocopying (except under the statutory exceptions provisions of the Australian Copyright Act 1968), recording, scanning or by any information storage and retrieval system without the prior written permission of Random House Australia. Any unauthorised distribution or use of this text may be a direct infringement of the author’s and publisher’s rights and those responsible may be liable in law accordingly.

The Patient

ePub ISBN 9781864714968

Kindle ISBN 9781864717617

A William Heinemann book

Published by Random House Australia Pty Ltd

Level 3, 100 Pacific Highway, North Sydney NSW 2060

www.randomhouse.com.au

First published by William Heinemann in 2009

This edition published in 2010

Copyright © Mohamed Khadra 2009

The moral right of the author has been asserted.

All rights reserved. No part of this book may be reproduced or transmitted by any person or entity, including internet search engines or retailers, in any form or by any means, electronic or mechanical, including photocopying (except under the statutory exceptions provisions of the Australian Copyright Act 1968), recording, scanning or by any information storage and retrieval system without the prior written permission of Random House Australia.

Addresses for companies within the Random House Group can be found at

www.randomhouse.com.au/offices.

National Library of Australia

Cataloguing-in-Publication Entry

Khadra, Mohamed.

The patient.

ISBN 978 1 86471 167 7 (pbk).

Cancer – Patients – Australia – Biography.

Medical care – Australia.

Bladder – Cancer – Treatment – Australia.

362.1969940092

Cover design by Henry Steadman

Cover photograph © Corbis

To HK, AK and SK, without whom there is

neither past nor future.

Acknowledgements

My gratitude and warmest thanks are extended, without reservation, to my agent, Sophie Hamley, from Cameron Creswell, and to the staff at Random House Australia: my publicist, Alysha Farry, my editor, Kevin O’Brien, and my publisher, Nikki Christer.

Writing uses up time, which I borrow from my family. My eternal gratitude goes to my best friend and wife, Michelle, and to my sons, Adam and Sam.

Finally, as an author whose inspiration is drawn directly from hospital wards and operating theatres, my words are created out of the pain and anguish that I witness and that my patients endure. After the publication of Making the Cut, I received hundreds of communications from patients whose lives had been impacted by illness, trauma and cancer, and who had found a resonance through the shared experiences of others. In a sense, they had been comforted by knowing they had not suffered alone. I am extremely grateful for their feedback, as knowing I have been an instrument of that comfort is what has sustained me as a writer.

Author’s Note

As surgeons, we dip in and out of our patients’ lives much like a flying insect touches on a pond. The insect lands for a moment, then flies to another spot and lands again. It remains, throughout its short life, unaware of the vast and intricate complexity that lies within the pond – currents swirling this way and that, life systems building and collapsing. Surgeons, like the pond insect, keep themselves from landing too heavily on any one spot, lest they drown in that patient’s sea of sorrows. For a surgeon, ignorance is not just bliss but a matter of survival.

The central character of this book, Jonathan Brewster, is a conglomerate of cancer patients whose lives I have dipped in and out of in the ongoing course of my career as a surgeon. Some I met soon after their diagnosis, some once they had already developed an advanced or terminal cancer. My path crossed these patients’ paths at different points on their life journeys. I witnessed each patient reach new stages of spiritual evolution and awareness – for some, on the way to their final demise. To preserve confidentiality, I have amalgamated them into one patient and fictionalised large parts of their lives, relationships and interactions with medical staff.

This patient’s interactions with me are, from time to time in the book, narrated from my point of view, as is my own experience of being a cancer patient, so I necessarily appear in this story under my own name. I have, though, changed the names, personal details and characteristics of all other patients, doctors and medical professionals, along with the name of the hospital itself, also for reasons of confidentiality.

The principal surgeon who treats Jonathan in the book is a character who has been created to portray some of the characteristics of a bad surgeon. The events attributed to him are drawn from hearsay and public records, and his existence is designed to highlight the negative possibilities that can occur without the good governance of the Royal Australasian College of Surgeons and the various medical boards that regulate standards and review competence. It ought to go without saying that most surgeons are not like this.

It should also be noted that the episodes and encounters narrated in this book are drawn from my entire career as a surgeon to date, rather than adhering to the chronology of my CV – so those people I meet in the book who are based on people I have met during my career do not correspond to the places or times in which I actually met them.

Everything contained in these pages is nevertheless as true and accurate a reflection of what takes place in Australian hospitals every day, from both the patients’ and the doctors’ points of view, as I could render from my own experiences.

We understand more about the intricate anatomy of the human being since the Visible Human Project, completed by the US National Library of Medicine at the end of 1995, created three-dimensional computer models by finely slicing the bodies of two deceased donors – including a condemned prisoner put to death by lethal injection – then scanning and digitising the resultant images. Macabre, yet useful in gaining a greater understanding of the human body. In much the same way, I have attempted to slice my patients’ life stories into small segments and reconstruct them so that we may understand more about health and the health system.

The health journey is often also a spiritual journey, and you will find many of my beliefs and attitudes transplanted into Jonathan’s story.

Preface

I was fortunate enough in the year 2000 to lead a team that started Australia’s first rural clinical school, in Wagga Wagga, in New South Wales. In Sydney, medical students undergoing clinical training were assigned to doctors and viewed patients by peeking over the white-coated shoulder of senior clinicians. In rural south-west New South Wales, students could not have that luxury: there simply were not enough clinicians. A radical new approach to medical training had to be found. Our team’s solution was to rotate the student experience by 180 degrees. Instead of assigning the students to doctors, we assigned them to consenting patients. Thereafter, whenever these patients accessed the health system, their students went with them. If the patient had an X-ray, the student was there. If he or she had an appointment with a specialist or went into hospital for an operation, the student was there as well.

The rural students gained a longitudinal view of their patients’ health journey, unlike their city counterparts, who saw the small segments of their patients’ lives that intersected with the doctors they were assigned to. The patient-centred rural curriculum produced medical students who had a far more mature view of the healthcare system. They saw the system from the patients’ perspective and were able to appreciate the need for health-care teams to work in concert to achieve good outcomes.

In Making the Cut, I sought to portray the lives of patients as they interfaced with me in my capacity as a surgeon. So doing, I exposed the reader to a large number of different stories and patients.

In this book, I focus on one patient’s journey. While he is one patient, with one disease, I hope the reader will forgive me if I say that he is, in some ways, all patients and all diseases. My portrayal of his journey through the health-care system is intended to reveal its shortcomings, its triumphs, its cruelty, its compassion. Just as the Wagga students followed the progress of individual patients, in this book you, the reader, will see things more from the patient’s than from the doctor’s point of view.

Some might criticise the darkness of this book. I should note that bladder cancer, the disease suffered by the central character, is treatable and even curable in some cases. The miracles of modern medicine have brought about cures for many of the diseases we used to regard as hopeless. There are patients who walk away from the public-hospital system satisfied with the care they received. My intention in this book is in no way to negate their good experiences. However, as a surgeon, I see much variety in disease and the cruelty it inflicts: the slow-onset disease that tortures a woman until she can bear it no longer; the murky, insidious disease that creeps up on a man without his knowledge; the lump that grows slowly in the darkness of a body crevice; the hardness of a breast that tests the ‘till death do us part’ promise. If this is not the ultimate of cruelties, then what is?

Throughout human history, disease and pain have been the strongest agents of spiritual awakening. I have no idea why, in His creation, God made human beings more likely to gain enlightenment through suffering than through good humour, health and laughter. Yet, through the annealing fire of suffering and disease, people gain insight – insight that comes at great cost.

Of course, we all have some way of rationalising the pain we suffer. The Hindus believe in reincarnation and the possibility that your next life will be better; the Muslims, including myself, that you will suffer less in the afterlife; the Christians that Jesus loves you and that faith ensures eternal life in heaven. Regardless of the wonderful spiritual writings of all the world’s religions, spending night after night in the hospital caring for these patients – the beloved of God – I still believe that disease is God’s cruellest creation.

Mohamed Khadra

CONTENTS

Cover

About the Author

Title Page

Copyright

Dedication

Acknowledgements

Author’s Note

Preface

Prelude

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Chapter 13

Chapter 14

Chapter 15

Chapter 16

Chapter 17

Chapter 18

Chapter 19

Chapter 20

Chapter 21

Chapter 22

Chapter 23

Chapter 24

Postscript

Making the Cut

Prelude

Jonathan Brewster had been told to prepare an acceptance speech, so it was with a sense of triumph that he rested his knife and fork on his plate and surveyed the scene at the annual marketing-awards dinner. It had been a long hard struggle, but at 47 he could truly say that his career had taken off; for a year now he had been heading up his division, and profits were up. It had meant even more hours in the office – albeit a much bigger office, with floor-to-ceiling windows overlooking the whole city. It also meant he could get a house in the kind of suburb that makes you enjoy giving your address out to others and that his girls could finally go to the private school he had always dreamt of sending them to. Tracy, his wife, was radiantly beautiful tonight, as ever.

Little did Jonathan Brewster know that at the very moment he was smiling and waving at other dinner guests and checking that his speech was still safely in his pocket, cells in his bladder were rapidly multiplying. In fact, they had started growing the day he was promoted. Each day, they had multiplied at an increasing rate. By now, they had formed themselves into the most beautiful fronds, like delicate red coral emanating from his bladder wall. Some of the cells had burrowed deep down into the wall. Others had formed sheets, like scarlet carpets, extending into the channel between the lining of the bladder and the blood-rich tissue underneath. Some of the cells had acquired the ability to travel – to leave the bladder and explore new and wonderful parts of the body – though none had done so yet.

His name was called to accept his division’s industry award. He kissed Tracy, rose from his seat and walked to the stage, beaming and waving to a colleague here, a jealous competitor who missed out there. This was his moment of glory.

And the rapidly multiplying cells in his bladder would have to wait only until dawn to have theirs.

1

Jonathan Brewster stared at the macabre scene that surrounded his toilet and was filled with an overwhelming fear.

Just a quarter of an hour ago, his biggest concern had been getting out of bed in the cold and interrupting his sleep a good two hours before he had to get up for work. He had tried to ignore the pressure in his bladder that had awoken him, rolling first one way, then back the other, until finally he’d found the right position: lying on his back, with his knees drawn up. But this had only worked for a few minutes; then the discomfort of holding on had exceeded the discomfort of getting out of his cosy bed.

Not wishing to wake Tracy, he’d tiptoed into the en suite bathroom, walked quickly to the bowl, lifted the seat (he was well trained by his wife) and stood there in the dark holding his penis, waiting.

Nothing had happened – except that the pressure had become more uncomfortable, more intense. Slowly, a trickle had commenced. Then it had stopped. A deep spasm had hit his groin, making him gasp. It would have been almost sexual had it not been for the unbearable desire to urinate that had accompanied the pressure in his pelvis. The spasm had strengthened, and Jonathan had found himself letting out a faint hum from his throat; he’d realised he’d been holding his breath.

Suddenly, it had felt as though a plug had come free from his penis, and then there’d been a gush of urine. The relief had been wonderful.

Dawn was filling the sky with a gentle light, bringing the bathroom dimly into view. He’d been curious to see that his urine had sprayed all over the bowl, the floor and the soft white mat he’d been standing on. It had occurred to him that in the half-light he should not have been able to make out spots of urine. That he could had indeed been strange.

Jonathan had closed the door gently and turned on the light. At first he could not grasp the macabre scene that confronted him. His senses were overwhelmed by a profound terror, the type that makes hair stand on end and skin go icy cold.

The urine in the bowl, on the floor and on the white mat was red. In fact, it looked very much like blood. His blood. His legs feeling weak, he sat down roughly on the cold white tiles, shivering at the sudden change of temperature. Jonathan’s world was turning around him. It all went black, and he fell backwards, hitting his head on the door.

Tracy heard the loud thud and rushed out of bed. ‘Jon, what is it?’ she cried out. ‘Jonathan!’

She had to push on the door with her full weight to shift his limp body. One great shove and she had enough room to squeeze through. Blind panic hit her at the sight of blood all over the white bathroom and Jonathan’s naked body splayed out on the tiles. Shouting his name, she shook him, trying to wake him. His skin felt warm, but he was very pale. He reminded her of movies she had seen where the wife walks in to discover that her husband has committed suicide, but even as she reached down to check his wrists she knew this was a ridiculous thought; he had everything to live for. Jonathan’s eyes slowly flickered open. It was then that she glanced down and saw the blood at the tip of his penis.

‘Shit, shit, shit!’ she yelled. She was usually meticulous about her language, but ‘shit’ seemed to be the most appropriate response now.

Jonathan was trying to sit up.

‘Oh my God, Jon. What happened?’

‘I just needed to pee, and then it all came out suddenly, like a gush,’ he said. ‘When I saw the … the blood, I … I …’

‘Shh, it’s OK now, babes,’ said Tracy soothingly.

Jonathan had never been good with blood. In fact, he had a long tradition of fainting at the sight of it. At a rugby game at school, he had passed out when an opposition player’s head was split open during a rough tackle. He had even fainted during the birth of his first child, Emma, knocking over several instrument trolleys in the process. Minutes later, Tracy had given birth to Emma while the staff tended to Jonathan, who was flat on the floor.

But this blood was more frightening than any he had seen before. This was his blood. He felt faint again as he looked around the bathroom. The droplets and streaks of blood gave the scene an abstract horror, almost like modern art – a red Jackson Pollock.

‘Fuck, Tracy, that’s my blood there.’ He was struggling to understand.

‘Let’s get you back in bed,’ she said, trying to get him away from the scene so he wouldn’t faint again. She knew her husband well. ‘Do you think I should call an ambulance?’ she added.

‘No, no, I’ll be right. I just don’t know where this came from. I should help you clean it up,’ he said, avoiding looking at the bowl.

‘No way. You get back to bed.’

Tracy got her husband to bed and went back to the en suite, where she took some bathroom cleaner and a sponge from the cupboard under the sink and began cleaning up the mess. Then she started on the toilet – but something immediately caught her eye and she stopped. In the bowl was a black object about the size of a scrunched-up tissue. She bent down to look at it closely and, as she did, she gagged. It was a clot of blood. She flushed and then quickly scrubbed the bowl. By the time she’d finished, the room looked more like a bathroom and less like a crime scene.

‘I’ll make us coffee,’ she called out as she washed her hands.

Jonathan nodded; he was checking his pager for messages, mainly to comfort himself with the familiarity of this everyday task. He was still pale but was returning to normal quite quickly.

‘You know, Jonathan, maybe you’ve got an infection or a stone or something,’ Tracy said when she came back in the room.

‘It’s cool, Tracy. I feel fine now.’

‘No, no, you need to go see someone, Jon. There was like a … a clot thing in the toilet. We’ll get onto the doctor as soon as he opens this morning,’ she said and headed for the kitchen.

She was already mentally rearranging her day. Tracy could see her schedule laid out like a series of blocks in her mind’s eye. First was getting the girls to school, then she had meetings with four clients lined up and then they had Anne Marie and David coming for dinner, so she was supposed to shop and cook in the afternoon. Jonathan was forever making generous gestures that Tracy always seemed to end up having to fulfil. Anne Marie and David were nice enough, but this was a school night and she’d told Jonathan she was facing a busy week. He’d said, ‘Don’t worry about a thing. I’ll arrange it all – shopping, cooking. You relax.’ As usually happened, he had had a last-minute meeting scheduled that was ‘really, really important’, so the job had fallen to her. Situations such as this had caused conflict during the course of their married life, but never to the extent that it diminished Tracy’s love for him. Many of their friends were already onto their second marriages, but Tracy and Jonathan still shared a wonderful marriage, even with the frustrations that Jonathan created.

‘I’ll ring and cancel dinner,’ she said as she brought in the coffee. ‘You’ve got the board meeting on today, haven’t you?’

‘Yeah, I have to make that presentation. I’ll be finished about six – don’t cancel dinner. Honestly, I’m fine. I feel OK. Thanks, Trace,’ he said as she handed him his coffee.

‘Uh, Jon, are you nuts? You’ve just peed blood everywhere and you want to have some people over for dinner that you hardly know? You must be kidding.’

‘It’s just that I think Anne Marie could wind up being a big client for me. And you enjoy her company. She’s just like you – intelligent, professional …’

The sweet talk was getting Tracy even more irritated. ‘I’m cancelling dinner. And you’re going to the doctor.’

Jonathan could tell when Tracy was not to be swayed; he gave up the notion and they finished their coffees in silence.

He rested his cup on the bedside table and realised he once again felt the need to urinate. Tracy followed him into the en suite. They stood over the bowl, waiting to see the colour of his urine.

‘If there’s more blood, we’re going straight to the hospital,’ Tracy said.

‘I can’t pee with you standing here looking at me.’

‘For God’s sake, just do it.’ Tracy was impatient now. Impatient and scared. Thoughts of disaster flashed through her mind. What if her husband was sick with something serious?

Jonathan was grunting now, trying to force urine out. Finally, he urinated. It was lighter than before, but it was still bloody. The sight made him feel faint again.

Tracy got him back to bed, called her mother and asked her to come and sit with the girls. Her mother and father lived two streets away and were used to filling in the childcare gaps. They were early risers, so they were awake when the phone rang – but still, they were understandably shocked.

Tracy dressed quickly, threw Jonathan a tracksuit and explained to the girls what was happening. Jonathan still looked a little pale, so when her parents arrived Tracy was the one who got in the driver’s side of their new car. She had not mastered the gears, and it was a clunky ride to the Victoria Hospital. She dropped Jonathan off at the front door of the Emergency department and went to park the car. The bright-red signs inside the building left him in no doubt about which way he was meant to go.

2

Fuck, I thought as my beeper went off again. I was just finishing off in theatres. A boy of 12 who’d had a sore left testicle for the past day had been admitted. This was a urological emergency, because if he had torsion of the testis – when one of the testicles becomes twisted within the scrotum – its blood supply would be compromised. If that lasts for longer than the magic number of four hours, the tissue dies and the testis has to be removed. The only real option was immediate surgery to explore his scrotum.

While I was always careful, I did feel an enormous extra pressure on me because his father was a barrister renowned in the field of medical professional negligence. As the Urology registrar on call, I had thought it best to first contact the head of department, even though he was at home.

Registrars are trainee specialists who, after graduating from medical school, have gone through three of the tiers of the hospital system, from entry-level intern (which lasts a year after graduation), to resident (the position between intern and trainee specialist), to securing a training position, which typically lasts for three years before the registrars are ready to take their specialist examinations. As they are still trainees, albeit experienced ones, they report to the specialist on call. In this case, it happened to be the head of department.

In his sleepy state, the head had given me permission to perform the surgery, adding, ‘Ring me if you have any troubles.’ This was a standard response, in line with the truism that a registrar’s competence miraculously increases after midnight.

I had incised the boy’s scrotum and revealed his testis, which in fact was in torsion and terribly ischaemic – starved of blood and therefore oxygen. Irreversible damage had already occurred; I had no choice but to take out his testis. I did that and then closed his wound. It was now 1 am. I had been operating for over 16 hours in a row.

‘Dr Khadra here. I was paged …again,’ I said down the phone once I had finished the surgery. I was cross and tired. I had not eaten anything since breakfast the previous day except for some biscuits, and my head was starting to hurt. It will probably turn into a migraine, I thought. Maybe I should take an anti-migraine pill.

‘I’ll just see who’s looking for you.’ It was the ward clerk.

The phone clunked. In the background, I could hear the general din of Emergency. It was obviously busy. Some nights, it seemed that every diseased human in the world had descended upon the Victoria Hospital intent on testing out the system and finding its faults. Tonight was such a night.

I was sitting in the theatre tearoom, where, in the past, before economic rationalism, one could actually get a meal. ‘Hello … Hello … Helloooooo,’ I said into the phone, speaking to no one in particular. I heard someone’s voice nearing the phone, and then it clunked again.

‘Hello, who is on the line?’ asked a new person, a woman.

‘Dr Khadra. I’m the Urology registrar. I’ve been paged.’ I probably wasn’t doing a good job of hiding my growing exasperation.

‘Did anyone page Urology?’ she shouted to all of Emergency – and into my ear.

Clunking again – the phone being placed down on the desk roughly. I decided to hang up and just go down in person.

The junior resident – who was only just out of his first year as a doctor – was looking somewhat shell-shocked when he greeted me.

‘I’m glad you came down. We have an absolute doozy here. I really need you to take a look.’ As he spoke, he led me to a cubicle. I parted the curtains and saw a heavily tattooed obese man.

‘Hi. My name is Mohamed Khadra. I’m the Urology registrar on call. What seems to be the trouble?’ I asked as I nodded to the resident to let him know he could go. He chose to stay.

‘You don’t look like a Mohamed,’ said the tattooed man, smiling. ‘I expected you to be black!’ I heard that comment at least once a day. I just waited for him to start talking about his urological concerns. ‘Well, me ring tore out,’ he said.

‘Your ring?’ I could not quite grasp what he was saying, as this sounded more like a job for the Proctology department.

‘Yeah, me ring.’ As he said this, he nodded towards his groin.

‘Do you mind if I have a look?’ I asked, dying to solve the mystery.

I pulled down the blankets and lifted up his white hospital gown. There was a pool of blood between his legs. The end of his penis had the dramatic appearance of a frill-necked lizard. Hanging from a loose bit of torn skin was a large metallic ring, a Prince Albert. It had been inserted through the end of the man’s urethra and then out through the middle of the penis. To this was attached a chain, which ascended to another body-piercing extravaganza around his nipple.

‘How did it tear?’ I asked.

‘Well, I was watching a movie with a friend of mine and I got up and had to bend down to change the video. As I stood up, I think I stepped on the chain, and wumph … the ring got torn out.’

‘It must have been very painful.’ I could not help but wince.

‘It was, doc, it was,’ he said sadly.

‘I’m just curious to know, why did you have it inserted in the first place?’ I really was curious.

‘It makes sex so much more pleasurable, doc. You should consider it.’

There was no way on earth that I was going to adorn my penis with a Prince Albert.

‘Can you fix it?’ he asked.

‘Yes, we can. We need to get you to theatres as soon as possible and sew your penis back up.’

‘And how soon do you think it will be before I can have another one?’

For a moment, I hoped he was joking, but no, he was serious. ‘I suspect never. You have a complete tear through the penis, the urethra and the skin. It will take a while for all of that to heal. Even then, I suspect the skin will be too thin to be able to bear the weight of another Prince Albert.’ I resisted the temptation to tell him he needed psychiatric care a lot more than he needed another ring.

‘Hey, is there any chance of something for the pain, doc? I think it needs to be morphine or pethidine.’

I guessed he must also be a narcotic addict. ‘I’ll see what I can do,’ I said – and wrote him up a script for some anti-inflammatory medications for the pain. He was not happy.

I went back up to theatres to see if I could book this man’s operation. After hours, theatre access was very limited. One had to battle with all the other surgeons trying to do their emergency cases.

‘Marlene, what’s on the table now?’ I asked the night theatre supervisor, who had been in the position as long as anyone could remember.

‘Why do you want to know? What delights have you got for us now?’ She guarded theatre time fiercely.

‘I have a fellow who has a nasty laceration on the end of his penis. It will take a couple of hours to get it all back together again. What time do you think we could get a guernsey?’ I asked, looking as cute as I could.

‘Why can’t he wait till later in the morning? Cancel your elective list and do him instead.’

‘The boss will be very cross. He’s lined up a drug rep to bring in the new laser-prostatectomy machine to try it out. It’s going to be a circus.’

Jim, the head of Urology, was an expert at extracting money from the hospital administration for new technologies. Several of his previous acquisitions were in the store room, collecting dust. He was always falling victim to the intensive marketing techniques the medical-technology companies used on doctors to make them feel that without the latest technology they were offering their patients a lousy standard of care. Public patients were waiting for years to get their hips replaced, but millions of dollars were spent on new technology that was redundant before the hospital had even recouped the cost.

The old equipment would have been useful to hospitals in the developing world, but red tape made donating it impossible. One bureaucrat had prevented a disused heart–lung bypass machine from being donated to Kenya lest it malfunction in the future and the Kenyans decided to sue the hospital. Even more distressing to any with a sense of social justice towards the developing world was that most new technologies have very questionable cost–benefit analyses when one weighs their purchase for our hospitals against providing hospitals in developing countries with even the most basic of needs. Some lack antibiotics, anaesthetic solutions and even suture material. They make do, and we spend more.

Jim had been impressed with the marketers’ pitch for the laser-prostatectomy machine at a conference in Paris and was angling to purchase one for the Victoria Hospital. His arguments would be along the lines of needing to keep the hospital at the forefront of health care: how can you call it a teaching hospital when the technology is ancient? The machine will save money in the long term. The cost can be amortised by shorter hospital stays for patients. If his debates with administration failed, he could always use his secret weapon: he was one of the few people in the city who had direct access to the health minister; they had gone to school together.

‘Well, there’s a vascular case on table, and it’s going to be followed by the orthopods,’ said Marlene, trying to find a solution. ‘You could probably follow.’

‘Thanks, Marlene.’ It was going to be another night with no sleep and me getting uglier for it.

3

It was just after 6.30 am, and Jonathan was standing at the glass screen that bore a sign reading ‘Reception – Report Here First’. The clerk behind the glass was speaking on the phone in a low whisper, and Jonathan guessed she was trying to settle a child somewhere.

‘Look in the laundry. I’m sure I washed it and put it in the dryer, and if you can’t find it there, wear the green one … I have to go now … I have to go.’

She looked up at Jonathan and held up a finger to signal that she would only be a minute. He had a desire to urinate again, but he could hold on. The clerk hung up and turned around to take a form out of one of the slots behind her desk.

‘Name,’ she said, looking down at the paperwork rather than at him.

‘My name, you mean?’ He was genuinely confused.

‘Who else’s, love? Your name, please?’ There was a note of impatience in her voice as she waited for him to volunteer the information.

‘Jonathan Brewster,’ he answered, and thus began the interrogation required to establish him as a patient, an entity in the hospital.

‘Address.’

He told her, with his usual sense of satisfaction, but there was no reaction from the clerk.

‘Are you in private insurance?’

He wasn’t sure whether Tracy had joined them up or not. She was always going on about how they might need it one day. Jonathan’s argument was that they were in good shape and were better off spending the money on a nice dinner once a month. Anyway, there wasn’t much difference in treatment, was there?

‘Have you been here before?’

No, he had not.

‘OK. Take a seat. The triage sister will be with you shortly.’ Jonathan didn’t know that ‘triage’ meant the system of dealing with patients in order of urgency, and that, once the nurse had ascertained he presented no immediately life-threatening symptoms, his wait was going to be a long one. The clerk dismissed him. Her job was done.

Tracy had finished parking the car and came up to him. ‘What’s happening?’ she asked expectantly.

‘I have to take a seat and wait.’

They sat in plastic chairs not far from the reception. Daybreak was colouring the sky with its pretty hues of pastel pinks and yellows, but the light struggled to overcome the perpetual cold fluorescent daylight of the Emergency waiting room. Jonathan was distracted by the television set, which blarged a Christian preaching program. A bright-blonde woman, who appeared to have a permanent smile due to botched plastic surgery, was quoting a verse from the Bible:

A whip for the horse, a bridle for the ass, and a rod for the fool’s back. Proverbs 26, verse 3. God tells us clearly that some people will only change, will only obey, when they are punished, when they are given a rod for their back …

Why is it that they’re always American? he thought. And why am I sitting here listening to this stuff? The scriptures brought back memories of a strict upbringing and filled him with revulsion. He turned his mind to his board meeting later that morning, and he felt he should be at the office by now, putting the finishing touches on his presentation.

‘Did they say how long it was going to be?’ Tracy interrupted his thoughts.

‘She said a nurse will see me soon, but, honestly, I’m feeling fine now. When I bumped my back yesterday on the kitchen cupboard, I must have hurt my kidney. It’ll settle down. Let’s go home.’ He was hoping that he could get out of the hospital and prepare for that meeting.

‘You leave here before you’ve seen a doctor and I’m leaving you!’ Tracy had a playful smile at the corner of her lips, but Jonathan could see she meant business.

He sat back. The plastic chair was already beginning to get uncomfortable. Looking around, he realised there were about 30 people in the waiting room. He was gasping for a cigarette but knew that this would enrage Tracy, so he resisted.

Opposite him sat a fat woman with a child who must have been about a year old sprawled in her arms, deeply asleep. The child had a small plastic tube coming from his nose, which made him look almost like a baby crow, to Jonathan’s eyes. The mother was staring blankly into the distance.

Jonathan looked at the mother’s dirty cotton dress and wondered whether she had a job. Maybe she was one of those people who lived off government handouts – sponging off everyone else to get her medical treatment, her bills paid, food vouchers. Tracy could see the faint disdain upon his face and almost read his thoughts. She squeezed his hand, as if to say, Stop staring. He looked away.

Not far from where they were sitting was an old man who looked yellow and had very scaly skin. His gut was swollen, but his arms and legs, face and neck were emaciated. He looked like a pregnant yellow stick insect. Jonathan was staring at the man’s stained towelling robe when he heard a sharp scream. The double plastic doors to Jonathan’s right that read ‘No Admittance – Staff Only’ flew open and a young man, perhaps in his early 20s, ran out, immediately chased by three security guards and two nurses.

‘Fuck off! Just fuck off! I just want to go home. Go fuck yourselves, all of you.’ He was hoarse with the screaming. His face was creased with deep lines; there were sores up and down his arms and neck, and he was tattooed with Gothic letters around his neck and upper arms. Several bits of metal had been pierced through his eyebrows, nose and lips.

‘Come on, mate. Calm down. We’re just here to help you. Just calm down.’ One of the security guards was edging towards the young man with his arms held out in front with the palms facing down in a calming gesture. The young man was looking around him, eyes darting this way and then that, looking for an exit. The other security guards were circling around him slowly. Suddenly, all three of them lunged forward and grabbed his legs, and they all fell to the ground.

The man started screaming his lungs out again. A nurse holding a syringe with clear fluid in it shouted, ‘Have you got him secure?’

‘As good as he’s going to be. Go for it!’ yelled the first security guard at the top of his voice.

She reached forward, took the safety cap off the needle and plunged it into the man’s thigh. The screaming reached a crescendo now. It could best be described as wailing. The security guards used their full combined weight to keep him held down.

‘Bloody ice,’ said one of the guards. ‘Why do you do it to yourself, mate?’

But the young man was now sedated and unable to respond. A trolley was brought over, and the team lifted the man onto it and wheeled him back inside.

‘That’s a bit of excitement,’ said Tracy.

The blood he had passed a couple of hours earlier seemed to fade in significance as Jonathan sat in the Emergency department confronted by humanity at its sickest, humanity gone astray, humanity on drugs, humanity at its smelliest. This was not where he belonged; he was a different cut of person. He was revolted by the sights and smells. How did these people get to be this way? Jonathan’s life had not exposed him to the world’s underbelly. He believed that if you worked hard, you made it. People who failed, failed themselves through a lack of effort. This place was filled with human failure, and he did not like it one bit.

‘Let’s just go. Honestly, I’m fine now. I don’t need to see anyone.’

‘No,’ replied Tracy emphatically. ‘Let me check how long before you’re seen.’ She went up to speak to the clerk behind the glass, but she just said something about being busy. The clerk was experienced enough to know herself that Jonathan’s symptoms were unlikely to be immediately life-threatening, so the triage nurse could just get round to him in her own time. How important his board meeting was did not enter the equation.

Two hours later, the triage nurse came out and called his name.

‘Can I come in, too?’ said Tracy.

‘Why, can’t he speak for himself? I only need him for a moment.’ The nurse was not to be messed with. She was a big woman with cropped hair and skull-and-crossbones earrings. Tracy sat back down as her husband was led to the triage office. The nurse waved for him to sit and, without a word, dragged Jonathan’s arm forward to take his blood pressure. She unfurled the gadget from a hook on the wall and wrapped it around his upper arm. The pressure started to rise. He panicked for a moment that it was going to crush his arm.

‘So, what brings you in?’ she asked. She still had a stethoscope on and was letting the pressure down and taking his blood-pressure readings.

Jonathan related the events of the early morning: his bloodied urine, the clot, the second, slightly less bloody urination. He was halfway through the story when she rose and dismissed him from the room. She had gathered all the information she needed and had noted it down. ‘Haematuria. Vital signs OK.’ Now it was time to go and triage the next unfortunate. Jonathan could wait. There were far sicker cases to attend to.

He went back and sat next to Tracy. ‘She just took my blood pressure and said we have to wait.’

Tracy nodded, looking resigned. The morning show was now on the television. They were about to interview the health minister over the dramatic increases in waiting times to have elective surgery.

‘State health system in crisis’ read the title at the bottom of the screen. The minister came on and reassured the public that a task force would be established to look at the state of the health system and to make recommendations to the government on how to fix the problems. The minister was vitally concerned that all citizens must have access to a good, safe health system, one that met the needs of the whole population. Then it was on to an ad break.

Two nurses and a doctor had stopped to watch the interview. They looked disgusted by what they’d heard.

‘Classic buck-passing. Form another bloody task force. Can’t everyone see it’s just to get this issue off the front page? When are we going to have a minister with some spine?’ the doctor said, shaking his head with disbelief. ‘Look at these poor bastards in the waiting room. Not one of them is going to be looked after the way that bloody minister would expect to be if he came in here sick.’

‘What did you expect?’ said one of the nurses. ‘He wants to be re-elected. He’s not there to bring genuine reforms to the system. And even if he did, you doctors wouldn’t let him. Remember last year when I got that grant to improve the patient’s journey through the health-care system? You doctors torpedoed it.’

‘The doctors didn’t torpedo your project. Nobody understood what the hell you meant when you said you wanted to “improve the patient journey”. It was airy-fairy, hand-holding bullshit. The money all got frittered away on useless reports.’

The nurse shook her head with disgust.

Tracy got up and said to her, ‘Excuse me.’

‘Yeah?’ the nurse replied.

‘We’ve been waiting quite a while. Do you know when a doctor might see my husband?’ As Tracy spoke, the doctor edged away and the other nurse departed with him.

‘You’ll just have to take your turn, love,’ said the nurse, and she walked away rapidly to join the others.

Tracy turned around to see looks of quiet satisfaction on the faces of the patients who had been waiting all night. No one has any special rights here, lady, their expressions seemed to say. We all get treated like shit. Though Jonathan felt individual, he was but one of an ocean of patients using the Emergency department that day, and every day, in every hospital, in every part of the world.

From the time Jonathan gave his name at reception, he waited a total of eight hours before being seen by an Emergency doctor. By lunchtime, he had been beside himself with impatience. He had got up to complain several times about the wait. Each time, the clerk had said, ‘I’ll see what I can do,’ then she had got on with her work without a second’s thought about Jonathan. Tracy had called to cancel her clients and that night’s dinner. Jonathan had rung work to say he wasn’t coming in. He had tried to simply leave a message, but the receptionist had insisted on putting him through to his boss, Paul Carter, who’d been concerned about making sure his presentation could be handed over to someone else. Jonathan had suggested delaying the meeting, but Paul had insisted that this was not an option. If Jonathan was unable to be there, then Jake – Jonathan’s arch-competitor – would do the presentation for him. Jonathan had asked to be put through to his secretary and had given the necessary instructions somewhat reluctantly.

The board meeting was going ahead without him, and Jonathan was no closer to being seen by a doctor. He was tired of waiting, distressed at Jake stepping into his shoes and impatient to leave. On top of it all, everywhere he looked there were more off-putting smelly patients.

Tracy had sensed what he was thinking. She’d quietly placed her hand in his lap in a reassuring gesture.

It had been a further two hours before he was sitting on a trolley in the non-acute end of the Emergency department of the Victoria Hospital.

4

The doctor, who spoke with a heavy Greek accent, was a beautiful, fine-featured blonde woman dressed in a bright-red sleeveless short dress that accentuated the golden colour of her hair and the deep blue of her eyes, which must, thought Jonathan, give her an irresistible hold on almost every man who cast his fortunate eyes upon her. He was enthralled and was having trouble dragging his gaze away from her breasts. Her nipples protruded through her dress – she didn’t seem to be wearing a bra. She took a sip from a cardboard cup, and a little cappuccino froth stuck to her upper lip. Slowly, she licked it off, as if to tease her male patient into total slave-like submission.

‘So, tell me what happened,’ she said.

‘I’m fine, really. My’ – he was going to say ‘wife’ but changed course – ‘friend, partner, thought I needed to be checked out.’ He was trying so hard not to be a patient. He was at a bar, attempting to impress this magnificent creature before him.

To the doctor, he was the fiftieth patient she had seen since starting her shift early yesterday evening. The day intern, meant to take over from her, had not turned up, so she’d been forced to stay on and do a double shift. So far, she had declared four people dead on arrival, had lost another four and resuscitated more than 16. This man was quickly irritating her.

‘Allow me to judge whether you should be here or not. What is the symptom you have come in with?’ Her tone was terse.

‘Well, yesterday I bumped my back on the cupboard in the kitchen. I was on my way out to dinner. We had an award ceremony, and then, after that, I went home. Everything was fine, until this morning I woke up around dawn desperate to pee – urinate, I mean. There was blood in my urine. I urinated a second time, and there was still blood. But during today it’s settled, and there’s been nothing since.’

‘Has this ever happened before?’ She was already writing request forms for a full blood count, a study to make sure his blood was coagulating properly, an ultrasound of his kidneys and bladder, a mid-stream urine test to rule out infection and a test to check if there were cancerous cells in his urine.

‘No. Never,’ he said.

‘Any other illness? Heart, lungs, abdomen, et cetera?’ She glanced up at the clock – she had another three hours of her 24-hour shift to go and wanted this man out of her way.

‘Fit as a bull,’ he quipped.

She looked up at him, a pitying smile on her face. ‘Smoker?’ she asked.

‘Very little now. I used to smoke a lot, but I cut down about a year ago.’ Tracy was always on at him to stop.

‘OK. We’re going to run some tests, and then we’ll see what to do. I’ll also need to examine you.’ She wrote up the last of the forms in silence and stood up. ‘Please, you get into this gown. Take your clothes off first. I will return in a couple of minutes.’ She got up and drew the curtains around his cubicle.

He undressed but wasn’t sure what to do with his underpants. Should he take them off or keep them on? He always had this dilemma when he was having his occasional massages. If he took his underpants off, the masseuse could misinterpret that action as a request for something more than a platonic massage. However, if he kept his underwear on, then it was inevitably in the way and diminished that deep relaxation he yearned for. He had an image of the blonde doctor and decided to keep his underpants on, and his socks. After slipping the gown on, with the opening to the front, he sat on the edge of the trolley, attempting vainly to keep his front covered. He then remembered an article he had read in a trashy magazine about how keeping socks on was a turn-off for women, so he quickly took them off. He was half-thinking about maybe taking his underpants off as well when the doctor returned.

‘Lie down, please,’ she barked.

First, she took his blood pressure and pulse, then she parted his gown and examined his abdomen. She pressed deeply, giving him a strong urge to pass wind. He resisted, but only just.

‘Please roll over. I need to examine your back passage.’ She had already turned her back to him and was donning a rubber glove and opening a package of K-Y Jelly.

‘Is that absolutely necessary?’ he said.

‘Yes. Roll over.’

Jonathan Brewster reluctantly rolled over and pulled his underpants down gingerly.

The blonde beauty had a long and probing index finger. He winced, more with embarrassment than with pain. It was all over in a matter of seconds.

‘OK. I need to take blood,’ she said. There was a distinct smell of faeces in the cubicle now. This added drastically to Jonathan’s sense of embarrassment.

After putting on a new pair of rubber gloves, she put a tourniquet on his arm, tapped the skin a few times and decided on the vein from which she would harvest the blood. Seconds later, she had several full vials and was removing the needle from his arm. The curtain was pulled open abruptly. It was the nurse he had seen arguing with the doctor in front of the TV.

‘Corina, cardiac arrest in cubicle four,’ she shouted.

‘Please label these tubes for me, Vanessa.’ And with that she pushed aside the curtain and left.

Through the open curtains, Jonathan saw sights he had never seen in his entire life. The red beauty who was just at his side was now barking orders to staff at the cubicle directly opposite his. ‘Intracardiac adrenaline. Come on, hurry up. Keep that cardiac massage going!’

There was a woman who looked to be at least in her 90s. Jonathan could see that she had soiled herself. There was an awful stench spreading throughout the Emergency department. More sickening was the sound of her rib bones breaking from the cardiac massage. The grating, horrible sound made Jonathan gag.

A nurse handed the doctor a syringe, and she called out to the burly intern to stop massage, then plunged the needle into the front of the old woman’s chest.

‘Anything?’ shouted the doctor.

Silence. Then, the beeping that Jonathan had seen on a multitude of TV shows. The heart stirring to beat once again.

‘Yesss!’ The doctor looked immensely satisfied. ‘Keep her on the infusion and get her up to Coronary Care pronto,’ she called out to no one in particular yet to everyone in the cubicle.

Everyone was suddenly aware of a very old man standing at the doctors’ desk in the centre of Emergency.

‘Today was our sixtieth wedding anniversary. Is she going to be OK?’ He was distraught but understood that his wife had been given a reprieve. The Greek doctor had worked a Lazarus miracle.

‘Would you like to see your wife, sir?’ The intern, Charlie, was doing his best, but he had little experience himself of grief. During their intern year, medical students were transformed by their sudden confrontation with human suffering. It did one of two things to them: either filled them with intense compassion – the minority – or it hardened them so that they stood aloof to pain. Charlie was on the way to becoming one of the latter, who formed the majority of the health profession. The rhetoric was that you needed to be objective if you were to deal with the loss, grief, unfairness, sadness and pain that illness dished out daily, without fear or favour. The Emergency department was the feeder tube into the hospital and hence was a place of concentrated despair. He knew that, while the man’s wife was alive now, her cardiac arrest meant that she would probably be dead within a year.

An orderly came to see Jonathan. ‘I’m here to take you up to the X-ray department. You’re having an ultrasound of your kidney and bladder. Lie down, and I’ll wheel you.’

‘Thanks.’ Jonathan did as he was told, and the orderly elevated the sides of the bed and wheeled him out of Emergency down a long corridor to the lift, which took him up to the X-ray department. There, he was parked in a corner for an hour. Finally, a young adolescent – or so she seemed to Jonathan – came by and wheeled him into the ultrasound room.

‘Can you take your gown off, please? And your underpants?’ said the young woman. Jonathan appreciated the unambiguous instructions, which left no room for conjecture. ‘We need to do an ultrasound of your bladder. When was the last time you passed urine?’

It had been a few hours, which she said was good as it would make the pictures of his bladder more distinct. She spread copious amounts of sticky jelly over his flanks and his lower abdomen; the jelly was very cold and made Jonathan shudder momentarily. The young radiographer adjusted a few settings on her machine and then commenced, gliding the ultrasound instrument across his skin.

Jonathan lay there as the machine sent sound waves through his body and captured them again to form images of his internal organs – he remembered having it explained to him when Tracy was pregnant. It was really quite clever machinery, he thought. But why were they looking at his bladder when it was his kidney he’d bumped? The darkness of the room and the quiet noises of the machine were soporific. His mind floated back to his home, the award ceremony last night, his mother-and father-in-law, who were minding the girls. He recalled giving his speech and wondered whether he had done well. The radiographer pushed some knobs on the front of the ultrasound machine. Then, with her left hand she moved the ultrasound gadget directly over his pubic bone while twirling knobs on the machine with her right. It was like watching a conductor controlling an orchestra.

The door to the room was flung open, snapping Jonathan out of his reverie. He quickly tried to find something to cover himself with, as an old man wearing spectacles entered the room. He ignored Jonathan and directed his gaze straight to the ultrasound monitor.

‘What have you got so far?’ the man asked.

‘His kidneys seem to be OK, doctor. I’m just doing the bladder now. Uh-oh. What do you think that is?’

‘Go back over the right lateral area again for me,’ the doctor directed.

‘Over here?’ she said.

‘Yeah, that’s the interesting bit. Yes, it’s definite. Take a picture of that. Make sure there’s nothing else on the left as well.’ The doctor turned to leave.

Jonathan could stand it no longer. ‘What can you see?’ he asked. ‘Is there something I should know?’

‘Don’t worry. We’ll send the report down to the doctor in Emergency, and they can sort it out there. Just relax. Enjoy the attention.’ The old man was gone.

‘Who was that?’ Jonathan asked.

‘Chief radiologist on duty,’ said the young woman, her eyes still firmly on the screen. Every now and then, she would press a switch with her foot and he would hear a high-pitched ping. Each ping signalled the capture of a picture, a small part of the overall jigsaw.

About an hour later, Jonathan was back in the Emergency department; he asked a nurse if Tracy could come in and sit with him. When the nurse returned from the waiting room, she said, ‘There’s no one out there called Tracy.’

‘She must have gone home to the kids. Can I use a phone, please? Tracy has my wallet, and I don’t have any change for the phone.’

‘Yeah. Just wait a moment and I’ll see if I can bring you the cordless.’

An hour later, there was still no phone, but the doctor in red reappeared. ‘Look, we have all your results now. You have something in the bladder. Maybe tumour, maybe stone. I spoke to the Urology registrar, Dr Khadra. He’s going to come down and see you. He’s just finishing a case in theatres and will be here after that.’ With that, she was out of the cubicle.

It had been over 30 hours since I had arrived at the hospital to begin my shift, and Jonathan was my last patient before I could go home, assuming no others came in. The old aphorism of ‘knife before wife before life’ had been drilled into me well. There was no question of my asking for time off on the grounds that I hadn’t slept for a couple of days. My super vising specialist would have simply laughed as my career disappeared down the plughole.

One of the surgeons had visited the British Surgical Meeting earlier that year and had come back with news of a growing push in the UK for safe working hours among doctors. The surgeon was brave enough to report this to the main weekly meeting of doctors at the hospital, Grand Rounds. The meeting had erupted with laughter and derision. The pain in my back and legs was suddenly telling me that maybe safe working hours were not such a bad idea. However, I would never have voiced that to anyone lest I lose my job or be thought of as lazy or soft. General practitioners and dermatologists can opt for lifestyle, not surgeons. Surgeons surge and physicians fizz. Safe working hours, what a joke. They will never implement or allow it, I thought. I turned my attention back to the patient at hand.

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.

5

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 treatment 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.

6

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.

7

Jonathan got himself to work early and answered his messages. All the while, he was looking up at the clock. At 9.01, he rang the urologist’s rooms, which he had established were located not too far from his office.

‘Our opening hours are eight-thirty to five o’clock, Monday to Friday. If you have an emergency, then please go to your nearest …’ The voice changed from a recording to a real person, a young woman. ‘Hello? Hello? How can I help you?’

‘Hi, I need to make an appointment,’ said Jonathan.

‘Can you hold for a moment?’ the receptionist said and was gone before Jonathan could say, ‘Well, I’m in a bit of a hurry.’ He was left listening to Big Ben-type chimes: four notes played in a variety of sequences, over and over again. Jonathan heard several renditions, and each time he got more agitated, more upset.

‘Hello, have you been attended to?’ It was a different voice this time.

‘No. I’m trying to make an appointment. I have blood –’

‘Just hold the line. Shouldn’t be much longer.’ Big Ben played its tune again. Several minutes passed.

‘Hello. Were you waiting to make an appointment?’ The first receptionist was back.

‘Yes, please.’ Jonathan sounded exasperated.

‘When would you like to see the doctor?’ she said.

Jonathan consulted his diary. ‘Look, I have a spot between three and four this afternoon. I also have an opportunity around six this evening. Any of those times suit?’

There was silence. The girl tittered. Jonathan was confused.

‘I meant do you prefer a morning appointment or an afternoon appointment? The first available slot is in three months’ time. I can give you mornings or afternoons from then on.’

The girl waited.

‘Are you serious? Surely I can get an appointment sooner. It’s pretty urgent. I’ve had blood –’

‘What do you want to do? I have other patients waiting,’ she said.

‘Well, what choice do I have? I’ll take the earliest available afternoon slot, I suppose, but it’s not exactly … well …’

‘Not a problem. I’ll post you an appointment card with the details. Please bring with you all the X-rays, blood-test results and any other tests you’ve had. Make sure you also bring the referral. There will be a charge of a hundred and fifty dollars, payable on the day. Thank you.’

It was well rehearsed. Jonathan hung up the phone with resignation. The rest of the day, he dodged comments from his colleagues.

‘Are you OK, mate?’

‘You look fine.’

‘I’m sure this is nothing.’

‘A friend of mine had blood in his urine – turned out to be nothing more than an infection. These days, they can cure anything.’

With each reassurance, Jonathan became more worried. He rang his wife. ‘Trace, the specialist can’t see me for three months.’

‘Oh, babes, that’s crazy. I thought going private made it quicker? You can’t wait that long!’

‘I know, it’s nuts. Do you have Brian’s phone number?’ he asked. They’d met Brian, a radiologist, at a party some months ago and had gone to dinner with him a couple of times since. He was more than a radiologist: he was the head of the radiology department at another big hospital.

‘Good idea. He might know how to get you in sooner.’ Tracy gave him the number, and Jonathan called straightaway and related his story.

‘Oh, God. You don’t want to see that doctor anyway,’ said Brian. ‘She’s hopeless. They’ll only have referred you to her because she’s on call this week, so she automatically gets all the Emergency patients with urological problems. Let me make a call and get back to you. I know a good urologist: Derek Johnson. Let me see if I can pull a few strings for you.’

An hour later, Brian rang back. ‘I’ve got you an appointment next Monday at ten o’clock. Make sure you tell Derek you’re a friend of mine.’

‘Thank you so much, Brian. I don’t know how to repay you.’

He was genuinely grateful to Brian for helping him get an earlier appointment; a feeling of relief washed over him. Leaning back in his chair, he thought to himself that the health system was quite corrupt. It was about who you knew. Well, he was glad that he knew someone who could steer him through it.

The rest of the day, and throughout each of the ensuing days, he tried to get on with his work, but his mind kept returning to the blood, the hospital and the doctor’s words: ‘Maybe tumour, maybe stone.’ So it really could be a tumour, he thought, and then quickly told himself, but tumours aren’t always malignant. The sites he found on the internet, though, all featured the word ‘carcinoma’. What did that mean? Wasn’t that cancer?

8

Jonathan sat in the doctor’s waiting room enjoying the classical music coming from the CD player in the corner. It was soothing – just what he needed. He loved music and had an eclectic taste, acquired almost entirely after he’d left home and was no longer under the control of his father. He remembered the trouble he got into at home once for buying a record, Pink Floyd’s Dark Side of the Moon. It was as if Jonathan had taken up devil worship. Even classical music was not tolerated by his father.

‘God made music so that we can worship him with it, not give ourselves pleasure!’ his father had declared after he had belted the boy and confiscated the LP. Jonathan had grown up in the shadow of his tyrannical father. Staunchly religious, his father had no time for anything other than working hard and praying hard. The only songs they played at home were hymnal songs of praise. The only art was devotional. It was not until Jonathan, an only child, rebelled at the age of 16 and left home that he was able to make his own life. To this day, Jonathan and his father had not talked about the conflict. They had started seeing each other again after the birth of Jonathan’s first child, Emma, and were now cordial, if terse and tense.

It was not that Jonathan was anti-religious, more that he didn’t believe in the God that his father espoused: a fearsome God who destroys towns that do not obey his decrees; a vengeful God; a jealous God. Surely this was just man-made religion. Surely, infinite wisdom, mercy and grace did not come from a judge sitting on a throne deciding whether, on the basis of your conduct, you should spend eternity having your flesh burnt off your body or surrounded by angels playing harps. This was not a God that Jonathan could believe in, could pray to, could ask for help.

‘Brewster? Mr Jonathan Brewster?’

Jonathan looked up from the old magazine he was reading to see the doctor standing beside the reception desk with a file in his hand. He was a middle-aged balding man with a slight paunch. He had a kindly face and a prominent nose. Nice suit, Jonathan thought as he stood up and followed the doctor into his consulting room.

‘Please come in.’ The doctor’s voice was soft but firm.

He sank into his leather chair and signalled Jonathan to sit down. ‘So, tell me what happened,’ he said, staring down at the notes, test results and referral before him on the desk.

‘I’m sure I’m wasting your time, but last week I woke up with this intense need to pass urine, and then I went to the toilet and passed a lot of blood. It happened twice, and since then everything’s been fine. Nothing like this has ever happened to me before.’ The doctor continued to look down at the paperwork in front of him as Jonathan continued: ‘I went up to the hospital and had all sorts of tests and X-rays, and then they said I needed to see a specialist, so here I am. They said it could be a stone or maybe a tumour. I read a bit on the internet and saw something about carcinomas.’

‘Well, yes. It could be a lot of things. The most worrying thing is this appearance on your ultrasound. Let me show it to you.’ Derek Johnson stood up and turned on the X-ray viewing box on the wall, above his chair.

Jonathan had only heard one word: ‘worrying’. Did he say ‘worrying’? What does he mean, ‘worrying’? What does it mean when a doctor uses that word? He focused his attention back onto the conversation.

The doctor pointed at a grey area on the ultrasound and said, ‘See this part here? Can you see how the bladder curves around but it’s interrupted by a protuberance from its surface? That looks like it could be a tumour.’

‘A tumour? So do you think this could be a cancer?’ said Jonathan disbelievingly.

‘I’m afraid so.’ Derek looked at the patient now, waiting to see his reaction. If he sensed that the fellow was not coping with the news, he would soften his next words. If he felt that he was coping, he would keep going.

Jonathan was struggling to take it all in. Cancer. Tumour. Bladder. ‘So, what do you need to do next?’ he asked, trying to appear composed despite the tide of anxiety he could feel rising within him. He wanted to cry. Sensing his lower lip beginning to tremble, he bit it to keep it still.

But Derek had picked up on the signs of sheer fright. This bloke is a wimp, he thought. Better keep it short and not too involved. ‘Well, we need to get you admitted to perform a cystoscopy. That’s a procedure where we insert a telescope with a light on the end of it into your bladder, and then we check out the appearance of this growth and take some biopsies. If it’s possible, we can resect it away at the same time. There are some possible complications. You can bleed afterwards. Of course, you do have to have a general anaesthetic, so you can have a heart attack, a stroke and a thousand other problems. If you are happy, please sign here.’ This was called an informed consent. Derek Johnson could remember a time when patients just trusted their surgeons to do what was right. Now, with the increasing litigation problem, one had to spell out all the side effects of an operation to the satisfaction of the patient, explain the reasons for having the operation, the consequences of not having it and answer every question the patient asked. Derek thought this to be a waste of time, and his consent talks had remained fairly perfunctory. He had read the literature that suggested that no matter how much time one spends on a consent, patients remember less than ten per cent of what they are told in a consultation with a doctor.

This certainly applied to Jonathan, who had stopped listening after the words ‘insert a telescope’. ‘Is this serious, doctor?’ he asked.

Derek had been asked that question a thousand times. He never knew what to answer. What he wanted to say was, ‘Well, if you consider having a growth in your bladder that could cause you to die serious, then, yes, it’s serious.’

Instead, Derek said, ‘The vast majority of these tumours are superficial. Once we resect them from your bladder, then that is usually all the treatment they need. You will need to be monitored afterwards, however.’ It was the prerehearsed answer he gave every patient who asked this question. ‘By the way, are you in a health fund?’ he asked casually.

‘No. Why? Does it make a difference?’

‘Well, only in so far as if you had private health insurance I could get you into a private hospital this week and do your operation straightaway. Of course, in that case I would do your operation. Otherwise, I can put you on the waiting list at the Victoria Hospital and we can take our chances,’ the doctor said matter-of-factly.

‘When you say “take our chances”, doctor, do you mean as to how long we wait or who will be doing the operation? I’ve heard that if you go to the public hospital, it’s probable that a trainee would be doing the operation.’ Jonathan had read the horror stories in the papers about unqualified trainees doing operations for which they were not competent. Derek Johnson enjoyed these articles because they increased his private practice considerably. He earned a lot more per operation in the private hospital than he did in the public hospital, so the more patients who took out private insurance or paid for their own operations in the private hospital, the more profitable it was for him.

‘Well, it is a teaching hospital, and hence the trainees have got to learn.’ He smirked as he said it, knowing it was the type of statement that frightened the patients into paying. ‘I am the supervising surgeon at the Victoria Hospital, though, so at the very least I will be there to oversee the operation.’

‘Can I pay for you to do my operation privately?’ asked Jonathan.

‘Absolutely. Yes. My secretary can give you a quote, and you can decide which way to go. Do you have any other questions?’

Jonathan’s mind was a blank. He wished he’d taken Tracy up on her offer to come with him. She would’ve known what to ask. She would’ve known what to say and do.

Still numb with the shock of it, Jonathan left the doctor’s room and went and waited for the secretary, who was dealing with another patient.

‘So, is the doctor taking out the stitches in your penis today?’ he heard her ask.

‘Yes. He said to come back today to have them taken out.’ The man’s face flushed red as he looked around the waiting room and realised that there were ten other patients engaged intently in this conversation about his penis. Now that the secretary had broadcast his private details throughout the waiting room, did everyone realise he’d had a penile prosthesis inserted and was here to get instructions on how to inflate it, ready for use?

‘Take a seat, then. I’ll check with the doctor.’ The man sat down. The secretary now turned her attention to Jonathan.

‘Yes?’ she said.

‘The doctor said that you might be able to give me a quote on having my operation in the private hospital.’ Starting to get embarrassed as well, Jonathan was whispering.

‘Did he say which operation you were having?’

‘Yeah, the one where they stick a camera up the … up the, um, you know, to look inside the blad–’

‘A cystoscopy?’

‘Yeah, I think that’s the one.’ Jonathan nodded, his face now as red as the previous patient’s.

The secretary turned to her computer, found the right file and printed it out. She handed the information to Jonathan. ‘Have a read and let me know,’ she said. The vast majority of patients baulked at the cost and ended up going public. She gave Jonathan the forms for the public hospital as well.

The quote for the surgery was huge, but Tracy was insisting that Jonathan go to the private hospital.

‘Honestly, I think I should just wait and have it at the public,’ he told her firmly over the phone from his office. ‘He said that most of these growths are very superficial and cutting them out is enough.’

‘Well, if you think that’s best. God, if we’d only bloody signed up for health insurance. When does he think you’ll get in if you go public?’

‘I don’t know when he can get me in.’

‘Don’t forget about our holidays, Jon.’ Her tone was alarmed; she’d fought hard to get him to book some time off work.

‘Yeah, I’ll tell his secretary to avoid that week, but surely I won’t have to wait that long anyway – our holiday’s months away. Is there anything else on our calendar that’s unchangeable? OK, Trace, I’ve gotta go now. I’ll let you know later.’

His in-tray was piled high, and he’d missed three meetings that morning – important meetings that influenced major projects he was working on. The sooner this thing is treated and I’ve put it behind me, the better, he thought.

He dialled the doctor’s surgery and told the secretary he would go public. The wait, she told him, was going to be about two months.

‘Jesus Christ! This thing could be a cancer!’

Jonathan heard only silence from the secretary for a few seconds, and then she spoke, slowly and firmly: ‘Mr Brewster, I’m not the one that determines who gets in and who does not. You take your turn, and they call you when they have a spot.’ Jane handled calls like this every single day from patients who were concerned about when they were going to get their treatment. At 22, she wondered whether she would be better off finding a job where her major concern could be like some of her friends’, such as whether her nails had chipped on the keyboard that day, rather than the pain of the doctors’ cancer patients – the type of pain that makes a person wish for death; the type of pain that hollows out a man and creates, instead, a walking skeleton. Jonathan was deeply worried and concerned, yet to Jane he was but one of many callers in a similar – or worse – position. Though she hated to admit it to herself, he was just another irritation for her to endure before 4.59, when she could switch off the computer and turn on the answering machine.

‘OK, thanks for your help.’ Jonathan hung up.

He was to repeat this conversation several times over the next few weeks. Several times, he had a strong urge to pay to go private, but he and Tracy had never been good with money. While he had a substantial income, they had huge expenses. To any who observed them, they must have seemed comfortably off, but the reality was that they spent more than they earned and had borrowed a lot. There were payments to make on the house, school fees, credit cards, entertaining and good clothes. Every now and then, they would go on a budget. Then they would need a holiday or a new table for the dining room, and another credit card would be filled. Banks were fighting to give them more credit cards and higher limits, and Tracy and Jonathan were only too happy to accept the next level of American Express torture or the Platinum Mastercard.

They had certainly not saved anything for a rainy day. Jonathan’s father had been strict with money, and as an adult Jonathan had rebelled, becoming a spendthrift. Now that he was making some real money, he wanted his girls to have everything that he hadn’t as a child.

A couple of times during those weeks of waiting, his urine was pinkish. He missed several more meetings at work, and the pile in his in-tray grew. People were starting to get irritated at his inefficiency, and Paul asked weekly what date he would be going to hospital to get his operation done.

Frustrated that Jonathan couldn’t give him a definite answer, he said, ‘Well, for the time being, make sure you hand those big projects to Jake. We really want you to get well, and I don’t want any added pressure on you right now.’ How kind his boss was being.

It was seven weeks later when the call finally came from the Admissions department, and by the end of that week, at 6.30 am, he presented himself at the Victoria Hospital.

The admissions procedure made him feel much like he was in a mob of cattle at a sale yard. Instead of his skin being branded, he had plastic bracelets fitted to his wrist and to his ankle. Is there a chance of my arm and my leg being separated? he thought. He answered the same questions several times on a multitude of coloured forms. Each time, a different clerk, nurse or intern went through the same routine. Why are you here? What operation are you having? When did you first notice the blood in your urine? Are you allergic to anything? Are you on any medications? Jonathan became irritated. Why did they need the same information a thousand times? He hadn’t seen Derek Johnson since the consultation in his rooms, and he needed to ask him some questions about the operation and about his recovery afterwards. Derek was nowhere to be seen. In fact, he wasn’t even in the hospital yet; he was still doing his ward rounds at one of the three private hospitals where he also had patients admitted.

Tracy was getting the girls ready for school. Her mother would come over in the afternoon to look after them so Tracy could come and visit him, but for now he was all on his own and could merely fume inwardly.

A nurse who had a manner that made her seem better suited to working for the Gestapo told Jonathan to remove his clothes and handed him an antiseptic wash. She instructed him to wash himself with it, then get into a white gown and come back and wait to be called. Jonathan obliged, walking into the bathroom and locking the door behind him. Immediately, he noticed the brown stains on the shower curtain, the streaks of faeces in the toilet and the tap dripping into the sink, forming a green stain. The floor was slippery, and he noticed a clump of hair stuck to the tiles in the corner, as if a mop had been used to paint the floor with grime rather than to clean it.

He was glad he hadn’t eaten since last night or had any coffee that morning, on orders from the doctor’s bitch secretary, because he now felt nauseous. He dry-retched into the toilet, took his clothes off and placed them in the paper shopping bag he had been handed, and stepped naked into the shower. Adjusting the temperature proved almost impossible as the slightest movement of the tap made the water alternate between scalding hot and freezing cold. The antiseptic cream was difficult to lather, but he spread it around himself as best he could. He placed a large amount of it in his palm and spread it over his genitals and into his buttocks, around his anus, as the nurse had told him to. Once he’d rinsed and dried himself with the hand towel he’d been given, he donned the gown and an elasticised hat and went back to the Urology waiting room.

The nurse came back soon afterwards. ‘OK, so you’re having a gall-bladder operation today –’

‘No. I’m having a cystoscopy,’ he cut in quickly. If only Tracy were here to share his disbelief.

‘Oh, the ward clerks have typed up the wrong operation on the sheet. Hang on, and I’ll get it corrected. You had a shower for nothing. But it won’t do you any harm.’ With that, she bustled off.

The anxiety Jonathan was already feeling about going under the knife had rapidly escalated. How could they get his operation details so wrong? How could they make an error of this magnitude? He even started to worry about whether he smelt. Otherwise, why would she say the shower wouldn’t do him any harm? What an odd thing to say. He sniffed under his arms, but all he could smell was antiseptic soap.

Just then, he saw Derek appear at the reception desk. ‘How are the troops, sister?’ he asked one of the nurses sitting doing her paperwork.

‘Sorry, are you talking to me?’ she asked.

‘Yes. How were my patients overnight?’ he said, frustrated.

‘Do you mind asking someone else? I’m in a hurry to finish my shift. Who are you, by the way?’

She was one of the agency staff that public hospitals relied on. With a worldwide nursing shortage, there weren’t always enough nurses to stand in for those who were away on sick leave or holidays. Private agencies had been established that would, at a moment’s notice, send a nurse to cover a shift. The problem was that the agencies paid far more per shift than the hospitals could afford to pay their full-time nursing staff, so a large number of nurses resigned from their hospital jobs and joined agencies, to earn better salaries. The hospital system had been plunged into a downward spiral of inefficiency and escalating costs due to their larger and larger nursing bills.

It was impossible to maintain esprit de corps on the wards because there was only a small group of permanent staff. As more of the staff became disheartened, more would leave. Administration would appoint some of the nurses as managers and task them with trying to work out why there was a problem with understaffing, which of course added to the problem of understaffing.

Exasperated, Derek reached for the notes trolley and started wheeling it around the ward. The team’s junior resident, Damian, was in the second room.

‘Hello, doctor. I’ve just finished seeing your patients. Everyone’s fine,’ said Damian assuredly, aiming to please.

‘Where is Mohamed? Did he see the cystectomy from yesterday? Is there much in the drains?’ he asked.

‘Three hundred and fifty mls in the right one and about two hundred and eighty in the left. He said to leave the drains in. Is that OK by you?’

Derek nodded and asked, ‘How about the prostate in bed three, the old man?’

‘Do you mean Mr Frederick?’ Damian said, reaching for the notes.

‘Yeah, I think that’s his name. The old fellow that was admitted over the weekend in retention.’ Derek was becoming impatient with having to deal with the junior.

‘Yes, sir. He’s voiding well and is continent. We were going to send him home today. Do you want to see him?’ Damian knew the answer before he asked the question. Derek rarely saw the public patients; it was left to the registrars to manage them. His definition of training and teaching was to let the registrars do the work and learn by experience. Public patients, as far he was concerned, needed to accept that the trainees had to perform their operations on them to gain vital first-hand experience. He only stepped in if there was something that the registrars couldn’t handle.

‘No. If you’re happy, then I’m happy.’ He smiled, turned and headed for theatres.

Surgeons are often criticised for their habit of referring to patients by their disease: ‘the prostate in bed three’, as Derek said, or, as a doctor in another ward might say, ‘the liver in bed eight’ or ‘the spleen in bed 16’. It is sometimes held up as a failure of compassion or a coldness on the part of the medical profession. The alternative is to refer to Mr Jones who is worried sick about dying from lung cancer and has three children, a sister and a wife depending on him. For most doctors, it was far preferable to keep a distance and refer to him as ‘the lung cancer in bed five’. Derek was a firm believer in this system. He believed it meant his treatment was not hampered by the soppy and weakening effects of being reminded that his patients were human beings after all.

The male change rooms were the usual mess, with bloodstained theatre garb overflowing from the laundry baskets. Derek found a spare clothes hanger and started to change. There was a knock at the door. It was Elizabeth, the anaesthetist.

‘Are you dressed, Derek?’ she asked from behind the door, which was ajar.

‘Yes, Elizabeth. What can I do for you? Have you decided you can’t resist my body any longer?’ He was always taking his bantering to the edge.

‘Your patient, Jonathan Brewster – he wants to speak to you before the operation. He has some questions. What do you want me to tell him?’ She knew that Derek hated talking with patients before their operations. He believed that by the time they got to theatres, they should have asked all the questions they wanted to ask.

‘Which one is he? Is he the bladder cancer?’ he shouted through the door.

‘Yes. The youngish man.’

‘OK, I’ll come and speak to him. He’s one for the registrar to do, though. I was hoping Khadra would do him, but it looks like I’m stuck with Damian.’

She was gone down the corridor to see Jonathan and reassure him that his surgeon was coming to speak with him. Derek walked in shortly after her.

‘Hello. You had questions?’ he asked, curtly.

‘Hello, doctor. Yes. Um … will you be in to see me after the operation to tell me what you found?’ Jonathan’s nervousness was apparent in his voice. He had been lying on the trolley in the anaesthetic anteroom for over an hour waiting his turn. So far, all that had happened was that the anaesthetist had placed a cannula (the plastic tube used to keep a passage into the blood supply open) in the back of his hand and had flushed it with some sterile saline. His heart was racing, and his mouth felt like the bottom of a parrot cage.

‘Look, I’ll try and see you, but sometimes they send you home before I have a chance. My resident will definitely come and see you. I’ll get the result of the biopsy within a week, and I would like you to make an appointment and come and see me then, if you don’t mind. OK?’ And, with that, he placed his mask on his face and passed through the door to the operating theatre.

Elizabeth injected Jonathan with midazolam, a sedative with amnesic properties, and thereafter he would remember nothing else. He was wheeled into the operating theatre, where Don McLean was blaring from the CD player in the corner. Derek was on the computer checking the New York closing prices. Damian was scrubbing. The nurses were preparing the instruments. The orderlies moved Jonathan onto the operating table. Soon after, he was connected to a number of monitors, then Elizabeth worked one of the miracles of modern medicine by injecting him with drugs that would render him unconscious for just the right amount of time needed to perform the lesser miracle of surgery.

Jonathan was now exposed from the waist down. The orderlies raised his legs up in the air and attached them to stirrups. Thankfully, he was asleep.

Damian walked in drying his hands, then donned a sterile gown. He reached unconsciously for the iodine disinfectant and slopped the liquid over Jonathan’s exposed skin.

‘How was your birthday party on the weekend, Lisa?’ He was addressing the scrub nurse.

‘It was a hoot, Damian. You should have been there. We waited for you,’ she said.

‘I was in here all bloody weekend. Torsion after retention after stone. It was just never-ending.’

He placed sterile drapes around Jonathan’s legs and abdomen, leaving his genitals exposed, then connected the cystoscope to a supply of clean water.

‘Ready to start, Elizabeth?’

‘Go ahead. Thank you for asking.’ She gave him a smile. Anaesthetists loved to be asked whether it was OK for the surgeon to start. It was a sign of respect and allowed them to be prepared.

Damian inserted the long metallic scope through the meatus – the eye – of Jonathan’s penis. Images from the tiny television camera attached to the end of the scope were shown on a screen visible to everyone in the theatre. First the urethra, the long tube through which urine comes down the penis, could be seen. Then the prostate, a little bit obstructive, and then the big dark chasm that was the bladder came into view. Damian drained it of urine and then expanded it again with water. He examined first the left side. There was a bright stain on the wall, like a patch of red carpet. Next he looked at the right side. Here a large cauliflower-like growth bobbed in the fluid.

‘He’s got a bloody big tumour here, doctor,’ he called out to his boss.

‘Yes, the ultrasound and the CT scan he had confirmed quite a nasty one. It looked to me like it might be invasive,’ he said as he left the computer and came to look over his resident’s shoulder at the television screen. ‘Has he got any carcinoma in situ as well?’

‘Yes, over on the left, I think.’ He moved the camera to show his boss the red carpet-like lesion. The red patch was made up of sheets of aggressive cancer cells that had not yet formed into clumps or masses but were just as dangerous.

‘Resect the tumour right down to the muscle, and then take biopsies from the left lateral and from the prostate as well. This guy might end up losing his bladder.’ He turned and left the theatre to go to the tearoom. That was all he needed to do there; Damian could finish the case, then start on the next one and call him in for that.

‘It’s pretty big.’ Damian hadn’t seen too many tumours in his life; this was a big operation for him as it was only his first year in Urology. He was hoping to get onto the training program next year.

‘You’ll be right,’ said Derek on his way out the door.

Damian removed the cystoscope, unscrewed the camera and screwed on a different kind of instrument, a resection scope, which would allow him not only to see inside the bladder but also to operate on it.

Near his foot were two pedals that controlled the resection scope. If the surgeon wanted to cauterise tissue – burn it – he pressed the left pedal with his foot. If he wanted to cut it off, he pressed the right one. What Damian didn’t know was that when the nurse who had set up for the procedure had connected the scope to the diathermy machine, which produced the electric charge necessary for cauterising, she had accidentally reversed the pedals.

Part of the tumour was in Damian’s sights on the screen. It was so big that he couldn’t see the whole of it at any one time. He went to begin cutting, by pressing down on the pedal on the right. There was a lot of smoke and boiling in the bladder, but not much happened to the tumour.

‘It looks like the left and right pedals have been reversed,’ he said, to no one in particular. He adjusted his stance and started again, this time pressing his left foot down. It felt odd to be using the wrong foot, but it worked properly this time. Slowly, he moved around Jonathan’s tumour, carving small portions of it away. Every now and then, he would stop to empty the bladder of all the bits of tissue that had accumulated. These would be collected and sent to the pathologist for analysis to see what type of tumour they were dealing with.

Damian, who was in his second year of surgical training, having completed his necessary year of internship, spent a lot more time picking out his next female companion than studying his books. For that reason, his theoretical knowledge was deficient – but he was great with his hands and was going to be a great surgeon one day, in keeping with the aphorism repeated throughout the medical profession: a physician is someone who knows everything but does nothing; a surgeon is someone who knows nothing and does everything; a pathologist knows everything and does everything, but always too late.

Damian had reached the base of the tumour. Reminding himself that today the left pedal was for cutting, he took one more slice – and suddenly cut across a large, pulsing arterial bleeder. He immediately had a ‘red out’. Fighter-jet pilots use the term when G forces drop so low – when the plane makes a sudden dip, for instance – that blood infuses their brains and they start to have blurred red vision, just before they fall unconscious. Urologists call it a ‘red out’ when bleeding in the field of operation overwhelms the water or other clear fluid being used to irrigate the bladder, so you see nothing as you operate, apart from bright-red blood. It’s very frightening unless you have well-defined procedures to find the bleeding point and cauterise it. The heat immediately seals the flesh and stems the blood flow.

‘Please call in the surgeon,’ Damian said in a tense voice. The unscrubbed nurse ran to the tearoom in search of Derek Johnson.

Damian started to see if he could identify the source of the bleeding. He emptied Jonathan’s bladder, and almost pure blood drained out. He then asked the anaesthetist to raise the pressure on the irrigation, and then slowly and steadily looked around the edges of the wound he had created while removing the tumour. With the increased irrigation pressure, he could just make out the lining of the bladder, and after several bladder-emptying manoeuvres he found the bleeding point. He steadied the resection scope, preparing to cauterise it, just as Derek came into the room.

‘I have found the bleeder,’ Damian told him.

‘Well, what are you waiting for? Buzz it!’ barked Derek. He wasn’t happy about having his conversation with the newly appointed professor of surgery cut short in the tearoom.

Damian steadied the cystoscope again and quickly pressed the left pedal to cauterise the bleeder. Simultaneously, two things happened. He realised that he had pressed the cutting pedal instead of the cautery pedal, having reacted instinctively. The second was that, once again, there was a red out. This time it was almost purple.

‘Oh, fuck!’ shouted Derek, and he went to get scrubbed to take over from the young registrar.

Damian was struggling. He looked up at the anaesthetist Elizabeth, who was checking some blood that she had asked for from the blood bank as soon as he’d hit the arterial bleeder. She was a great anaesthetist.

‘Don’t worry. It can happen to anyone. He’ll fix it,’ she said in a calming voice.

Derek came back in, his gown half-hanging off him. The nurse was trying to do up the back of it as he sat down and took over the resection scope from Damian. He found the bleeder and pressed the left pedal down. The cutting came on again.

‘Who the fuck reversed the polarity on the foot pedal? Reconnect them, please. I need them in standard configuration.’ He knew he could adapt, but he also knew that in the heat of the moment, when the blood and shit hit the fan, things needed to be the way they were designed to be. Not reversed. Not different. Just the way they were designed to be. He hated any changes when operating, be they to his operating team, the instrument layout or any other part of his theatre, let alone left and right pedals being swapped. Meticulous attention to detail was how patients had good outcomes, but young doctors and nurses didn’t seem to understand its importance. What he didn’t seem to realise is that he should have remained in the theatre in the first place, leading by example, rather than working on his political agendas in the tearoom.

Derek found the bleeding point and cauterised it; the bleeding stopped almost immediately. The irrigation won against the blood, and the image on the screen was clear again. He quickly finished the resection, took the biopsies he needed from the other side of the bladder and prostate, and took out the scope. Minutes later, a catheter was inserted into Jonathan’s bladder and he was transferred to the recovery suite by the anaesthetist, none the wiser to the dramas that had threatened to take his life.

9

‘I can’t breathe … I can’t breathe!’ Jonathan was shouting at the top of his voice in the recovery unit.

‘I have a doozy here,’ the nurse attending him said to the nurse in the next cubicle. ‘It’s OK. Just try and relax, and breathe normally,’ she told him in soothing reassuring tones.

‘Please let me sit up. I need to urinate. Help me, please.’ Jonathan was in a blind panic. The pain in his groin was unbearable. He felt as though he was wetting himself.

‘Can you come with me to check some drugs, Susan?’ she asked her neighbour. Nurses had to visit the drug cupboard in pairs, so there was always a witness to the exact drug and dosage taken, to avoid abuse by staff. It was not uncommon for narcotics to go missing. Seconds later, she was back with a sedative and a narcotic to subdue Jonathan’s pain, his anxiety and his complaints.

‘I really need to urinate. Please. I’m going to wet myself.’ He was still shouting but more slurred than before.

‘You have a tube in your bladder collecting your urine. It just feels like you need to urinate. Just calm down,’ the nurse said, with a slightly sterner edge to her voice.

Jonathan got up on one elbow, threw off his sheets and looked down to see a plastic tube emanating from his penis. The tube seemed to contain two different passages, as bright-red fluid was draining from it while a clear fluid was passing into it from a bag hanging on a stand nearby. He felt faint and fell back onto the bed. The sedation was beginning to work, as was the narcotic.

A couple of hours later, he awoke in a ward. Tracy was sitting in the chair next to his bed, sleeping. He grunted, and she immediately woke and sat forward, a concerned look on her face.

‘How are you feeling, darling?’ she said. ‘Any pain?’

‘Not really … only if I move, and then the tube seems to dig into my bladder. What did the doctor say?’

‘He hasn’t been around yet. The nurse said he comes in only after he’s finished in theatres.’ Tracy had checked several times, but no one knew anything more about Derek Johnson’s movements.

Jonathan looked around the room in a dazed state. There were three other beds. Opposite him was an old man who was making a gurgling noise. He breathed through a tube inserted through a hole in the front of his neck, and it seemed from the spluttering noise he was making that there was a plug of mucus blocking it. Every now and then, he would try to force the mucus out of his breathing tube through the hole in his neck, to no avail. The curtains of his cubicle, his pyjamas and his sheets were covered with little spots that looked like moths from a distance, but the reality dawned on Jonathan that they were previous mucus plugs.

Next to him was a young teenage boy with a broken arm. Tracy whispered to him that she’d heard he had been waiting for three days for a plate to be inserted into his arm by an orthopaedic surgeon, but other cases had kept coming in that were more urgent. A white substance was scattered over his bedsheets, which at first Jonathan couldn’t make out – it turned out to be plaster from several days previously when they’d put on a temporary cast to stabilise his fracture. Nobody had changed his sheets since then, and, to top it off, he was still in the school uniform he was wearing when he was brought into the hospital.

The curtains were drawn around the cubicle on the other side of Jonathan’s, but through a gap he could make out that it was occupied by an older man. A beautifully dressed woman of about 60, no doubt his wife, was giving him a bath. This menial task seemed at odds with her impeccable clothing – it looked as though she might be wearing a Chanel suit. From the care with which she bathed him, it was obvious she was very much in love with her husband and devoted to him. She turned her head and caught Jonathan’s eye. Her eyes were sunken and looked as though they had shed an ocean of tears, but Jonathan could also see in them immeasurable inner strength. He smiled. The woman held his gaze for a moment then turned away.

Today was one of the rare days that Derek decided to do the rounds instead of leaving it to the juniors, and he started off with Jonathan. Normally, if he did ward rounds he liked a large entourage, which could include medical students, nurses, interns, residents and registrars. Today, he had an audience of only Damian.

‘All went well today in theatres. The cystoscopy confirmed the tumour. We cut that away and have taken biopsies from different parts of your bladder. We won’t know much till we see the results of the pathology. Should be through in about three days. How are you feeling? OK? No questions? Right, see you later then.’

Derek was well practised at the post-operative spiel. The sooner he finished with Jonathan, the sooner he could get through the ward round and get to the next hospital. He needed to see his patients at three private hospitals before he could get home. It was more important that he see the private patients himself, as they didn’t have the luxury of a registrar and a resident to look after them when he wasn’t there. In addition, they paid money for him to conduct their surgery.

Tracy spoke up: ‘Do you mind if we ask some questions?’

Derek turned around, visibly disappointed that there was going to be a delay. ‘Yes, sure. What would you like to know?’

‘Well, you said you took biopsies. Biopsies usually mean some sort of cancer. What has Jonathan got? Do you mean that this thing in his bladder is a cancer? We’d hoped it could be stones.’ She was teary.

‘Well, I did say that we would not know anything until the pathology comes through. But Jonathan does not have stones. He has a tumour of the bladder. Probably caused by him smoking. We don’t know if it has invaded into the bladder or has spread anywhere yet. We need to wait for the pathology. OK?’ The subtext was: Please do not slow me down now; I really have a lot to do.

Jonathan was quite numb. He had heard so many words that confused him and that he thought could never be associated with him: cancer, tumour, spread, invade. Were they dealing with an alien invasion of his body? Images came to his mind of Sigourney Weaver having some gross creature bursting out of her chest. Tracy was dumbstruck. Derek was pleased with himself. He had been able to demonstrate the elements of good communication to his junior colleague. After all, teaching was part of his job at the hospital. He turned away and stood waiting for him to follow.

At the exit from the ward, he shouted, ‘Where is the charge nurse? Virginia is never here when I come in. What type of meeting is she at now?’ He was talking about the nurse in charge of the ward. These nurses used to be called charge sisters, but now they were ‘nursing unit managers’.

In fact, Virginia was at her fourth meeting for the day, a gathering of the Hospital Equipment Committee. A senior anaesthetist had requested bigger garbage bins in one part of the hospital, and this agenda item had taken up most of the time allotted for the meeting. In preparation for the discussion on the hospital’s policy regarding garbage-bin sizes, a long paper had been written on the topic.

Most of the members of the committee, especially the hospital’s general manager, opposed the anaesthetist’s desire for a larger garbage bin. ‘We have always used the 45-centimetre bin,’ he said. ‘This issue has been rejected by the Waste and Recycling Committee on the basis that 60-centimetre bins may contribute to additional waste generation in the hospital. I see their point: if there are bigger bins, then it is likely that doctors and nurses will put more garbage into them on a per capita basis.

‘It was also considered last week at the Interdepartmental Quality Control Committee and the Intradepartmental Quality and Audit Junior Management Committee. Both committees have voted against bigger garbage bins. The stated reasons were simple: smaller garbage bins mean fewer back injuries from wardsmen lifting them. Although the difference in weight is only about one point eight kilograms – I asked the biomedical department to analyse this difference – the possibilities are that, over time, we may see more injuries from the repetitive picking up of these bins. So, on balance, I think we should reject the suggestion for bigger bins.’

The general manager had finished his monologue, and the majority of the committee went on to vote in his favour. The senior anaesthetist was not going to get his larger bins.

Derek, meanwhile, was still in the ward trying to find a nurse. He knew that his resident would hand over his patients’ files to a nurse for him, so it wasn’t that he had to find one; it was a matter of principle. The nurse looking after Jonathan was on a break. Virginia was at her meeting. There was no one around. He went to the central nurses’ desk and saw that the board was lit up with calls from patients needing something. It might have been that they had pain, they were thirsty, they needed help getting to the toilet, they needed their medication now – but the only nurse on the ward was attending to a sick patient and couldn’t answer the numerous buzzers calling her to the patients’ beds.

‘They reckon we want them to be handmaidens, as if doing a ward round with me makes them handmaidens. I just want them to do their bloody job!’ he shouted and with that set off to find a nurse who was either not in a meeting or on a break, to tell her about his patients and what they would need over the next 24 hours. He found her in the storeroom counting stock for one of a series of audits that had been demanded by management, to account for the large amount of stock that regularly went missing. This week, it was a snap audit to make sure that all the syringes were accounted for.

‘I have just seen the bladder cancer in bed 14D,’ he said and glanced down at his notes to find the patient’s name. ‘Brewster. I know you’re not looking after him, but I want to hand over to someone. He needs more irrigation. His return is quite dark.’

The nurse looked at him blankly. Derek had no confidence that she was going to increase the irrigation to his patient’s bladder. His lack of confidence was wise. Of the 30 patients on the ward, four had intravenous infusions that had run out, 12 had not received their medications on time, 28 had not had their sheets changed since admission and all 30 had not had a wash in the last three days.

The whole face of nursing was changing rapidly and for the worse. At a time when most professional groups were trying to inject more industry experience into university degrees, nursing had retreated from hospital-based training in favour of university-based education. This move seemed to be led by nurses in academia with their heads in the sand who were artificially creating a fear that hospital-based training diminished nursing as a profession and produced instead handmaidens for doctors. For the vast majority of doctors, nothing could be further from the truth. Now, instead of being part of a team, nurses came out of university with a resentful attitude towards any who made them feel like they were nurses. It was as if, since university-based nursing education, the graduates in nursing wanted to do anything but nursing. Hence, the plethora who sought to take on traditional doctoring duties by becoming nurse practitioners, when what the system needed most of all was nurses – nurses proud of nursing and proud to be part of that most honoured of professions.

The chances that this particular surgeon was going to get his patient’s irrigation increased were minimal. Who did he think he was, anyway? The nurse went back to counting the syringes for the audit.

Tracy and Jonathan sat in the cubicle in silence. A multitude of thoughts ran through their minds but none they could bear to say out loud to each other. Images of death danced around like ghosts in the dark. For some time, Jonathan had been bleeding heavily through the tube sticking out of his penis.

‘I need the nurse to help me. I think the tube’s blocking up. My bladder feels like it’s about to burst.’ He pressed the buzzer. After several minutes, Tracy went to look for a nurse. One of them had come back from a break and promised to come over shortly.

Jonathan was writhing now. He pressed on his lower abdomen to try to relieve his pain, but it was no use. ‘Oh … pleeeeeassse … someone help,’ he groaned. Tracy went again to talk to the nurse.

Finally, she came. Using a syringe full of saline, she washed out the blood clots that had been blocking the catheter. Then she connected a new bag of saline and began running it through the catheter into Jonathan’s bladder at a higher rate. He got instant relief.

He sensed that the three other patients in the room had been watching the whole thing.

‘Hard to get them when you need them,’ the old man opposite said, holding to his throat a gadget that picked up vibrations and translated them into a robotic-sounding voice.

Jonathan said nothing but silently swore he would not come to the public hospital ever again.

That evening, and overnight, his catheter blocked several times. Each time, it took longer and longer to get help. The next day, he looked a haggard man, with sunken eyes. It was then that his father came for a visit.

Jonathan was sleeping. His father reached out with his hand but stopped short of stroking his head. Instead, he lifted his eyes to heaven in a silent prayer for his son. Thoughts flew through his mind of the first day this boy had come into his life, a gift from God. He and his poor departed wife, Jonathan’s mother, had raised him, and it was heartbreaking to see him going through this now.

Jonathan stirred. ‘Hi, Dad,’ he said. He could see the fear and concern in his father’s face – the same expression he had seen when they had visited his mother in hospital together when she first got sick. ‘I’m sure it will all be fine, Dad.’

‘Sh, shh …’ he hushed Jonathan. ‘I know you hate it when I go on, but can you find a bit of comfort in Psalms, just this once? “But thou, O Lord, art a God full of compassion, and gracious, long suffering, and plenteous in mercy and truth.”’

What Jonathan really wanted was for his father to hug him, to hold him, to tell him it was all going to be OK, but his father was not capable of such a show of emotion, even though none could fathom the depths of his love for his only son.

Jonathan replied, ‘“And all his sons and all his daughters rose up to comfort him; but he refused to be comforted; and he said, For I will go down into the grave unto my son mourning. Thus his father wept for him.”’ He uttered the verse perhaps in a vain attempt to impress his father, or perhaps because it captured so well the pain and anguish of the man who now stood before him.

Mr Brewster smiled a broad grin, proud – and slightly amazed – that his son could remember the lessons he had for so long fought to teach him. ‘Genesis, chapter 37, verse 35,’ he whispered, and Jonathan noticed that his eyes had become teary. Mr Brewster reached out and held Jonathan’s hand. They stayed together in silence for some time, and then he left to let Jonathan rest.

Tracy had paid for the television above Jonathan’s bed to be connected, and when she came to visit they turned it on to the mid-morning news.

‘The interim report of the review of the Victoria Hospital instigated by the health minister today announced that the hospital was adequately resourced for the level of patients it received.

‘The minister did admit that the winter had seen a greater than average pressure on beds, because of the increase in admissions from pneumonia and flu-related illnesses. Welcoming the review, the minister went on to say that his department looked forward to receiving the final report of the task force and would take their recommendations on board as the department moved forward with the process of reform in the public-hospital system.’

The patient across the room put his speaking device onto his throat and said as loudly as he could, ‘Bullshit! Fucking liars, the lot of them!’ He then said to Jonathan, having managed to catch his eye, ‘Look around you, mate. This place is a disaster. Have you used the toilet yet? It stinks. It’s dirty. The food they give you tastes like shit. The nurses are nowhere to be found. Maybe there isn’t enough of them, maybe they’re just lazy. How many times did you have to press that buzzer of yours to get someone to fix that saline? Look at it, it’s run out again. You’ll get clots, and nobody gives a fuck!’

A nurse came in carrying a two-litre bag of saline to replace the empty one. ‘Shut up, Bill!’ she called over to him. ‘God, he raves,’ she said to Jonathan. ‘He used to be a surgeon in this hospital. He smoked a lot. Then he had to have his larynx taken out because he got cancer, and now he can’t practice. Every time he comes in, he raves about how things used to be – before the nurses “took over”.’ She shook her head. ‘We just run around every shift trying to do the best we can.’

‘The nurses always pull that overworked stunt on us to shut us up!’ Bill retorted. ‘Doctors can’t say anything. We’re just picked on. Silenced. Nurses turn into bureaucrats, and then they control the health system. Look around, Miss Nurse. Are you proud of what you’ve created?’ Bill paused for breath, as he had plenty more where that came from. When he was the surgeon at the Victoria, he was known as a zealot for quality and safety. He turned back to Jonathan: ‘Ask Miss Nurse over there how many patients here have a complication caused by a nurse or a doctor? One in five! One in five patients suffer an adverse outcome as a result of incompetence by someone here. Then some committee changed the definition of adverse outcome so that the rate came out at one in ten. Tell me we don’t live in a totalitarian state.

‘Instead of reform, they announce new reviews. They send nurses off to do projects: improve the patient’s MRI experience! Improve the patient’s Obstetrics experience! For God’s sake, the whole house is falling down and they are deciding on light fittings.’

‘Shut up, Bill! You’re disturbing everyone.’ The nurse’s tone was irritated but amused.

‘I cannot be shut up! They can take out my larynx, but I’ll still shout! People deserve a better health system.’ But Bill had to stop because of a coughing paroxysm brought on by his attempts at vehement shouting.

‘Breathe slowly, Bill,’ said the nurse, walking across to his bed. ‘Just breathe it through.’ She rubbed his back, calming him.

Perhaps it was Bill’s rant that brought it on, but Jonathan suddenly realised it was time to test the former doctor’s assessment of the state of the toilet. He told Tracy that he needed to go. He swung his feet out of bed and onto the floor and stood up.

‘Stay there, Mr Brewster. I’ll come help you,’ called the nurse.

‘No, no, you’ve got your hands full. My wife’ll help me,’ he said. His head was light, and he wobbled at first, but he regained stability quickly. Tracy organised the various tubes around him and placed the bags of fluids on a mobile drip stand for Jonathan to take with him.

He slowly edged towards the bathroom in the corner, which was shared by the four of them, and pried the door open. Tracy offered to come in with him, but he said he couldn’t go if she was there. As she waited on the other side, he closed the door and surveyed his surroundings. His immediate response was to gag. There was a rank odour, the shower stall was stained and mouldy looking and the toilet seat had urine all over it. That was enough to give Jonathan constipation. He turned around and came straight out. ‘I’ve lost the urge,’ he said to Tracy, who helped him back to bed.

Minutes later, Derek appeared for a morning ward round. ‘How are you today? The return looks good,’ he said, investigating the bag that was collecting Jonathan’s urine. ‘No temperature? Pain seems well controlled. I think we might take the catheter out and see if you can pass water and send you home. OK? I’ll leave instructions with the nurses. You have done very well. Normally, I would keep you an extra day. OK? See you in my rooms when the pathology results are in. Well done.’ And with that he was gone.

It was six hours before the catheter was removed. By then, it was too late to send Jonathan home, due to the time it would take to complete all of the paperwork necessary to discharge him.

When I did my evening ward round, Jonathan was looking well and was sitting alone, tapping on a laptop. I was always surprised that no matter how sick male patients were, they always hung on to work, often bringing it with them to the hospital. I have never seen a female patient do that. Men are compelled to proclaim their profession, carrying on with the telephones and laptops; they continually desire to grasp at the world.

‘How are you feeling, Mr Brewster?’ I asked.

‘Well, fine, I suppose. I wish I knew more about what’s going to happen to me.’

‘We’ll know soon enough. Most cases of bladder cancer are superficial and do not progress, so it is possible that the operation you’ve had will have knocked it on the head. Now, we just need to make sure that it never recurs, and your doctor will probably talk with you about the need to have regular check-ups.’ I was trying to reassure him.

‘My wife and I have won a trip to Africa in a charity auction, all expenses paid. It’s only a few months away. Do you think we’ll be able to go?’ he asked.

‘Look, I really don’t see why not. However, we do have to wait for the results and work out what else needs to be done. Where in Africa are you going?’ I asked.

‘We’re going to South Africa, Johannesburg, and then to Zambia to see the Victoria Falls.’

‘Do you have any kids?’ I asked.

‘Yeah, two girls. Not that I ever see them. I seem to be always at work or travelling. Maybe it’s time to change all that.’

He wasn’t going to change. I had seen so many patients express the desire to change their lives after illness. They never did. Sometimes, they changed superficial aspects. Several I knew had divorced after a major illness – but they soon married someone who was almost an identical twin of their first spouse. Sometimes, patients claim they’re going to work less or travel more or spend more time with their kids. Once the illness is cured, they forget their promises.

‘I hope you do. Life is very short,’ I said.

‘I hope you don’t mind me asking, doctor, are you a Muslim?’ He had obviously guessed by my name.

‘Yes, I’m Lebanese in heritage. I was brought up here but born in Ghana, in West Africa.’

‘Really? I visited Accra once. We had a contract there. It’s a fascinating place.’

‘Nurse! Someone! Help!’ It was the lady whose husband was in the next bed. He had stopped breathing.

I rushed over to start resuscitation and simultaneously felt his chest and his carotid-artery pulse, on the side of his neck. There was no pulse. I thumped his chest.

‘Doctor, can I see you for a moment?’ It was Virginia, the charge nurse. She had her arm on my shoulder and was pulling me back, away from the patient. I ignored her for a few seconds.

‘He is NFR,’ she whispered.

‘Are you sure? Is it documented?’ I asked. The initials stood for ‘Not for resuscitation’. There came a time in the care of a patient when it was regarded as being unethical, even cruel, to resuscitate him when his breathing or heartbeat stopped. Continuing to be alive was no longer feasible. It was illegal to end life but not illegal to refrain from administering life-saving care. Some called this euthanasia, passive euthanasia. However, the decision was always a difficult one and needed to be made in consultation with the family. His wife would have been called upon to agree to this decision prior to the notes being marked with ‘not for resuscitation’.

I always felt a great sense of frustration when it was apparent that the community seemed to expect doctors to make decisions about life and death. I had often heard criticisms of the torture that was inflicted on patients by doctors applying the full force of medical care to an elderly patient whose life had become unbearable. Yet, doctors were also part of the community. There were those who supported euthanasia and others whose religious beliefs would never allow them to make decisions of this nature. There were those for whom even the NFR sticker was an abomination. Instead of expecting doctors to make these decisions, society needed to have a dialogue that included euthanasia as a discussion topic. The politicians would not legalise it until they had a clear message that the majority of voters accepted euthanasia as a viable and moral end-of-life alternative.

‘Yes, I have the notes here,’ she said, showing them to me.

I stopped and looked up at the elegant woman standing by his bed. I took his pulse again. Nothing.

‘I’m sorry, there is nothing we can do. He has passed away,’ I said and gently came round the bed to console her. She had signed the NFR form herself, but when he had stopped breathing she’d panicked.

‘May he rest in peace,’ I uttered. She placed her head on my shoulder and cried. Virginia took over and whispered to her about arrangements and the mundane issues that follow death.

I left the woman in her care and left the ward. As I was walking down the corridor, I ran into Jacob, the slow meticulous surgeon. He was about to start his ward rounds, so I began walking back with him.

‘Did you know that Michael retired today?’ Michael was one of the hospital’s urologists.

‘No, I did not,’ I replied.

‘We’ll be advertising his place shortly, but it will be a mixture of an academic position and private practice. Do you think you’d be interested?’ he asked, knowing the answer.

‘Absolutely!’ I replied.

‘What about Switzerland? Didn’t you have a job lined up there?’

‘It was tentative at best.’

Virginia came running towards me in the corridor. ‘Do you think you could please come back and write up Mr Zudarsky’s notes? He needs to be pronounced dead.’

‘You go on. I’ll be fine on my own,’ said Jacob. ‘I just have one patient to see.’

I returned with the nurse and wrote in the notes of the dead man, because without me writing, he was not officially dead. My thoughts were full of hopes for what lay ahead. Becoming an academic and a consultant at the Victoria Hospital would be a major achievement. How fantastic it would be to achieve my life’s ambition. I wrote the words quickly: ‘Respiratory arrest. No heart sounds. No response. No pulses. Patient expired 7.18 pm.’

Life, death, hope and failure: this was the human condition.

10

When Jonathan went home the next day, he was immediately comforted to be in his own space and to see his own bed, with his own sheets. The girls were at school, and Tracy was running errands, so he was at home alone.

He pressed the button on the answering machine and held his pen ready to take down numbers and messages.

The first message was from Jake: Jonathan was to worry about nothing; everything was under control in the office; just relax and get better. Jonathan had a sinking feeling in the pit of his stomach. Evil was afoot. His job was under threat.

Ill at ease, he walked over to the door that led to the garden, passing various luxuries and chattels he and Tracy had bought during their married life together – a spending orgy that had accelerated when his income had increased and then again when his promotion had come through. He felt a deep paranoia about the possibility of losing it all. Jake’s tone on the answering machine was one of triumph. Jonathan walked outside to get some air and have a quiet smoke.

Tracy had employed a gardener, an Indian-or Pakistani-looking man, who was raking leaves into a pile.

‘Good morning, sir. I am Ahmed, the gardener,’ the man said, clasping his hands together in a praying pose above his head. Jonathan felt an obligation to clasp his hands together too. ‘I’m very sorry to hear your news. I hope you’re well now.’

‘Yeah, yeah, I’m fine, thanks.’ After his days in the public hospital, he was touched by the man’s compassion; they’d never even met before.

‘Allah takes care of all,’ replied the gardener softly and went back to his raking.

It was the kind of thing his father might say – ‘God takes care of all’. Jonathan had always rejected his father’s view that Christianity was the only truth, the only way. He had always believed that maybe the wisdom contained in the Bible was no different from that in any other holy book, no matter the religion or the language it was written in. Perhaps there was only one essential truth – such as love, for instance. The love this gardener felt for his children – was it any different to the love Jonathan felt for his girls? He guessed not.

Now that he had been forced to stop, forced to think about things, Emma and Kate were much on Jonathan’s mind: he couldn’t help but feel he could’ve played a bigger role in their lives, and he found himself wondering what kind of a legacy he was leaving them.

He sat down. He looked at the set of eight white designer outdoor chairs and remembered the day that he and Tracy had put them on their credit card.

What was his life all about? He’d helped Tracy create Vogue Living right here in the house, but if he died tomorrow, what memories would he leave his kids with, what lessons? They deserved the wisdom and strength of a father who could see further than they could … and though he hated to admit it, maybe further than he himself could. ‘This house, this land, it’s all just stuff,’ he whispered to himself. What he really needed was wisdom – wisdom to hand down to his girls for when he wasn’t here any longer.

Jonathan gathered his thoughts and looked behind him to make sure no one had heard him. He was deeply embarrassed to be thinking such airy-fairy and morbid thoughts. It wasn’t as if he’d just been handed a verdict of certain death, after all.

As if to wash away his discomfort, Jonathan went back inside and took a shower. He stood under the stream feeling the healing warmth of the water all over his body. He placed both hands up on the wall and let the water blast onto his head. Even that couldn’t stop thoughts of the gardener, his hands raised in prayer, thoughts of his father, his mother slowly dying in a nursing home, God, Allah, Jake, the operation he’d just had, the threat of cancer, his daughters, whom he hadn’t seen for a week or more, the fact that he hadn’t made love to his wife for over a month, his maxed-out credit cards, his used-up sick leave, Tracy’s lack of clients.

When he stepped out of the shower, just as deeply troubled as he was before, he heard the phone ring.

‘I’ll get it!’ yelled his eldest daughter, Emma. The girls must have just got home from school.

‘Dad, are you home? It’s the doctor,’ she shouted up the stairs.

‘Thanks, sweetheart. Can you take a message? I’ll be down in a sec,’ he shouted through the en suite door.

Jonathan dried himself, put on his tracksuit and found Emma and Kate in the kitchen having a snack. He squeezed first Kate then Emma in a hug, and then both of them together. Emma said matter-of-factly, ‘The lady at the doctor’s says you have to call urgently to make an appointment to come back and see him.’

He went to the study and dialled the urologist’s number. ‘Hello, it’s Jonathan Brewster here. I have a message to call and make an appointment.’ Jonathan was breathless.

‘Can you hold the line?’ the secretary said and then put him on hold without waiting for his answer. She returned a couple of minutes later.

‘Yes, doctor would like to see you about the results of your surgery. Could you come in on Tuesday morning at nine forty-five?’

‘That’s nearly a week away! Is there nothing sooner?’ Jonathan was beside himself with impatience and anticipation.

‘No, Mr Brewster. If there was something sooner, I would have told you about it. Doctor is operating all day tomorrow, and he is away for two days after that. The earliest is Tuesday. Can you make it, or do you need me to find a time later that week?’ she asked.

‘No, no. That’s fine. I’ll be there.’ Jonathan hung up; he’d given up on the niceties of ‘please’ and ‘thank you’ with the doctor’s secretary, as there didn’t seem much point.

When Tracy came home minutes later, he immediately told her the doctor wanted to see him on Tuesday about the results of the operation. Jonathan was walking down the stairs towards the kitchen, a zombie-like absence to his gaze.

‘Did he say anything?’ Tracy was anxious to know. She clearly dreaded the worst.

‘No. It was just the secretary,’ said Jonathan.

‘So, your test results aren’t coming in till next week?’ asked Tracy, confused about the wait.

‘I think he’s got them already – it’s just that he’s not available to see me any sooner.’

‘God, doesn’t he know how desperate we are to find out what’s going on? Why is he making us wait? What’s the point?’ There was an edge of hysteria to her voice.

‘I don’t know … the secretary said he was away for a couple of days.’

‘Yeah, it’s OK for him to take holidays while we sit here sweating blood for the results. One minute, they say it’s an infection or a stone, then maybe it’s a tumour … oh, but they’re not sure what kind. We still don’t know anything!’

‘It’s OK, Tracy. We’ll make it through. We will make it through.’ He was hugging her now; her head was on his chest as she sobbed.

Emma and Kate began crying too, and they came up and put their arms around both their parents.

Through the lounge-room window, the gardener looked in at the scene and with deep compassion in his heart said a prayer for the family.

The phone rang again. It was Jonathan’s boss, Paul Carter. ‘How’re you going, mate? Do you think you’ll be back to work this week? Take as much time as you like, though. Everything’s under control,’ he said reassuringly.

‘I’ll be in tomorrow, but I’ll have to duck out for a bit next Tuesday.’

11

Everyone at work was treating Jonathan differently. Gossip and speculation had been rife in the office for days about how serious his condition was; they were amazed to see him back at work so soon.

He himself was more impatient than normal. Uncharacteristically, he snapped at his secretary for failing to send some memos, the state of his desk, a few unanswered emails. At a meeting that morning, he found himself doodling, absent in thought and disengaged from the now seemingly trivial expectations placed upon him at work.

‘Sorry, I was just somewhere else. Could you repeat that?’

Carter had a caring and benign, almost priestly, look on his face as he repeated his assertion that profits were descending and that Sales and Marketing had to pull something impressive out of the hat if the end-of-year forecasts were to be met.

‘Any suggestions, Jonathan?’

‘Uh, let me take it on board, and I’ll get back to you with some suggestions this afternoon,’ said Jonathan, without the slightest idea what he would get back to him with this afternoon.

‘With Jonathan’s permission, I suggest we take another look at TV advertising,’ piped up Jake. ‘I’ve been doing the numbers on it. I really think it would suit this product, and I did a bit of arm-twisting and managed to screw the networks down on price so it fits within the budget.’ He was right on top of this stuff. Jonathan was deeply embarrassed that his junior had taken control. Since when had Jake turned into a TV expert?

‘What do you think, Jonathan? Do you think it could work?’ Carter was trying to appear to involve Jonathan.

‘I suppose so. I really thought it was too expensive, but if Jake has managed to get the price down, then we should look at it, and soon.’ He tried to sound like he was cool, but inwardly he was stumbling.

Later that day, he was keenly aware of mumblings in the corridors. His colleagues would suddenly go silent when he walked into the room. Most of his workmates had the same benign look on their face that he had seen that morning on his boss’s, but they also had an awkward nervousness that reminded him of Rowan Atkinson’s bumbling priest in the film Four Weddings and a Funeral.

‘We thought you’d take more time off.’

‘Is Tracy … OK? How are the kids handling it?’

‘My cousin had blood in his urine – turned out to be a strange infection. Anyway, a few days of antibiotics and that was all there was to it. He had an operation and everything – you know, where they look up his spout – just like you have had. It is going to be fine.’

Jonathan was suddenly embarrassed that people knew the details of his operation. He blushed. One of his co-workers noticed and tried to make him feel better. ‘We heard about the operation, mate. I’m sure it’s going to be OK. Do the doctors know what it is yet?’

And, finally, the words he had feared: ‘Watch your back with that Jake.’

Jonathan just smiled, thanked everyone for their concern and reassured them that it was all going to be OK. He was fine, thank you.

He wanted them all to go away. He wanted them to either talk to him genuinely or just be quiet and ignore the situation. Since the beginning of this whole thing, no one had really asked him about his feelings. No one broached that subject.

His feeling of isolation was only accentuated by a phone call from Tracy that afternoon. ‘What are we going to do if this is something serious, Jonathan?’ she asked him. She was at home sorting out the monthly bills and was getting anxious. ‘How are we going to survive? We don’t have anything put away.’

‘I’m well insured, Tracy,’ he said. ‘We may not have health insurance, but we certainly have life insurance. You and the girls will be well looked after if I die.’

‘Don’t say that! You’re not going to die, Jon. Why would you say something like that? I’m just trying to work out how we’ll get by if you need some more time off.’

‘I don’t know, Trace. I just don’t know.’

‘Maybe I can forget changing careers and starting my business and go back to being a temp – but, even then, it’ll be hard to make ends meet on the kind of salary I can get. I wish that damned doctor had told you whether you were going to need any more treatment. Are you sure he didn’t say anything on the phone the other day?’ Tracy was desperately seeking answers that were not there.

Finally, Tuesday came.

‘So, how have you been?’ said Derek.

Jonathan and Tracy took no comfort from the concerned look on the doctor’s face.

‘Fine. What was the result of the pathology?’ Jonathan’s apprehension was making him so nauseous that he wanted the truth immediately.

‘Well, we have indeed received the pathology results, and I’m afraid the news is not good.’ Derek paused to see the couple’s reaction. They glanced at each other and then looked back at him, nodding expectantly for him to continue.

‘The pathology shows you have a T1 carcinoma of the bladder with CIS in the random biopsies we took.’

‘What? T1? CIS?’ Though Tracy was struggling to comprehend the doctor’s jargon, from her tone it was clear she understood the gravity of his pronouncement.

Derek directed his explanation to Jonathan. ‘In the right side of the bladder, you have a tumour, a cancer. We removed the protruding growth, but it has also burrowed slightly down into the bladder wall. It does not look like it has invaded into muscle. If it had, then you would probably be looking at a cystectomy – that is, removal of the bladder.’ Derek held up a diagram of a bladder and started pointing at the various parts. ‘At this stage, the cancer is in the superficial layers of the bladder. In addition, there are cancer cells over on the other side of the bladder. They are also superficial.’

‘So, there’s a cancer in my bladder, but it hasn’t spread?’ said Jonathan.

‘Well, we know it is quite superficial. We don’t yet know if it has spread to other parts of your body. You will need to have a bone scan and a CT scan – which is like an X-ray – to help us determine if it has spread or not. In addition, you will need to have some blood tests, and then we’ll need to see you again next week to start treatment.’ Derek had a room full of patients. He really wanted to make this as brief as he could.

Tracy started crying, and, ironically, Jonathan comforted her, putting his arm around her shoulder. Derek wrote up the various forms required to put Jonathan through the next lot of tests and handed them to him. The tests would be done in the private radiology suites down the road, and Derek marked the request forms urgent so that there would be no unnecessary delays in getting the results.

‘OK, my secretary will make the various appointments and we will see you again next week. Any questions?’ The doctor had already risen up out of his chair. In an instinctive response, Jonathan and Tracy got up as well. Jonathan clutched his forms – his passport through the health system – and they left the room.

Minutes later, at the front desk, they had their diaries out, cancelling this event, that dinner, their attendance at a school concert, while the secretary made the appointments.

When they pulled into the driveway, Jonathan’s father was waiting on the doorstep.

‘Oh, Tracy, I don’t know if I can handle him today,’ mumbled Jonathan.

‘What did the doctor say?’ was his father’s greeting.

Jonathan unlocked the door and let him in. ‘Have a seat, Dad. The doctor reckons that they found a cancer in my bladder. It hasn’t taken hold yet, but I need to have more tests before they can decide exactly what to do.’

His father sat silently for a moment, trying to absorb what his only child had just told him.

‘Please, let us pray together, son.’ He held out his hand.

‘Not now, Dad.’ Jonathan stood up and went over to the bottom of the stairs. ‘Please, not now!’

As he went up the stairs to his study, he could hear his father shouting after him. ‘If not now, then when? When, Jonathan?’

‘Never!’ Jonathan shouted back.

Tracy came in with two cups of tea and handed one to her father-in-law.

‘You need to talk to him, Tracy. He needs God more than ever now. He needs Him.’

‘You need to give him a bit of space. He’s not concentrating on work, on the girls, on anything in his life.’ Tracy was pleading as much for herself as for Jonathan.

‘That’s exactly why he needs to make contact with the Lord. This illness he’s gotten, this is not random. God has caused it to teach him lessons about life and about mortality. I know I haven’t always got on with him, but you, Tracy, you have his ear and his heart. Please tell him to look beyond his present suffering to the glory that awaits.’

Tracy stared pitifully at him. There was no question that he loved Jonathan with all of his heart; his son was the blood that coursed through his veins, the breath that gave him life each day. For this man, God was so real. He saw Him; he talked with Him; he read words that he believed with absolute certainty God had written. But Tracy’s view of religion was that it was not so much about God, about truth, about knowledge, as it was about clinging to a rigid belief and creating an ‘us’ – the believers, who deserve saving – and a ‘them’ – everyone else. Like Jonathan, she found her father-in-law’s Bible-thumping hard to take. Yet she had sympathy for the man, especially on a day of bad news such as this. Tracy sometimes felt there was something insincere about his absolute conviction. It was almost like he was shouting loudly so that the demons within him could hear. She had no evidence for this. It was simply a hunch, an intuition. She dismissed the thought.

‘Would you like to stay for some lunch?’ she asked.

‘Thanks, love, but no. I’m going up to see Mary.’ Mary was his wife, Jonathan’s mother, who had suffered a stroke about three years earlier and was living in a nursing home. One tiny clot – measuring only about four millimetres in diameter – had travelled a distance of about six centimetres from her neck to one of the end arteries in her brain. End arteries have no other tributaries to feed them in case of blockage, so the clot blocked blood supply to part of her brain. Once a part of the brain gets no blood – no oxygen – it only takes about three minutes for irreversible damage to occur. In Mary’s case, over the course of about ten minutes, she was converted from an elegant, well-spoken, intelligent and beautiful woman into a body that lay in a bed unable to move.

Her nutrients came by way of a tube down her nose into her stomach. Every three hours, she was turned to avoid pressure sores. She recognised no one; her eyes were able only to open and stare. She did not move, did not speak, did not interact, did not react. The only noise that came from her was an almost constant groaning sound, and her face was contorted in a permanent wince. The nurses had to keep her in a nappy. Every now and then, she would get so constipated that a nurse had to manually remove the impaction. She needed 24-hour nursing care.

Mr Brewster visited almost every day, catching the bus from his house to the nursing home to sit with his wife. Whenever she had an infection, he gave orders for it to be treated. When her heart had started failing about a year ago, he gave orders for the tablets to be crushed and injected down the tube to her stomach. Many a time, the doctors and nurses raised the topic of ‘being kind’, of ‘letting her go’, of ‘allowing nature to take its course’. Mr Brewster’s answer was always, ‘I want everything possible done to help her live out her life.’ He would not allow any talk of passive euthanasia. Every sore was treated to its fullest. At one stage, she suffered bowel obstruction and would have died had it not been for Mr Brewster’s insistence that she be transferred to the Victoria Hospital to be operated on. He still nearly cried each time he remembered overhearing one of the thrusting young surgical trainees saying, ‘I have no idea why they don’t just let this old biddy die. But if the husband insists we operate, then who are we to say no? If they’re cactus, they’re good for practice!’ Mr Brewster had put in a complaint and took satisfaction in having received a written apology from the resident.

Tracy visited every now and then, but Jonathan had long-since given up visiting. His view was that the doctors and nurses who kept her alive were inhuman monsters. He found the smells and sights of the nursing home so overwhelming that it was a struggle for him to breathe whenever he was there. There were rows and rows of patients exactly like his mother. Some, the better ones, sat in wheelchairs in the television room for part of the day. They would be hunched over, held in the chair only by a seat belt, their eyes gazing at their lap. Perhaps they were listening to the morning shows, which were turned up to maximum volume to cater for the majority of patients whose hearing had long departed this earth, waiting for the rest of their bodily functions to catch up.

After Mr Brewster had gone to the bus stop, Tracy went up to see Jonathan, who was checking his emails.

‘Anything interesting?’ she said, saying the only thing she could think of, to get him talking.

‘Crap. Jake is at it again,’ he muttered at the screen. ‘Has Dad gone?’

‘Yeah, he’s gone to see your mother,’ she said softly.

‘Why can’t he just let her go?’ As he said that, he buried his head in his hands. Jonathan was scared. Even though the doctor couldn’t be certain yet of the full scope of his cancer, he knew that his life was surely unravelling. His thoughts were dominated by the idea that something unnatural was growing inside of him. Ever since the surgeon had spoken the words to him that afternoon – ‘a tumour, a cancer’ – he had felt a sense of foreboding that emanated from his mid-section. He could almost feel the cells reproducing, taking root, travelling inside of him. He thought about the upcoming tests to see if it had spread. Even the word itself – spread – was frightening. Spread like a germ, like an evil spirit. A blackness spreading through my body, he thought. He shuddered.

Tracy walked over and hugged him to her. ‘We will be fine. We’ll make it together,’ she whispered.

12

Derek and I were trying to get a pencil out of a woman’s bladder. She had presented to her general practitioner several times with bladder infections and each time had been given antibiotics. Each time, the infections recurred. Finally, she was referred to Derek, who was sensible enough to order an ultrasound of her bladder. There, to his surprise, was a pencil.

‘How did this get into your bladder?’ he asked.

‘Well, my husband and I were making love, and he used a pencil to try to stimulate me more. We were both drunk at the time. I had no idea that it had been lost up there.’ She was less than embarrassed telling him the story.

What a macabre situation: a pencil stuck up the urethra into the bladder. The patient obviously had what we lovingly call in medicine the ‘Fith Syndrome’, ‘Fith’ being an acronym for ‘fucked in the head’.

Now here we were trying to get the thing out of her bladder. It had been over an hour, and each time we grasped it with our instruments it would slip away. The decision had to be made whether to open her bladder surgically and remove it that way. One last attempt and we would have to open her.

My interview for a consultant’s position at the Victoria Hospital was that evening. If I was successful, I would get an academic position as a lecturer or, if I was lucky, senior lecturer at the university. It would be my name at the top of the patients’ charts. They would be my patients, undergoing my treatments and the operations I advised. This was the pinnacle of surgical training, the graduation.

As Derek worked away at the pencil, in my mind I rehearsed answers to the interview questions that I thought were likely to come up. I knew who would be on the selection panel: the professor of Surgery and the head of Surgery, plus Jacob, one or two of the other urologists in our department, an external representative from the College of Surgeons and the mandatory administrator from human resources to ensure that equity was upheld.

These days, such decisions are often made prior to the interview, and there is no spontaneity because the questions have to be written down and vetted by the equity officer in advance.

Back in the early 1990s, when I was being interviewed, there was none of that formality. An interview could decide your future, and there were no holds barred. Any question was allowed, from ‘Are you married?’ to ‘When are you planning to have children?’, which a female colleague of mine was asked in her interview.

We still had to get this damned pencil out of this woman’s bladder and then repair another penis laceration before I could get to the interview.

‘You’ll have to open her up,’ Derek said. ‘I’m giving up. There is no way to get it out endoscopically. Will you be OK on your own? I have to get back to the rooms. I have to see that young guy you saw in Emergency – you know, the one with bladder cancer. It turned out to be a T1. He’ll probably need his bladder out eventually.’ With that, he was gone. I thought for a minute about Jonathan Brewster. He was young for bladder cancer. Pity. But I hoped he would come to the Victoria to have his treatment so that I could end up taking out his bladder. A cystectomy would be good practice for me.

I put away the endoscopic instruments and put the patient in the standard position on her back. We prepped her and scrubbed. I called another registrar down from the ward while the anaesthetist was changing the patient’s anaesthetic to ensure it was suitable for an abdominal incision. I rushed everything and everybody so that I could get started as quickly as possible.

‘Scalpel,’ I uttered. Focus on this case now. Forget about the future.

‘Can you just wait a moment? I still haven’t got her ready.’ It was the anaesthetist, struggling with the patient’s airway. Finally, he secured a tube down her throat to oxygenate her while we operated.

It was a quick operation. A horizontal lower-abdominal incision and retraction, to pull the edges of the abdominal muscle apart. Stay outside the peritoneum and the bladder should be on view. Diathermy across the bladder, and there it is, open. Put a finger in, and out comes the pencil. Close up.

Done properly and without any bleeding, the operation took about ten minutes. It reassured me that I had all the required skill of a consultant. Only the interview stood between me and glory.

‘Are you going to use clips or a subcuticular stitch?’ asked the scrub nurse, wondering how I was going to close the abdominal skin.

The scar would look nicer if I used a stitch under the patient’s skin, but I was in a rush and so clips – surgical staples – would do. I should have enjoyed this case, but I was too nervous about the interview.

Now I only had to repair the penile laceration I had seen in Emergency earlier and get it to the recovery room, before going off to try to get a job for the rest of my life. The patient was a 22-year-old gigolo whose 60-year-old benefactress had caught him in bed with a younger woman. The older woman had bided her time, then one night got a knife while he was asleep and attempted to cut off his penis. She had been unsuccessful but had made some deep gashes, which needed to be sutured.

I had asked him how he’d got his injury, and at first he’d kept insisting that his penis had got caught in the shower door. So I’d pulled out the ‘big doctor’ routine: ‘Mate, your life depends on you telling me exactly what happened. I’m a doctor, and I need to know the truth so that I can repair this injury properly.’

It was then that the truth had come out.

By the time I had sewn up the gigolo in theatres, changed into my suit and got up to the administration suite where my interview was to be held, I had a dry mouth, sweaty palms and the inevitable nervous cramps. I found a toilet and relieved myself, only to find that by the time I had finished and washed up the panel were ready and waiting for me.

I rushed into the boardroom and sat down at the vacant end of the oak table. My interview was to be held in a room designed to fill visitors with awe. The walls were covered with portraits of the hospital’s medical superintendents dating back to the 1800s, and it felt to me as if there were a hundred observing the interview. In fact, there were 12, which was plenty in itself. They were introduced to me, but many of their names and ranks were just a blur. The weight of history oppressed my chest, and I could hardly swallow. The chair of the panel was the professor of Surgery. ‘This is an interview for senior lecturer and consultant in Urology …’ He gave the usual introduction describing the position and the expectations.

The panel members then took turns asking me questions.

‘We have read your impressive CV. Could you summarise it in a couple of minutes and then tell us how you would contribute to the Victoria Hospital?’

Easy question to start with, as I’d fully been expecting it. I rattled off my pre-prepared list of the various contributions I could make, including teaching and research. I talked about my PhD in progress and the research projects I was working on.

‘What would you do if you felt that one of your colleagues was impaired?’ It was Jacob.

It was a good question, because it tested a candidate’s wisdom. There was a legal position, a moral position and then a pragmatic one. If I gave the impression that I would apply the letter of the law to all such situations, the panel might be wary about my loyalty to my colleagues and the department. On the other hand, if I seemed like the kind of person who would fail to act, they might question my integrity as a professional. In my answer, I tried to cleverly strike a balance between morals and expediency.

‘What do you understand by the term “equal-opportunity employment”?’ It was the human-resources-department representative. I had to say the right things to make sure she felt that I would adhere to their policies. I omitted from my answer the fact that there was no such concept as ‘equal-opportunity employment’ in practice at the hospital and that on my first day as a registrar I had been questioned about my origin, background, birthplace, religion, schooling and parents.

I also failed to mention the comment a surgeon made when he found out that I had obtained my medical degree from a newer university, as opposed to a traditional medical school. He took great delight in telling me that in his view the medical school I had attended should be scrapped and that it produces little more than social workers.

I also neglected to tell the human-resources rep about the hundreds of times I had been made to feel inferior through comments about my name, my religion or my culture. I smiled and told her what she needed to hear: all was fine and I loved the department’s policy.

The next question caught me by surprise, and I had no answer prepared for it. It was asked by the professor of Surgery.

‘What would you regard as your greatest weakness?’

This is the hardest of all interview questions to answer. No matter what I said, it could be construed as a reason not to employ me. For example, ‘I find that I work too hard and devote too much time to the hospital at the expense of my family’ could be followed by the counter question, ‘So, Dr Khadra, you’re finding it difficult to balance home and work. Do you think this could result in a problem further down the track?’ Then I could look like I was on the brink of divorce.

I have subsequently asked this question in almost every interview I have conducted, and it amazes me what profound weaknesses people will report in the heat of the interview. One candidate admitted to me that he found his consumption of alcohol a weakness. Another that he felt he needed to work harder. A third that his memory was lapsing. All disastrous answers in an interview for a medical position.

My mind did not fail me during this interview, and I gave the best answer I could, the only appropriate answer. ‘My greatest weakness is interviews. I find it hard to show my best during interviews.’ If I was going well in the interview, then the panel would feel that I was even better than I had shown myself to be. If things were not going well for me, then the panel might put my poor performance down to interview nerves.

The professor smiled, recognising that I had not taken the bait. I smiled back, knowing the same.

‘Well, thank you, Dr Khadra. We will be in contact with you shortly,’ he said, and with that I was dismissed.

By the time I arrived home, there was a message to ring Jacob.

‘Welcome aboard. The panel decided to appoint you. You’ll be starting in January.’

Immense elation and relief spread throughout my mind and body. I jumped for joy at the news. I think I uttered the words ‘thank you’ over a hundred times. Sheer triumph overwhelmed me.

‘There is a slight issue, though.’ Jacob was trying to tell me some bad news, and I was not listening. ‘There will be no office or secretary. You’ll have to supply that yourself.’

Suddenly, silence. My triumph turned to confusion and then to wariness and disappointment. As a visiting medical officer (VMO), one had no research and teaching role or salary but a high income due to unfettered rights to private practice, including consulting rooms, an office and a secretary supplied and funded by the hospital. As an academic, I would get a meagre salary but have restricted rights to private practice.

I was keen to throw myself into a career in academia, but not without any financial support. Give me the low salary of an academic and I would do the research and teach the registrars and attend the conferences – but I needed a place to see patients and someone to assist with making bookings and sending out correspondence. Without those, I might as well have applied to be a VMO and at least enjoyed the high income that came with that position.

I was bitterly disappointed because I would have to put my energies into creating a private practice that could fund the overheads of a set of rooms. There would be little time left for academic pursuits, research and teaching. Urology had a shortage of academics because the temptations of private practice kept so many of my colleagues fully occupied. They had little or no time to progress knowledge, contribute to the training program for new urologists and develop themselves and the profession.

The celebration following my acceptance of the position was a reserved and sad one. Colleagues patted me on the back at the apparent triumph of being appointed to the Victoria Hospital, and meanwhile my heart burnt with the unfairness of the conditions of my employment – conditions that guaranteed my failure both as a private practitioner and an academic. An empty victory indeed.

I could not understand why every other academic appointment had been offered the enticements of rooms and a secretary. I still don’t understand why I was victimised in this way. Regardless, I commenced practice under these circumstances.

13

It was now over two months since Jonathan had first had symptoms. He and Tracy were waiting patiently in Derek’s waiting room while the secretary played solitaire on the computer. They were waiting for the doctor to arrive from theatres, where apparently he had been held up.

Jonathan had had to take several days off work over the last week to have his tests, because openings for appointments were scarce and the tests were time-consuming to have.

The reason for Jonathan and Tracy’s patience at this point was all the practice at waiting they’d had since the tests had begun. It was a more impatient Jonathan who’d fronted up to have the first one.

‘Are you here for a bone scan?’ The young ward clerk had looked up from her desk while he was reading the signs on the wall above her head, trying to work out whether he was in the right section of the Victoria Hospital.

‘Yes, I am!’ Jonathan was relieved to have found it.

‘The scanner’s broken down today,’ she said. ‘We’re waiting for parts to come, so I’ll have to reschedule your appointment.’

‘What do you mean, you’ll have to reschedule my appointment? I’ve taken a day off work. I cannot afford to take any more time off work.’

‘All I can do is reschedule you.’ The girl’s matter-of-fact tone made Jonathan livid.

‘Are you serious? This is absolutely ridiculous. Why didn’t anyone ring to tell me? I wouldn’t have taken the day off.’

The ward clerk just stared at him, waiting for him to finish ranting. Most of the other patients had simply made another appointment; he was only the third patient to make a fuss. It wasn’t her fault. Why was he angry at her?

‘So, do you want to make an appointment?’ she said.

‘What bloody choice do I have? What’s the soonest I can get one?’ Jonathan wanted his disgust to be plainly apparent to her. As she looked down at the appointment book, he was about to ask her to pass his criticisms on to her manager, but just then he spotted the old fading poster on the column behind her head: ‘We value your feedback. We’re working towards the best health system.’ Nothing was going to change because of his rant. He felt almost embarrassed that he had even wasted his breath on this young woman who cared little about his opinions, or any other patient’s.

‘This Friday, 9 am. That’s the earliest I can give you, OK?’

Almost everyone he had dealt with in the health system so far had finished their statements with ‘OK?’. It was like code to say, ‘We know this is far from ideal, this is far from suitable, but this is all you are getting, OK?’ It is not OK. I want it to be different, thought Jonathan. Well, that is not possible, OK?

Jonathan had returned on Friday after an unsettled day back at work. The same girl was behind the counter.

‘Are you here for a bone scan?’ She looked at him with those uninterested eyes. Several people sitting in the waiting room looked up, waiting for his answer as well.

‘Yes. I had an appointment on Wednesday, but when I came in you said the machine wasn’t working. As I didn’t get a call cancelling that appointment, I can only hope that no news is good news today.’

Jonathan’s sarcasm was lost on the girl. ‘Oh, yes. The machine is working today. What’s your name, please?’

He told her his name.

‘Please take a seat. Won’t be long,’ she said as she moved his medical records to the pile of files of patients waiting to be done.

Jonathan found a seat in the waiting area, a U-shaped row of seats around the walls opposite the front counter. He immediately noticed a big Middle Eastern woman with a head-covering on. Next to her was a woman he guessed was her daughter and a young grandson who looked at Jonathan with suspicious eyes that pierced him steadily. The grandmother had her hands crossed in front of her voluminous abdomen and was looking up at the ceiling as if in silent supplication.

Next to them was an old man, perhaps 90, who was impeccably dressed in a navy blazer and grey pants. Jonathan recognised the blazer to be a Gieves and Hawkes. He was impressed. Yet the man’s skin was a sickly yellow-tinged grey. There were lumps under the skin on his neck. Jonathan smiled at him when he caught his eye. The man just stared back. In one corner, a middle-aged woman was sitting with a drip stand next to her. She had a scarf on her head, but not because she was Muslim – she was covering her baldness. Chemotherapy, thought Jonathan. He nodded to her. She smiled back, but only half her face moved; the left side was paralysed. Jonathan was repulsed. Again, he had the feeling that he didn’t belong here at the hospital. Next to him was a spare seat with old magazines on it. He picked up a Woman’s Day and started thumbing through it.

His five companions and he sat quietly and patiently for a very long time. Every now and then, the mother whispered to the child to be quiet or to stop playing with something. When the digital clock on the wall above the old man in the good blazer read 9.45, Jonathan got up to ask if it was going to be much longer.

‘Shouldn’t be too long, OK?’ said the girl behind the desk.

At 11, still no one had been called in from the waiting room to have his or her test. Jonathan had long run out of patience by then. He was unspeakably angry at having to wait. ‘Why is this taking so long? My appointment was at nine. How is it that I have waited two hours? How can you be this disorganised? I could have gone, done other things and come back if you’d let me know. I’m a very busy man.’

The girl behind the counter simply waited for him to finish talking. ‘Shouldn’t be too long, OK?’

Jonathan returned to his seat and looked for some sympathy in the faces of his waiting-room companions, but they were seasoned users of the Victoria Hospital. They knew that their energy was best spent protecting themselves from the onslaught of the diseases that were threatening their continued existence on this earth. The girl behind the counter was not worth expending energy on.

The woman with the half-paralysed face said, ‘I’ve long stopped asking questions like that, you know. Ha! I have been waiting here since eight. The ward nurses just plonked me here. My drip has run out. Do they give a shit?’ She was struggling to draw enough breath to speak.

‘I’d appreciate it if you could be civil, please.’ It was the old man. ‘I’m sure they’re doing their best.’

She sniggered, then shook her head ruefully. She had so little time left, and she was wasting it in a waiting room in the Victoria Hospital to have a bone scan that was only likely to announce the extent of her tumour’s progression. It was an academic matter; she was a dead woman walking. But she didn’t have the strength to say, ‘I’m not playing this evil game any more. I’m going home to die.’ There was no one at home. Anyway, she still clung to the hope that she might be one of the lucky few at the Victoria Hospital to be included in a trial of that new type of chemotherapy the doctors were telling her about that had some promising early results in Scandinavia.

‘Why are you here?’ she asked the old man.

‘I have a carcinoma of the lung,’ he said, without betraying any emotion. ‘And yourself?’ he asked.

‘Brain tumour. How about you, young man?’ She was looking at Jonathan.

‘I’ve got a growth in my bladder,’ he said. It hurt him to say it out loud to strangers for the first time – he felt as if he had only now taken ownership of the problem – and he struggled to hold back the tears.

A nurse came out. ‘Youseff Adnan,’ she said slowly and haltingly, purposely struggling with the name to highlight its difference.

The younger Middle Eastern woman picked up her child. He was old enough to walk, but somehow he seemed to enjoy being scooped up by his mother. He was smiling. She walked towards the nurse, with her own mother by her side.

‘Is this Youseff?’ the nurse asked.

Mother and grandmother looked down at the child. ‘Yes,’ said his mother softly, ‘this is Youseff.’

‘This way, please.’

The three left in the waiting room sat in silence until the old man broke it. ‘I felt sorry for myself because I had no shoes, until I met the man with no feet,’ he said as the boy disappeared with his carers around the corner.

‘Fucking world,’ the woman whispered to herself.

Eventually, at 12.30, Jonathan’s name was called.

He was shown to a change room and told to strip completely. The small white gown he’d been given didn’t cover his body, and he felt like he was wearing a miniskirt.

‘To see if the cancer has spread to your bones, we’ll be injecting you with a radioactive solution, and then this big drum here will be positioned above you so that we can measure where your cancer is,’ said the nuclear physician. ‘It will take about half an hour to do the test. It won’t hurt, but you’ll get a metallic taste in your mouth when the solution’s injected. OK?’

Once again, the ‘OK’. It was not OK. I do not want to be here. I want to be back at work, or, better still, at home in bed with my wife, making passionate love to her. I want to be on an island sunning myself. I want to be shopping for clothes. I want to be playing with my kids. No, it is far from OK.

‘Yes, fine,’ Jonathan said.

As he spoke, the man placed a rubber tourniquet around Jonathan’s arm, then he patted the back of his hand to raise the veins. With a syringe, he drew up some solution from a vial that had radioactive signs all over it. Jonathan saw a skull and crossbones on it as well. This can’t be good for me, he thought. The doctor removed a cannula from its package, donned gloves and took the cover off the needle.

‘Sorry, I’m going to faint, I think.’ Jonathan felt extremely light headed.

‘Just lie down then.’ The doctor pushed on Jonathan’s chest to lie him down on the metal table on which the test was to be conducted. Jonathan looked up at the big metal drum and the fluorescent lights shining in his face, bright and silent witnesses to all the suffering in this hospital. Just as he composed himself, he suddenly felt a sharp deeply uncomfortable pain in the back of his hand.

‘Shit, I’ve missed it. I’ll just have to try again. Your veins are really difficult,’ said the doctor.

‘Sorry,’ said Jonathan, feeling ashamed that his veins were causing trouble.

Another sharp pain.

‘That’s better. I’m going to inject you now. You could feel some warmth going up the arm as I do this. Oh, I’d better take the tourniquet off now. We don’t want your arm to drop off, do we?’ The doctor was making light conversation, to reassure Jonathan.

Jonathan was not reassured.

‘OK?’

Jonathan nodded.

‘I’ll be stepping out of the room now. You will hear a lot of whirring and mechanical noises. Please try and lie still. Do not move at all. It shouldn’t take too long.’

Jonathan heard the doctor’s footsteps as he left the room. A big red light came on. The drum started moving, descending towards Jonathan until it was only a centimetre in front of his face. He panicked slightly.

‘Stay still, please.’ The doctor’s voice came to him through a speaker somewhere in the room.

Mechanical noises now. The drum started to move again. This time it was slowly edging its way down Jonathan’s body, to his feet. It seemed to take an eternity. His back was getting sore lying on the metal bed, and it took a lot of effort not to move to relieve the pressure on his tailbone. Suddenly, the drum stopped and then ascended to its starting position, about a metre above the bed.

‘All over now. You did well. That wasn’t so bad, was it?’

‘For whom?’ said Jonathan, at which the doctor smiled.

He had gone to the hospital another day for a CT scan and blood test; now he was in Derek’s waiting room with Tracy, grasping all the results in his hands and waiting, with his newly acquired patience, or resignation, for Derek to appear to interpret them for him. The doctor rushed in, spoke briefly to his secretary, who suddenly became animated, and disappeared into his room. Minutes later, he came out and asked Jonathan to enter.

‘Did you have the scans and blood tests I ordered?’ he asked before Jonathan and Tracy had sat down.

‘Um. Yes. Here they are.’

There followed a long silence as Derek arranged all the scans on the X-ray viewing box behind his desk. Slowly and methodically, he went through each of the images, as Jonathan sweated expectantly.

‘Good news. The bone scan and CT scan show that the cancer is still contained in your bladder. We now have to talk about treatment. The two options are cystectomy or BCG instillation.’ Derek was once again talking his special language, with the air of a schoolboy who knows the answer to the question the teacher has just asked.

Jonathan and Tracy were sitting before him with baffled looks on their faces. It was Tracy who spoke up. ‘Please, doctor, I don’t understand what you just said.’

‘Well. As you know, the cancer was superficial. But it’s an aggressive type of tumour that has already made roots in your bladder. I was concerned that it may have spread. However, the bone scan and the CT scan show that there is no evidence that it has travelled anywhere.’ He paused to gauge their reaction. ‘It is amenable to treatment. Now the two treatments that would be appropriate would be either removing your bladder completely or treating you with weekly instillations of tuberculosis – what is called BCG treatment.’

It was Jonathan who spoke now. ‘Tuberculosis? Isn’t that dangerous?’

‘If you take certain types of tuberculosis and instil them into the bladder, we find that they do not cause tuberculosis. However, they set up an inflammatory reaction in the bladder that then destroys the cancer cells. It was ingenious research that first let us know that this was the case.’ Derek looked quite proud but got no reaction from the couple. ‘Anyway, some would argue that it is best to take out the bladder, but most urologists would agree that for your age and stage of cancer at least a trial of BCG treatment is worthwhile. The choice is yours, of course.’ Derek waited for their response.

‘I don’t know, doctor. What do you advise?’ asked Jonathan. He and Tracy both looked worried and confused.

‘Look, I feel that BCG treatment gives us a chance to salvage your bladder. It entails coming into the hospital once a week. We place a catheter into your bladder, and then we place a solution into it, which stays in there for about 15 minutes and is then drained out. Nothing could be simpler, really.’

‘And you’re sure it isn’t dangerous?’ Jonathan was nervous about the whole idea.

‘Of course, there are some possible complications. Some patients end up with cystitis – they need to go to the toilet all the time. There are other complications, some serious. There is a small number of patients who die from the treatment. These are usually older and less fit patients. If it doesn’t work, then we still have the opportunity to take out your bladder. OK?’

Jonathan was getting really sick of hearing that ‘OK’. Take out my bladder? What is he talking about? How would I pass urine then? And I thought he’d taken out the cancer already. Why is he talking about more treatment? BCG? Sounds like a cricket ground somewhere.

Tracy could see that Jonathan was overwhelmed and it was time for her to take charge. ‘If that’s what you advise, what do we need to do next?’

‘I’ll make the necessary arrangements,’ Derek said.

That night, after the whole family had gone to bed, Jonathan stayed up, unable to sleep. He put his headphones on and selected Pink Floyd’s Dark Side of the Moon on his Discman. This album was reserved for times when he needed to calm his mind. He had played it constantly when he’d been doing his high-school examinations. He’d played it the day he’d left home. He’d played it the night, a year before he and Tracy had got married, when she’d told him she was pregnant and they’d decided she would have a secret abortion. And he’d played it a couple of days later, after she’d miscarried. He’d played it the night he’d been planning to ask Tracy to marry him. He’d played it the night before he’d resigned from his previous job and later that week when he’d been offered his current position. Now, he played it because he needed to blast the negativity out of his mind.

Myriad thoughts haunting him, he walked around the house. At midnight, he went into his daughters’ room. There was the essence of innocence asleep in their beds: Emma and Kate, breathing quietly. They were unaware of the man standing in their room struggling to hold back tears. They had grown so much, so fast. He was suddenly aware of the passing of time, especially his own. The realisation had struck him that he may not see his girls finish high school. He may not be the one to walk them down the aisle.

Why was he thinking these dark thoughts? The doctor had said they could control this cancer. They could cure it. Still, deep inside, Jonathan was preparing for the possibility that he might not survive. Disturbing questions haunted him, replaying themselves in his mind like a broken record. Was his life what he wanted it to be? Was he at peace with himself? If this was as old as he was destined ever to get, and if he’d somehow known about it early on, would he have the job he currently held? Would he be married? Would he have this house or the mortgage or the car or the designer life?

Each time he thought about these things, he felt genuinely that he would not change much in his life, even if he’d always known his life was destined to end this way, at this time. However, the questions kept being asked. He decided to go down to the garage and get the car out. He drove as if on autopilot as the wailing woman on ‘The Great Gig in the Sky’ improvised her orgasmic cries. He stopped at the local 7-Eleven and bought a packet of smokes and a lighter. The drag of that first cigarette was overwhelmingly comforting. He hadn’t smoked for weeks now, but fuck it – what did he have to lose? He drove to the beach, parked the car and went and sat on the sand. If he knew for sure he was dying, maybe he would have smoked more right there and then. What would be the point of holding off? He giggled to himself, imagining himself smoking ten cigarettes at a time. The waves were pounding away not far from where he sat.

Months earlier, the family had had a long weekend up the coast, and he was reminded of it by the sound of the surf. They had lunched one day at a vegetarian restaurant in a boutique health spa that Tracy had just gone to for a massage. There was a large pond in the middle of the restaurant, and he was struck by the beauty of a fully opened lotus flower. A heavenly pink colour, its petals were perfect. Its beauty was the type of beauty that could almost make a man believe in God. But as lunch was served, the lotus flower began to close. By the time they were having dessert, it was no more, just a greenish-brown bulb. The owner of the restaurant, seeing Jonathan’s disappointment, came over and said to him, ‘Only change is constant. Everything is transient. At least, that’s what Buddha said. Life is suffering: you’re born and enjoy your youth and health and then it too withers away, like the lotus flower.’ She smiled in a New Agey way and glided off to take plates from the next table. Jonathan and Tracy had rolled their eyes at each other, and he hadn’t thought much more about it – but now the woman’s words had taken on a new significance.

At dawn, as the sun rose and painted the dark water with a purple glow that gradually turned to yellow, Jonathan was sitting on the sand with several butts around him. He wearily returned home in time to see Tracy stir out of her slumber.

‘Did you get up early?’ she said sleepily.

‘Yeah. I’ll bring you coffee.’

Life went on. The profundity of his thoughts throughout the night were replaced by the profundity of making breakfast for the girls, getting them ready for school, having a shower and eating.

He drove to work that day, and every day. He was now leading a double life. There was the Jonathan who participated in day-to-day events, conversations and plans; and then there was the Jonathan looking upon his own life as though it were a movie he was watching. The inner Jonathan looked on. Here was a life living its life, like a fly feasting on faeces, before it begat other flies and then met its demise. No more nor less than a fly. That is what his life meant.

His friends started to treat him differently. They didn’t know how to deal with the fact that he was now always withdrawn. They found the pressure of not mentioning the unmentionable too great. He had trouble sharing his fears with Tracy; he didn’t want to scare her or the girls. And so Jonathan’s life became quite lonely, despite being surrounded by the same people and the same worldly clutter.

Two weeks after he received his pathology results, Jonathan Brewster went for his first treatment session at the Victoria Hospital.

He stood at a reception desk that read ‘Admissions’. There was no one there. The phone was ringing. The desk was cluttered with patient records, notes and X-rays. Down the corridor, he could hear a woman screaming. Doctors and nurses were entering and leaving a room, and each time the door opened the screaming sounded louder.

‘Help me. Help me,’ the woman called out in an Indian accent. She sounded young. ‘Please, God, make the pain stop. Make it stop!’ The nurse was running now, carrying a kidney dish with a syringe in it. A painkiller, probably, thought Jonathan. There was a time when he would have been able to block out the woman’s suffering, ignore it, but now his heart reached out to this poor woman. It could be me screaming out like that one day. He dismissed the thought.

The screaming down the corridor continued for several minutes but became softer, until eventually it stopped. Jonathan figured that the painkiller must have taken effect. The nurses and doctors came out of her room, walking slowly. One of the doctors came around behind the desk, sat stiffly on the chair and opened up a folder full of notes. He looked up at the clock behind Jonathan, and then wrote down the time. Jonathan became aware of a different sound. Sobbing. Wailing. A child was crying, almost screaming with grief. ‘Please don’t die, Mum. Please don’t die.’

‘Where’s the boy’s father? For God’s sake, the kid’s only eight years old,’ said one of the nurses under her breath to the doctor behind the desk, who simply shrugged.

‘Lives in another city now, with a new family. Hasn’t even been in contact with his son. Would you believe it?’ answered another nurse.

‘So who’s been looking after him all this time?’

‘The woman’s friends were popping in to look after him, I think, but he’s going to be a ward of the state now, poor little bugger. Child services have got a foster home lined up for him – I’ll call them to come get him.’

As she picked up the phone to dial, the first nurse finally noticed Jonathan and asked, ‘Are you OK?’

‘I’m here to have a dose of BCG for my bladder cancer. I have a letter from my doctor.’ He was surprised by how articulate he had managed to be. The blood had drained from his face, and he felt shattered.

‘I haven’t heard of that being given here. Let me see your letter.’ The nurse was the unit manager. She had a graduate certificate in Management and Finance and was well on her way to leaving the wards and getting her promotion to administration, where she would be free of this constant screaming that filled her daily life. She felt impatient with Jonathan for being unaware of the department he was due to attend.

‘This is the cancer ward. You need to be in the day-stay suite. Go downstairs to level three and then turn sharp left. You’ll see the reception desk there.’

As Jonathan headed to the lift, she turned and addressed the doctor behind the desk. ‘Do you mind using the doctors’ office, please? This area is for nurses. It’s not for you to write your notes here. We have precious little space as it is.’ The doctor was obviously junior, and he apologised as he left, though he was clearly resentful. ‘They truly are stupid, some of them. There are clear policies that are there for a reason. Where’s the ward clerk going to sit when we recruit one?’ She seemed to be addressing no one in particular.

‘Can I help you, love?’ Gail, the ward clerk for the day-stay suite, was a buxom rounded woman in her 50s who’d been in her position for over 30 years. She had seen a lot of changes in health care. There was a time when doctors ran the health service. They were the good times, she recalled. Now it was managers, nurses and bureaucrats, which meant her job had become far less about patients and much more about policies. She had to enter all kinds of details into a computer that had never been considered necessary before: how many patients were treated each day, who treated them, when they came and when they left. She knew she was only a small cog in a big machine, and yet she maintained her humanity, her compassion, and she continued to treat one and all with the respect they were due. The doctor was always addressed as ‘doctor’ or ‘doc’ and the nurse always as ‘sister’. Patients were ‘love’ or ‘Mr’ or ‘Mrs’. She never addressed anyone as ‘Ms’.

‘I’m here for BCG treatment for my bladder.’

‘Right, I’ll get sister for you. Please take a seat over there. Won’t be long.’ Gail got up from her seat, and, as she passed him, Jonathan could smell her considerable body odour. Her nylon floral dress was well worn; he could see stains in her armpits. Yet he immediately liked this woman. She was warm, friendly and respectful.

Within minutes, a nurse appeared. ‘Would you like to come in now, Mr Brewster?’ she asked.

‘No,’ Jonathan answered instinctively, and the two exchanged wry smiles before he walked into the treatment room.

It was a simple room with a freshly made bed, a sink in the corner and a cupboard with a large vent over it.

The nurse took Jonathan’s letter and read it, placed it on the desk next to the vent and then turned to him. ‘My name is Vera, and I’ll be administering your medication today. Do you mind if I ask you some questions before we start?’ Her accent was difficult to pinpoint, but Jonathan thought it may have been South African. Her compassion was overwhelmingly welcome. She was only young, perhaps late 20s, with blonde hair, blue eyes, clear skin. Jonathan just wanted to curl up in her arms.

‘No. Ask anything.’

‘You are very much younger than our standard patient for BCG. How did you know you had bladder cancer?’ she asked with a concerned look on her face.

‘I had blood in my urine one morning. Then I had a bladder resection, I think they call it. That’s when they found T1 cancer and CIS.’

‘Carcinoma in situ.’

‘Yeah, that’s it. I know some patients go to libraries and do research on their disease. I really want to know as little as possible. I just want it gone.’

‘We get both types of patients here. It’s OK not to want to know.’ She went on to ask him about his health, his smoking history and his allergies. She was very thorough. ‘OK, now I’d like to tell you about what we’ll be doing. I’ll shortly be asking you to take off your clothing, and then I’ll ask you to get into this gown. I’ll then put a catheter into your bladder through your penis.’ She showed him the tube in its sterile wrapping. ‘I know it looks large, but I’ll inject you with a local anaesthetic first and use plenty of lubricant, so it shouldn’t be too bad, apart from being a little uncomfortable. I’ll then place the medication in your bladder through the tube and leave it in for about 15 minutes. During that time, I’ll get you to move around from side to side so that we get coverage of the entire bladder. Then I’ll drain it out, take out the tube and you’ll be on your way until next week. Any questions?’

‘No, I’m fine. I’m ready.’

‘I’ll leave the room now. Please take off your clothes and put this gown on for me.’

After she’d left the room, he did as she asked. He considered leaving his underpants on but realised that this was exactly the bit of clothing she most needed off. He donned the gown and sat down on the side of the bed. Shortly after, there was a knock.

‘Are you ready?’

‘Yes, I’m dressed. I mean, undressed,’ he said.

‘Lie down, please.’ She had brought in a trolley with various instruments on it. After washing her hands in the sink and drying them with the paper towel on her trolley, she put on gloves.

‘OK, lift your gown for me, right up to the waist.’ Jonathan was embarrassed to show this pretty young nurse his nakedness, and she quickly picked up on it.

‘I’ve seen hundreds, you know. Come on, I’ll not tell if you don’t tell.’ She was smiling at him in a friendly way, and he reluctantly pulled up his gown.

The cold sterilising solution hit his penis and scrotum like a splash of ice. He felt his testicles retract. She worked efficiently and quickly. Before he knew it, she had his penis in her left hand stretched upwards and into the eye she had injected a local anaesthetic jelly. Jonathan yelped. It stung severely.

‘It will soon go numb.’

Sure enough, it did. Then, she took the large rubber tube – the catheter – and inserted it into his penis. He yelped again.

‘Oh, God!’ he screamed as the tube went past his prostate into his bladder. His eyes were teary.

‘The worst is over now.’

She drained the urine from his bladder. Still working quickly, she took hold of a large syringe and injected its clear contents into the end of the catheter. It was the strangest sensation to feel fluid flowing up into the bladder instead of flowing out.

‘Now, five minutes on your back, five minutes on your left side, five minutes on your right side and then we drain the fluid. Do you have any pain now?’ She had covered him up and had taken off her gloves.

‘No, it’s fine now.’

Within minutes, Jonathan started feeling warmth in his pelvis. When it was all over, she took out the catheter and went through some paperwork with Jonathan. ‘OK, see you next week at the same time. You can get dressed now, and, when you feel up to it, you can leave. I’ll be waiting outside to make sure you haven’t got any dizziness or other problems.’ With that, she left the room with her trolley and medication.

Jonathan got dressed, came out and Vera walked him to the lift. As they went down the corridor, he turned his head and saw a large room that contained patients sitting on reclining chairs, hooked up to intravenous drips.

‘They’re some of our patients getting chemotherapy,’ she said and stopped at the door of the ward to say hello to a few people. Most of them were bald or balding. Some of the women had scarves on. Some of the intravenous drips bore the skull and crossbones.

‘Are you OK? Does it upset you to see them?’ she said, studying his face.

‘It’s awful. They look so awful. I hope I’m never in that position.’

‘I hope not too,’ she said and touched his shoulder with her hand.

‘I don’t know how you work here. You must see so much suffering.’

‘Yes. But we also see the cures. It is not all doom and destruction.’ Her voice was upbeat and professional, but, from a sadness he saw in her eyes, Jonathan thought she might not be entirely convinced.

Tracy was waiting at the end of the corridor to pick him up.

‘You didn’t need to come. Honestly, I could’ve caught a cab.’

She wanted to know all about his treatment. He could think of nothing but the nurse, Vera, and the gentle way she had laid her hand on his shoulder.

‘Your father’s waiting at home. He wants to talk to you,’ Tracy said.

‘Oh, fuck. That’s all I need.’

14

‘Your mother is dead. May she rest in peace.’ Mr Brewster was short and to the point.

‘When … how?’ Jonathan sat down, feeling light headed.

‘She died this morning, Jonathan. You were going in for your treatment, and I didn’t want to disturb that, especially the first time. There was nothing you or anyone could have done, son. Her heart stopped, and the doctors and nurses worked on her for over three-quarters of an hour, but it was her time. The Lord chose to bring her back to His kingdom.’ He pulled a hankie out of his pocket and wiped his eyes.

Jonathan felt his mother had been dead for several years; it was just that her heart had chosen today to stop. He was sad yet also relieved. Earlier on, when he had been visiting her regularly, every now and then he’d got the feeling that she was actually conscious and that she was aware of everything around her but was trapped in her non-functioning body. Whenever he thought that might be the case, he got a suffocating sense of claustrophobia. He imagined his mother trying to scream, to say ‘I’m in here’. Often, he would suffer nightmares in which she called out to him and he was unable to respond. There was a barrier between them.

That barrier, of course, was her dead brain tissue.

Jonathan looked at his wife. ‘Did you know, Trace?’

‘Your dad told me this morning. He asked me to keep it from you until after your treatment this afternoon.’

‘I didn’t want you burdened with this. I wanted you to concentrate on getting better. You need to beat this evil thing in your bladder. The Lord provides the wonders of modern medicine and –’

‘Dad, what are the arrangements?’ Jonathan interrupted.

‘Your mother’s funeral will be at the end of the week. It’s all taken care of.’ Tracy and her father-in-law had made all the arrangements while Jonathan was admiring the beauty of his BCG nurse.

When his father had left, Jonathan went upstairs to his study and put on his headphones; he needed to drown out his thoughts, his grief, his loss. Only a couple of months ago, his life was stable and within his control; his future had seemed limitless. Now, bit by bit, everything he knew was falling away, unravelling.

Jonathan read the eulogy at his mother’s funeral and spoke well of her, remembering the woman she was before her illness. The family priest led the usual prayers and committed Mrs Brewster to the grave, as Jonathan stood with his father, family friends and relatives.

Two days later, it was time for Jonathan’s next dose of BCG, and he was in the lift on his way up to the day-stay floor. He was running late, which made him agitated because this seemed to be the only department at the Victoria that was ever on time, and if he missed his appointment they might send someone in before him. He couldn’t afford to take a second longer off work than he absolutely had to.

The doors on the ground floor opened, and an elderly man with sunken eyes shuffled in. Jonathan was irritated by the interruption to his ascent from the car park. Not only that, the man was slow and feeble, delaying him even further. Their eyes met momentarily, and the man could sense Jonathan’s irritation. He apologised for holding him up, then, as the lift doors closed, asked, ‘Are you a patient or a visitor?’

‘Patient,’ said Jonathan tersely.

‘I’m sorry to hear that. My wife’s in having chemotherapy. They’re so good here. Look after her really well. Bill’s me name,’ he announced, holding out his hand.

‘Jonathan.’ He shook Bill’s hand reluctantly. They arrived at the floor, and the lift door clanked open. Jonathan knew where he had to go and sped towards his treatment room, leaving Bill behind.

Vera was there again, and first she came in to ask him how he had felt after the previous week’s treatment. ‘You seem really distracted today. Have you been sleeping?’ she asked with concern.

‘My mother passed away. The funeral was only a couple of days ago,’ he said, his tone flat.

‘Oh, that must have been really tough.’ Vera sat on the side of the bed with her hand on his.

‘I don’t know. In a way, it was a blessed relief for her, for us all. She was sick for a long time,’ he answered. ‘It’s never easy, though. Even when you’re expecting it, it’s never easy. That finality. All I can think of is the wonderful times I had with her. Hugs. Conversations. Before she got sick.’

‘Do you think it’s harder, going through your mum passing away while you’re in treatment?’ Facing a loved one’s death often made people think about their own mortality, and she imagined it must be even more confronting for cancer patients such as Jonathan, but she wanted him to voice it to himself.

‘I did have a strange feeling, like I could see myself down in that casket. I kept thinking: what would my daughters say or do? How would they get on? I have life insurance, so they would be OK financially – well, at least the insurance would pay the mortgage off. But how would they grow up without me? Would my wife marry again? I really hope this treatment works.’ He had said more than he was usually comfortable to.

‘Are you religious?’ she asked.

‘No. I don’t even know if I believe in God any more. My father’s trying to get me to start praying again, but I can’t be bothered.’

Suddenly, a loud beeping noise interrupted their conversation.

‘Oh, shit. Cardiac arrest. I’ll be back as soon as I can,’ Vera shouted as she ran from the room.

Jonathan was left alone in the treatment room. He could hear shouting in the corridor outside and people running.

He opened the door out of curiosity. There, in the middle of the corridor was the elderly man he had seen in the lift, lying on the floor. Doctors and nurses were kneeling around him. Someone had ripped his shirt front open and was doing cardiac massage, while another was trying to insert a tube into his mouth.

‘Where is the defibrillator? For God’s sake, this is a circus.’ It was the Oncology resident whom Jonathan had seen around the hospital before.

Vera came over, struggling under the weight of the defibrillator. The doctor placed both paddles on the man’s chest. ‘Ventricular tachycardia! Give me two hundred and stand back.’

They were all looking at Vera as she dialled up the electrical current on the defibrillator.

‘Ready,’ she shouted. Now all eyes turned to the doctor.

‘Stand clear,’ he said and pressed his thumbs down on the paddles. The patient’s back arched up, the electrical current contracting his muscles as if he were in an electric chair. The patient soiled himself, and the smell wafted throughout the ward.

‘Bill! Bill!’ a woman was hysterically screaming.

Jonathan looked down the corridor and saw a frail old woman standing in the doorway of the chemotherapy room. Trailing on the ground behind her was her drip stand and the tubing that she had been hooked up to for receiving chemotherapy. She seemed oblivious to it as she began to make her way down the corridor.

‘Bill!’ she screamed again. She pushed past the crowd of nurses, doctors and orderlies and flung herself on the man’s chest. It was pandemonium.

‘Bill! What are you doing on the floor? Get up, Bill. You’re making a fool of yourself, Bill. Bill?’ She was out of control now. As one of the orderlies tried to pull her away and allow the resident to use the defibrillator again, she cried out, ‘Leave me alone. Get your hands off me.’

The oncology resident looked up at the clock. ‘Time of death, 4.43 pm. I’m sorry, Mrs Jeffreys. We have done all we can.’ He stood up and signalled to the orderlies to move him onto a bed. Mrs Jeffreys was trying to resuscitate her husband.

‘Wake up, Bill! Wake up! What is going on? What are you doing? Leave him alone. He will get up in a minute. He has probably tripped. Get your hands off me.’ Vera had her arms on Mrs Jeffreys’ shoulders.

‘I’m sorry, Mrs Jeffreys. You have to let them put your husband on the trolley so we can move him out of the corridor. I’m sorry. He is gone.’ Vera was whispering softly. Mrs Jeffreys was now sobbing.

Jonathan stood staring as they moved the man’s body onto the trolley. A nurse attended to Mrs Jeffreys’ arm and gathered up the felled equipment, spilt chemotherapy and debris. They moved the man’s body and his wife to a spare treatment room, and within minutes the corridor was back to normal. A man in a white coat accompanied by what appeared to be eight medical students walked up the corridor, discussing some aspect of medical science or other. They walked over the exact spot where Bill had died only minutes previously. Almost every square metre of this hospital must have seen a death, a tragedy, a passing.

Jonathan hated life, hated disease. Here was a man who only a short time ago had been in the lift with him trying to strike up a conversation. The suddenness of his demise caught Jonathan’s breath. He didn’t know he was going to die today. Had he made preparations? His wife needed him. Jonathan was lamenting for himself as much as he was for Bill and his wife. The tragedy of her being left alone at her time of greatest need struck at Jonathan’s soul. This is a terrible place, he thought, looking at his surroundings. It had revealed to him that humans are vulnerable, subject to the whim of life’s roulette table. Unaware of their fate, they wander around convincing themselves of the permanence of the things about them that they can touch, hold and feel.

Vera returned and saw that Jonathan was deep in thought. Whenever there was a death on the ward, there was a lot of repair work to be done, restoring hope to the hopeless. But Jonathan needed time to process the full force of what it meant to be mortal and suffering from a life-threatening disease. The association with recurrent deaths seemed to be instilling in him a sense of his own mortality, and he did not like facing the abyss. He tried to steady his feelings by recalling that the doctor had told him his cancer was amenable to treatment, curable even. Vera saw the fear in Jonathan’s eyes, as she had seen it in a thousand patients before him and would see it in a thousand more again. She knew that there was nothing she could say or do to help him alleviate it.

Jonathan left that day a very troubled man, struggling to digest the tragedies of the hospital. Later, at home, he mechanically turned on his answering machine. There was a message from Carter.

‘Please ring me when you get a chance. I think you and I need to talk.’ Jonathan’s heart sank. He knew the tone. He knew the content. Jake had been making advances on his job ever since he got sick, and he was in a position to take over all of Jonathan’s projects.

‘Why have you got all your stuff from the office here?’ Tracy was confused to see two boxes on the dining-room table containing the various goods that Jonathan had at the office: pictures of the girls, a framed ‘Desiderata’, his desk set.

It quickly dawned on Tracy what the boxes meant, and her eyes got teary. ‘Girls, go up to your room and do your homework. I’ll fix dinner,’ she said, in a slightly too bright tone.

Jonathan just sat on the lounge with his head in his hands. He didn’t know what to say or do. He had been sitting there almost the whole day.

‘Carter – what a heartless bastard.’ Tracy was shaking her head now. She took a deep breath and walked over to sit beside her husband. ‘Jon, only one thing matters now, your health. We’ll work through this together.’

‘Tracy, let’s face it, we’re fucked. Who’s going to take me on while I’m in the middle of cancer treatment? Everybody’s heard about it. I couldn’t possibly get the kind of job that pays what we need to live the way we do,’ he said.

‘Jon, I can try and get a job.’

Jonathan didn’t want to cause Tracy any more anxiety, but the time for mincing words was past. She had to understand the extent of the financial straits that they were now in. ‘My redundancy will hardly last us three months. Even if you do get a job, it’s unlikely to be able to cover all the mortgage, love. We’ve got nothing saved up in the bank.’

Tracy nodded slowly, trying to deal with this new reality.

‘Trace, we’re going to have to sell the house, the cars, cut down all our expenses. If we get onto it straightaway – real-estate agents, car dealers, the works – we might get it all done in three months and be OK after the redundancy money runs out. I hate to say it, but I think we’ll have to take the girls out of private school.’

‘Oh, Jon, we are not the only people who’ve had to make difficult decisions in their lives. The girls changing schools is hard for me to think about too, but if it has to be done, then we can do it. The other things – the house, the car – it’s all just stuff. What really matters is us, us as a family.’

The corporate world is not a charitable one. The drive for profits and earnings is paramount. If you cannot make the grade, you cannot draw a salary. Jonathan’s boss felt terrible, but he had pressure from above. Jonathan himself had terminated several employees over the years. He had never given them much thought in the past, but now their faces haunted him. James, for example, a 55-year-old man with school fees, mortgages and leased cars. There was certainly no charity shown to him when his performance went down. After half a lifetime spent at the company, he had little hope of getting another job. The same day, Jonathan’s boss had brought in a bottle of champagne to toast Jonathan’s half-year results. His division had been the most profitable. The last anyone had heard of James, he had started drinking and his wife couldn’t take it any more and had left with the kids. Now Jonathan was the latest victim of the ‘screw you’ corporate world.

Over the next few days, his and Tracy’s attitudes began changing. They were no longer ‘at home’ they felt as though they were renting someone else’s house. They began to hate this house that had once meant so much to them. Their clothes, their cars, their house were now nothing but nooses tightly squeezed around their throats. They felt suffocated.

Tracy worked efficiently and solidly to gather their material goods together to sell. As subtly as possible, to avoid upsetting Jonathan, she would fill up the car boot with her clothes, ornaments, silver frames, vases, crockery, good cutlery and sundry souvenirs of their travels and take them to various second-hand dealers around the city. Soon, she discovered that most of their things were worthless to sell. She started making frequent calls to the Trading Post to place adverts for the cheaper items and to the auction houses to sell the few that did have some value. Each time, she gave her parents’ telephone number as the contact.

After four weeks of BCG treatment, Jonathan was once again urinating blood, and frequently. In fact, he could hardly stay out of the toilet. He was urinating every half an hour now, night and day. Vera checked him for infection and assured him that he didn’t have one; it was only a reaction to the BCG, which was to be expected.

At three one morning, he could no longer take it. He woke Tracy. ‘Please, I really need to go to the hospital. I’m urinating straight blood.’

Tracy called her parents to come quickly to stay with the girls, and half an hour later she and Jonathan were at the Victoria Hospital Emergency department.

15

Tracy and Jonathan were struck by the large red neon light outside Emergency. Whether through a planned act of electrical vandalism or by some fluke, several letters were out, so instead of reading ‘EMERGENCY’ it read ‘-MER---CY’. Jonathan and Tracy looked at each other and smiled.

‘Anything but mercy, I would have thought,’ Tracy commented. Jonathan didn’t care whether or not he received mercy. He just needed to be seen.

They walked into the brightly lit waiting room and up to the clerk behind the glass. It was the same woman who had been there on their first night – the night that started the whole ordeal.

‘Yes, can I help you?’

‘My name’s Jonathan Brewster. I’m a day patient here. I need to see a doctor.’

‘Just fill in this admission form, please.’

‘But I’m already a patient here. I have chemotherapy for my bladder in the day-stay suite.’

‘You will still need to fill in the form.’ There was no changing this woman’s mind. The policy was clear. Everyone had to fill out the form.

Jonathan thought, This woman could be replaced with a three-line computer program:

Say ‘Fill out form’.

If form filled in, then contact triage sister.

Else say ‘Fill out form’.

Jonathan gave up arguing and took the form. Tracy shook her head in annoyance, took the form from Jonathan and commenced filling it out while he went to the toilet again. As he walked back, she looked up at her husband and realised he was not a young man any more. He had deep lines across his face that she had never before noticed. He was a bit stooped and his hair was greying. Was it the pain? Was it the cancer? The constant going to the toilet was hardly helpful either. It had certainly all taken its toll, and for one so young he was looking so old.

He sat down next to her roughly, sullenly. He had been so quiet since he had lost his job, withdrawn. Tracy had got on with the tasks of daily living: arranging, cleaning, organising. Meanwhile, he had been sitting for hours on end in his study with his music playing or walking around the house like a zombie.

It was only a couple of weeks before the auction would be held. Everything that could not be sold had been packed into boxes and placed in his father’s garage. It was going to be a tight squeeze, but they were moving in with Mr Brewster. They would move just before the auction, so the girls could be spared the trauma of losing their home while they were still living in it. Mr Brewster lived not far from the girls’ school and had offered to take over their school fees. At least they were to be looked after. Jonathan dreaded the possible strings that came with his father’s offer of shelter and schooling: daily family prayers; grace before each meal; church on Sundays; Bible reading. Yet what choice did he have?

Tracy handed in the form, and they began the usual wait on the uncomfortable chairs. Midnight-to-dawn television again. Jonathan looked around the waiting room. There were several people waiting for care, staring straight ahead or trying to catch up on sleep.

After sitting for some time, the TV and the fluorescent lights burning holes in his tired eyes, Jonathan noticed from the corner of his eyes, just outside the doors, a man lighting up a cigarette. He looked familiar. It took him a moment to place him – it was their gardener.

Jonathan got up and went outside. ‘Hey. What are you doing here?’

‘I work here part-time, Mr Brewster. I’m a night-runner for the hospital, carrying blood here and there for tests and transfusions. Children cost a lot, you know,’ he said, chuckling. ‘My pager has gone quiet at last, so I’ve popped outside for a smoke. I’m sorry to see you here. Is Mrs Tracy with you?’

Jonathan nodded and confirmed the man’s name. ‘It’s Ahmed, isn’t it?’ It was Tracy who had employed him, and Jonathan had only seen him a couple of times since then. He was so glad, though, to see a familiar face, even if it was just the gardener’s.

‘Please tell Mrs Tracy that I’ll have the garden looking very nice for the auction. I understand you’ll be living with your father from now on. That is so good. I would love my children to live with me in my old age. I suppose I’m a bit old-fashioned.’

Ahmed stopped speaking to watch a car pulling up to the Emergency doors. The front passenger-seat window wound down, revealing two transvestites.

‘Hey, is this the Emergency department?’ Hearing a baritone voice coming out of someone whose face was made up like a woman’s was very odd to Jonathan.

‘Yes, you can park over there and the reception is just …’ The driver had already taken off for the parking area before Ahmed could finish.

‘You must see some sights here, Ahmed. I’m amazed you’re not working somewhere else.’

‘My brothers and cousins, we set up a milk bar together, but they accused me of stealing some money out of it, and we have had a dispute ever since. I have tried so many times to prove my innocence, to reconcile with them. After they went to lawyers, it became impossible just to talk, so now we ignore each other.’ He shook his head sadly. ‘They walk around the mosque pretending to be very good Muslims. The women wear the head-covering, and they go to great lengths to demonstrate that they eat only halal meat. They have gatherings every Saturday night to which I’m no longer invited. I know from others that they spend their time talking behind my back. Who in the eyes of God is perfect? Meanwhile, the bills need to be paid, so I garden, I work here, sometimes I drive a taxi … work is work.’

The transvestite driver returned, supporting his friend, who was limping. He was barefoot, his wig slightly dishevelled, his make-up running. It was obviously a long night of partying that had gone very wrong. The driver’s make-up was also running, his mascara now halfway down his face, carried by what must have been rivers of tears.

‘What the fuck are you staring at?’ It was the driver addressing Jonathan.

‘I’m sorry. I didn’t mean to …’ Jonathan wasn’t used to seeing things like this.

They passed by and entered the waiting room to report to the front desk.

‘Do you want one, Mr Brewster?’ Ahmed was holding up his packet of cigarettes. ‘We should really go and stand over there, though, away from the night nurse. She is so stickler for rules.’

Jonathan looked back at Tracy through the glass: she had her eyes closed and was leaning back on the wall. He went with Ahmed around the corner, and soon they were both enjoying the deep pleasures of a shared smoke.

‘This will kill you, Ahmed. It’s probably because of this stuff that I’m in the position I’m in.’

‘We all die. Smoking kills. Of course it does. So does life. So do vegetables. So does my wife’s korma. So does oxygen. So does drinking two litres of water a day. It all kills. Newsbreak: we all die. You, me, all of us. Maybe they will cure your bladder and you will die of a heart attack trying to throw your grandchildren up in the air. Maybe you die of vitamin poisoning. It is not news that we die. But here is the question: how many of us live?’

‘Jonathan!’ It was Tracy shouting from the front doors.

‘They are calling for you,’ Ahmed said. Jonathan threw his cigarette on the ground and stomped it out, leaving Ahmed to enjoy the rest of his break.

A nurse led Jonathan through Emergency, where nurses and doctors were running around like ants on an ant heap. Almost every cubicle was filled. The resuscitation bay where the trauma victims went had blood on the walls. There was someone lying there with a sheet over his head. It had obviously been a high-speed car accident. Jonathan felt woozy and looked away.

Finally, the nurse brought him to a vacant cubicle. The transvestite was being attended by a doctor in the cubicle on his left, separated from Jonathan by only a curtain. ‘I have tried, doctor, but I can’t. They will not come out.’

‘I really need to know why. Why would you insert two oranges up your backside?’ Jonathan was shocked.

‘Doctor, you cannot know any sexual pleasure until you experience it. Trust me, it is heavenly. Now, do you think you can get them out?’ The driver was sniggering in the background.

‘Please lie down and pull your underpants down. I need to examine you.’ Jonathan could hear the bed rattle next door and then the curtain move as the doctor leant down beside the bed. ‘Good God!’ the doctor exclaimed. Quickly, he apologised for his outburst. ‘I’m sorry, it’s just that I haven’t seen anything like this before. I’ll need to consult with the surgical registrar. You can get dressed now, and I’ll be back in a few moments. Meanwhile, we’ll need to get an X-ray of your abdomen to see if there has been any other damage – and perhaps some blood tests. Please don’t eat or drink anything from now on. When was the last time you had anything to eat or drink?’ The doctor was obviously planning surgery, Jonathan thought.

The curtains in Jonathan’s cubicle parted, and a young Indian nurse came in to take Jonathan’s blood pressure and pulse. She also took some blood for analysis.

‘You are a patient in the day-stay clinic, is that so?’ she asked, looking at his paperwork.

‘Yes, I have a bladder cancer that is being –’

‘We have called the Urology registrar, and he is coming down to see you,’ she interrupted. She gathered up her stethoscope and was gone.

Jonathan was left alone again. He could hear a woman talking in the cubicle to his right.

‘We’ll have to take samples from her, take some of the semen for analysis. I’m sorry, but it’s vital. I know she’s been through a lot, but it’s so important to be able to prove what happened.’ He guessed it was a female doctor; she was speaking in soft hushed tones.

‘It’s OK, Julie. They have to do this. I’ll stay with you.’ It was another woman’s voice in the cubicle. At first, Jonathan could not work out what was happening. Take semen samples from a woman?

‘The police will also want to interview you and Melissa as soon as the doctors are finished. You need to tell them exactly what happened. I know this is a lot to go through, but he has to be put away. Julie, you need to do what is right for your daughter. She should never have to go through something like this again.’ The mother began sobbing. Jonathan had a great urge to part the curtain slightly to see how old the daughter was.

‘It’s OK, Mum. Let them take the sample.’ Jonathan could not believe his ears. It sounded like a young girl. Perhaps nine or ten. Around the same age as his daughter Kate.

‘Fuck,’ whispered Jonathan. What type of man would do that? He thought of his own daughters and what he would do if someone hurt even one hair on their head. He missed them terribly. Even since he’d lost his job, he hadn’t seen enough of them, because he had been holed up in his study, preoccupied by his worries. He hadn’t been much of a father to them. He really needed to spend more time with them, to nurture them.

His curtains parted again. It was a doctor who was vaguely familiar to Jonathan, one of the registrars.

‘Hello, Mr Brewster. What has been happening?’

When Jonathan related his symptoms and told him about the amount of blood in his urine, the registrar said he would have to admit him. He would speak with Jonathan’s doctor in the morning, and they would probably have a look in his bladder to make sure the cancer was responding to treatment. There were no free beds in the ward, so he would have to stay in Emergency for the remaining hours of darkness. The nurse came in with more forms to fill out. Then Jonathan asked if he could go out and tell his wife.

‘They’re going to keep me in. You go home, Trace. I don’t want the girls to wake up and find both of us not there.’

She hugged him tight then left, and Jonathan went back into Emergency.

He stood at the opening to his cubicle and looked across the U-shaped Emergency department with the staff area in the middle of it. Here was a sea of human suffering. From the dim, distant days of high school, a fragment of Hamlet came back to him: ‘the dread of something after death, the undiscovered country from whose bourn no traveller returns’.

It amazed him that he could still remember bits and pieces he had memorised before exams so long ago. The undiscovered country from whose bourn no traveller returns. He wondered where his mother was now. Was she just dead in the ground, rotting away? Or was her spirit here with him in the cubicle? Whenever he thought of his mother now, it was always as she was before the illness, before she had become shrivelled. She was his shelter, away from the religious zealot that was his father.

‘Are you there, Mum?’ he whispered. No answer, yet he felt an eerie sense of companionship. He shuddered. ‘What is happening to me, Mum?’ he whispered again. There was a strange calmness in his mind. For the first time in such a long time, his mind was still. Out of the stillness, he heard the faint sound of his mother’s voice. It was as if she was comforting him as she had when, as a boy, he had hurt himself. Soft tones, where words mean nothing. It was obviously his imagination playing tricks on him, he thought.

He needed to go to the toilet again. He resented the fact that his body had stolen from him a moment during which all time had seemed to stand still and he felt safe, at peace. His damned bladder.

He got up and asked a nurse rushing by with a syringe where the toilet was. She just pointed to the corridor. He walked down to search for the toilets, passing on his way a room labelled ‘Quiet Room’. In it was a family grieving. Two women, one older and one quite young, were hugging and sobbing. Some men with tattoos and wearing bike leathers stood around them. One stared out at Jonathan and closed the door. Two police officers walked towards Jonathan. They looked intently at him.

‘Mr Sawyer?’ one of them asked.

‘Er … no … Brewster,’ he mumbled.

‘Sorry to trouble you, sir.’

The other officer knocked on the door to the Quiet Room. ‘Mr Sawyer?’ he asked, with what sounded to Jonathan like feigned concern.

‘Yeah. Dad, the cops are here to speak with ya!’ a tall man with the most tattoos yelled over his shoulder. Then he turned back to the policemen and said in a quieter voice, ‘He’s very upset. Do you think you could keep it short, mate?’ Jonathan guessed they were the family of the man in the resuscitation bay. The dead man.

Jonathan found the toilet and pushed on the door, but it was locked. He stood for a minute deciding whether to go into the handicapped toilet. Just then, the door swung open.

An Asian man wearing the saffron-coloured robes of a Buddhist monk stepped out and, smiling, held the door open for Jonathan.

‘Oh. Thank you.’ Jonathan just stood there keeping the door open, watching the man walk down the corridor. He was an old man and yet had the spritely step of a 12-year-old. Though Jonathan had only looked into his face for a few seconds, he was tremendously struck by the man’s radiant smile. It was not a forced smile; it was a smile from within, a smile that was unintentional, unavoidable, a smile that Jonathan imagined said, ‘I know what there is after all of this, and it is fine.’

Jonathan went into the toilet, and as he urinated he looked at his face in the mirror to the side. He hadn’t shaved for several days. He looked like some haggard criminal. Dark rings surrounded his eyes. Deep wrinkles scored his face. Counting back, he realised he hadn’t showered in three days. He smelt his armpits. They were almost fishy, putrid.

He washed his hands and went back to his cubicle.

In a cubicle on the opposite side of the room, the Buddhist monk was attending a very old man in bed. The priest placed his hands together in a prayer position and raised them to his forehead before entering the room. Jonathan had seen this action in India, where Tracy and he had gone before they got married, in the days before children, loans, mortgages and responsibilities. The beggars on the streets and the porters at hotels would raise their hands in that prayerful position towards him and Tracy. He never felt deserving and would reward them with large tips.

The monk, as if sensing Jonathan’s gaze, suddenly turned around. He faced Jonathan and raised his praying hands again and bowed. That radiant smile was so overwhelmingly disarming. Automatically, without any thought, Jonathan placed his hands together and bowed towards the old monk. They shared a moment of peace and compassion while the patients around them went about the business of suffering and the doctors and nurses went about the business of tending to their suffering.

Sometime later, as Jonathan was floating between sleep and wakefulness, he looked up to see the monk at his bedside.

‘Do you mind if I sit?’ asked the monk.

‘No, please do. I could use the company,’ answered Jonathan. ‘You’re a Buddhist, right?’

The man nodded and smiled that smile again.

‘So, what do you make of all this, then?’ asked Jonathan, with a sweep of his arm to indicate the Emergency department.

The monk turned and surveyed the room, then turned back to Jonathan and answered, ‘Doctors rush here and there to fix up the bodies of these people. Nurses run to help ease their pain. Meanwhile, above it all, beneath it all, there is a truth from which none of these people can escape: suffering is part of life. Life is suffering.’

It was just like the woman had said at the restaurant with the lotus flower – only somehow this time Jonathan realised he needed to listen with the utmost attention. Here, beneath the fluoro lights of the Emergency department, these two men had silently forged a bond. Jonathan imagined they were travellers on a long trek, meeting in a teahouse along the way, swapping tales.

‘This world – and this body – is only a part of the journey. It’s not a beginning or a destination. Everything changes, including your body. Everything is transient. In meditation, we try to learn to see all of this with calmness, contentment, with clarity.’

It was as if the joy in the monk’s heart was contagious. A peaceful feeling the likes of which he had never experienced infused Jonathan. He, too, felt joy in his heart.

Noticing the calm expression on Jonathan’s face, the old man said, ‘There is an inner ocean of calm that is not beyond you. It is in you, a space you can visit whenever you need to. It is like a room where all is quiet and clear, whose door is open to you whenever the spirit needs to heal.’

The registrar appeared at Jonathan’s bedside again, pausing to look quizzically at the monk. The old man stood, bowed, and with that was gone.

‘Mr Brewster?’

‘Yes. Oh, sorry. Yes, doctor?’

‘I have spoken with your doctor, and he feels we need to get you to the operating theatre today and examine your bladder again. It’s obviously a worry that you’re bleeding again.’ The registrar’s tone was blunt.

‘I’m due for another BCG today. Do I need to have that?’ Jonathan was confused. How could he be operated on and have his BCG in the same day?

‘No. I’ll ring them after nine and cancel it. If the doctor thinks you need to continue on that treatment, then he will arrange it again next week. Any questions?’ The registrar was already walking away as he spoke.

16

Washington DC is a fabulous city. I had just been there for a week at a conference and visited all the sites, in between attending some of the conference sessions. It was a city of memorials: I had enjoyed reading the inscriptions on the Jefferson and Lincoln memorials in particular. Washington is also a city of contrasts. Georgetown University, in the area known as Northwest, is surrounded by some of the most affluent suburbs in the US. The diagonally opposite part of the town, the Southeast district, is among the most dangerous and poverty-stricken areas of the US. The shadow of the Capitol Building, an imposing visual feast of a structure, casts its cloak as the day progresses over the bitter poverty of the Southeast and the breathtaking affluence of the Northwest.

The hospitals of the Southeast offer care that makes some of the hospitals I have visited in developing parts of Africa look modern and cutting edge. By contrast, the hospitals of the Northwest are among the finest in the world. It all comes down to whether you can afford to pay for health care or not.

My plane home landed at 6 am, and I went straight to work at the Victoria Hospital. I hadn’t slept on the plane. Economy class, the smallest space that a person can physically fit into, is designed to ensure that sleep is not on the menu.

Damian handed over to me the various disasters that lay waiting. I was in my final weeks as a registrar, but he had been acting registrar throughout the week that I had been away; now, he handed the burden back to me with glee.

‘Oh, and finally, that young bladder-cancer patient came in overnight with bleeding. He’s still in Emergency. Derek wants to cystoscope him. I don’t think we’re going to get to do it until late today. We have a lot of cases waiting.’

Securing time in operating theatres was a battle fought day and night by surgical registrars in all of the public hospitals in the country. The high emergency case-load was no surprise. Over the years, statisticians and health economists had plotted, with uncanny accuracy, the expected case-load of emergencies on any day of the week. The hospital bureaucracy knew that on a given day there would be x number of cases. And yet, being allocated times to operate on the multitude of patients that I and every registrar saw in Emergency each day seemed as difficult a task as finding a hidden treasure in the Andes. First, one booked the case on the emergency list. Then one waited while the super vising nurses or anaesthetists prioritised the cases and then slowly worked through them in order. Hence, if a patient presented to hospital with a knife in the heart, his or her operation would be done almost immediately. Top priority. However, if a patient came in with a broken arm, a stone blocking the kidney or bleeding from the bladder, the wait for surgery could stretch to several days. All the while, new cases were being seen and added to the list. Add elective surgeries such as hip replacements, prostate operations, hernia repairs and other cases of similar importance and the waiting list got even longer.

Much of a surgical registrar’s time was spent battling for theatre slots. ‘I really think my case is more urgent!’ the registrar would say.

‘Well, if you think so then you will need to speak to the other 16 surgeons who are desperate to do their cases also,’ the anaesthetist or nurse would answer.

Long waiting lists are a major concern for a health minister because the longer patients wait for surgery, the more they complain. The list at the Victoria Hospital was huge. When I booked a patient in the Urology Clinic for their prostate to be operated on, they could wait up to 18 months.

The previous year, the health minister had been pleased to tell the public that the waiting list for elective surgery had been cut to zero. The media rejoiced. The reality was that the definition had been changed. Formerly, once a surgeon had decided a patient needed an operation, he or she put the patient’s name on the waiting list. Now, they were to put the patient’s name on the list only when the hospital had allocated the patient a time to have his or her surgery. By a stroke of the pen rather than a slice of the scalpel, the waiting list had been cut almost out of existence. The alternative, of course, was for the government to acknowledge that health resources were not adequately distributed. The operating theatres were one place that obviously needed more money, better organisation or greater efficiency.

Meanwhile, Jonathan sat in Emergency waiting for his operation for the rest of the day. It was almost seven in the evening when he was finally taken upstairs. I was standing at the doors that led to the theatre complex.

‘Hello there. You’ve been having some bleeding, Damian tells me. We will soon get to the bottom of it. How have you been?’ I asked.

‘Not well, doctor. I’ve had enough of this business. Do you think it can be fixed today?’

‘All we’ll be doing today is trying to ascertain where the bleeding is coming from. If the cancer has grown despite treatment, then we need to know about that. Your doctor is in just finishing a case. I’m sure he will come and discuss it with you further.’ I placed my hand gently on the back of his, for reassurance. I did this instinctively. Years later, when I was to go through my own cancer ordeal, I realised how important human touch is. Through a simple reassuring touch, so much care, compassion and empathy can be transmitted. It is so much more powerful than words.

An orderly came to take Jonathan into theatres. He was working on his own, so I thought I would give him a hand. We brought Jonathan’s bed into the anteroom adjoining the theatre where he was going to be operated on. The orderly placed the notes on the side of the bed.

‘We will be with you shortly,’ I assured Jonathan. He just lay there looking so vulnerable. I felt sorry for the man.

I went into the theatre and told Vincent, the anaesthetist, that Jonathan Brewster was in the anteroom.

‘Is that the bladder cancer?’ Derek asked.

‘Yeah, the one that’s had the BCG and is now bleeding,’ I answered.

I had interrupted an intense conversation the two men were having about the hospital review while Derek operated on a private stone case. Every now and then, there was a private patient on the list in the public hospital. Such a patient was generally referred to by medical staff as ‘MBF positive’. MBF was a large provider of health-care insurance.

I sat in the corner listening to their discussion and finished the cup of coffee I had obtained several hours ago. It was almost iced coffee.

‘Anyway, they sent round a memo from administration. It was just crazy. It said something like the management is aware that there is low morale in the hospital, and so they are going to spend extra to have the clinical areas of the hospital cleaned. Can you believe that? Someone remind me: isn’t a hospital supposed to be clean anyway? They were the ones who outsourced the cleaning in the first place, so it now costs more than it did before, yet the hospital is so dirty that our morale is affected. They just defy any form of logic known to man or beast.’ It was Derek, shouting at the top of his voice.

‘Someone should show the memo to the people conducting that review the minister established. Have they asked for your views?’ said Vincent.

‘Don’t be stupid. The only people who’ll testify before the review committee are the ones who’ll tell them everything’s rosy. The committee doesn’t want to hear the truth.

‘I’ll tell you exactly how it will go. They’ll bring in an MP who is ostensibly independent. They’ll assemble a few retired healthcare professionals desperate to make their name so that they can get their next title, their gong for community service, their government nod. Then they’ll interview a few people here and there carefully selected by administration. You think the hospital’s general manager is a fool? He’s a self-preservationist of the highest order. In a couple of weeks, they’ll release the report. The minister will get on TV and say, “I will implement the majority of the recommendations.” Everyone is happy. End of subject. Next week, the news is about something else, and few can remember the disaster until the next time it rears its ugly head.’

Derek finally stopped to draw breath, and the scrub nurse piped up. ‘I hear surgeons complaining and carrying on, but every time we have a meeting of the theatre committee, no surgeons turn up. You’re always too busy in your private rooms making money. You don’t give a shit about the decisions that are made each day here in the theatres. I remember when you used to turn up and chair that committee, doctor. Now you just sit here and whine about the state of the health system. At least us nurses have got on and done something about it.’

‘You nurses only turn up to those meetings to avoid work,’ Derek blustered. ‘I’ll come to meetings that are held after hours, because if a nurse is willing to give up her spare time then it must be worthwhile.

‘I’ll tell you what the function of administration should be in this hospital. Their real job should be nothing more than to make sure that when I come in to operate, I have the correct stitches I need and the light bulb is changed.’ Derek was clearly enjoying himself.

‘Come on, Derek. You can’t believe that. You need people to administer the budgets, the resources. Running a hospital must be a very complex thing,’ Vincent said, defending the nurse.

‘It is complex. The problem is that the people running it have no idea what it’s like to be at the coalface. Let me ask you one thing: what’s the purpose of the health system?’ Derek seemed to be asking the whole theatre all at once.

‘I suppose it’s to make sick people better,’ answered the scrub nurse.

‘Correct. That’s what it’s supposed to do – make sick people better. Now, if you designed a health system to do that, would it look like the top-heavy mess we now have? The answer is no. The purpose that this health system serves is ensuring that the minister is protected. Do you know what proportion of the health budget is chewed up in preventing the minister from being on the front page of the paper? What proportion of the budget is administration and bureaucracy?’ Derek stopped briefly, as if waiting for their answer. ‘No. You wouldn’t know. Nobody knows. You know why nobody knows? It’s impossible to get the figures. You look at the annual report of this hospital or the annual report of the health department. You’ll find line items for doctors, nurses, pharmacy, radiology, pathology … but no line item for management, bureaucracy, administration. The best estimate I’ve heard is that it takes up about 40 per cent of the health budget. More than half this hospital’s buildings are administrative blocks. There are as many administrators working in this place as there are nurses.’

‘How long have you got to go with this operation?’ cut in Vincent, who wanted to plan the rest of the evening’s surgery. ‘Shall I give the next guy some midazolam?’

‘We’re almost there. Go ahead and give it to him.’

Vincent disappeared into the anteroom to give Jonathan a little sedative. We all suspected he was listening to the whole conversation. His sedative, though, would mean he’d remember very little of what he had heard.

Having finished the operation, Derek removed the equipment from the patient. A few minutes later, Jonathan was brought in. I scrubbed as he was put to sleep. When I returned, he was asleep with his legs up in the air in stirrups, ready for me to cystoscope him. Derek stayed around, as much for the company as out of curiosity. I inserted the large resecting cystoscope through the eye of Jonathan’s penis and slowly advanced into his bladder. Emanating from the left side of his bladder wall was a large fungating tumour – it had the appearance of a clump of red bushes. It was advanced and looked aggressive.

‘Shit. This guy’s in trouble,’ said Derek, looking at the screen. ‘He hasn’t responded to the BCG. In fact, it looks like he’s progressed. Do some biopsies and a bimanual examination, would you, Mohamed? I’ll see you tomorrow.’

I performed the biopsies, removed the scope and examined his pelvis internally. I felt the large, hard and craggy mass that was the cancer in his bladder. It was obviously aggressive. What a tragedy, I thought. The man was only young, perhaps a few years older than I was. He was facing a significant crisis, of which he was currently blissfully unaware. He had a lovely wife, and I remembered him telling me about his two daughters when he’d had his first tumour resected. How sad.

By the time I had got to my car, I had forgotten all about Jonathan. Surgeons cannot store the suffering of their patients. They need to have the ability to let go. The Hindus call it swaha, a Sanskrit word that implies breathing out the trouble, freeing oneself of the pain. The Thai Buddhists do it physically. They write down their problems and troubles on the outer skin of a hot-air balloon and then launch it upwards. The effect is to physically take away their bad luck. Jonathan’s journey was his to travel, and by the time he awoke I would be asleep, dreaming of happier things.

17

It was about one in the morning when Jonathan awoke in the ward, in the same four-bedded room as last time. Opposite him, the light was on, and the gaunt old stubbled man in the bed was straining against his shackles and shouting out. ‘We will not give in to you. You can take my head off if you want to. You will not win this war. The Allied forces are on their way. When they see these medical experiments you’re conducting on us all, you’ll see what they’ll do. You’re all in big trouble.’

An Asian nurse was trying to give him a sedative injection. ‘Calm down. It’s no good the way you talk. Calm down, Mr Swinson. Calm down,’ she was saying with a very heavy accent.

The patient in the bed next to Mr Swinson was also awake. ‘It’s no use, love. He thinks he’s back in a Japanese prisoner-of-war camp. He’s all right during the day, but he’s been behaving like this every night since you’ve been doing the night shift. He’s confused, poor old fellow.’ The man, who was in his 50s and whose arm was in a cast and suspended from a drip stand, sounded compassionate but exasperated.

Jonathan felt wetness between his legs. ‘Help, please. I think I’m bleeding,’ he called out to the nurse.

‘I’ll be there in a short while, as soon as I finish here,’ she said. ‘I’m by myself. Please wait, OK?’

‘No. It is not OK. I’m bleeding here. Please. Help me.’ Jonathan was panicked. He looked for the button to turn on the light and in the dark found the television instead. It came on loudly. The headphones were not plugged in.

‘For Christ’s sake, shut up,’ said the man in the bed next to him. ‘Can’t we get any sleep in this fucking hospital?’

‘Please respect yourself and us. Don’t swear. You have filthy mouth,’ said the nurse, who was still trying to find a vein on the old man while he continued to accuse her of conducting scientific experiments on him in the prisoner-of-war camp.

She finally came over just as Jonathan had found the light in his dazed state.

‘It is only the catheter. No problem. You are not bleeding. It is just the fluid from the bag,’ she said. His catheter had come adrift and was leaking bloody urine into the bed. The nurse hooked it back up, turned the light off and left. His bed sheets needed changing, but she was too busy to do that now. It could wait.

Jonathan was wide awake now. The sheets were uncomfortably wet, but he did not want to complain. He wondered what they had found during his surgery. He wondered what time it was. The old man had calmed down a bit and now was just slurring his abuse. The man next to him was snoring like a bear in the woods again, after his earlier outburst.

Through the window, Jonathan saw a faint red glow from the neon lights illuminating the entrance to Emergency. He hoped that Tracy would come and visit him at a reasonable hour in the morning. Meanwhile, he really wanted to get up and walk around, but he was tied to an intravenous drip and the catheter. He slept very little these days and seemed to need to get up in the middle of the night to have a walk. He picked up the various tubes and attached them to the drip stand and got up. There was a loud crash as the nurse-call cable fell off the bed onto the floor, the plastic button shattering.

‘Jesus Christ,’ grumbled the man in the next bed.

Jonathan walked out of the ward into the corridor. The nurse was sitting at the desk reading a magazine. She looked up briefly. ‘Everything OK?’ she asked.

‘Yes. I’m just going for a brief walk.’

Christmas was on its way; he hadn’t realised how close it was. The ward had made an attempt to decorate. There was an old plastic tree in the corner with coloured lights blinking on and off. Pretend presents had been wrapped and placed under it. Tinsel decorated the corners of the ward and hung lazily across the corridors. On a board at the desk was a row of coloured lights, one to indicate each bed in the ward. They were lit in a random pattern of patients who needed the nurses’ help, and they unintentionally added to the festive feel of the ward.

Jonathan walked past other four-bedded rooms and noticed that along one side of the corridor there were single rooms. In one, several people stood around a dimly lit patient who was gasping on an oxygen mask. He guessed it was the night-time vigil that played out each night in every hospital around the world as family waited for someone to die. One of the family members came out into the corridor and quietly closed the door behind her. It was a young woman, about Tracy’s age, who smiled softly at him. She opened the door to the ward tearoom, and he followed her into the brightness of the room. She went to the sink and started to make a cup of tea.

‘Could I make you something while I’m here?’ she asked in hushed tones.

Jonathan looked around the room, expecting her to be talking to someone else. When he realised it was only him in the room, he nodded.

‘Tea?’ she asked.

‘Yes. Please.’ He sat down on one of the plastic chairs. ‘Is it your father who’s ill?’ he asked gingerly.

‘No, it’s my brother. He has lung cancer. We don’t expect him to last through the night. My mother and sisters are with him.’ She became teary telling him but quickly composed herself. ‘And you, what are you in for?’

The words ‘in for’ struck Jonathan. Was he in for something, like a disaster or an event? Or was he in for a crime he had committed? ‘Bladder cancer.’ He was getting used to saying it.

‘Do you have any family?’ she asked.

‘Yeah, two daughters, nine and eleven. No, ten and eleven. Emma and Kate. Emma’s my eldest. And my wife, Tracy. Hopefully, they’re all at home tucked in.’ He winced at saying the word ‘home’. He did not have a home any longer. He was itinerant, soon to be living at his father’s house. The woman placed the cup of tea on the table in front of him.

‘It must be hard to be going through what you’re going through. I can only imagine the pain you must be feeling. Have the doctors told you what treatment you need?’

The concern of this stranger, who was herself suffering, touched Jonathan. ‘I had an operation last night. I’m waiting to find out what they found,’ he said.

‘I better get back to my brother. I wish you the very best,’ she said and touched the back of his shoulder as she left.

Jonathan sat silently in the tearoom, yearning for her to come back. He thought of his wife and children, of the fact that perhaps, one day in the not-too-distant future, he too might be in a room with the hushed tones of death around him. Once again, on this journey he was on, Jonathan confronted the possibility of his death coming sooner than he had hoped. What is the process of dying? he wondered. The man down the corridor was obviously about to find out what happens on the other side.

He closed his eyes and tried to imagine his mother’s face, as he liked to remember her, before the stroke. Instead, a macabre thought about her rotting in her grave popped into his mind. He imagined her body falling apart, bit by bit. He had seen decomposed bodies on television, in documentaries, and the full realisation struck him that this is what would happen to him too when he died. A crushing sadness came over him as he imagined his wife and daughters at his funeral.

Suddenly, there was a clatter at the door. Looking up at the clock on the wall, Jonathan was surprised to see it was five in the morning, and the cleaner had arrived. She came in and changed the bins, wiped the sinks and mopped the middle of the floor. Then she took the same mop and wiped the walls with it. Jonathan couldn’t believe what he had just seen. He went back to his room and waited for the day to commence.

I met Derek on the ward at about 6.45 am, and we went to see Jonathan first.

‘Did you sleep well?’ asked Derek and immediately continued, ‘Look, the cystoscopy yesterday has shown that you are not responding to the BCG treatment. We hoped that you would, but your cancer has progressed. I think we have no choice but to advise definitive treatment. You have two choices in my view: radiotherapy – ray treatment – or a cystectomy, where we take your bladder out completely. It’s an …’

We could both see that Jonathan had tuned out at this point, as his eyes had completely glazed over.

Derek paused and regained his attention. ‘Given your age, I think I would advise the latter. We can schedule your surgery for later this week as an emergency, and I think it should nail the cancer on the head.’

Jonathan was now pale with confusion and fear.

‘Where’s your wife today? Do you want me to speak with her as well? It’s a big decision, of course, and you’ll need time to think it through. I’ll be in my rooms throughout the day. Perhaps you could get her to call me, OK? Well, I’m sorry it’s not better news, but I think we need to move fast to help you beat this thing.’ With that, Derek patted Jonathan on the back of the hand and left the room with his retinue of residents in tow.

I returned after the ward round to find Jonathan sitting up in his bed, dazed.

‘I felt that perhaps you needed to talk about what we found in theatres last night,’ I said. This was an uncharacteristic show of compassion on my part. I had always been a driven surgeon for whom the technical repair of the patient was the means of displaying care. To sit with a patient and talk about his or her feelings was something I rarely did. I preferred to refer the patient to the social worker instead.

‘I’m trying to process it all, doctor. What does it all mean?’ he asked.

I reiterated Derek’s conversation and did my best to explain the possibilities that lay ahead.

‘So, how do I urinate if they take my bladder out? I don’t understand.’

‘We can substitute your bladder with a new bladder or use a small piece of your bowel to carry urine from your kidneys out through a hole in the side of your abdomen.’ I pointed to where the stoma would be sited outside his body. ‘The urine would drain from there into a bag that you attach and change whenever it’s full.’

Jonathan looked more and more faint as I spoke. As I helped him lie down in the bed, I wondered how I would react if the same news was given to me. I never envisaged for a moment that soon I too would have to make decisions about illness, treatment and death.

‘Will I be able to get home before the operation? I just need some breathing space. I want to go back home.’ The word ‘home’ stuck in his throat. He brought his blanket up to his neck as if to hide from the truth and the realities that were now hammering him. One moment, he had an infection or a stone. Next moment, it had turned into a cancer that could be removed with just a simple operation. Then he had the BCGs, which he was sure were doing him some good. Suddenly, it had turned into a major operation with new bladders and having to carry bags around to collect his urine outside his body.

Coming all at once, it was too much for him. Jonathan was breaking down. He was deconstructing. I looked at him and thought of what new recruits in the army appear like at the end of boot camp. They are put through a gruelling regime of punishing physical and mental torture until the people they were have left their body and they are empty shells to be filled and turned into obedient, rule-following machines. There was one difference. He was now a hollowed-out shell, but Jonathan had nothing to fill that shell with. He closed his eyes, and I imagined the past three months of his life were playing out like a fast-forwarded movie. Then blankness. He probably could not even visualise the future.

I sat silently with him for a while. Soon the curtains parted, and Tracy was there to take over the hand-holding. I returned to being a surgeon. Later that day, Jonathan’s bleeding settled, and I was able to take out the catheter and send him home.

I was very surprised to find out subsequently from Derek that Jonathan had persevered with the BCG and chosen not to have his bladder out. He apparently could not face the thought of having to carry his urine around with him outside his body. I wondered how he had come to that conclusion or who had suggested to him that risking his life to preserve his vanity was a viable option. It was not my issue, as I was no longer Derek’s registrar and was now a senior lecturer at the university and consultant in urology at the hospital. I didn’t meet up with him again until over a year later. When I did, it was not as his doctor.

18

I sat on a bed in one of the cubicles of the Nuclear Medicine department’s waiting bay trying to avoid being recognised by other staff. I had been through the entire gamut of medical care in the preceding couple of months because I had discovered a lump in my neck that had turned out to be a cancer. To make things worse, it had spread. Two bouts of surgery and a treatment called radio-iodine ablation, which was supposed to have killed my cancer cells, had left me a shattered man.

Just over a year previously, I had taken up my position at the Victoria Hospital, and now I was in need of the staff. I tried to keep my use of the hospital’s services to a minimum, because I didn’t want to interact with the staff any more than could be helped. What I hated most of all was when they asked how I was. Was it from a macabre desire to see my suffering or because they genuinely wanted to alleviate it? ‘How are you feeling now?’ I dreaded the very words. Do not ask how I am or what I need. Instead, simply make my family a meal, pay a bill, take my children out to the fun park or get your wife to take my wife to the movies. Do something – anything – that is useful, but do not, for God’s sake, ask me how I am.

The only good thing about getting cancer is that, paradoxically, one develops an extraordinary degree of patience and the ability to wait. One waits for biopsy results, treatment, surgery, tests. One spends the entirety of the rest of one’s life, no matter how long or short, waiting.

That day, I was waiting for a scan to see whether the treatment had controlled my cancer.

An orderly headed towards the cubicle opposite mine to collect the next patient for their scan, and once the curtain was parted I saw on the bed a man in a white hospital gown. I read the name on the end of the bed: Jonathan Brewster. His eyes met mine. Had I not read the name, I would not have recognised the gaunt man I now saw lying in a bed about to be taken in to have a bone scan. Tracy was standing by his side. I remembered her as a beautiful woman, but now deep lines of premature age seemed to have altered her face into a permanent mask of sadness. She recognised me before Jonathan did and whispered something to him. Disbelief immediately registered on their faces.

‘What are you doing here?’ asked Jonathan.

That was the other inane question I had been asked a hundred times by my colleagues, and which galled. Coming from a fellow patient, it seemed more acceptable.

I explained my story briefly and then asked about Jonathan.

Tracy explained how he had opted to finish the BCG treatment instead of having his bladder out. But, after nine weeks of BCG, he had some cancer left behind and so needed radiotherapy of his bladder. ‘He finished his radiation almost a year ago. We were so hopeful then, Dr Khadra. He got his strength back, and we even went on that holiday to Africa. Jonathan would not let me sell it to get the cash back. God, it was fantastic. We went from Johannesburg up to the Victoria Falls and stayed at a hotel right on the Zambezi River. When we came back, he was even well enough to start looking for jobs, and then this back pain hit him. It’s all really knocked him about,’ she said. ‘Our GP has sent him in for a bone scan.’ She recounted the story chronologically and efficiently, just like a good patient – or his advocate – should.

The orderly began to wheel Jonathan away, so she bade me farewell and followed him. As they disappeared down the corridor, I recalled my own holiday at the River Club on the Zambezi River. Images of sunset over the Victoria Falls momentarily took me away from my own predicament to happier times.

‘Khadra?’ The orderly was back to take me to my test.

When it had been completed, I had to wait for the radiologist to report the result. Around me in the waiting bay were all kinds of patients: the dying, the sick and the ‘worried well’. Most of these would have been men and women who until recently were not a part of the patchwork quilt of disease that is a hospital. The vocabulary they’d had to learn – the names of treatments and diseases and tests that were unwelcome but now integral parts of their lives – would have altered all of them deeply. And my knowledge of disease had not lessened its impact on me. In fact, succumbing to it myself had altered me fundamentally. At the very least, disease alters one’s sense of mortality and shakes any notion of being able to depend upon or expect anything from life. In the space between the ticks of a clock, a life can be converted by disease or trauma from a reliable continuum to a continued reliance: a reliance on the health-care system.

But could the health-care system be relied upon? The individual components of the system provide a high level of care; it is the lack of unity between these components that strips the system of compassion and comfort. A car-accident victim might rely on up to 20 hospital departments, each with their own communication system, bureaucracy and jargon. It would not be uncommon for his medications to be doubled up by doctors from different specialities, each focusing solely on one small part of the overall man. The elbow surgeon looks after the elbow; the knee surgeon the knee. The radiologist reads the black-and-white film that to her represents his whole condition. The pathologist looks down the microscope and notes small changes to his cells, spread out over a glass slide for analysis. There is no doctor responsible for our crash victim’s overall well-being or for guiding him through the maze of surgical procedures, advice, medications and decisions he must make.

Medical staff have a basic will and duty to help patients, to cure them, to be liked by them – but patients are often left with a very different impression. Perhaps the health minister is the one to blame. The job of the health minister and departmental staff is to ensure that the health budget is not blown and that there are a minimal number of complaints from patient-advocacy groups.

It used to surprise me, anger me to learn that the health department stifles activity in order to meet the budget. Once a hospital has no more money for surgery, its theatres are closed and patients are diverted to other hospitals, perhaps with some residual budget still available so they can operate. But not everyone who wants or needs an operation will get one.

Some people argue that hospitals should use the money they are given more wisely and boost their productivity. They suggest that if staff were paid bonuses for improving their output, hospitals would be run far more efficiently. For example, nurses could be paid a bonus based on how many patients come through their ward or how many beds they change each day or even how clean the ward is. Doctors’ bonuses could be based on positive outcomes, the number of patients they see and patient feedback. The orderlies in theatres could get bonuses on the basis of how many people they move. This may alleviate some staff inefficiency, but it would do nothing to target the real problem: the inefficiency inherent in the system through ineffectual and unrealistic policies generated by the faceless bureaucracy.

Sadly, putting more money into health care would not solve the problem by itself. Just how much of the country’s gross domestic product should we spend on health care? In India, it is very low. In the UK, the figure is about six per cent. In Australia, it is nine per cent. In the US, the figure is approaching 16 per cent. Yet no one would argue that the quality and safety of health care in the US is twice as good as Australia’s health-care system, or perhaps three times as good as the UK’s. What was really needed was leadership, in terms of our politicians getting the message through to society to expect and accept that our health-care dollars are rationed. Nothing more and nothing less.

As I waited for my results, to learn whether I was to live or die, Jonathan was waiting across the other side of the room. He was dressed in his street clothes and looked more like a human being and less like a patient.

‘How have you found being a patient, doc … being on the receiving end?’ he asked.

‘It certainly makes you think,’ I said dismissively. He did not push it. I did not want to get into a long discussion with him about my feelings, for I knew he had his own burdens and worries. I did not tell him how lacking in compassion I had found the system. Fleetingly, I recalled how my surgeon had told me with glee that I would of course know that the five-year survival rate for my type of cancer was really high. I had quoted statistics of this kind to patients myself, expecting it to make them feel better. When the same probabilities were quoted back to me, I resented it, almost to the point of violence. I didn’t want to know the five-year survival rate. I wanted to know the ten-year rate, so that I could bank on seeing my children get to high school. I wanted to know the 20-year rate, so that I could have a chance of seeing them graduate from university, or even the 30-year rate, so that I, like others whom I envied, could hold my newborn grandchildren in my arms. How dare you presume to tell me about two-, three-or five-year survivals? I had thought.

Yet I, like the surgeon treating me, knew that the majority of studies on cancer quote those short time spans. Yes, medicine has made huge strides in dealing with cancer. Leukaemia, testicular-cancer and lymphoma treatments are triumphs of modern medicine. Lung, breast, bowel, prostate and bladder cancer are now often controllable and, in many cases, curable. However, the statistics don’t alleviate the pain of the uncertainty of one’s own cancer outcome, the pain of being reminded that life is transient. We reach out to touch the hand of a loved one in the expectation that they will be there for the foreseeable future. We all know it won’t be forever, but being unaware of precisely how long we have left protects the human psyche. Once life is circumscribed by disease into periods of days, months or years, we become prisoners on death row.

‘Are you still working?’ I asked after a small silence.

‘No. I lost my job. We ended up selling our house.’

‘I’m sorry to hear that.’

‘It’s actually not that bad. I spend much more time with the kids, and I read a lot now. I went to school, but that was it, so I’m enjoying catching up on my education.’

‘What are you reading now?’ I asked.

‘Hemingway, The Old Man and the Sea.’ He held it up for me to see. It was poignant and ironic at the same time. The journey and the loss.

‘Dr Khadra!’ It was the radiologist calling my name.

I went to hear the judgement being read. As I walked in, I hoped that not only my results would be good but Jonathan’s too.

There was no sign of my cancer on the scan. I was clear – at least for a while. As I left, I saw Tracy and Jonathan walking out of the hospital, hand in hand. I felt glad that their love had been sustaining.

As I walked out of the hospital, I thought again about the question that Jonathan had asked me: what was it like on the other side of the desk, the surgeon as patient? Individually, the doctors, nurses and other clinicians looking after me had been reasonable – excellent in some cases. It seemed to me that it was the dilution of individuality into an overriding system that created the lack of compassion, the incompetence and the wastage.

So often I had heard people say that, perhaps now that I was sick, I would learn more about compassion, care for patients better. They had perhaps seen the film The Doctor and seemed to want to impose that rosy plot on me. I did not identify with the character in that movie. Being sick did not suddenly make me want to be more compassionate. However, it made me understand how unprepared my patients are for illness, for trauma, for the unexpected and for sudden life change. In fact, most of my patients had never faced their mortality. Perhaps it was beneficial to live in ignorance of their mortality while that ignorance lasted, but, as a result, the problem they had with the health system was that they needed it to provide more than health care; they needed it to provide wisdom.

19

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.

‘I think a single-layer stitch should do it.’ He was taking a risk at Jonathan’s expense because it was quicker.

Having stitched up the hole in the bowel, Derek removed the prostate and urethra, the tube that Jonathan used to be able to pass urine through. He then lifted up the bladder and kept dissecting it from his abdomen, working his way up towards the top of the organ. He cut across both ureters, the tubes connecting the bladder to the kidneys above, and sent a section of them to be examined in the pathology department to make sure they were clear of cancer. He finished removing the bladder, then set about isolating and cutting out a section of Jonathan’s small bowel and converting it into a tube to carry urine from his kidneys.

They were several hours into the operation when the pathology department rang to say the lymph nodes and the ureters were clear of cancer. ‘We sent that stuff ages ago,’ Derek said. ‘I’m glad we didn’t wait for it. We would have been here till midnight.’ Most surgeons waited for the pathologist’s report before deciding whether or not to continue the operation. If cancer had spread to the ureters and lymph nodes, it was likely to have spread throughout the patient’s body. In those circumstances, removing his or her bladder would usually be pointless and inadvisable.

Derek inserted the ureters into one end of the tube he had formed from a piece of small bowel and fixed it so that the other end opened at the surface of the skin on the belly. Jonathan’s urine would flow into this newly formed tube instead of flowing towards his now-removed bladder. A stoma ring was then attached to his skin at the external opening of the tube with biocompatible glue so that a bag could be attached to it to collect urine. Finally, Gemma closed the abdomen; Derek usually let her do this part while he wrote up the notes. The wound was dressed, and Jonathan was transferred to the Intensive Care unit for monitoring overnight. He had a tube in his windpipe to help him breathe. He had a tube from his nose to his stomach draining away his digestive juices because for the first few days after surgery his intestines were paralysed and would not drain the juices away. The juices were pushed up each time he coughed or moved. Despite its discomfort, the tube was far better than vomiting post-operatively. He also had an arterial line, a central venous line and several drains in his abdomen.

The next morning, Jonathan opened his eyes and started to make gurgling sounds. The tube down his throat was irritating him.

‘You are fine,’ said a nurse in a comforting tone. ‘You’re in the Intensive Care unit. I’ll take out your tube now, and you’ll feel a lot better. Don’t try to talk. You won’t be able to.’ She was speaking in a loud voice with her face directly over Jonathan’s. ‘You have a button under your left thumb. You can press it if you have pain. It will automatically give you intravenous medication to help control the pain. Make sure you use it as often as you need it. You cannot overdose yourself. It is designed to prevent that. OK?’ She was working on the tube as she spoke.

Tracy was allowed to visit that morning but couldn’t stay longer than a few minutes as she started sobbing uncontrollably to see her husband in this state. During the surgery, his legs and pelvis had been elevated, and, because the surgery had taken so long, his face was now swollen. She almost couldn’t recognise him. Later, Derek came in to make sure his handiwork had survived the night.

Images drifted into and out of Jonathan’s mind as he lay in that Intensive Care bed. Tracy and his daughters, his father, Carter, Jake, all swirled around like leaves in the wind. At some point, his father came in and said a quiet prayer beside his bed. The girls visited briefly. Slowly, reality replaced fantasy, and he was able to focus on the present.

By the beginning of the second day, he was much more in focus and for the first time started feeling pain. There was a sharp pain that overwhelmed him whenever he moved, and then there was a deep and dull pain. It was constant and invaded every waking moment. By the end of the third day, he was unable to sleep because of it. His medication was increased. There was talk of him being unusually susceptible to pain, a weakling. Eventually, the nurses became curt with his constant grunting and complaints. Patients who complained too much did not endear themselves to hospital staff.

‘Can you pinpoint where you are feeling the pain exactly?’ Derek asked on the evening of the third day.

‘There’s the sharp pain where the wound is. That seems to be getting much better now. But there’s another pain. It’s deep down somewhere.’ Jonathan couldn’t explain it any better than that.

‘If it continues another night, we’ll send you down for a CT scan,’ Derek said, his tone reassuring.

When Tracy came in to visit that afternoon, the receptionist at the hospital’s front desk stopped her and asked if she had a minute. ‘The accounts manager needs a quick word, Mrs Brewster. She’s in her office expecting you.’ The receptionist guided her around behind the reception desk.

‘I’m so sorry to bother you at a time like this,’ said the accounts manager. ‘I know you must be very worried about your husband. However, the original quotation we gave you only included one night in Intensive Care. Mr Brewster has needed to be there for three nights so far, and it looks like he will need an extra night. That has added a considerable amount to the bill, and I just need to know whether you will be making another deposit to cover this extra amount.’ She was polite but to the point.

‘How much are we talking about?’ Tracy had a faint edge of panic in her voice.

‘Well, all up it’s about double what we quoted.’ The accounts manager had had this conversation with several people each week since she’d started working at the private hospital five years ago. It was the low point of her job.

‘I see. I’ll talk with his doctor and my father-in-law. We’ll sort it out somehow.’ Tracy left without thanking the woman. This is a business, she thought, a straight-out business. There is no humanity or compassion here. She was right, of course. Private hospitals are designed to make a profit for the shareholders. They provide good care, and some even provide wine with dinner. However, they are not charities. Some of the most exclusive and costly private hospitals are run by the Catholic Church, as if to dispel any notion of a separation between church and stately matters.

She pushed the call button at the door of the Intensive Care unit. ‘Mrs Brewster to see my husband,’ she called into the intercom.

‘Just a minute, please. We’ll be with you shortly,’ the ward clerk answered.

‘That’s odd,’ muttered Tracy under her breath. Normally they just let her in immediately.

The reason they didn’t was that just five minutes previously Jonathan’s wound had started seeping fluid. At first, the nurse thought it was a small haematoma – a build-up of internal bleeding – beneath the skin, but she soon realised it was much more than that. The fluid was bloodstained initially and then turned greenish. It was the contents of Jonathan’s bowels. His wound had formed a fistula – an opening – from his bowel out to the surface of the skin. He was essentially leaking shit onto the front of his belly. Left untreated, he would be dead within a couple of days.

Derek had been called, and he in turn had called Gabe and Gemma and lined up the theatre for urgent surgery. Tracy saw Derek rush into the Intensive Care unit and felt a jolt of fright. She sensed that something dreadful was happening to her husband. Unwilling to wait any longer, she pushed through the doors and into Jonathan’s cubicle. Immediately, she was struck by an overwhelming smell of faeces and urine. The dressings on the front of his abdomen were soaked with a greenish fluid, and Jonathan looked very frightened. Her first reaction was to vomit, which she did onto the floor next to his bed.

‘What’s happening? What’s going on?’ asked Tracy, looking at the nurse and then at Derek.

They stood silently for a moment, then Derek took her by the elbow and said, ‘Let me talk to you outside.’

‘Don’t leave. Please talk to me. What is going on? I want to know too,’ demanded Jonathan.

Derek turned and guided Tracy back to Jonathan’s bedside. ‘It looks like we have had a small setback. When we did your surgery, the bowel had to be opened to make the tube that’s now draining your urine away. It looks like there is a small leak from where the bowel was cut and sewn back together. This sometimes happens and is of no major concern. It looks worse than it is,’ he said, trying to look unflustered. ‘What it does mean is that we need to take you back to the operating theatre and open you up again to fix it. It is a small setback.’

‘But this is going to cost more money.’ Jonathan was the first to speak. ‘Could this be done in the public hospital? I can’t afford to stay here any longer.’

‘Look, this is an emergency. We need to operate on you tonight,’ replied Derek.

‘I want to be transferred to the public hospital. I refuse to have any more treatment here.’ Jonathan’s tone was adamant.

‘If we take you to the public hospital, it might be a couple of days before we can get your operation done,’ said Derek. He should also have told them that if Jonathan had the surgery done in the private hospital, he would get paid about six times more than if the operation was done in the public.

Tracy and Jonathan looked at each other, not knowing what to do. Tracy said, ‘We’ll work it out later, darling. The only important thing now is to make sure you get your operation done.’

‘That’s the attitude. Look, I’ll see if I can talk to the accounts department here and get your bill reviewed. After all, making you better is our first priority.’ Derek gave a reassuring smile, but to Jonathan it looked like a sinister smirk. Jonathan was too weak, too sick to think this through. He had to rely on Tracy. Had he been compos mentis, he would have thought about the conflict of interest that Derek Johnson had in advising Jonathan about where to have his operation.

An hour later, Derek, Gemma and Gabe were reassembled in the theatre for the unpicking of the wound, the saline washouts of the abdomen and the attempt to find the leak. Assistant and anaesthetist were not happy to be there. This was the third patient they’d had to take back to theatres that month with Derek.

‘Did you tell the patient about the hole you made in the bowel during the cystectomy?’ Gemma asked. The theatre went absolutely dead. Everyone was stopped in their tracks, including Derek. Gabe and the nurses looked at her disbelievingly. Perhaps it was her tiredness that had made her speak out. Perhaps she had not really meant for the question to come out sounding so accusatory. Or perhaps she simply could no longer contain her unease over the surgeon’s dishonesty and ineptitude. Derek had her fixed in his steely stare.

‘Well, did you?’ Gemma repeated.

He was inwardly stung by her accusation that he had not told the patient that his incompetence had caused the complication. She was right – he had indeed not disclosed his little accident with the bowel to Jonathan – but he was not going to let an assistant surgeon get the better of him. He pulled himself up to his full height and said, ‘What are you saying, doctor?’ His voice was menacingly slow and deliberate.

Gemma quailed at his tone and immediately thought of all the ways he could make her life very difficult. She needed him more than he needed her. Assistants were a dime a dozen, and her income was derived primarily by assisting him. She glanced across at Gabe, hoping for support, but he was fiddling with the various settings on his monitoring machine to avoid partaking in the embarrassing confrontation that was now playing out.

‘I simply meant that it must have been hard to tell him that the bowel had leaked,’ she said in a conciliatory voice. She was sweating profusely with the tension; she had been on the precipice of challenging a surgeon with a mighty reputation for defeating his challengers. ‘Of course, it’s probably best not to worry him further given that he’s in such dire straits as it is.’

‘I see what you mean. He’s running out of money too. I’ll probably have to transfer him to the public tomorrow to recuperate after this.’ Derek was allowing her to exit with her pride intact.

After several hours, Jonathan was taken back to the Intensive Care unit. Derek went and found Tracy in the waiting room.

‘Look, he is fine now,’ he told her. ‘We had to remove a little bit more of his bowel. In the previous operation, we had to make a small hole in his bowel to ensure that we could get his bladder out, and he had a leak from that hole. I think it’s probably due to the stress he’s under. I’ve asked the staff to take extra-special care and to let me know if there’s any change in his condition. I suggest you go home and try to get some sleep.’ With that, he turned his back and was on his way home.

Tracy did not heed his advice but rather rang the button to gain admission to the ward so that she could see her husband. She stood silently, in shock, at the end of his bed while a nurse wrote down his vital signs. It was difficult for Tracy to understand how it was possible to insert so many tubes into one man. Some were draining blood, and some were draining a greenish fluid, obviously the remnants of what had leaked out from his bowel rupture. Another tube was draining urine. It was so frightening to see the man she loved in this state. A ventilator was inflating his lungs, helping him to breathe.

The only part of his body that seemed like it hadn’t been invaded was his feet, and she gently placed her hands on them, hoping that he could somehow feel the love she was sending him telepathically. How had they come to this? Why had life dealt them this blow? This husband of hers – who, until recently, was her partner, her rock – now looked more like a piece of meat in the butcher’s window. She couldn’t stand to see him like this and told the nurse that she was going to go home for a sleep. She hadn’t seen the girls for at least two days. Thank God for her father-in-law and her parents, who were taking turns caring for them.

Jonathan remained unconscious for the next 24 hours. Meanwhile, Derek arranged for his transfer to the public hospital.

20

‘Jonathan Brewster. Forty-eight. Cystectomy five days ago for T1 CA of the bladder. Suffered a bowel leak post-operatively. Laparotomy and repair yesterday. He has been stable since theatres. Drainage has been acceptable. Vital signs stable. No allergies. He is on antibiotics and had his last intravenous dose at 4 pm.’ The nurse who had accompanied Jonathan from the private hospital was handing his care over to the Intensive Care staff at the Victoria Hospital.

‘Who was the surgeon?’ the registrar said and flipped through the notes, which the nurse had just handed him. ‘Uh-huh, I see. Need we say more?’ She gave him a knowing look by way of answer.

‘Hook him up, and let’s get this show on the road,’ the registrar said to the private nurse. He was keen to make sure Jonathan was stabilised after being transported from the private hospital. It was only 20 minutes away, but he knew that transport was a dangerous time for an unstable patient. ‘Put him in bay 6.’

The beds in the Intensive Care unit were in bays laid out in a U shape around a central medical and nursing centre from which the staff could monitor all the patients closely. It was always a busy ward, but Jonathan had been ‘lucky’, in that a 16-year-old drug addict had died a couple of hours ago, freeing up a bed.

In the bay to one side of Jonathan’s was a woman who was fighting for her life after losing her unborn twins the night before due to her placenta coming loose. She had lost double her blood volume, any chance of having children and her uterus from emergency surgery. She had been trying through IVF for years to have children. Her husband sat in silent vigil next to her bed.

In the bay to his other side lay an 18-year-old motorbike-accident victim. A ventilator was driving his lungs up and down to make sure that they, along with his cornea, heart, kidneys, liver and pancreas, were well oxygenated so that they could be transplanted into recipients who were even now being matched throughout the country. Soon, he would be relieved of all his organs and allowed to die. In some ways, he had died at the scene of the accident, the force of which had converted his brain from a complex and miraculous computer to a mash of dead and dying cells, even though his heart continued to beat. Tommy’s lights were on, but there was no one at home. His girlfriend, who had been riding on the bike with him, was now in the morgue.

Diagonally opposite Jonathan was a middle-aged diabetic man who had slept with a prostitute on a business trip to Hanoi and developed a groin itch. His frequent scratching of his scrotum had broken the skin, which then became infected. Embarrassment prevented him from bringing it to the attention of his family doctor, with whom he played golf every week. His diabetes meant that his immunity was low, so the infection grew and festered. The skin over his scrotum began to break down, then so did that of his penis and finally the tissues in his whole lower abdomen. By the time the surgeons got to him, he had lost the entirety of his lower abdomen skin, as well as the skin of his penis, scrotum and groin. He smelt like a latrine. His infection was still spreading despite the extensive surgery he had undergone. Every treatment had been thrown at him, including the most expensive antibiotics in the hospital. Nothing was going to work. Within hours, he was going to be dead.

Working in Intensive Care is heartbreaking. The doctors there need to have deep psychological, spiritual and medical insight. They finesse the most technically advanced treatments and work miracles on patients who would have died without their specialised intervention. The heroic and often costly treatments coupled with the manpower ratio of over one nurse per patient make a night in Intensive Care more expensive than a night in a suite in almost any of the grandest hotels in the world. Many doctors call it Expensive Scare instead of Intensive Care. Despite the cost and the efforts of staff, the death rate is high. Doctors in Intensive Care wards are well advised not to get attached to patients, because a lot do not make it.

Intensive Care units are only ethical if we value the life of the individual above the community’s well-being. This is not a belief that is held throughout the world – for instance, in Eastern thinking the community and family is more important – and nor is it in the interests of advancing the human race as a whole. This ability to put the interests of the community and family ahead of the individual is especially seen in matters of marriage. To this day in India and the Middle East, marriage is not about love alone but about what is good for the families involved. In fact, marriage ceremonies in the Hindu tradition are more to unite two families than the two individuals. Yet, in the developed countries we hold the rights and interests of the individual ahead of the community, and the huge resources we apply to save a single child with an otherwise fatal deformity can make the evening news almost any night of the week. The lives that would be saved by applying the same amount of money to community-wide preventative treatments and policies is not newsworthy.

This would be defensible from a health-spending perspective if the money available for health was limitless. It is not. Making decisions where we put the individual ahead of the community means that we spend hundreds of thousands of dollars on experimental chemotherapy to gain an extra week of life for an individual with terminal cancer while we let the elderly wait 18 months or more to have a much-needed hip replacement or a prostate resection in our public hospitals. The health dollar needs to be prioritised, and society has been unwilling to engage in discussions about rationing.

More importantly, the developed countries are killing themselves with excess. The more that people eat, smoke and drink, the worse their health becomes. Creating a healthier community would drastically decrease our reliance on expensive hospitals and treatments, on antibiotics and operations. The cost savings would be enormous. It could be argued that closing every Intensive Care unit and placing the equivalent expenditure into preventative health measures would far better serve the community. Stop people smoking, decrease alcohol consumption and get people to eat a healthy diet and lives will be saved, more lives than could be saved by highly technological Intensive Care units. However, our social system values the life of an individual above the good of the community, so we spend enormously on the prevention of death instead of the preservation of health.

Looking beyond our own borders at the global community, it is hard to see how it is ethical to spend enormous amounts on preserving the lives of individuals in Intensive Care units in developed countries while the same amount of money could be used to dig wells for clean water or provide nutrition to the millions of children who die each year of starvation and water-borne disease. If you happen to be born in a developed country, then your life is worth a million African children’s lives.

Of course, it would be unpopular for a health minister to propose that we redistribute health dollars equitably around the world. The reality is that they would lose the next popularity-contest election, and none of them want that. Moreover, it is easy to hold this holistic point of view until it is one’s own son, mother, father, daughter who is requiring the medical care. Then the cost to the community is far from one’s thoughts.

In the Intensive Care staff’s tearoom, the television was blarging the latest on the review of the Victoria Hospital. The health minister was standing at a press conference beside the chairman of the review committee.

‘I would like to thank the chair of the review committee for the thorough and far-reaching recommendations they have made, and I want to take this opportunity to say that I’ll be implementing most of the findings of the review.’

The head of the Intensive Care department turned away from the screen, to the nursing-unit manager, and asked, ‘Did they manage to speak with you about the lack of resources here?’

‘No, I think they ran out of time. I heard they didn’t make it to Anaesthesia either. It was the usual whitewash.’ They shook their heads and walked back to the bank of monitors in the centre of Intensive Care.

The head of department looked down at the monitors and said, ‘Bay 6 seems to be a bit tachycardic. He might be struggling against his tube. Can someone check it out?’ The registrar heard and heeded. He went down to the bay to see why the patient’s heart was beating so fast.

Jonathan was trying to spit out the tube in his throat that was helping him to breathe. ‘What are his blood gases showing?’ the registrar asked the nurse looking after him.

‘They’re not too bad.’ She was a middle-aged woman who had left nursing when her children were born and had returned as part of a government-funded initiative to address the shortage of nurses. One of the old breed of nurses, she could recognise a sick person from the end of the bed. She knew that Jonathan would be fine without his breathing tube in place. She didn’t need the battery of blood-gas analyses to let her know. However, the medicine she was now a part of demanded that all of the tests were done prior to any decisions being made. She had returned after her sojourn to a health system that only made decisions based on pathology or radiology confirmation. Without the numbers or the image, no decision got made.

The registrar did not examine Jonathan but looked down at the sheet of blood-test results. ‘I think we should take out his tube and put him on an oxygen mask. He might feel more comfortable.’

‘Thank you, doctor. I don’t know what we would do without you,’ she said sarcastically. He thought she was serious and puffed his chest out with pride.

Jonathan spent another four nights in Intensive Care, unable to sleep, eat or drink the whole time. He lost almost 20 kilograms and resembled a meaty skeleton lying in bed. The children were loath to visit him in hospital because they found it too frightening. Tracy made all sorts of excuses to him why they hadn’t come – netball training, a friend’s birthday party.

One morning, sitting on the recliner next to his bed while the nurse bathed him, he realised that if an attractive woman had been sponging his body in the past he would have been embarrassed at being unable to control his sexual feelings. Now, he felt nothing. The other thing that occurred to him as the nurse bathed him was just how ugly it was to have a bag attached to his abdomen collecting urine. He wondered how, if he was ever well enough to get out of hospital, he would manage to make love to Tracy. Would she be repulsed by this plastic bag on his side? Would she divorce him or have an affair? Had Jonathan had the energy for it, he would have cried. He just looked up soulfully at the nurse, who reported to the registrar later that day that Jonathan seemed a bit depressed.

Derek made an appearance late in the evening. ‘How are you feeling? OK?’

‘Well –’

Jonathan was going to speak, but Derek interrupted him. ‘Great, I’m glad. Look, the pathology results have finally come through from the cystectomy. The results show that we got the entire cancer out and the lymph nodes in your pelvis are clear.’ He paused to allow Jonathan to thank him for the news.

However, Jonathan was taking in very little. He was quite embarrassed because he was actually sitting on a bedpan, trying to defecate. He had not opened his bowels for many days now – in fact, since before the initial surgery – and the nurses had told him that he was almost ready to eat, if only he could pass wind or open his bowels. He had been dutifully attempting to on a metal bowl, sitting up in his bed, when the surgeon had appeared and launched into his news about the results.

Figuring that Jonathan had no questions, he continued, ‘I have asked Dr Khadra to take over your care here in the public hospital. He is around here a bit more and can do what is required. I have discussed it with him, and he has agreed.’

As the surgeon walked away, Jonathan passed a rather long and high-pitched fart, which, thanks to the sound chamber created by the tight seal between Jonathan’s behind and the rim of the bedpan, was amplified to produce a pure clarinet sound. For a moment, Derek appeared alarmed. He looked around, checking if it was a patient’s cardiac-arrest alarm. Then he checked his beeper. Out of sheer embarrassment, Jonathan said nothing.

When the coast was again clear, he finally managed to open his bowels, but the effort exhausted him. He placed the bedpan on the stand next to his bed, put the cover on it and fell back into his bed and slept, too drained to celebrate being allowed to eat and the good news about his cancer.

When Jonathan was physically well enough, he was transferred to the Urology ward, where it was back to low nursing numbers, fewer resources and the consequent patient griping. His eyes met with those of the man opposite, whose arm was heavily bandaged and in a sling.

‘What’s the matter with your arm?’ asked Jonathan.

‘Well … nothing was the matter with this arm. It was actually my left arm that had a nerve trapped in the wrist. They had some mix-up and cut open my right arm instead. Then the bloody thing got infected, and now I’m stuck here with my good arm in a sling and my other arm still needing an operation. They’re a bunch of shonks here. The nurses don’t know what they’re doing. I’ve been given the wrong dose of antibiotics twice in the last week. The place is filthy. The food tastes like shit. And wait till you see the way they treat the poor bugger next door,’ he said, nodding in the direction of the man in the bed beside his, who was motionless and had a tube coming out of his chest.

Just then, a nurse came up to the man with the sling and looked at his chart. ‘Have you been given your antibiotics yet?’ she asked.

‘Yes, they gave me them at twelve,’ he said, through gritted teeth.

‘The morning staff haven’t recorded it in your chart. So you’re not due again till four, is that right?’ she asked.

He just nodded. As she walked away, he muttered, ‘I hate this place. They don’t even know whether I was given antibiotics or not.’

A doctor and young nurse walked up to the bed of the man with the tube in his chest.

‘Mr Jenkins, the oxygen in your blood is a bit low,’ said the doctor. ‘I think we need to turn up the oxygen for you and also increase the suction on your chest tube.’ Mr Jenkins didn’t move or say a word. The doctor looked at the nurse and said, ‘I think we need to turn up the oxygen and suction.’ Then the pair walked from the room.

‘What’s his story?’ Jonathan asked the man with his arm in a sling.

‘Bad car accident – tore one of his lungs,’ said the man, wincing. ‘He’s got that tube sucking air out from around the lung while it heals. At least, that’s what I heard the doc say the night they brought him in, but, in this place, who knows what the hell they’re doing?’

About half an hour later, the young nurse returned to the lung patient’s bed and drew the curtains around him. Jonathan heard fiddling and clattering. Then he heard the man gurgling.

‘I can’t breathe! I can’t breathe … help!’ the man shouted breathlessly.

The nurse must have pressed an emergency button, Jonathan figured, because a loud siren started sounding and within seconds a more senior-looking nurse and the doctor who had been there earlier came running towards the bed.

‘What the hell are you doing?’ Jonathan heard the doctor shout from behind the curtain. ‘Why is the oxygen connected to the chest tube?’ Jonathan heard more cluttering. ‘It’s OK now. Are you all right, Mr Jenkins?’

Finally, the doctor and the two nurses came out from behind the curtain and stepped into the corridor. Jonathan couldn’t quite make out what the senior nurse was saying, but then he heard the doctor, loud and clear.

‘I did not tell her to put oxygen down the chest tube. That is one way to kill this man. There are lots of others. God Almighty. How could she have done that?’

More whispering and talking.

‘Sister, I did not! Look, you know that your staff member has stuffed up here. Why are you trying to blame it on me?’

Jonathan strained to hear the more senior nurse, whose face was red with anger, but she was still whispering.

‘My order was not confusing,’ retorted the doctor. ‘And even if it had been, the physiology is absolutely clear. If you pump oxygen into the space around a man’s lungs, the pressure on his heart will kill him in a minute or so. Any nurse should know that. I’ll take this up with the boss, and I’ll be writing an incident form.’

He was walking away as the young nurse said something that Jonathan couldn’t quite catch. The doctor replied, ‘Fine! You do that, then.’

21

On my morning ward round the next day, I lamented the shell of a man who was lying in the bed before me. We talked for a while, and it became clear that Jonathan was depressed.

Having been through my own cancer experience not so long ago, I felt a great sense of affinity with him. I could not help but feel his pain, his anguish. The picture of his children next to the bed made my heart ache, and I was no longer impartial. Once upon a time, I could go home and forget about the sea of troubles at the hospital. Now I knew how each needle, stitch and drain felt. I also knew that the incisions into the bodies of my patients were nothing compared to the deeper incisions into each person’s soul, their dreams, their imagined futures, that unexpected illness or trauma makes.

There was a time when I would have been oblivious to his broader needs. I would have regarded Jonathan as a man with a disease that needed curing. Like most surgeons, I would not have stopped to imagine that he needed more than a cure; he needed healing. If there was one good thing that had come out of my cancer, it was that I recognised he needed help. Perhaps I was the one who should have sat with him and helped him through his psychic groans. However, I was not yet emotionally strong enough to be able to do that, and he could not wait for me to recover from my experiences, my own staring contest eyeball-to-eyeball with the Angel of Death. I arranged for a social worker to help him through it.

The next day, she came to see him while I happened to be doing my rounds. Sadly, she was inexperienced and spouted the usual social-worker questions such as ‘How do you feel?’ and ‘Body image is important to you?’. I could tell immediately that Jonathan was turned off by it. She must have sat down for a long while afterwards to write up her notes about Jonathan’s mental state, because several very detailed pages made their way into his file. But she didn’t come back.

Physically, at least, he gradually got better, and he was able to leave hospital six weeks after having his cystectomy.

My life had settled back into a busy routine after my bout with cancer. In fact, it was easier to be busy. I yearned to be busy. I yearned to get back to work. The only thing that punctuated work was my family and the occasional check-up. As a result, my research was progressing well. Using my background in both education and surgery, I was helping to rewrite a medical curriculum at the university. Each week, I also spent some time supervising a masters student, trying to get my PhD written up and, finally, seeing my patients.

For those patients who could not afford to pay to see me in the rooms that I had to have at an exorbitant cost, the hospital provided a weekly Urology Clinic. It was a memorable experience to run the clinic, which resembled a MASH unit. Each afternoon, there would be upwards of 50 patients booked in. The whole Urology team contributed. The residents and registrars saw follow-up cases and talked with a consultant specialist when they needed to check on a course of treatment. The consultant specialists, of which I was one, saw all the new patients, and we used the consultations as an opportunity to teach the registrars.

‘So what do you think of this X-ray?’ I asked a registrar one day. The patient was sitting right there – as they often were when my colleagues and I put registrars through their paces.

‘There is calcification around the bladder … ummm … I have never seen anything like it … ummm.’

I usually led the first-or second-year registrars to an answer, but I was not about to show mercy to this, or any other, third-year registrar. These were doctors just about to sit their specialist examinations.

‘Just describe it then, doctor,’ I said to the hapless third-year. ‘It is doctor, isn’t it? You aren’t just pretending? You actually do have a medical degree, don’t you?’

‘Yes, sir. I have a medical degree,’ he said, looking uncomfortable. ‘This is an intravenous pyelogram showing a bizarre pattern of calcification around the bladder. The appearance could be consistent with bladder cancer.’

Here was my big chance to humiliate. The other consultant specialists and I had all been through this and had sworn never to treat our registrars in the same way. But the temptation was too strong; the sport of humiliating registrars is too much fun to resist. It was a drug that all of us could become addicted to. In anticipation, I had already briefed the patient on what his condition was – reassuring him that it wasn’t, in fact, a cancer – and tipped him off to the fun I was about to have with this registrar.

‘So, Mr Thompson, this could be a bladder cancer, but it could be a possum in your bladder or it could be a stone … You would be happy with a surgeon who felt he could have a diagnosis, wouldn’t you?’ Patients loved getting a rare glimpse of the life behind the mask.

Turning back to the registrar now, I said, ‘It could be anything, doctor. What do you think it is? Perhaps you might like to ask Mr Thompson a question. You are allowed one.’ I was enjoying the barbecue so much.

‘Do you have a family history of cancer?’ the registrar asked.

‘No. Not the question you should ask. Do not bother answering that, Mr Thompson.’

‘Do you smoke?’

‘No! Wrong question.’ After several more attempts, I gave the registrar a clue. ‘Ask Mr Thompson if he has travelled recently.’

When Mr Thompson volunteered to the registrar that he had been on a missionary trip to Southern Africa, I asked the registrar, ‘Does that help you, doctor?’

‘It could be some sort of infection?’ The penny still had not dropped.

‘What type of infection? Where in Southern Africa was he? Did he swim in any lakes, for example?’ Despite my obvious clues, the registrar was still not getting it, so it was finally time to let him off the hook.

‘Have you ever heard of bilharzia? Schistosomiasis?’ I asked with a demeanour like Rumpole of the Bailey expounding wisdom and virtue. The patient had a classical case of bilharzia, an infection of the bladder caused by a parasite known as a schistosome, with calcification, which gave the bladder an eggshell appearance on X-ray.

‘Please present this case to the department meeting next week with a presentation on the life cycle of the Schistosoma and its relationship to swimming in Lake Malawi, in Africa.’ Registrar dismissed. It was a hard way to learn, but lessons learnt this way were learnt for life.

The clinic was a funnel through which passed some of the most interesting cases in Urology, but to save costs many hospitals have phased out this valuable learning opportunity. For patients who didn’t have a lot of money, the clinic was a great opportunity to receive good medical care, while contributing to the future of medical education. Of course, not every patient was willing to have their medical diagnosis and treatment used for teaching, and we respected their right to refuse.

After I had seen out Mr Thompson with the prescription he needed to clear up his infection, I picked up the next set of notes from the nurses’ desk. They were Jonathan Brewster’s. Unable to afford to see me in my private rooms, he had been coming to the clinic for follow-ups. I had not seen him for months, as his last couple of appointments had been with one of the registrars. I was seeing him myself this time because the registrar had told me his back pain had returned, and I was concerned. I called his name. Out of the throng of patients in the waiting room, one head started to rise slowly upwards. His back was so bad that he was struggling to stand. I went over and helped him to walk towards my room. This was one patient I wasn’t going to ask to act as a teaching prop.

There was obviously something going on in his back. His bone scan had been clear, but perhaps we were missing something. I was suspicious that he could have some metastases (secondary cancers, which have migrated from the original site of the disease) that were affecting his spine, and a CT scan could show the early stages. I booked one for him and then arranged to see him again in the clinic in a week.

My suspicions were confirmed. He had metastatic cancer in lymph nodes in his abdomen, which were eroding into his vertebral column bone. There must have been microscopic cancer deposits in his lymph nodes that had been missed at his first operation. Even if they had been picked up, the cards had been dealt already. It would not have influenced the course of his disease. I related the news to him and Tracy.

‘What are my options, doctor?’

Chemotherapy was the only available option. He looked resigned and impassive, numb. Tracy made all the arrangements. She had taken to carrying a large organiser with her in which she noted all his appointments and filed his results.

‘We’ve been trying so hard to get our life in order outside of the hospital visits, clinics, stoma-nurse appointments to help him with the urine bags and then all the treatments,’ she said as she flipped pages. Tracy was always the organiser, the one who was practical. I felt so incredibly sorry for this couple.

Many people assume that the hardest thing about being a surgeon is the exactitude with which one must operate on a human being or the life-and-death decisions one must make in a split second. It is not. At least in the operating theatre a surgeon is doing something: alleviating suffering, intervening on behalf of the patient, fighting against the Angel of Death. It is the times when surgical intervention is not possible that haunts a surgeon most. The helplessness of being unable to intervene creates the greatest of all distress in the job of a surgeon.

I wished there was some healing I could offer this man. I could not remove his anguish or cure his cancer. He was beyond my ability to heal with steel. I now needed to sit back and watch him being tormented by the oncologists and their pharmaceutical-company backers with the myriad poisons designed to slowly kill cancer while leaving the patient barely alive as a result.

Perhaps my agony was clear on my face.

‘You know, doctor, of all the doctors we have met here, you have shown us the most kindness,’ said Tracy. ‘Jonathan has a lot of respect for your opinion and your kindness. You are truly compassionate.’

I was embarrassed and at the same time saddened to my core. My eyes were brimming over with grief. What had I done for this man, save talk with him now and then? I had offered him good care and had spent some time listening at each of our meetings. Why had he picked me out to be the representative of compassion on earth? All I could surmise was that the rest of his care must have been very lacking indeed. I reached out and placed my hand on the back of his. He grasped it and with teary eyes stood up and left. I made the arrangements for his chemotherapy and rang the Victoria’s oncologist who specialised in uro-oncology (tumours of the urinary tract).

A couple of weeks later, Jonathan turned up for his first dose of chemotherapy, a gaunt and skeletal man walking slowly and deliberately. Vera greeted him with her vivacious smile. He nodded briefly and sat down in one of the recliner chairs he had previously seen – and dreaded – in the chemotherapy room. He had his blood tested and was given his first dose of the mixture of poisons that would hopefully do a better job of killing cancer cells than of killing Jonathan.

Within a few days, he was nauseated, then clumps of hair started falling from his head, chest and legs. His appearance became increasingly frightening. In the evenings, he would go to bed early, missing dinner because he wasn’t hungry. Life had fallen to a drastic low for Jonathan. He tried to read but found his concentration was poor. He could watch only a little television without feeling motion sick and needing to vomit. Gradually, he became more withdrawn, more silent.

At his chemotherapy session each week, he would silently walk into the treatment room with no expectations, no hope – a desolate human being. He would hold out his arm and hardly interact with anyone or his surroundings.

After his third dose, Vera became worried about his state of mind. The social worker who saw him previously in the ward was called again and arranged to see him the next time he came in for chemotherapy. Jonathan despised her insistence on finding out how he felt. He simply answered, ‘I feel like death.’

‘Hmmm, so you feel like dying?’ she asked, using the reflective listening skills she had learnt in her three years at university.

Jonathan sighed and said, ‘If I felt like dying, I wouldn’t subject myself to this slow poisoning the doctors are putting me through.’ He wondered what she was writing laboriously in his notes – probably labelling his behaviours and feelings, as if by naming them she could somehow understand what he was going through. Not that she truly seemed to be listening to him. ‘I said I feel like death,’ he continued. ‘Hollow, empty, buggered. Look, I’m feeling pretty tired now …’

‘So, you’re tired.’ Another attempt at reflective listening. ‘You’d prefer to see me another time?’ She had gained a distinction in her social-work course but had failed in empathy here. She and Jonathan had no connection whatsoever. Half-listening to their difficult and stilted inter action, Vera understood that the social worker was not doing any good for this man and showed her out.

Later, as Vera was beginning Jonathan’s chemotherapy, his oncologist and a registrar came by and looked at his charts. ‘His neutrophils are pretty low. His alkaline phosphatase seems to be rising. Do you want us to repeat the CT abdomen?’ The registrar was trying to impress the oncologist.

‘What’s a neutrophil?’ asked Jonathan.

The two doctors looked at each other, confused that the patient had spoken during their deliberations. It was the oncologist who broke the surprised silence.

‘Neutrophils are responsible for maintaining your immune status. Normally, the chemotherapy affects the bone marrow, and this in turn lowers your white-cell count. This means that you may be more susceptible to bacterial infections.’ He was really proud of his ability to simplify complex medical concepts for patients under his care. Jonathan had understood not a word. He just looked up with a confused passivity that the doctors interpreted as comprehension. Silence meant consent.

Jonathan sat at home each day and waited for either a medical appointment or his dose of chemotherapy. In the afternoons, he loved to wait in the kitchen for his girls to come home from school. It was as if he was catching up on his years of neglect and the childhoods he had deprived himself of seeing. Their exuberance, their energy and the vehemence of their articulate chatter about their school day gave him an appreciation of the grace they had brought into his life, an appreciation he had never previously felt. How is it that he had allowed himself to miss the past 12 years of these wonderful lives? Now, it was as though he needed their sheer life force to drive him onwards. Each afternoon, he would regale them with stories about his youth, his own childhood. When Tracy came home, the girls would often be sitting around their father deep in conversation. His immortality, he knew now, could only be achieved through the remembrances and reminiscences of these children.

Jonathan and his father had developed the most unlikely of all friendships. Being under the same roof had not pushed them further apart, as Jonathan had at first feared, but had gradually, inch by inch, made them more tolerant of each other’s beliefs. They still disagreed but were growing to accept that for the good of their relationship – and Mr Brewster’s relationship with his granddaughters – they would need to respect each other as men and agree to disagree. Jonathan would put up with his father’s occasional monologues about religion and the afterlife; in turn, his father had become less adamant that Jonathan’s only hope was the same religion he clung to. They would sit together on the back porch – Jonathan smoking, his father sipping tea.

Before his cancer, Jonathan mostly ignored his father, along with all of the other people who seemed irrelevant to his life: the ones who couldn’t help him in his career, provide good contacts and networking opportunities or boost his and Tracy’s social standing. His father had always been a source of embarrassment, a reminder of the mediocre life that Jonathan had always striven to leave behind, a middle-class office worker who had slogged hard at a dull nine-to-five job with nothing to look forward to but a modest superannuation fund at retirement and church on Sunday. Yet, here he was sharing his precious time with this man. They had rediscovered a bond that allowed the two of them, father and son, to sit in a comfortable silence sharing the togetherness of affection and mutual respect.

Since the dawn of time, there have been these moments between men – the sharing of thoughts and feelings without words. Whether on the edges of the rift valley in Kenya, or in the shadow of the great rock of Uluru in Central Australia, or in the glow of a fire after a day’s successful hunting, men have shared each other’s company through silent bonds and quiet contemplation. Jonathan had not experienced this in his corporate life, where noise, din and empty words were the norm. Standing around a bar with a drink in hand was only an opportunity to meet someone of influence, entertain with a patter of party stories and jostle for alpha-male status. He had never felt the true manliness that he felt now, when there was no struggle for superiority, no one to try to impress.

Sometimes, silence gave way to a discussion about the big issues, but they tried to stay amicable and not get into a fight, even though Mr Brewster was still a devoutly religious man and Jonathan was not. In fact, he had become even less so as his sickness had worn on.

‘If ten-year-old Kate behaved like God behaves in the Bible – wreaking revenge and giving way to anger all the time – I would punish her,’ mused Jonathan one day.

‘God has his reasons, son. They’re just not always apparent to us – after all, we’re only human,’ replied his father.

‘But it doesn’t make sense. Just when I get my head above water, establish myself, get the job I’ve wanted my whole life, God decides to put me through all this?’

‘Jonathan, I’d give anything to turn back the clock so you didn’t get sick. But perhaps the flaw in your argument is that if God is merciful then there should be no suffering. What if suffering is the only tool that God has to bring about salvation, understanding? What if without suffering, humans don’t learn?’

‘I don’t know, Dad. You saw what Mum went through. And I certainly haven’t found any truth or beauty in the suffering that I see in the hospital. I haven’t found the profound answers to life.’

Occasionally during his treatment, Jonathan needed to be hospitalised for complications. A patient’s kidneys sometimes have trouble handling chemotherapy. Jonathan’s kidneys were coping fine, but because of his lowered immunity he developed severe infections and needed intravenous antibiotics.

Around Jonathan were a number of patients with whom he was becoming familiar over time. Weekly blood tests, physical examinations, chemotherapy sessions and occasional stints in hospital were shared by a band of people brought together by their synchronous clash with the evils of cancer. The tumours that threatened their lives had formed them into a battalion of the living – a battalion facing the darkness that awaited them if the wonders of modern chemotherapy failed. As time went by, Jonathan saw some triumph over death, such as the 26-year-old father of three whose testicular cancer was cured by the intravenous poison that coursed through his veins, and the mother of six whose breast cancer retreated on a weekly basis as each dose of medication was given. For each of these triumphs, there were also the failures. The kidney-cancer victim whose slow demise was agonising to watch, or the 90-year-old prostate-cancer patient whose wife had insisted he receive an aggressive regime of treatment with bad side effects, while his empty eyes cried out for relief from the torture. ‘Help me, someone, help me,’ they seemed to say.

One day after chemotherapy, sitting at the entrance to the hospital, smoking and waiting for Tracy to pick him up, Jonathan was jolted from his gloomy reverie by an older, turbaned Indian man who started talking to him. ‘I’m so sorry to be disturbing you, but I could not help noticing that your shoes are on the wrong feet.’ The Indian was moving his head in a characteristic side-to-side motion.

‘Sorry, were you talking to me?’ Jonathan had been deep in thought about the pain in his spine, which seemed to have increased rather than decreased with chemotherapy.

‘Yes. Your shoes are on the wrong feet. Would you like me to help you with them?’ The man kneeled before Jonathan and started to remove his shoes. Jonathan pulled back momentarily and then just let the man change his shoes from one foot to the other. Indeed, he had got them the wrong way round. It was amazing that he had not felt it. Jonathan thanked him and asked if he was a patient in the hospital.

‘No. My name is Mr Sharma, and I come in each day and see the Indian patients in the hospital. I ask them if they need anything. Some of them do not speak English, so I help them with translation or just keep them company. Some ask me to tell their fortune, and I do that. Voluntary, of course. I do not ask for money. I have nothing else in my life now, so it gives me something to do each day. And you? You look like you have been through a lot.’

‘Cancer. I’ve had I don’t know how many operations, radiotherapy, chemo …’ Jonathan trailed off, exhausted.

‘This life has brought much suffering. All the less to be endured in the next,’ Mr Sharma said and smiled comfortingly.

‘What do you mean?’ Jonathan’s curiosity was aroused.

‘The suffering of this life will mean that when you are reincarnated next, there will be less to learn, less to suffer. It is all for a reason. Nothing happens without your permission and your ability to bear it. We only suffer what we’re able to bear. If we bear that suffering well, then we create good karma, and that karma lives on beyond this material world.’ Mr Sharma was looking at Jonathan intensely now.

‘So, you believe in reincarnation?’

‘Yes, I do. Have you ever considered it, Mr …?’

‘Brewster, Jonathan Brewster.’ Just then, his deliberations on whether Mr Sharma had a point were interrupted as an ambulance pulled up to the reception bay and the driver got out.

‘I’ll see if we can find a doctor to come and certify death. The body stinks. Just leave him in the back,’ he said over his shoulder to his fellow paramedic as he walked through the doors to Emergency. Soon, he emerged with a junior doctor in tow.

‘We were called to the place by his next-door neighbours,’ said the paramedic. ‘They could see the smoke coming out of the garage. They went to investigate and found him in the front seat of the car. He’d been there a while, apparently. He was dead as a dodo when we arrived, doc.’ From his blasé tone, it was clear that the driver had seen it all before.

The back doors of the ambulance swung open, and the smell of car fumes hit Jonathan and Mr Sharma standing metres away. They watched as the paramedic unzipped the black bag and the doctor placed his stethoscope on the man’s chest.

‘Yep, he’s dead all right. I’ll fill out the paperwork for you inside. Give me five.’ The doctor disappeared into the Emergency ward, and the paramedic went after him to wait for the right forms to allow them to deposit the body at the morgue.

‘May God rest his soul. I hope that he has learnt something in this life and will be more contented in the next,’ said Mr Sharma.

Jonathan was deathly silent. In the not-too-distant future, it could be him being certified dead. He shuddered at the thought of his children growing up without a father or Tracy remarrying. He turned back to talk more with Mr Sharma, but he was gone.

22

‘You’re making great progress. Your CT scan shows that there’s been no progression of your cancer in the last six weeks. There’s a spot on your lung here. I think it’s probably nothing, but we will get another X-ray in about three weeks. Meanwhile, you can go home, and we’ll see you in the clinic in about a month.’ And, with that, Jonathan was discharged momentarily from the agonies of chemotherapy. The oncologist appeared very happy with his handiwork, and the treatment had apparently gone well.

‘Isn’t that great, darling? That is fabulous,’ Tracy said on their way back to the car park. She was excited to get good news at last. ‘I think this calls for a celebration. Let’s go to dinner. Your dad will be happy to babysit.’

‘That’s a great idea, Trace.’ Jonathan was trying so hard to sound convincing. ‘Where did you have in mind? Your choice. You’ve put up with enough. You deserve some fun.’

Tracy thought for a moment and said, ‘How about that great Vietnamese restaurant where we went for our anniversary?’

Early in the evening, they were getting ready to go out. Jonathan quietly crept away when Tracy was in the shower and vomited in the downstairs toilet. He washed his face with cold water to try to put some brightness into his complexion. At the restaurant, he excused himself to go the toilet three times to vomit. The last time, he was too drained to stand, so he knelt down in front of the white enamel toilet with its seat up. There were pubic hairs on the rim, and someone had urinated around the edge. Jonathan rested his head on one hand, his elbows on the rim, waiting for the next wave of nausea. When he had finished vomiting, he got up, washed and returned to the table.

‘Are you OK? You seemed to be gone a long time.’ Tracy was still trying to have a good time, but she was getting worried.

‘I’m fine, babes. It’s good to get out and about again, isn’t it?’ he said, trying to change the topic.

‘Jonathan, you look pale – were you throwing up?’

‘No, no, Tracy. I was talking to the waiter. He was telling me about the aquariums they have for the seafood.’ Jonathan was attempting, with great bravery, to let his wife have just one night that wasn’t haunted by his disease. Tracy was not convinced. She signalled the waiter and asked for the bill.

Jonathan was back to the toilet, vomiting twice more before, finally, the bill came and they could drive home. By the time he lay down in bed, Jonathan was beyond exhausted. He fell into a deep sleep, during which his late mother took hold of his hand and drew him towards her on a journey. He could feel her hand as she led him towards her path. He woke with a start, sweating profusely. He needed to vomit again. This time, as he convulsed over the toilet bowl, he felt Tracy’s hand on his shoulder. When he had finished, she wiped his face with a cool washcloth and took his temperature.

‘We need to get you back to the hospital again. This is not good. You have a fever.’ Tracy was right, and Jonathan wasn’t going to argue.

Both knew the drill as they again walked into Emergency in the early hours of the morning: the waiting, the forms, the triage nurses, the exhausted doctors. They settled down for the long wait.

About three rows away was a young boy vomiting into a bowl that his mother was holding. He had the typical chemotherapy baldness that Jonathan now recognised with ease. A couple of seats away from them was an old man coughing uncontrollably and beside him an older woman holding a blood-soaked handkerchief over a cut on her head that had obviously bled considerably over the course of the night. Blood had spotted the whole of the front of her nightgown.

Jonathan’s head was hurting bitterly now. Perhaps it was dehydration or perhaps something more sinister. Between the debilitating nausea, the pounding in his head and the constant ache in his back, Jonathan was feeling beaten. He was sweaty and overcome with a dizziness that made it a struggle to remain upright.

‘I reckon they should send them back to Pakistan. I cannot stand that bastard.’ It was the night nurse talking with the receptionist. She was speaking in hushed tones, but Jonathan and Tracy were sitting nearby and could hear her words.

‘What’s he done now?’ the receptionist asked.

‘You know how yesterday he sent that 18-year-old girl home and told her she should not be on the pill and that she should maintain her honour by refraining from sex until she was married?’

‘Oh, yeah. That was crazy.’

‘Well, we just had a hooker in with gonorrhoea, and he gave her a religious lecture about how she’ll never find a husband because she didn’t preserve her virginity.’

For over a decade, universities had been telling the government about an impending shortage of doctors, with no response. This was compounded by the fact that graduates were increasingly choosing lifestyle over income. Many were content to work in medicine on a part-time basis so they could maintain hobbies, sports, family and other interests, rather than work gruelling hours.

Those who are motivated by money are often lured overseas by large tax-free incomes in countries such as Thailand, the United Arab Emirates and Saudi Arabia. Western-trained doctors are walking the corridors of hospitals in Bangkok, Singapore and Dubai; medical tourism ensures they are kept busy and paid well. For local patients, the gap between what the insurance companies were willing to pay for medical treatment and what the doctors charged was increasing. So, more and more patients were realising that instead of making a large gap payment to get a knee replacement done locally, a patient might choose to pay less and fly to Bangkok, have his surgery at one of the excellent newly built hospitals and have a holiday. The results are comparable to anything in the West. Plastic surgery, breast implants and penile prostheses, to counteract impotence, are all done overseas for a fraction of the cost of having them done locally. The cost savings are partly because companies sell medical products for lower rates to some countries. Take India, where the parts necessary for a hip replacement cost a fraction of the price they do in the UK, the US or Australia.

Now the staffing crunch had hit the hospitals, and there was a drive to recruit doctors from developing countries. Pakistan, Nigeria and India were prime targets for recruiting. The doctors quite often knew little about the culture, the norms and the accepted social values in Australia.

‘He truly is incompetent,’ spat the nurse. She was one of a growing group of health professionals who resented the influx of foreign-trained doctors into the health system.

Jonathan was looking at the nurse, whose tongue and lip piercings were glinting in the overwhelmingly bright fluoro lights of the waiting room. She noticed him staring and hushed her voice to a whisper. His attention was then caught by a high-pitched voice shouting outside.

‘Fuck off. Just fuck off, you bastard. Let me go. Take your hands off me.’ A young dishevelled girl ran in through the entrance. Her blouse had been torn, and her bra was showing. She was carrying one of her high-heeled shoes and was limping on the other one. Her make-up had smudged to one side so it looked as though it had been not quite matched up with her face in a photographic retouch.

‘Come on, love. I was only joking. You know I love you. Come on. You don’t need to do this.’ A heavily tattooed, inebriated man was holding onto her hand and trying to pull her back out the door.

‘Just watch me, you fuckwit,’ she screamed. The old man and lady winced and frowned all at once, giving them the appearance of carved pumpkins at Halloween.

‘Excuse me, is this where I report a rape?’ she shouted.

‘I did not rape her. She’s just joking. Ignore her.’

‘Just fill out this form and the triage nurse will attend to you shortly.’ The receptionist made no exceptions. The man gave the girl a shove and stormed out of Emergency. Jonathan wondered whether the Pakistani doctor the nurses were talking about would be assigned to see her.

‘Mr Jonathan Brewster?’ Jonathan looked up, and standing there holding his file was a doctor who fitted the description. ‘Hello, Mr Brewster. Please come in, and we will see how we can help you.’ Jonathan followed the doctor with Tracy in tow.

He was compassionate, competent and pleasant. Jonathan felt an instant ease with this man, who deftly inserted a cannula into a vein in his arm to rehydrate him and administered anti-nausea medication. The doctor even stayed past the end of his shift into the morning to ensure that the Oncology team would see Jonathan without delay. It was difficult to reconcile the ferocious description the nurse had given of his cultural insensitivity and the reality of this apparently decent man who alleviated Jonathan’s suffering, if only for a night. At dawn, he disappeared for a few minutes. Jonathan guessed he had gone to say his morning prayers.

Once Jonathan had been stabilised, Tracy left to attend to the girls, and once again he was alone in the hospital, a number fending for itself. It was late in the afternoon before there was a bed available on the Oncology ward, in a four-bedded room. Jonathan unpacked his overnight bag. He was now well practised in making sure he brought it with him to hospital. It contained a picture of his daughters and his wife. ‘I am a human being with a family,’ the picture seemed to cry out. The bag’s other contents were toiletries, his favourite pillow, spare pyjamas and a robe. He always brought a book to read. This time is was The Prophet by Kahlil Gibran. He opened it up and started reading.

‘Jonathan, I’m so sorry to see you in again. What is the matter?’ It was the familiar Indian voice of Mr Sharma.

‘I was vomiting a lot. They admitted me this morning. And you, are you visiting someone?’

‘Mr Gupta there has leukaemia. I have been tending to his needs.’ Jonathan looked up to see a wizened man in the corner bed who had grey, almost waist-length hair. His veins seemed to bulge over his wasted hands. He was sitting up with his eyes half-closed, looking much more like a corpse than a living human.

‘Oh, you are reading The Prophet. It is indeed a book of great wisdom. The man who wrote that is more Hindu than most Hindus, more Christian than most Christians and more Muslim than most Muslims. His wisdom is timeless. His words are universal truth.’

Jonathan put the book down and stared at Mr Sharma. Universal truth: was there such a thing? Here around the wards lay agony and triumph, defeat and courage, honour and cowardice, charity and conceit. All of the manifestations of humanity could be found in this one corner of the hospital. Perhaps he didn’t need to read the wisdom of Gibran or any of the other philosophers throughout history. Perhaps he simply had to open his eyes to the colours of humanity around him. Above them all were the stars and the infinite universe – silent, uninterfering, divine, permissive. What did the multitude of stars and planets in the universe amount to before life had graced them; and what would they amount to after all life was gone? Nothingness. Meaningless nothingness.

The man in the corner would soon die. His body would start to decay immediately. Before long, it would be cremated and become ashes – ashes scattered into the universe. His carbon molecules might end up in a plant – say, grass – and be eaten by a cow. This could then be eaten by a little boy who would grow into a man. Cyclical recycling. This made more sense to Jonathan than reincarnation, his father’s idea of God or the notion of universal truth.

The leukaemia patient called out to Mr Sharma, and he left Jonathan to his reading.

Jonathan found it hard to focus on the words because of the man opposite him, who looked about 60. He had a laptop in front of him and a phone to his ear and was shouting instructions to his secretary, checking emails and typing one-handed responses. A takeover deal wasn’t going well, and he was concerned about his potential losses. The intravenous antibiotics he was receiving had run out, and he was cursing that the nurse had not replaced the bag.

Jonathan went to sleep late that night, and when he awoke the man was no longer there and had been replaced by an elderly woman. She just lay there, seemingly incapable of moving or doing anything. She didn’t speak, even when greeted. Breakfast was delivered to her and soon after was taken away by the catering staff. The same thing happened at lunch-and dinnertime that day, and breakfast-time the next. ‘Is she eating much?’ a doctor doing his ward rounds asked a nurse.

‘No, not much at all. She has no appetite. The food just goes back to the kitchen the way it came,’ she reported back.

‘Well, if she doesn’t eat in the next couple of days we will have to put in a central line and feed her artificially.’

That night, soon after the lights were dimmed to allow the patients to sleep, a large clot formed on the main artery in the old woman’s neck that supplied blood to her brain. The clot steadily increased in size and was buffeted by the constantly pulsing blood from her heart. As the clot grew further, the buffeting split a large part of it off from the arterial wall, and the fragment travelled upwards into unfamiliar territory. It stopped briefly at the entry to the base of the skull and then continued swiftly upwards into the brain. The clot was stopped suddenly, jammed in the artery as it narrowed slightly. As a result, no blood could flow to the old woman’s brain. In the dark, the old woman’s eyes opened, and she had dreams of her childhood in Ireland, the warmth of her father’s hand, her wedding day, her children on swings in the park. As the light extinguished from her thoughts, she breathed out slowly and deeply, and her heart stopped beating. Minutes later, she convulsed a bit, but in the darkness no one noticed.

When the nurses did their 6 am observations, they found her hardened cold body and did not know what to do. There was much running backwards and forwards. Should they press the cardiac-arrest button? There was no documentation in her notes that she should not be resuscitated. The policy specifically stated that they should press the button if the patient was not documented. They did not have the authority to declare that a patient was dead. The nursing-unit manager came and said, ‘Press the button. She is not documented. Start resuscitation.’

The button was pressed, and the circus was called to town. Nurses, orderlies, equipment. Finally, a doctor, responding to the alarm, walked in. ‘What’s the story?’

‘We found her in this state just a couple of minutes ago, and we pressed the arrest button.’

He walked up to the patient, told the nurse who was trying to resuscitate her to stop and looked up at the monitor. There was no cardiac activity. He felt the woman’s neck.

‘She is fucking stone-cold dead. What is going on here? Is this some sort of joke?’ He was not a particularly diplomatic registrar. ‘Time of death was probably four hours ago. I’m calling it. Cancel the arrest alarm please.’

Jonathan, watching the whole thing from his bed, was devastated. He covered his face with his hands and felt grief for the woman and a sense of hopelessness about his own situation. The curtains were drawn, and the circus moved on to await the next call. Jonathan got up and washed his face and went for a walk to clear his head. He got into a lift and stood at the back, shrinking away from everyone else.

‘Oh, thank God. Thank God. I really never thought that we would get him home,’ said a woman in her mid-20s to an older woman who he guessed was her mother. ‘I can’t believe he’s finally coming home tomorrow. God bless those doctors and nurses. They are saints, really.’

‘I’ll never forget that day the police came and told me about the accident. Truly, they have done miracles to get him to live and walk. I can’t wait to have your dad home.’

So something good was happening in the world. Life and death followed Jonathan wherever he went. He missed the sterile environs of his corporate world of so long ago – it felt like almost a lifetime now – where he’d had no cause to think of mortality. He idly wondered what Jake was doing and realised that he wished him neither evil nor well. Like almost everyone aside from Jonathan’s immediate family, he was irrelevant to his daily struggle to stay alive.

23

Jonathan and Tracy sat silently as the oncologist explained that the persistent nausea and vomiting was not a result of chemotherapy. The problem was that the tumour had done something unexpected: it had seeded in Jonathan’s brain. The increased pressure in his skull due to the tumour was causing the vomiting.

‘It is all quite evident here on the CT scan.’ The doctor pointed to the celluloid films from Jonathan’s most recent tests. Jonathan felt sick again. Tracy had no interest in looking at them. The doctor seemed fascinated by the extent of the tumour.

It was a simple explanation. No frills. No softening of the blow. Despite the months of treatment, the operations, the sacrifices they’d made, the tumour had moved into an area of the body that was immune to chemotherapy, protected by the blood-brain barrier. Jonathan had been handed the death sentence, just without the red robes of the judge or the black hood on the executioner’s head.

‘Surely there’s something that can be done, doctor?’ Tracy was in tears.

‘Well, there is experimental treatment in which the tumour is excised surgically and then radiotherapy is administered to the brain. This is followed up with chemotherapy, to kill any remaining cells elsewhere in the body. The prognosis is not good, but there are some reports in the literature that are promising. I’ll see if I can get the neurosurgeon to come up and talk with you both.’ The oncologist was clutching at straws. He felt obliged to suggest something. Anything. This man was young and his wife was pleading. What can I do? I can’t just sit here and do nothing, he thought. What trial can I put this man on? What research is there to help me help them?

Jonathan held Tracy’s hand. So far, it had been a matter of surviving until the treatments were complete, because there was somehow still hope. Now it just seemed that the treatment was endless, with no hope of success. Brain surgery, radiotherapy, chemotherapy. They were both reeling at the doctor’s pronouncements. The other patients in the ward could hear the conversation, masked only by a cotton curtain, and were now silently eavesdropping. Despite their own predicament as cancer patients, hearing of the misfortune of others gave them comfort and diminished their own sense of suffering. This Schadenfreude kept many of them alive.

The curtains were swung back as the doctor left. Tracy and Jonathan sat in bewildered confusion. So many thoughts raced through their heads. Flashes of anger that the treatment had not worked, that the cancer had escaped, that their suffering and the amount of money they’d spent had been to no avail.

Jonathan’s father was sitting with the two girls in the waiting room, expecting to visit. Finally, Tracy went out to tell them, and at the sight of them she broke down in tears. Mr Brewster took her in his arms.

‘It’s not good news,’ she managed to say. ‘The doctor says that there is a part of the tumour that has gone to his brain. He’s going to need more surgery.’ The girls were now hugging her too. The nurse in charge of the ward showed them into a quiet room away from the prying eyes of visitors and patients.

‘Can I get you a cup of tea?’ she asked.

‘No. We’re fine. Thank you.’ Mr Brewster spoke on their behalf. ‘Can I go and see him, Tracy?’

‘I think he’d like that.’

Mr Brewster walked up the corridor of the Oncology ward with a heavy heart. He had read between the lines and realised that Tracy was clinging to empty hope when she mentioned surgery. It was not supposed to be like this. A man should be buried by his son, not the other way around. He had prayed so hard for Jonathan’s treatment to work, for him to be cured, for God to extend his graceful hand to save him. He stopped for a moment, then turned around and left the ward. He didn’t have the strength to stay composed in front of him. He left the ward without farewelling Tracy, went straight down to the ground floor and ran into the park opposite the hospital. There, for the first time in his life, Mr Brewster challenged God’s will.

‘I have given my life to you. I have prayed. I have read the Bible each day. I have been loyal and lived a good life,’ he said out loud, looking up at the sky. ‘I have never asked you for worldly goods or for wealth. I have asked but two things of you: save my wife and save my son. That is all I have asked. Where are you now? Where are you? What could you possibly gain by this cruelty to my son? First, you took my wife. Now, you want to take my son.’ With that, Mr Brewster took out the small Bible he kept in his top pocket and threw it up in the air, as if to throw it back to its author. He picked up a stone and threw it upwards too. The stone and Bible fell to the ground, as dictated by the laws of physics, and the sky remained silent. There was no thunder, no sudden shafts of light, no burning bush. Mr Brewster fell to his knees in the park, angry about the unfairness and cruelty of life. His faith in a merciful God had slipped away, leaving him a bitter and hollow man.

As Mr Brewster stared at the grass before him, a young man of 20 stopped his red Ferrari at the nearby traffic lights. He looked across to see an old man kneeling in the middle of the park. Strange, he thought. His phone rang, and his assistant spoke in code to say all was in order and that his private jet was waiting at the airport. He was on his way to a drug deal that would net him millions. The lights changed, and he accelerated away, dismissing the man in the park as some homeless hobo. Life was carrying on as normal, dispensing its rewards and punishments seemingly at random. Eventually, Mr Brewster got up slowly from his knees and headed back to the ward to see his dying son.

Tracy and the girls were in with Jonathan, who had on his lap a colourful ‘get well soon’ card that Kate had painted at school that day. Tracy gathered the girls up and they farewelled Jonathan with a kiss. He was left alone with his father, who stood silently at the end of the bed, staring down at him. Father and son were holding back tears, the son feeling like he had let the father down and the father filled with regret that he had not shown his son the love that brimmed in his pained heart.

He walked around the bed and held his son’s hand, brought his other hand underneath Jonathan’s head and pulled it to his chest, hugging his boy with all the love that a father could have. Jonathan brought his arms around his father’s back and cried unashamedly, sobbing out his pain and anguish. Gently, the father set his son down again.

‘What do you think you’ll do? Have treatment or not?’ He did not wish to make the same mistakes with his son as he had made with his wife, whose suffering had gone on too long due to medical intervention. The doctors constantly suggest treatments – that does not mean you have to take them. A patient is obliged to question the doctors’ advice.

‘I don’t know, Dad. I’ve had enough, really. But I don’t want to orphan my kids if there is some hope. I don’t know. I’ll think about it over the next couple of days and see. The doctor says there have been some good reports in the research.’

‘It will all become clear, I’m sure.’ His sobbing having subsided, an exhausted Jonathan fell asleep. Mr Brewster did not want to wake him, so he just sat next to his son, holding his hand in silent contemplation. He remembered Jonathan’s childhood, the times he and Jonathan had spent playing chase, the rocking horse he had constructed for him. Normally, Mr Brewster would have prayed at a time like this. No prayers came to him now. No words deafened his thoughts. Instead, images, sounds, smells, reminiscences of joyful times sprang to his mind. It was midnight before Jonathan stirred again.

‘Dad, what time is it? Why aren’t you home yet? How are you going to get home?’ Jonathan asked sleepily, then turned and fell asleep again.

When Jonathan woke again and opened his eyes in the dim ward, his father had left for the night. He sat up to silently meditate on his fate. Surgery on his brain, radiotherapy and then more chemotherapy. Now there was a daunting set of treatments, with even less promise of success than any of the treatments that had already failed. He had had enough. Medicine had offered all it could, and now the doctor could offer him nothing but a vague possibility of extending his life. What was the alternative? Death. Death, but with dignity.

Memories of his girls being born came to his mind, and he smiled happily to himself. Memories of his mother and father, his childhood. His thoughts turned to Tracy. His adoring wife had been through enough. He regretted that he was not going to be there for her in the future. She was going to have to bring up their girls alone. A widow. His smile turned to sadness. She had loved him far better than he had ever loved her. Even before the cancer, his wife was the only one who backed him throughout his ordeals – his ladder-climbing at work, his quest for a better job, and a better one after that, on and on. She had prepared him for each interview and had sat in silent vigil waiting for an outcome, had kept life going for the family at home while he sought advancement. He had justified his total absorption in his career on the basis that he was doing it for her and for the girls. He was not. He faced that truth now. It was all for him. His ambition. His fantasy of self-actualisation, as if it could come through a job title or status. He lay in his bed filled with the regrets of a life spent taking instead of giving.

As dawn’s early light started to filter through the windows of the ward, Jonathan resolved that he was going to have no further treatment. He was not going to go ahead with the advice the doctor had so gingerly given. Clinging to false hope with nothing but a guarded prognosis was not the way a man should die. Jonathan resolved to die with dignity. Die in his own way. He got up, went to the nurses’ desk, asked for a pen and some paper and returned to bed. He wanted suddenly to write a message to his girls – something to guide them, to help them on their life’s journey. He put the paper down. He could not find the right words, something profound enough. Then, it came to him, from a passage he had read as a young man and kept with him all his life: ‘This too shall pass’.

He was still well enough to walk and travel, and he wanted to live again before he died. By the time the nurses had started their morning activities, he was dressed and standing once again at the nurses’ desk.

‘I wish to discharge myself, please,’ he said.

‘Well, that is not possible. The doctors will be coming in shortly, and you can discuss it with them. Mr Brewster, please go back to your bed and wait for their ward round.’ The nurse did not want to go through the paperwork.

‘I wish to discharge myself now, please. You cannot hold me against my will.’ He was adamant. He had had enough of being a passive victim.

The nurse got on the phone and called me. Jonathan’s case was currently caught in a crack in the monolithic departmental structure of the hospital, between my Urology team and the Oncology team, who were looking after his day-to-day care. It was six-thirty; I came straight in.

‘Hi there, Jonathan,’ I said gently. He was fully dressed and packed. He was obviously determined.

‘Dr Khadra, I’ve just had enough,’ he said. ‘I don’t want to continue with all of this unless there is some definite hope in going through the hell of more treatment. Can you reassure me of that?’

‘Jonathan, your oncologist feels that there is a chance with the triple-therapy approach – the brain surgery and then radiotherapy and more chemotherapy. There have been some reports around the world of patients responding.’ I was taking the coward’s way out of this situation. What I should have said is, ‘Jonathan, go home and spend some quality time with your family before the end comes. Do not let the hospital lead you into more experimentation and torment.’

Tracy entered. The nurses had called her at home and urged her to come in.

‘What’s going on?’ she asked, looking panicked.

‘Tracy, I want to go home. They’re not going to offer me anything that I want to put up with. I want to be with you and the girls without having to put up with more surgery, radio and then more chemo as well.’

‘Doctor Khadra, you have to tell him that he needs to stay and undergo the treatment,’ she said. ‘What is the choice, Jonathan? You have to stay.’

I sighed and thought, It is better said than left unsaid. I would not have been able to live with myself if I had not at least presented another option.

‘Tracy, Jonathan’s cancer has a very low chance of being cured or controlled by the treatment that’s been proposed. The complications are high. It is possible that during the brain surgery to remove the tumour, the surgeon could cause neurological damage. He could end up paralysed or perhaps even die on the table. I suppose I just need to present the alternative. It is an option for Jonathan to choose to reject further medical treatment and let nature take its course. I really feel that it is his choice.’

Tracy was crying. She knew that it was right for her husband to come home. They had both had enough of the ravages of hospital treatment.

‘I see 18-year-old boys dying down in Emergency. I see 80-year-olds dying too. We’re all on the same journey. What we don’t know is when. Tracy, we cannot make each other live forever.’

She was sobbing fiercely now, grieving that her husband was going to leave her much sooner along the path than she had ever envisaged on their wedding day.

‘Are you sure there is nothing to be done?’ She covered her face with her hands.

‘Tracy, I really don’t want any more. I need to live. I need to have some life before I go.’ Jonathan was standing his ground.

I went and rang the oncologist and explained the situation. He agreed with me that it was truly clutching at straws to make him undergo the triple-therapy regime. He suggested a script of steroids, in the form of dexamethasone, which would reduce the pressure in his skull.

I returned and gave Jonathan the script, then asked him, ‘Is there anything that you would like to do before you die, Jonathan?’

He looked sidelong at Tracy. ‘I would love to go to Paris again. Do you think it would be OK to travel, doctor?’

‘They have great hospitals in France, Jonathan.’ He shook my hand firmly as I farewelled him for the very last time.

24

The check-in clerk at the George V Hotel realised immediately that the guest in front of her was not well. His patchy hair, his slow and deliberate walk, his wasted frame. She excused herself, spoke to her manager and returned with the good news that they had been upgraded to a rooftop suite. Tracy thanked her effusively, and the concierge took their bags.

‘I love the smell of this place.’ Jonathan was in seventh heaven. As soon as they got into the room, they rang the girls. They had thought about bringing them, but this was Tracy and Jonathan’s time.

Early evening, they went for a walk down the Avenue George V and on to the Champs-Elysées, past the pen shop where, years before, Jonathan had splurged on his collector’s edition Dupont fountain pen. Life was as it should be. There was a cooling breeze in the air. They found a little cafe and ordered a coffee. He was breathing in the air, taking in the sights, absorbing the atmosphere.

Tracy’s attention was dominated by one thing: her husband, her soulmate. She was trying to commit each moment to memory – the feel of his hands, the subtle touch of his lips on hers, the baritone voice that was always just slightly too loud. They had laughed a lot so far on their holiday but cried even more.

He tired quickly, but each day they were able to go out and see one of the sights that brought Jonathan joy.

He sat for hours watching the priests and nuns of Notre-Dame preparing for the morning mass and sat in a pew behind the worshippers, staring at the beautiful statue of the Virgin Mary with her newborn infant. He took Tracy’s hand, and they lit a candle. For the first time in many years, Jonathan said a prayer. It was short and to the point: ‘God, if you do exist, look after my wife and girls when I’m gone.’

Tracy knew there was one very special place where Jonathan wanted to go, and she booked a car for that day. Giverny was a fair drive out of Paris. As they walked its narrow pathways between neatly planted beds of flowers, they marvelled at the colours.

When they returned that night to the hotel, he slumped with exhaustion. ‘I’m ready to go back home, Tracy.’

A couple of days later, Jonathan sat on the porch of his father’s home on a recliner. A blanket covered his legs, and a vomit bowl was within reach. The home palliative-care team had swung into action with advice for Tracy on how to keep him comfortable. The nurses visited once a day and helped to shower him and toilet him. He was hardly able to care for himself now. On the table next to him was an iPod connected to some speakers, through which he played his favourite music. As each day passed, his condition worsened. He lost the use of his right arm first, and then he found it hard to walk. Within days, he was slurring his speech and dribbling from the side of his mouth. His father and Tracy took it in turns to look after him and the girls. This was the intractable irreversible slide into death.

By the middle of the second week at home, Jonathan had lost control of his bowels, and his behaviour had changed drastically. He could not tolerate his daughters making any noise at all and would get angry at the slightest change to his schedule. He needed a constant vigil. The toll on Tracy was inestimable. She was exhausted, hollowed out, empty, gaunt. Her eyes stared out at the world from dark racoon circles.

Tracy and Mr Brewster had long and difficult conversations with the palliative-care doctors. Should he be transferred back to the hospital? Perhaps the hospice was the best place for him?

Jonathan’s father refused all such suggestions. ‘My son wants to die at home. I’ll look after him if no one else will. Thank you for your help. We do not need it.’

The smell of death hung around them like a black ring of smoke, seeping into every brick, every wall and every piece of furniture. At night, all that could be heard was the grunting of a dying man. Occasionally, he would yell out in his sleep, shouting at invisible memories, crying at hidden nightmares and calling to the ghosts of his past.

As dawn came at the beginning of the third week, Tracy was awakened by a gurgling sound that she had not heard before. Immediately, she realised what was happening. Jonathan’s father was then awakened by the sound of Tracy’s sobbing and Jonathan’s gurgling. He also knew what time it was.

He entered his son’s bedroom, now converted into a hospice, and went past the bin full of used tissues and the large oxygen cylinder. He placed his hand on Jonathan’s head. Jonathan was grunting and gurgling, moaning from time to time. Mr Brewster could see the veins in his neck still throbbing with his heartbeat and his chest moving air in and out.

Within minutes, Jonathan was still – free of life and of pain.

To look at the house from the street, one would see nothing amiss. The birds chirped their morning tunes. The suburb slowly stirred as the glow of pink and yellow hues in the sky dismissed the darkness once again.

In the Emergency department of the Victoria Hospital, a stream of patients had entered throughout the night with their ailments, their tragedies and their suffering. The health minister was about to go on his morning walk, and Jonathan’s surgeon, Derek, was already starting his morning ward rounds. The night nurses were clocking out, ready to leave, and the night doctors were documenting the saga of human woe they had witnessed. Ahmed was reciting his dawn prayers, and Mr Sharma was chanting his.

The Earth hurtled in its graceful and speedy journey around the Sun, and the Milky Way turned another couple of degrees relative to the silent universe, where nothing from Earth was ever heard.

All was as it had to be.

Postscript

And he said, ‘Come, oh beautiful Death; my soul is longing for you. Come close to me and unfasten the irons of life, for I am weary of dragging them. Come, oh sweet Death, and deliver me from my neighbours who looked upon me as a stranger because I interpret to them the language of the angels. Hurry, oh peaceful Death, and carry me from these multitudes who left me in the dark corner of oblivion because I do not bleed the weak as they do. Come, oh gentle Death, and enfold me under your white wings, for my fellowmen are not in want of me. Embrace me, oh Death, full of love and mercy; let your lips touch my lips which never tasted a mother’s kiss, nor touched a sister’s cheeks, nor caressed a sweetheart’s fingertips. Come and take me, my beloved Death.’

Kahlil Gibran, ‘A Poet’s Death is His Life’

To be a surgeon is to stand, without flinching, in the sea of human suffering and use one’s entire resource of knowledge, skill and intelligence to battle it.

An intern makes his first cut and is ridiculed by his tutor. An old woman is brought back to life against her will, only for the unexpected to happen a week later. A notorious surgeon is sent crazy by a massive brain tumour. The mother of a leukaemia-ridden child is driven to desperation …

In this compelling and beautifully written impressionistic memoir, Mohamed Khadra recounts stories from his life as a surgeon, from the gruelling years of training to the debilitating sleepless nights on call. He looks back at the doctors and patients who have shaped his career; at the endless stream of humanity – courageous, pitiful, admirable and dislikable – who have passed under his knife, as he recalls shocking tales of mistakes in theatre and the shattered lives of doctors defeated by the stresses of the job.

Documenting the damaging politics in our health-care system, the soul-destroying choices made for patients and the misplaced hope so common in the face of death, his dramatic account of a surgical life shows what happens when extraordinary events overtake everyday lives – including, even, his own.

‘Unputdownable … I read the book straight through one night …

A tough-minded book, but also full of love … Compelling

and memorable’

Australian Literary Review