chapter three: diagnosis

The students gather dutifully around the bedside. The consultant has the case notes in his hand and is reading them over. The patient is a male of forty eight years with multiple injuries sustained in a road traffic accident. He remembers this one because it made the national news and because he’d been held up in the traffic too. The fire was so bad it melted the carriageway and caused the biggest ever hold-up on the M1. Kept him from what he was sure would be a very boring conference. Seventeen dead, including the driver of the petrol tanker. Most of the rest school kids and their teachers in a mini bus on a day trip to Chatsworth House. They’re downstairs in the morgue now. This guy was one of the lucky ones. Thrown clear of his wrecked car after the tanker swerved across all three lanes, the ambulance crew found him in a field, almost 50 metres away.
‘Yeah, so how did her get so far into the field? He wasn’t thrown fifty yards through the air was he?’
It’s Posh Student to Speccy Smith. Voted the couple most likely to make a false diagnosis by the public schoolboy sector of the cohort, they keep each other company because no one else will. No one else apart from Spotty, that is. The trio are dramatically unattractive yet they nevertheless attract good grades. This in turn increase the social distance from the rest of the group. Even so the consultant doesn’t quite trust their judgement.
‘Why not? You think he crawled, with those injuries?
‘Yuck’.
The consultant peers at them over his wire frame specs and then goes back to the notes. The patient has been unconscious for two days now, in a medically induced coma. It’s not so unusual, after trauma such as this. But the consultant thinks there’s something else. He’s suspicious. He’s also read the accompanying police report. He wants to test the students on this. See if they can see through the physical injuries.
‘Mr. Smith. Diagnosis please’.
That shuts them up. Always does. They’ve got plenty to say to each other but try asking them to say it out loud. It’s not the medical and clinical skills these kids need, it’s social skills they’re lacking. Bedside manner. Cures more than antibiotics.
Smith shuffles in his shoes and pushes his glasses back up his nose and breathes out like he’s exhausted.
‘Anybody?’
The red headed woman, the older student of the group, an ex-nurse takes the notes from him in a practised fashion and goes over to the patient and leans towards his face.
‘Gary, Gary, can you hear me?’
The young kid with the acne and the brand new stethoscope slung round his neck like a college scarf has the bad grace to sman at this. The consultant down grades him with a glance and taps a memo into his Blackberry.
The redhead is undaunted. Probably had worse before now. And from professionals. She continues.
‘Gary’.
But Gary can’t hear her. Gary can’t hear a thing.
‘The patient has a GCS score of 5, with respect….’
It’s spotty, desperately trying to ingratiate himself.
‘You’re checking for what?’ says the consultant, ignoring him completely.
She moves away from the bedside before replying but not before touching the hand that’s lying outside the covers. She smoothes the wristband. She didn’t get his name from the notes. She saw it on the wrist band. She takes the arm in her hand and places it under the covers. The other arm, the one with the bandaged hand where the drip comes in, she leaves on the surface of the bedcovers.
The consultant mentally makes a note that he won’t entrust to his gizmo. This girl’s good. They say nursing is nine parts observation. He wishes the rest of these medical students would appreciate that they could learn a lot from the staff on the wards.
‘I was checking his hearing…
‘Because….’
‘Because hearing is often the first sense to return….
‘Or the last to go…’
Spotty shrinks into his collar and sidles closer to Posh Student for comfort but she’s got as much natural warmth as an electric fan heater.
‘And I was trying to establish some rapport with the patient.
Nobody’s smaning now.
‘And your diagnosis?’
‘The diagnosis isn’t important here. The patient is physically stable. The scoop and run flew him in in one piece, pretty much. The TTS was effective in assessing major trauma. X ray and MRI have identified no damage to cervical or thoracolumbar spine. No serious trauma apparent in adjacent areas. Tib and fib….the fib is healing freely, the tib has been plated. X-rays are good. Flail chest injuries, though…..’
Just here Clare traces a finger from Gary’s right shoulder down across his chest to his left hip where the seatbelt almost cut his torso in half. There’s a broad purple stripe there that gives him the look of a seventies footballer in a garish away kit. ‘
Clinically there’s not much more to do’.
Bingo.
‘Thanks, Clare. And thanks for an excellent demonstration of an ancient art. I trust the rest of you were taking notes.
Cue flustered pocket patting, shoe gazing and general eye avoidance. Jesus, in two months they’ll be making life and death decisions on behalf of other human beings. You want health advice…? The consultant has health advice. Go private. And pray for an Asian doctor. Chinese preferably. Or Indian.
The group stand around waiting to be told what to do. Honestly, if you told them to breathe in you’d need to add ‘breathe out’ a few seconds later.
‘Lunch, I think’.
With the students dispersed the consultant moves back over to the nurse station to make some calls. Clare meanwhile has hung back and approaches the bed again. She carefully rolls back an eyelid. She looks in at nobody looking out and checks behind the retina. It’s the only place on the body where you can actually get a look inside.
‘I don’t know if you can hear me, Gary’, she says, ‘but I’ll make a deal with you. If I can pull this off’, and she looks at the consultant through the glass, consulting his mobile. ‘If I can sort this I’ll pull out all the administrative stops for you, mate. I’ll see that you get on that research project. Brilliant recovery rates they've got. Almost makes you believe in the power of research'.

Gary goes quiet. So she steps back and aims the softest punch at his upper arm. Then she leaves the flimsiest trace of a fingertip touch on his forehead. The consultant looks up just then and sees a different student. He sees a woman in tune with her patients. He’d never doubted her clinical skills but he was uncertain about her ability to empathise, fearing it had been buried under the years of death, disease and dying. But looking at her now, well….what would you not do?
Clare then looks over at him. She decides that he may well be worth debasing herself for. After all, how else is a girl going to get an opening in the new stroke unit? He mouths the word ‘Lunch’ and points to his Rolex. Clare holds up five fingers. He nods.
She holds the lift doors for him and as he steps in she presses 24.
‘Isn’t the canteen …..’, but his voice trails away as Clare reveals a previously undiagnosed tendency for exhibitionism. It’s a long way to the top in this building. And Claire looks to be going all the way.
The consultant swears as his bleep goes off. It sounds quaint. When Clare’s bleep goes off too seconds later they both laugh. She swears, but properly and they laugh more. The relationship changes just there. It’s now a more equal partnership. They are co-conspirators. And as they re-enter the ward their haste camouflages the rumpled look of carelessly adjusted dress, of altered breathing, of a difference in the way they now look at each other, almost as if they had grown new eyes.
‘We thought he might be having another fit, but…..’ The nurse doesn’t need to say more. Gary is plainly fighting his bedclothes. In a moment they’re going to be off the bed. Gary is naked under the sheets. It takes Clare’s intervention to restore order. The consultant rolls his eyes in wonder. As if soothed by her presence Gary is immediately calmer.
‘What do you suppose goes through their minds?’ one of the cleaners asks her mate as they pass by at a safe distance, rattling their pails of concentrated superbug on the way to the sluice for a quick fag.
‘I don’t know about the patients, luv, but I can tell you what he’s thinking and it’s not professional’.
And with a backward glance at the transfixed consultant they exit the ward as Clare clears away a few specks of blood from Gary’s mouth.
‘Looks like he’s bitten his tongue’, offers one of the nurses. Clare and the consultant swop looks.
Clare is now leaning over Gary trying to decipher the words. She fumbles in her pocket as if the action will help translate his semi-conscious, rambling incoherence. Gary is full-on in what may be a dream sequence, if indeed a dream is what this is. Clare suspects otherwise. There’s too much missing information in the background notes to Gary’s admission. The nurses have left her to it. Well, there are six other patients all in equal need of attention. Ok, equal is stretching it a tad. None of them, for example, is capable of sinking the entire Trust in a multi-million pound legal affair just by the simple expedient of stopping breathing. And just then that’s precisely what one of the buggers does.
An alarm batters the fetid air and a crash trolley careens across the recently slopped floor surface. The consultant decides he may as well get his clinical practice portfolio up to date and rolls his sleeves to the elbow. Clare takes the opportunity to slip away to the loos where she takes the vial from her mate in pharmacy from her pocket and lays a short line on the cistern. She gasps as her heart changes gear and presses play….
There’s a lot of rumble and crackle but he’s trying to speak, to say someone’s name…..a woman’s name….is it Katherine…or Caroline? Over and over again. She rewinds, play, rewinds, play. Rewinds, play. Caroline.
The next day she contrives to meet the consultant after the ward round.
‘It’s about Gary’, she says. ‘There’s something else they’ve missed’
‘Go on’. The consultant has gone beyond amazed to something close to panic. If any of this shit comes back to him……
At this moment the suits are getting involved. More properly known as the Risk Management Directorate they are in the upstairs boardroom discussing the financial implications of the temporary loss of focus suffered by the locum anaesthetist. She miscalculated the gasses resulting in a scare for the theatre team and the briefest flatline on the monitors before an alert nurse pointed out the patient’s parlous condition and Gary came back from the dead before his brain had even switched off properly.
In the current climate of litigation and the heavily criticised blame culture which pervades the clinical side of the NHS the analysts have to assess whether it would be prudent to ‘fees up and pay up or sit tight and settle down to a protracted legal battle. The consultant has been implicated solely on account of having been the senior medical presence in ther building.
The suits rehearse the argument. The theatre sister defended the staff and pointed out that the tertiary assessment was just that, and that it was post-op. The admissions officer defended the sister, the A&E consultant defended the department until the stand-off threatened to paralyse the entire hospital. Hence suits are involved. More suits in here than Burton’s front window.
This isn't health care, this is paralegal. And Gary here could be looking at a fat cheque. No, make that obese. Obscenely obese. Six figures, easy. If he makes it, of course. He almost certainly will do but you never know.
And if he doesn't then somebody's looking at an even fatter cheque and several well-fed corporate types will be looking at new positions in provincial hospital trusts. In summary, Gary can't be allowed to shuffle off his mortal coil just yet, certainly not on the premises of this Trust anyway.
Clare can see the terror in his eyes and calms him down immediately.
‘Oh, it’s nothing medical. And I’m not sure what we can do for him now’.
The consultant can only repeat himself.
‘Go on…’
‘Well, getting back to the diagnosis....….I’d say this patient has a broken heart’