A Mistake, by Carl Shuker

A Mistake, by Carl Shuker (Fiction)

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Elizabeth Taylor is a surgeon at a city hospital, a gifted, driven and rare woman excelling in a male-dominated culture.
One day, while operating on a young woman in a critical condition, something goes gravely wrong.
A Mistake is a compelling story of human fallibility, and the dangerous hunger for black and white answers in a world of exponential complication and nuance.
‘You’d think Carl Shuker couldn’t get any better, but A Mistake is the novel at its visceral and emotional best. This is the most compelling book I’ve read in years. It pulls you along at breakneck speed through questions of failure, exposure and manners. Shuker reinvents the form with every novel and A Mistake is a masterpiece which feels more like a body than a book – the life pumps and glugs and flexes inside its pages.’ —Pip Adam

Cover design: Keely O’Shannessy
                                                            
Carl Shuker is a former editor at the British Medical Journal and the author of four novels – The Method Actors (Shoemaker & Hoard, 2005), winner of the Prize in Modern Letters in 2006; The Lazy Boys (Counterpoint, 2006); Three Novellas for a Novel (2008; Mansfield Road Press, 2011) and Anti Lebanon (Counterpoint, 2013). He lives in Wellington with his wife and two children.              

From: A Mistake, by Carl Shuker

A glass of milk with Voltaren and Panadeine

‘Hello there,’ Elizabeth said, leaning over the girl, smiling. ‘Hello. Hello Lisa.’ The girl looked up at her accusingly. ‘My name is Elizabeth Taylor. Please call me Liz. I’m the consultant surgeon and this is my registrar, Richard Whitehead.’

Elizabeth smiled wider for her.

‘How are you feeling?’

The girl lay in the bed in the emergency department and she was pale and very sick and there were black bruises under her eyes. She had an IV in one arm and was in her very early twenties. A white girl, small and thin and turning in her pillows, selfish, inward in her pain.

She looked away to the ED nurse who had been waiting with her. The nurse was a middle-aged Englishman standing with his feet together. He had a tag on his chest that read

#HelloMyNameIs

Awesome

with Awesome crossed out and Matt written underneath in Biro.

‘Where’s the doctor—’ the girl said.

Richard was beside Elizabeth, turning through the notes and murmuring.

‘She’s tachycardic,’ he said. ‘Up from an hour ago. Respiration 22 and steady, pressure is down, is why we paged.’

The girl looked past Elizabeth to the male nurse, and she said, ‘My shoulder. My shoulder hurts.’

Matt leaned down to her and he said, kindly, ‘Does it hurt in your shoulder now?’

‘Yes.’

‘Does it hurt when you breathe?’ said Elizabeth.

The girl looked at her wide-eyed and she said yes, and turned to Matt again and Matt watched her eyes, half-smiling down at her.

‘Okay. That’s okay,’ he said.

‘She’s got no pain at McBurney’s point,’ Richard said. ‘Doesn’t look like appendix. She’s had a total of 10 milligrams of morphine since 9:30 for increasing pain and 10 milligrams of Maxolon for the nausea.’

‘Where are you from Lisa?’ said Elizabeth in a conversational voice. ‘Lisa? Where do you live?’

‘Rotorua,’ the girl said, like a question.

‘Are you on holiday in Wellington?’ said Elizabeth. ‘We’re having a lovely summer down here aren’t we. Get out of the way,’ and Matt stepped quickly sideways.

Elizabeth pulled the gown off the girl’s stomach. She pressed gently on the right side above her appendix. The girl squinted and tensed. Then Elizabeth pressed gently on the left side of her stomach by a cluster of small moles and the girl half-squealed in a low wheezing exhalation. Her eyes outraged and wet.

‘Did that hurt, Lisa?’ said Elizabeth. ‘I’m sorry. You be brave now.’

The girl had started to cry and was looking at Matt. She made a keening sound then she said, ‘Where’s the other doctor?’

‘GP at Adelaide Road saw her three days ago,’ Richard said to the notes. ‘One day of cramping abdominal pain. Soft and tender abdomen with guarding at left iliac. Given trimethoprim, diclofenac, paracetamol, and sent away. She came back again three days later, from some camping ground in the Hutt, in a lot of pain. No bowel motion or urine for two days, elevated pulse, and they put her on IV fluids and transferred her here. Radiology suggests necrosis to bowel and organs and notes there’s an IUCD in situ.’

Elizabeth listened and looked down kindly at the girl.

‘Lisa,’ said Elizabeth. ‘Lisa. Are you pregnant, Lisa?’

‘No. No, I don’t think so. No? Is it a baby? Is it a baby?’ she said and she stared at Elizabeth and at Matt.

Richard flicked through the notes.

‘BhCG negative. It was added to the labs.’

‘Who did that,’ murmured Elizabeth.

‘It was a locum I think,’ said Richard and looked around the ED.

‘Good for them,’ said Elizabeth. ‘Someone’s on the ball. Who’s with her? Do you have someone with you like a boyfriend or your parents, Lisa?’

The girl looked left and right. Her breathing becoming more shallow, more desperate.

‘The boyfriend’s outside,’ said Matt.

‘Is your boyfriend with you Lisa?’ said Elizabeth. ‘What’s your boyfriend’s name? Is he from Rotorua too?’

The girl looked left and right again. ‘Stuart,’ she said and as she spoke Elizabeth pushed her stomach down again above her left hipbone with three fingers and this time the girl screamed.

‘Okay now, we’re going to take care of you, Lisa,’ Elizabeth said. ‘You be brave now.’

‘Where’s the doctor,’ she said, very angry now, and Elizabeth ignored her.

‘Well,’ she said to Richard.

‘Uh,’ he said, and he looked at the chart. ‘Clearly . . . intra-abdominal catastrophe. Immediate surgery to assess for ruptured viscus, bowel or appendix. Aggressive fluids and transfer to theatre for laparoscopy.’

Elizabeth said, ‘Well. Possibly. I think we’d rather provisionally suggest pelvic peritonitis maybe due to salpingitis. You said yourself she had no pain at McBurney’s and this was confirmed by examination right in front of you. Why add appendix to that list? Leaving yourself outs? I agree with the immediate urgent laparoscopy. Three units of packed red blood cells crossmatched and prep for theatre and page Dr Mirnov to consent her.’

Richard was nodding and nodding and staring at the notes.

Elizabeth turned back to the girl.

She was moaning and had closed her eyes.

In the corridors from ED to theatre Elizabeth’s sneakers slapped and squeaked. Her father’s only daughter, 42 years old, youngest and the only woman consultant general surgeon at Wellington. Sudden bursts of light as the sun went west over the valley as she walked and her sneakers slapped and squeaked on the shining linoleum. Mid-afternoon, now, clouds creeping south over Newtown. There was a black-eyed little sparrow trapped inside the hospital, testing the windows, flying from sill to sill down the corridor. As she walked she called Simon Martin to get on with a boring hernia repair she’d been about to begin when she was paged and then she called theatre to get ready for this girl.

‘Robin,’ she said into the phone. ‘Prep for laparoscopy and a peritoneal washout and removal of IUCD. She’s septic and will need antibiotic cover. Tell Vladimir we’re on our way. How are you, anyway?’

Elizabeth’s voice was cheery and pleasant. She had been up for 27 hours. This was the end of her on-call. She was so constipated she had not used the toilet in two days. It was useful for operating. She hadn’t drunk any liquids but coffee all day and her bowels burned and felt dry and heavy and wooden, reliable.

As she walked through the interrupted glares of southern sun Elizabeth had an abrupt verbatim recall of a brutal peer review comment she had received yesterday. It was a revise and resubmit on an editorial she and Andrew had sent to the Royal London Journal of Medicine, about the upcoming public reporting of surgical outcomes in New Zealand.

These authors have conflated several very different, very important issues and failed to produce a meaningful interpretation that usefully advances our understanding of any of them.

Andrew McGrath was head of surgery and dean of the Wellington campus of the Otago Medical School. It was her job to reply to the journal on their behalf. The Royal London Journal of Medicine was one of the Big Three, alongside The Lancet and the BMJ, most prestigious medical journals in the UK. Impact factor: intimidating. The third oldest medical journal in the world. Even to be gutted at peer review was something of a coup. Andrew would be in the corridors. Andrew would be at the upcoming conference in Queenstown. She’d better have something ready.

Elizabeth bore down, she focused, and the solution came, as it always did for her, when she bore down.

‘Robin, please make a note for me,’ she said as she walked. ‘Say: we are grateful for this reviewer’s comment and upon reflection we have adjusted those paragraphs at lines 120–130. I’ll recheck that. Say: however, we regret we cannot agree with his view given his previously published partisan position on public reporting of surgeons’ outcomes in the Royal London—2013 I think it was, I’ll check that, Robin—and something something really vicious there, and delete those paragraphs and replace with a reference to Carnaby et al., 2012, that’s C-A-R-N-A-B-Y, and say this quote: “For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.” That’s Richard P. Feynman who said that. F-E-Y-N-M-A-N.’

She saw herself moving in reflection in the hospital windows as the sun hit her. Small, straight-backed and uniformed in blue scrubs. Happy. The bird bumping against the glass inside her. Would it die in here?

Go, she said to herself, and disappeared again in the shadow.

‘I’ll check it but it’s something very close to that, anyway. All good?’

Robin was speaking.

‘Hold on.’

She flicked through the notes as she walked.

‘Yep. Last oral intake 7:30 this morning. She had a glass of milk, Voltaren and Panadeine.’

The girl was asleep. Her belly button all that was visible in the centre of a square of pale skin formed by the blue drapes. At her shoulders the drapes became a great blue crucifix shielding her head and Vladimir, sitting on his stool by the anaesthetic machine.

Elizabeth, gloved and gowned, said, ‘Now.’

Everyone, even the circulating nurse, stopped moving.

‘We will perform a classic Hasson open technique. Why?’

The nurses came back to life and moved about the theatre. Elizabeth pinched a fold of fat on the girl’s stomach with gloved fingers and squeezed it to open up her belly button. Richard leaned forward and widened the navel with the Littlewoods forceps.

‘Let’s give it a clean first, Richard,’ she said.

‘Sorry.’

‘Inevitably you will encounter material in the umbilicus initial prep has missed.’

The comment was directed at Josie the scrub nurse and she looked up.

‘It’s clean,’ Josie said.

‘We’ll see,’ Elizabeth said.

‘Do you want to do the checklist, Doctor?’ said Mei-Lynn. She was indicating the large poster of the surgical safety checklist on the theatre wall.

‘No, we don’t have time. Let’s get on with it. Now’—the doors flapped behind her as Richard scrubbed the girl’s belly button with a swab in forceps—‘get in there. Clean it properly.’

The doors flapped closed. The nurses had parted. Someone new was there. Elizabeth leaned back, rolled her neck in her shoulders and leaned down again to the belly button.

‘Hello, Andrew,’ she said.

‘Hello, everyone,’ he said. He was behind her, not scrubbed, wearing his double-breasted suit. ‘Carry on. Just looking in.’

‘For the benefit of those new here, Andrew McGrath, head of surgery. Welcome, Andrew.’

‘Yes, yes,’ he said. ‘Carry on.’

Elizabeth met eyes with Robin across the girl’s stomach. Elizabeth grinned at her but Robin didn’t let her eyes change.

‘Now. Why Hasson.’

Richard glanced up at Andrew as he cleaned and back down again. ‘Um, a 2014 review,’ Richard said, ‘found major and minor complications a percentage point safer for, um, open technique versus the Veress needle?’

‘But that particular study was an Indian review,’ said Elizabeth. She stood over the patient, pinching the girl’s stomach. ‘Context matters. Number five blade please.’

Andrew moved closer to the edge of the sterile field, almost standing among them to get a better view.

‘Andrew and I,’ Elizabeth said, ‘are working on a paper about publishing our outcomes. For a medical journal you might just have heard of called the Royal London Journal of Medicine. Aren’t we Andrew? Bit controversial. Publishing our numbers in the papers. Complications and patient deaths of named surgeons. Which for one we think ignores the stellar contribution to this girl’s care made by all of you.’

‘Mmm,’ Andrew said. ‘Well, quite.’

He leaned forward to watch.

Elizabeth took the scalpel from Robin and punctured the skin beneath the girl’s belly button and in one bloodless cut incised straight down a single centimetre.

She said, ‘And we’ve had a peer review come back that’s been let’s say somewhat suspicious of our conclusions.’

A couple of the nurses sniffed soft laughter. Richard flicked his eyes up to Andrew and back down again.

‘That peer review,’ Andrew said, ‘is from an Oxford don who’s actually Australian. He’s very partisan on the issue of publishing outcomes. And he doesn’t like me.’

The nurses looked at nothing but the operation and the instruments.

‘I’ve got a few ideas,’ Elizabeth said.

‘Very good,’ he said.

‘First of all—’

‘We can discuss it later,’ he said.

She stared at the incision. She felt her left eye twitch. She was tired. She made herself not look at Richard, or Robin. That sudden rage; it was interesting. She made herself find it interesting. She held it and turned it and examined it. How susceptible she was to the hand that pats the head not patting. And she used it to focus.

She placed the scalpel back on the tray and took the forceps and reached inside the wound and grasped a piece of the tough tissue under the belly button and pulled it up through the hole she had made. Richard grasped it with forceps on the other side and she took up the scalpel again and sliced a line down through it. Robin reached in with her forceps and grasped another piece of the tissue and they pulled it up and Elizabeth steadily cut her way through the stiff fascia, faster than she normally might. It was wet and white even against the girl’s pale skin but there was no blood. A little white bud of meat protruding at her belly button.

‘Just a few fibres at a time,’ Elizabeth said. Then, as she sliced, ‘The Cochrane review covered 46 randomised controlled trials of 13 laparoscopic techniques. What did they find, Richard?’

Richard said, ‘Um, they found with Hasson technique no events in any of 12,000 patient days, I think it was 12,000 wasn’t it, it was a lot, for mortality, gas embolism, or internal injury.’

‘It also found Veress needle method will score lower every time,’ she said. ‘Failed entry, vascular injury, visceral injury. Veress loses every time and if you assist a surgeon who attempts it you’re endangering the patient. It’s bullshit. Bad medicine. Now we see the peritoneum.’

The peritoneum was visible. Inside the small hole: a taut, veined white bag. Elizabeth pinched the fat fold and lifted it, pulling at the stomach. ‘We give it some traction,’ she murmured, ‘why.’

‘To avoid uh, to avoid damaging the underlying structures when we um, penetrate the peritoneal sheath into the abdomen.’

‘Yep, Richard.’

She leaned down with her forceps. The small hole was now held open with three pairs of forceps grasping tissue, and pressure from her pinch. She pushed the forceps into the hole and pushed it against the peritoneum until it popped through into the girl’s abdominal cavity. Behind her Andrew moved slightly to get a better view. She opened the forceps like scissors to widen the opening and then removed them and pushed her whole finger inside the hole in the girl’s belly and felt around inside for adhesions, for rips in the hole. When she removed her finger Robin leaned down and pushed a wide smooth retractor like a shoehorn inside the hole. The girl’s belly joggled and shifted and a clear fluid tinged with yellow was filling the hole but Robin held the retractor steady as Elizabeth leaned her forceps into it for leverage to sew a purse-string stitch, left and right. It was like a dance, but there was less pleasure in it now, being good, because it was a performance before him.

Elizabeth picked up the trocar from the tray. This one had no blade. It was a short blue pipe with taps around a handle like a thick screwdriver and she took the retractor from Robin and used the retractor like a plank to ease the pipe into the hole in the girl’s belly on a diagonal, screwing it left and right, drawing the leaking fluid to help it in.

‘Hasson,’ she said as she screwed it in, ‘has a small incision which leaves little or no scarring enhancing postoperative recovery. Hasson allows access under vision. Hasson won’t puncture the bowel.’

‘Thank you all,’ said Andrew. ‘Carry on.’

‘Thanks, Andrew,’ she said. ‘Get what you needed?’

‘Just checking in,’ he said.

‘Checking in.’

‘Yes.’

‘Cheers, then,’ she said.

‘Yes, yes,’ he said.

‘Cheers, cheers,’ Elizabeth said and grinned at Robin and the doors flapped closed.

There was a momentary pause and she blinked and breathed out through her nose.

‘Right,’ she said. ‘Let’s get on with helping this girl. We will be inserting three trocars into Lisa today. Trocar, from the French trois, meaning three and carre, or edge. The three edges of the blade opening a portal into the abdomen into which we now have access—12-millimetre for camera, light and gas to blow up her abdomen thus creating a pneumoperitoneum for us to work within, and 5- and 8-millimetre for other instruments as needed, and for drainage. We’re inserting three ports today, including camera, at the risk of repeating myself. Now. Maestro?’

They were smiling behind their masks as she made her small speech.

‘Yes?’ said Mei-Lynn.

‘Can you for crying out loud put the Slayer on, please. The 30-minute one.’

Robin audibly exhaled.

‘No,’ someone breathed.

‘Oh, come on,’ said Vladimir from behind the anaesthetic machine.

‘Do it,’ she said, and laughed at them. ‘Did you know, Richard, a recent study out of the US showed women physicians have measurably better outcomes than the men? Journal of the American Medical Association this year. Huge sample size too. Something to think about for all of us. And our dear leaders.’ The nurses were smiling and the atmosphere had changed again. ‘Did you also know,’ she said, leaning down, ‘first recorded use of the trocar was in 30 AD? Aulus Cornelius Celsus in the De Medicina. Originally used to drain fluids and gas from the abdomen. And that, my dears, is more or less what we’ll be doing today, 2000 years on.’

The two surgeons stood across from each other, their hands raised as if blessing the girl’s body before them, frozen for a moment. Robin screwed the gas pipe to the side of the trocar in the girl’s belly.

‘Gas, please,’ said Elizabeth.

The music began. Slayer’s Angel of Death, a thrash metal song that had been remixed until it was 30 minutes long. She liked to play it on repeat. It was hypnotic and repetitive and it helped her concentrate. The single metal riff that opened the song repeated and repeated and a German voice murmured above it. The girl’s abdomen rose as the gas inflated it like a pregnancy.

‘That’s the stuff,’ whispered Elizabeth, to the music, and to the pneumoperitoneum.

Robin took up the pipe of the camera and slid it into the end of the trocar and inside the girl’s body.

Above them on the screens shifting veils of flesh emerged from darkness.

‘Well, look at that,’ Elizabeth said. On the screen the tissues were red and inflamed. There were brown pits of abscesses along her fallopian tubes.

‘Extensive pus,’ Richard said.

‘Yep. Second trocar, please,’ Elizabeth said.

She made a small press cut at the lower left of the girl’s belly with her scalpel and took up the second smaller trocar.

‘Left lower quadrant, direct vision please, Richard,’ she said and he rotated the camera. ‘We insert the trocar under direct vision to ensure no damage to the underlying structures,’ she said. She pushed the trocar against the cut and the skin dimpled gently. The trocar’s sleeve, its blade extending at the pressure, cut and sank into the girl. Above them on screen the blue plastic tube emerged huge into the frame inside her, and the blade vanished away.

Then the girl’s abdomen sank slightly. The song’s riff repeated and repeated and the German voice murmured on.

‘Can we check gas flow please, Mei-Lynn,’ Elizabeth said.

Mei-Lynn went to the gas tower.

‘Extensive pus, indicating what do you think, Richard?’ Elizabeth said up to the screens. She pressed with her fingers on the girl’s tummy. Then to Mei-Lynn—‘I want ten mercury. What’s wrong with the gas? Richard, do you want to insert the last port?’

‘Yep, sure.’

Richard took up the last trocar from the tray like a dagger, the wrong way around, then inverted it so it rose from his fist. He looked up and saw she was watching.

‘How’s that pressure please,’ Elizabeth said, looking at him. ‘Extensive pus, indicating—?’

Mei-Lynn was at the tower and said, ‘Um, pressure is set to ten and flow rate is six but we’re not at ten yet.’

‘Have you changed the gas for Christ’s sake,’ Elizabeth said to the screen. ‘Go and get a new bottle.’

The Slayer droned on and on and it was very quiet otherwise after Mei-Lynn had left the room.

Robin went to the tower.

Richard hovered for a moment above the pale skin and Elizabeth looked down from the screen at him.

‘What’s up, Doctor?’

‘No problem—’

Elizabeth touched the skin in the very corner of the visible square of her stomach. ‘Is that the 5-millimetre?’

‘Uh—’ He checked it. ‘Yes.’

‘Well let’s get on with it. What’s wrong with that gas, Robin?’

Robin said, ‘The bottle’s full.’

‘Well, increase the flow. Come on.’

Richard took up a scalpel and made a small incision at the top right of her abdomen where she’d touched the skin and put the scalpel back down again. He placed the tip of the trocar against the small slit.

Robin pressed a button on the tower. ‘That’s six point five,’ she said and they watched the abdomen rise again.

‘Come on then,’ Elizabeth said. ‘This young woman is very sick and may be dying in front of us.’

Richard pushed the trocar hard into the girl and it sank slightly and stopped.

Elizabeth stared up at the screen with the camera handle in one hand. ‘You’re not through,’ she said. ‘Hurry up. Give it some welly. Indicating what, Richard?’

‘Indicating—’ he said, and he pushed the trocar into the girl.

On screen sudden bright blood rose in the seams of the red geography of the inflamed tissues. They watched as the blood filled the cavity. It rose and it rose and it did not stop, and so close on the tiny camera, lapping gently as if in a breeze.

‘—cut the mesenteric,’ Elizabeth said normally. She stepped back from the girl on the bed and raised her hands before her chest. Normally, she said, ‘Quick, we have to open.’

The Slayer was now playing the first riff with drums. Every change was elaborated at length because it was a remix of a three-minute song into a version 30 minutes long. The blood was filling her abdomen completely. Richard stood and looked at the screen. Like its meaning defeated him. Every change went forever until it collapsed into noise and resolved into the new change and everyone knew it was an Elizabeth Taylor favourite. The nurses were stopped and they were looking around.

Robin said, ‘—are we converting?’

‘Can someone please call fucking Mei-Lynn back in here?’ Elizabeth said normally. ‘How’s she doing, anaesthesia?’

‘Uh,’ Vladimir said, ‘systolic 90. Pressure is falling now.’

‘Robin, remove all the laparoscopic gear. B tray for urgent laparotomy and arterial instruments. Music off, get all this gear out of the way now.’

Robin stepped forward and grasped the camera handle. On the screen above them the image of the curved organs and the abdominal wall and the pools and bubbles of dark blood they lay within lapped and wobbled and then shot away, it all collapsed upon itself and disappeared down a tube and flew about the room, capturing their masked faces in single blurred frames as Robin pulled the camera from the port and dumped the apparatus on a trolley. She pulled the ports and trocars from the girl’s abdomen one by one, reaching in front of Richard to take the last one out, the hollow dagger that had stabbed the sleeping girl inside.

Mei-Lynn came back into the OR carrying the CO2 cylinder hanging heavy from one hand. She stopped when she saw the two surgeons motionless and Robin piling the tubes and instruments on the trolley.

Mei-Lynn looked around her. Then she leaned the CO2 cylinder down against the wall and came forward.

Robin hissed, ‘B tray quick, we’re opening.’

Elizabeth said, ‘Hurry up you silly cunt.’

Mei-Lynn turned and went quickly back out for the instruments.

The CO2 cylinder she’d left behind her slid slow then fast down the wall. It hit the ground and bounced and rolled away under the trolleys with brassy thunder.

‘Christ,’ said Elizabeth.

Before them the visible square of the girl’s stomach was still. The small holes bloodless and waiting and under them the chaos gathered.

Josie came forward to adjust the drapes.

‘Get out of it,’ said Elizabeth, and she stepped back again. ‘Robin. The B tray and the arterial instruments. How long will we have to wait.’

Robin came forward with a fresh trolley and adjusted the drapes.

‘Vladi?’ said Elizabeth.

‘Pressure is still falling. She is becoming difficult to ventilate.’

Elizabeth stared up at the clock.

‘I called for three units of red blood cells pre-op, can you please ask Betty to get the blood.’

‘Yes Doctor.’

‘Where are the fucking instruments please.’

Robin turned to the doors but Mei-Lynn had returned with the tray and laid it out, peeling back the sterile parcels. Elizabeth reached out and pushed them aside and took up the scalpel. In one stroke she made a foot-long cut the length of the girl’s belly between the leaking hole at her belly button and the hole for the port above her left hip. The skin dropped open and dark blood rose in spots in the white fat.

‘Diathermy,’ Robin said to Mei-Lynn.

‘No, we don’t have time,’ Elizabeth said. ‘I’ll do it myself.’

Around her the theatre staff stopped to watch what she was going to do. Elizabeth placed her gloved index finger against the side of the blade to control the depth of the incision and sliced in one long cut down again through the subcutaneous fat and sheaths of muscle and the peritoneum all at once and the girl’s bowel opened up and it was full of bright dark blood and the blood shone and moved freely about the organs so their colours and shapes were indistinguishable.

‘Vladi,’ Elizabeth said calmly.

‘Heart rate is 140.’

She leaned in and began to separate and divide the small intestines with her hands. Richard had not moved since he had inserted the trocar. Robin placed the suction tube at the side of the wound and the blood sank quickly. The only sound in the room was its sound, the gurgling inhalation and the grind of the machine. Elizabeth used both hands to lift and separate the heavy organs. She lifted them and looked and replaced them and moved them to one side.

‘There,’ she said. ‘There. And there. Suction. Put your finger on it.’ Robin reached in. ‘Not you,’ Elizabeth said. ‘Richard. You cut her.’

Robin swabbed the cavity with a piece of gauze and for a moment they saw the small dark slit in the back of the abdominal wall pumping blood. Richard pressed his finger against it before it disappeared. Their white gloves were up to their wrists in red. Elizabeth moved on and lifted the loops of small intestine, the slab of liver, the inflamed uterus, parting the organs, pushing the sick fallopians aside as the well filled with blood again.

‘There. There’s a cut in the IVC here and we need to extend the incision to clamp it,’ Elizabeth said.

She took up the scalpel again and extended the opening in the girl’s belly high and low in small tugging cuts. Robin added another retractor to pull back the skin and fascia of her stomach then leaned in. Elizabeth teased up the thick, leaking vein and held it with one finger over the cut. Robin clamped it above and below with steel clamps then suctioned out the blood and reached in to mop up with a wad of gauze and yet more bright blood filled the seams. There were five hands and four clamps inside the girl’s abdomen.

‘Careful with the ureter. Stay where you are. Govern these ventages with your fingers and thumb,’ she murmured, and sniffed a soft laugh.

She lifted her finger from the rent in the vena cava and it did not bleed any more. They were all paused and watching. Mei-Lynn finally turned the music off and there was silence. ‘Give us some Bach, please,’ Elizabeth said. ‘Sonatas and Partitas. Monica Huggett on violin.’ The girl’s organs moved with her breathing. Richard had his finger on the other cut. The music began, and they watched and then the blood in her rose again. She was still bleeding and it was then they saw the bright overflow pumping from nothing in the wide, strong ribbon of the psoas muscle.

‘That’s not the IVC, that’s the lumbar artery bleeding.’

Elizabeth took up the needle and sutures and she held the muscle in one hand. She examined it. She leaned back and selected forceps from the tray and leaned in. She began to suture the lumbar vessel deep within the muscle by feel.

It was all very quiet as they watched her work. There was the gurgle and grind of suction, then quiet, and she spoke normally and taught them.

‘This is a controlled emergency and not a chaotic emergency. The torrential bleeding from the vena cava is controlled with clamps and we can move in order of urgency. Richard has control of the posterior tear with his finger. The bleeding lumbar vessel is the most urgent due to the volume of bleeding and I am going to focus all my energy on that right now. Anaesthesia are you caught up?’

‘I’m not sure.’

‘We have a cut in the posterior abdominal wall from an uncontrolled trocar insertion that is controlled with digital pressure. We have a rent in the IVC which is clamped, and we have severe lumbar bleeding in the psoas that is posterior and deep I’m currently sewing with five-oh prolene,’ she said.

‘Thank you.’

As she sutured the others watched. Josie gathered the unused equipment. As she sutured Elizabeth whistled and hummed along with the Bach, little progressions that interested her, that moved her, and she murmured, who, quietly, now and again. As she pulled it off. As she nailed it, as she killed it.

‘Who.’

When she finished sewing the lumbar bleed she sewed the cut in the vena cava closed in seconds, and Robin unclamped it and as the blood flowed again the vessel swelled full and did not leak, and then she sewed the hole that Richard had been holding with his fingertip for 20 minutes. They hardly spoke during this part of the procedure apart from once, when Elizabeth said, ‘How much blood,’ and Robin checked the bottle on the suction machine and said, ‘About 1400 mills’ and held the big red bottle up. Vladimir said, ‘A lot.’ Elizabeth told Mei-Lynn to call and cancel the stump revision she had been scheduled to do and then she removed the IUCD and then she removed the girl’s appendix for good measure. Then they went on with the original operation. They mopped out the pus and washed the girl’s abdomen out with 5 litres of sterile saline. They closed up the wound with surgical staples and Elizabeth left Richard to sew up the port holes like a med student. They were finished at 5 p.m. with time for Elizabeth to have a cup of coffee and make her next operation at 6 and write up her notes afterwards. She visited the girl in ICU about 11 p.m. that night before she went home and the girl was awake and taking oxygen through a CPAP mask she didn’t like and then she died at 4 a.m. the next morning.

The US Space Shuttle Challenger, like all the space shuttles of the late 1980s and early 90s, was comprised at launch of three main parts known in the business collectively as ‘the stack’.

These three main parts are the shuttle itself, known as the orbiter, mounted at launch on top of a gigantic tank of fuel for the shuttle’s engines, in turn flanked by two solid rocket boosters, or SRBs, to propel the stack into space.

Two minutes after launch those solid rocket boosters jettison, at 45 kilometres in the sky, and they descend by parachute to the ocean, where they are retrieved, refurbished and re-used, like sterilised surgical instruments.

The SRBs look like pencils and they are 45 metres long and weigh nearly 600 tonnes. Most of that weight is their fuel, a rubbery solid material made of ammonium perchlorate and atomised aluminium powder called APCP.

Because of the weight of the SRBs they are built off-site in four sections by a contractor named Morton Thiokol, huge drums moved by truck and rail to be assembled near the launch pad. Each section of rocket is joined to the other using a simple joint, known as a tang and clevis. A U-shaped joint, running around the perimeter of the rocket, which receives a tongue—the tang—from the section beneath. There are, necessarily, minute gaps between that U and that tongue.

APCP burning at over 3000 degrees Celsius finds that gap.

So at two points thin rubber O-rings circle the rocket. These two O-rings are just 6.4 millimetres thick and they sit inside a groove in the joint that is under 8 millimetres wide, greased and protected by flame-retardant putty. When the booster fires, the heat and pressure forces the O-rings into the gap between the tongue and the clevis. This is called pressure actuation. The rubber changes shape; it is forced to, and the forcing creates the seal necessary for the rocket to function properly. The launch thrust shoves the tongue up into the U and the O-rings into their grooves and the rocket seals up tight under pressure of a thousand pounds per square inch. It’s all designed to move dynamically. To change as it plays. To adapt to the pressures it will face in a dynamic and predictable way. The stress is necessary for success.

When rubber is cold it is less flexible. Cold changes materials from a flexible, supple state to a hard and brittle state. The polymers are not moving. On the day of the launch of Challenger, January 28, 1986, it was 2 degrees Celsius. Part of the right-hand SRB faced away from the sun and there was a 6-degree Celsius difference between that side and the light. Each O-ring sits in a groove under 8 millimetres wide. They need to bounce back to seal that gap.

At just 0.678 seconds into the launch cycle there was already evidence of black smoke appearing above the O-ring joint on Challenger’s right solid rocket booster.

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