An Australian reconstructive plastic surgeon offers insight into the world of a surgeon-in-the-making in this excerpt from her debut fictional novel.
The child’s hand is grey and mottled.
I’ve crouched down next to the bed to examine it and now I stand up, the urgency of Ngoni’s phone call clear. We went to medical school together and he’s not often rattled, certainly not by a simple trampoline accident. He’s correct, the right forearm definitely has no pulse.
The boy is nine but looks younger, and is much too small for the adult-sized hospital bed crammed into a cubicle painted blue with fish stickers over the wall. He’s slumped down, his T-shirt riding up at the back and exposing his belly. The paramedics have strapped up his right arm, and in his other hand, he clutches a small green inhaler that whistles slightly as he takes ragged breaths. His eyes are glazed from the painkillers he’s breathing in. His mother hovers, too agitated to sit.
“We took him straight to X-ray,” Ngoni says as he pushes a computer on a trolley into the room. He points at the screen, confirming the severity of the fracture.
“What’s going on?” the mother asks, her voice shaky, the tear stains on her cheek matching those of her child. She’s looking at Ngoni. He waits for me to explain.
“He’s broken his arm just above the elbow and the fracture’s putting pressure on an artery. But don’t worry,” I reassure her, “as soon as the bone’s straight again, the blood flow will return to normal.” I have one eye on the clock above the bed. “What time did it happen?”
I don’t tell her that muscle cells deprived of blood start to die within a couple of hours. I don’t tell her that if it takes too long to restore blood flow then the muscles can swell within their tight fibrous coverings and die even hours or days later. In years past, kids with this fracture developed clawed fingers and permanent disability—and the best way of avoiding this is to straighten the bone and unkink the artery as soon as possible. I don’t want to tell her that this is a time-critical emergency until I have a plan. “I think . . .” The mother can’t remember how long it’s been.
She didn’t check the time when her son cried out. She didn’t look at her watch as she pulled him out of the narrow gap in the trampoline netting and called an ambulance.
Ngoni shuffles some papers and extracts a pink sheet. “The ambulance arrived at 11.03,” he says.
“They came quite quickly,” the mother adds. I check the time again. It’s already 12.30.
“And when did he last have something to eat or drink?”
“I made him and his sister a strawberry milkshake around ten.” I sigh. The anaesthetists are going to love that.
“Can you . . . ?” I start, but Ngoni’s already nodding. He’ll explain what’s going on to the mother while I organise an operating theatre. We don’t have much time. I tear off some ID stickers with the boy’s name, still on their paper backing, and run.
These corridors are familiar to me. Down the hall, up a flight of stairs and then around the corner—the operating theatres are located directly above the Emergency Department. I can plan what to do next while I’m moving.
Mei Ling is the surgeon who’s on call. She’s the first person I have to tell. I’m just the junior doctor covering for Orthopaedics today. Sure, I’ve worked on surgical teams for years but I won’t even be a trainee surgeon for another three weeks and then it’s a further five years to be a surgeon. I’m not allowed—nor qualified—to demand an operating theatre, no matter the urgency of my case. I try four times. Mei Ling doesn’t answer her phone.
I decide to organise a theatre anyway and then worry about a surgeon. Surely someone will be around.
“Woah, Emma, slow down!” Ibrahim puts his arms out to stop me with a laugh; I’ve almost bowled straight into him and his team on the stairs. He was my registrar four years ago when I first started working as an intern. I’m still grateful for his patience—medical school teaches us how to perform CPR but not how to treat conjunctivitis.
“Sorry, Ibrahim, I’ve got a supracondylar with a dying arm,” I say as I rush past.
“Good luck!” he echoes back, a floor away already.
Mei Ling calls me as I burst through the door into the bright hallway that links theatre and intensive care.
“What’s up, Emma?” she asks without greeting. After two decades as a surgeon she must know that four missed calls from the hospital mean an emergency.
“Nine-year-old, supracondylar, dominant hand, pulseless arm, heading to two hours post-injury,” I summarise for her.
There’s a pause.
“I’m on the other side of town. Can you get started? Tell theatre I’ve given you permission. At least if you can reduce it and restore blood flow, by then I’ll be there to help you pin it.” I hesitate. Over the last ten years—six as a medical student and four as a doctor—many surgeons have taught me bits and pieces of their craft. But I’ve never opened an operating theatre on my own before.
“I promise I’ll be there, Em. Besides, you’re an official trainee in a few weeks. You’ll be fine. You’ve got this.”
“Okay,” I reply, breathless from the sprint up the stairs and the sudden extra surge in adrenaline. I wave my ID tag over the proximity reader and the doors to theatre reception slide open.
“Hi, Em, you look like you’ve found something urgent,” Chitty, the clerk, observes.
I lean over the desk and search her schedule for the names of the anaesthetist and nurse in charge of theatre today.
“Geoff and Layla,” she says, pointing to the correct rows. “Give me the patient’s details. I’ll take it in to Layla and you can call Geoff.”
I scribble a note on the back of the patient’s ID sticker with a whispered thanks and find Geoff’s phone number in my phone. “What have you got, Em?” Geoff asks kindly. He’s my favourite anaesthetist. He even tried to convince me to specialise in anaesthetics rather than surgery, so I know he’ll take me seriously. He also knows that I’m acting up today. “Supracondylar, dead arm. Unfasted nine-year-old with a belly full of strawberry milkshake.”
“That’ll make things fun.” Geoff is dry. “Lucky timing, most of the morning operating lists have finished and we’ll delay someone’s start this afternoon. Do you have to wait for a boss?”
“No, Mei Ling said I could start. She’s on her way.” “Are you sure?”
I know Geoff isn’t being rude. I know that I’m unqualified and it’s his job to ask if the operation can be completed before he puts a patient to sleep.
Mei Ling is reliable. If she says she’s coming then she means it. But what if there’s traffic, what if she has an accident? Then I realise that I know what to do. I know that I can finish this operation. And I realise that Mei Ling, who never accepts a shoddy result, must think I can too, otherwise she wouldn’t have given me permission to start.
“Yes,” I say confidently.
“Okay, Em. We’ll send for the patient. We’ll work around the strawberry milkshake, just don’t be a typical registrar and rush us, okay?”
He called me a registrar, I think, and smile. It’s the first time.
I’m sitting on a stool looking at a satisfyingly pink hand when Mei Ling bustles in still tucking stray hairs under her clean blue balaclava. She inspects the small hand over my shoulder and studies the X-ray I’ve taken, but doesn’t ask for a theatre gown or sterile gloves.
“Good work. Are you going to pin the fracture now, or sit there grinning stupidly?” she asks, a smile in her voice.
One of the nurses hands me the drill with the pin loaded, the tool almost too large for my small hand. I strain to reach the trigger.
Mei Ling’s still watching. “Try your middle finger on the trigger with a big drill like that,” she suggests. “It’s got more reach.”
I set the drill down to reposition and it sits more neatly in my hand.
“Now screen with the X-ray so the pin’s at the tip of the elbow, and keep screening with the X-ray as you drive it in.”
The nurses cheer when the pin goes in on my first pass.
“Today’s your last day here, isn’t it, Emma?” Mei Ling asks as we walk to the change room together.
I nod and wave at Layla, the nurse in charge today, and think that I must come back and say goodbye to her. But then, how do I say goodbye to everyone I’ve ever worked with? I came to this hospital as a medical student, stayed on as an intern, worked my way up. Now, I’ve been one of the lucky few accepted to the training program to become a surgeon myself, and the College of Surgeons, which oversees our training, will assign me to a new hospital every year so that I can learn from as many different surgeons as possible.
Normally, hospital doctors go up in seniority and change jobs on the same day. I’ve begged a few weeks leave ahead of this promotion. “I’m off to Italy on a slightly belated honeymoon before I start at The Mount,” I explain.
She holds the door to the change room open for me and finds the clothes she’s messily thrown on a bench in clear haste. Maybe she didn’t have quite that much faith in me after all, I wonder. Is it too late to turn back, to write to the College of Surgeons and give up my training position, hand in my resignation to The Mount? But Mei Ling is smiling. She slips off her scrubs and deftly throws her dress over her head. “Emma, you’ll be totally fine,” she says, sitting down to change her shoes. “Look at you. You just did your first case on your own. Picked the problem and the urgency, organised everything, and then fixed it. You saved that kid’s hand. If there’s ever a trainee who’s going to thrive in surgical training, I’m sure it’s you.”
My heart swells.
This is an edited extract from The Registrar by Dr Neela Janakiramanan, Allen & Unwin, RRP $32.99, available now.
Dr Janakiramanan is a fully qualified plastic and reconstructive surgeon with special expertise in management of hand and wrist conditions. She operates privately at Epworth Eastern, Beleura Hospital and The Bays Hospital in Sydney.