The Appraisal

This story is by Odet Aszkenasy and was part of our 2018 Spring Writing Contest. You can find all the writing contest stories here.

**The Appraisal**

Mr. David Smythe, consultant surgeon looked at Dr. Andrew Norman, anaesthetist. Andrew nodded. Without hesitation Smythe plunged the 15cm long ‘Veress’ needle into his patient’s abdomen. Like a knitting needle, only hollow. There was a hiss as the carbon dioxide flowed in and inflated the abdomen until it was as tense as a balloon. His scalpel swiftly incised a hole, just wide enough to allow the fibreoptic operating camera through.

David tried to remember the name of this patient, number three on the list, whose gall bladder he was about to remove. However, his mind was on other matters. This afternoon he was to have his annual appraisal with Professor Howden, Head of Surgery. His stomach turned, a bead of sweat trickled down his forehead. Dripped onto his the right lens of his headset. Jane, the scrub nurse, wiped the droplet away.

“Tricky one?” said Andrew.

“Straightforward so far. Has someone turned the temperature up? It feels warmer than usual in here.”

“Nope, same as usual”

David grunted. The medical students in the operating theatre watched the television screen as he deftly dissected the tissues down to reach the gall bladder.

“Bloody appraisals, waste of time, just another way for managers to try to control doctors.” David spoke his thoughts out loud as he continued to cut.

“Totally agree, we’re never going to get rid of bad doctors with appraisals. Just a tick-box exercise ” said Andrew.

David knew it would be a difficult appraisal meeting. The departmental audit had shown, for the second year running, that his patients had a higher death rate than all the other surgeons in the department. But, as everyone knew, well everyone, it seemed, except Professor Howden, his patients were the most frail and ill. Howden had raised his eyebrows when he had presented the results and said that a third year of what he called ‘poor outcomes’ would result in the need for clinical supervision. And yet, in years of experience, Howden was actually his junior, having only qualified in 1994, by which time David was already a consultant surgeon. He was convinced that Howden only got the clinical director’s job by his management arse-licking, and undermining everyone else in the department who stood in his way.

David looked at the anatomy presented to him by the fibreoptic camera. This was the critical stage off the operation. To cut off the arterial supply to the gall bladder, and then to remove the gall bladder itself. He placed a tie around the artery and was about to start working on the bladder when the blood pressure monitor chimed it’s gentle but insistent alarm. Andrew stood up, opened up the drip to let the saline flow quickly. The alarm continued.

“David, we have a problem. I can’t maintain her blood pressure. Can you see any blood?”

“Absolutely dry as a bone here. Are you sure it’s not some kind of a reaction to the anaesthetic?”

“I don’t think so. She’s not got any signs of an allergic reaction.”

With that another alarm began to sound, the heart-rate monitor.

Andrew’s previously calm tone had gone. “She’s very tachycardic. Heart rate 160 per minute and blood pressure now only 70 over 40. Get me four units of blood, and a pressure bag”.

David’s heart sank. He realised that there was probably a hidden injury to a major blood vessel. He had done vascular work as a trainee surgeon many years ago, but he knew that he didn’t have the experience and confidence to tackle a major bleed. That was Howden’s territory. Howden was operating in room 3 that morning. Smythe considered his options. Should he call Howden or have a go himself? He hated thought of having to admit to causing a serious arterial injury during a routine laparoscopic cholecystectomy. At the very least he would have to present this case at the monthly morbidity and mortality meeting, attended by all his surgical colleagues. Worse still, there was no doubt that he would receive the insult of being put under the supervision of another, inevitability less experienced, surgeon. But the alternative, if he failed to stem the blood loss, was clear – a death on the table and a probably manslaughter charge. He agonised about for a few moments more, then made his choice.

“Give Professor Howden my compliments and say that I would appreciate his opinion”.

Amongst the surgeons, the term “my compliments” was code for them to come as quickly as possible to help with an emergency.

Andrew pierced the skin of her arms and slipped a large-bore cannula into her vein. He set the pressure bag to and force the blood in as fast as it would go. For a few seconds the alarms ceased their chiming. A sigh of relief. But the respite was brief, and the alarms resumed.

“I can’t maintain pressure” said Andrew. David felt a chill. Jane caught his eye “Should I call the crash team?”

“No, she hasn’t arrested yet” came David’s terse response.

“Not yet” said Jane.

It felt like an eternity but was probably less than two minutes. Professor Howden pushed open the the swing doors of the operating room with his rubber boot. He looked like a priest, hands held together near his chest to keep them sterile. He was followed by a small entourage of junior doctors and medical students. He took in the monitor readings. “Looks like you’ve got a bleeder.”

Without waiting for a response he took the scalpel off the operating tray and made a longitudinal abdominal incision about a foot long from just below the sternum. Under the pressure of the carbon dioxide that it had been inflated with, the tense abdominal wall split open. He delved inside, gently lifting her intestines and organs.

“No blood here. Let’s have a look in the retroperitoneal space”.

As he made the incision deep within her abdomen to enter the tissues just above the muscles of her back a fountain of blood shot out. “Suction! We may have a perforated aorta. Arterial clamp please Sister. Jesus David, looks like you shoved the Veress a bit too deep.”

“It’s a cholecystectomy tray Professor” said Jane “We don’t have a vascular clamp.”

“Just give me those” he said, gesturing towards the medium sized forceps lying on the tray.

“These are the biggest we’ve got” Jane passed him the largest forceps on the tray. “I’m just going to have to do this by feel. There’s too much blood. I can’t seem a thing. Suction. I need more suction.” There was no mistaking the note of panic in his voice, a sound that David had never heard before from Professor Howden. Smythe had an idea. “What if we lower her head? you might get a clear view long enough to get the clamp on.”

“Christ Almighty Smythe, that’s inspired. Alright by you Andy?”

The anaesthetist nodded “Go for it. Blood pressure is 60 over nothing. She’s going to arrest any time now”.

“You medical student, what’s your name?” The quiet, blonde-haired young lady who had been scrubbed and had stood observing throughout said “My name’s Danielle”

“Alright Danielle, on my count, I want you to turn that wheel under the table clockwise as fast as you can.”

“Ok? Suction and three, two, one. Now Danielle, now!”

Without hesitation Daniel spun the wheel under the table, clockwise as it was facing him, but anticlockwise from Prof Howden’s side. The patient’s head began to tilt up.

“Wrong way! Wrong way!”

The low volume of blood that had managed to reach her heart while she was still lying flat reduced to zero as gravity came into the equation. The cardiac monitor switched from its regular chiming alarm to a continuous piercing wail.

“Cardiac arrest. Call the crash team.” said Andrew “Commencing cardiac massage” and he started to thrust the sternum down with the heel of his hand.

Danielle spun the tilt wheel the other way as fast she could. At last the pool of blood that had obscured the surgeon’s view moved out of the way. “I can see it” said Smythe, “I can see the perforation. It’s in tha aorta. Give me the forceps. Now.” He snatched the forceps from Professor Howden’s hand and clamped the huge blood vessel just above the gaping hole that’s was still pulsing blood, keeping pace with Dr. Norman’s cardiac massage.

The cardiac arrest team burst into the operating theatre. “Administer intracardiac adrenaline” ordered Andrew.

“Are you sure?” asked Dr Jo Donagh, the dark-haired young female doctor leading the team.

“Yes. Do it.”

She quickly removed the three inch long needle-guard from the prefilled syringe and plunged it into her chest.

“Pressure 70/40. She’s back. Normal sinus rhythm.” announced Andrew. A round of applause broke out from the medical students.

A tear worked its way down David’s cheek. He quickly wiped it away. Wouldn’t do to show any emotion. He had made his choice. His career was over, but the patient would live.