Extremis

By Philip Berry

Stephen Newman is dying. The correct diagnosis has evaded the best medical minds, and nothing has been done to arrest his physical deterioration. When Nina Charan meets him in the emergency department of the London Academic Centre, she knows that something, a clue in the history, has been missed. As it becomes clear that her patient is not divulging all the relevant facts about his life, Nina experiences the same bewilderment and confusion that overtook her in PROXIMITY. A larger, deeper game is being played, involving medical ethics, politics, personal hypocrisy and a human life. Nina is once again manoeuvred into a position of crucial importance, one from which she will not be able to extract herself without tearing through the complex web of interests that has enveloped her.

EXTREMIS explores assisted dying, euthanasia, academic misconduct and whistle blowing. Set in London, New Orleans and Bolivia, it is the sequel to PROXIMITY.

• Language: English
• Publisher: Philip Berry
• Release date: Oct 6, 2019

Book preview

EXTREMIS

by Philip Berry

Copyright belongs to the author

All characters in this novel are fictional creations, and any similarity to real persons, living or dead, is coincidental and unintentional.

1

A revolving door delivered Nina into a high, glassy atrium. The noise of the street behind her was shut out, superseded by the murmur of disorientated, sad, relieved or anxious people - a multi-cultured, economically diverse throng. She had worked here before and saw that nothing had changed. Nina was back in the city, pulled back into a centre of excellence by consultants who had heard about her, who wanted her to work there.

She walked up to the eighteenth floor, seeking a once cherished view, but despite her featherweight frame she was soon hauling herself around the turns on the partially externalised staircase like a flabby, wilted jogger punished by her own silly resolution. The view had sustained her through crazy days and lonely, burdened nights. Physically unchanged to those who knew her, she was far less confident and far more fragile six years ago. Through seamless columnar windows the vista enlarged rapidly once the adjacent block had been surmounted at floor 14. The day was a clear one – early October. She swam in the blue space above, imagined a heat on her skin that was not in fact real, and dipped her eyes to the irregular, ever-fascinating skyline. Then she headed down to the level on which she would spend many days to come – the 8th floor, Department of Gastroenterology. Her private time was over.

Structural angles and forgotten but instantly familiar signs took her back to a tense afternoon when, as a junior working in the intensive care unit, she had been asked to seek out this place. This was a year before her arrival at Farsham - she had not yet chosen Gastroenterology as a career - and all she knew of the department was the academically stellar reputation of Professor Adam Jay. Before approaching his office she sought one of the less well known, correspondingly more approachable consultants, but none had been available. Professor Jay would surely be displeased at her interruption, unused to such run of the mill, clinical requests during a day of committees, scientific researches and obligations at the Royal College.

On that significant afternoon she identified Professor Jay’s door, retreated in search of a secretary to mediate for her, found none, and was obliged to knock. An unexpectedly fresh voice responded, Come in, and Nina eased the door open. He sat writing at his desk with a chunky silver-black fountain pen, a computer terminal placed to one side. With the composure that had stood her in such good stead over the years, Nina summarised her problem, made her request and bolstered it, politely, with irrefutable argument. He nodded, and she wondered, how can one so young have come so far? His black hair glistened like that of a Brylcreamed film star from another era, and surmounted an unlined face. He nodded; I’ll come down this afternoon, your patient is obviously in trouble.

She passed his door now, five years later, and saw that the sign had been replaced. There were extra letters after his name, relating to further honours. But she had no business with him right now, and opened another, smaller door, which led her up a tight spiral staircase to the junior doctors’ office. Here the age of the department, nestled within a modernised exterior, began to show. There were damp patches on the cream walls, and paint was peeling at the junction with the ceiling. The irregular shape of the rooms and connecting spaces had required craftsmen from another century to tailor-make the mouldings and sideboards. She felt dust settle in her nostrils, and the skin of her finger tips stuck momentarily to a banister that had not been cleaned properly. Clearly the housekeeping staff were unaware of this internalised garret, the source of so much groundbreaking research.

I wanted to catch up with you Nina. I think it’s important that you think about what you can achieve during your year here.

Professor Jay sat leaning back behind his desk, one foot resting laterally on a knee some distance from the thick edge of battered oak. Day three – he had remembered her.

I hear from my colleagues on the training committee that you’ll be looking for a consultant post in a department like this.

He looked up at the ceiling superfluously, indicating the entirety of his empire, But looking at your CV, I can’t see any sustained periods of research. You’ve focussed on your clinical training, quite understandably...a few papers here and there, but no further degree, no high impact publications...

Nina sprang to her own defence,

You're right Professor Jay, I've always been reluctant to withdraw from clinical work. If I'm away from the wards too long I start to miss it. I've asked supervisors whether a further degree is absolutely necessary...and they have been ambivalent.

Well, to get a job in an academic centre like this, it is probably necessary. But not always. It very much depends on the person. Have you made up your mind not to pursue research?

Not at all. If there was a project available I would love to get involved.

Something tells me that you were anticipating this conversation.

I did wonder. I had heard from previous registrars that there might be opportunities.

And you're interested in ethics as well I see. There were a couple of essays in your CV that I was very interested in.

I've had some exposure to ethical dilemmas.

Yes, you worked with Peter Owens, didn’t you? A very difficult situation.

It wasn’t too difficult for me. For the department, a real challenge, but his departure more or less coincided with mine. It was an interesting, uncomfortable time to be there, and to observe. There were some lessons to be learnt in how to conduct yourself as a consultant.

Have you seen him again?

I don’t think he's come back to the country Professor Jay...

Adam, please.

Sure…I don’t think he would look me up. I was just his registrar, and there were obviously a lot of things going on in his mind at that time.

It sounds as though you were loyal, Nina. That is a very nice quality.

Nina entered the Emergency Department to see how the day’s intake of patients was going, and was immediately taken to one side by the consultant in charge – a thin, diminshed man close to retirement.

That chap in cubicle seven, I'd like you to see him directly. He’s a Lord, I don’t recognise his name but a personal assistant came in with him and made a bit of a hoo-ha. I've already rung the top floor, and there's a private room available if he needs to stay in. You’ll see him?

Of course. Have you any idea what's wrong with him?

Not at all. He was screened by the triage nurse, and she came to find me directly. He doesn’t look well, I can tell you that much.

Nina picked up the casualty card but gleaned no useful information from it. She put all thoughts of his eminence out of her mind and entered the cubicle as she would that of any other patient. The grey haired man with anachronistic, bushy grey sideburns lay back on a pillow, one freckled hand extending from beneath a hospital blanket, resting in the palm of his wife who had just arrived. He was awake, and followed Nina’s progress across the cubicle towards him.

Hello sir, my name is Nina Charan, I'm the medical registrar on duty today. Is this your…

Yes, this is Linda, my wife.

Hello. Nina looked back to the patient,

Well, can you tell me what happened today?

You should know that I'm already seeing another doctor here. I've been unwell for a month now, and the symptoms got worse during a debate this morning. I'm due to see Doctor Li the day after next, but I couldn’t hold on.

So you have a blood disorder, I assume. Doctor Li is a haematologist.

It’s been assumed, and I'm fearing the worst obviously. I had a bone marrow test ten days ago and I was expecting to get the result later this week.

The interview had already gone off the rails from Nina’s point of view. To make a diagnosis she needed to know how he felt, what the symptoms were, when they had started...not who he had seen and what tests had been done already. This was a common problem with intelligent and well informed patients - they tended not to provide the unadulterated information that was required, rather embellishing it with other peoples’ interpretations.

Can we start from the beginning Sir? Can you tell me when you began to get unwell, what you noticed first?

I told Doctor Li all of this before, and my General Practitioner before that. Do you really want to know?

I think I'd better…

Call me Stephen, please. In another fifteen minutes you'll know more about me than anybody except my wife.

He laughed and looked around him, at the bland patterns of the cubicle’s curtains, but his eyes expressed concern, and Nina could tell that the prospect of receiving the bone marrow result occupied his mind. She understood his anxiety. He looked wasted, his skin was pale and she had already noticed a splatter of tiny bruises on an exposed forearm. It had to be leukaemia.

If you have the energy I'd very much like you to tell me what your symptoms were. It’s the only way I can make an real judgement. No point me seeing you otherwise.

I see! You make yourself very clear. I was fine until two months ago, when I began to feel hot at night. Then I started waking up to find the bed sheets sodden. Linda told me that I was sweating all night. My bones began to ache and I went off my food. I had a couple of nose bleeds, and that led me to the GP. A little bit of knowledge is a bad thing, but I knew that it was probably something wrong with the way my blood was clotting. Since then it’s been very gradual, but more of the same. I've been losing weight, despite trying to get as much food down as possible, I can't touch alcohol, but that’s no problem, and the sweats have continued.

Have you travelled anywhere recently?

No, I've been nowhere exotic. I have a very city bound life.

Any cough? Have you produced any sputum?

Nothing of the sort. I have been short of breath, but they put that down to anaemia. They said I didn’t need a blood transfusion…yet.

Any headaches, problems with your eyes, any fits, faints or black-outs?

A bit of a headache now and again, when the temperature’s high, but nothing more.

Have you taken your temperature?

Linda did, she said it was up to 38.5°C on one occasion.

Any shaking?

One or two episodes.

And no-one else in the family has been unwell that you know of?

Linda now interjected. No, we asked, Doctor. No-one’s been sick. Why do you ask?

The symptoms sound very much like an infection, but I presume those tests will have been done.

Lord Newman sat up now, the intellectual pursuit having grabbed his attention.

Doctor Li asked very similar questions, but in the end he told me that disorders of the blood can often give you these symptoms, and that many people mistake them for infection.

Nina stayed quiet, for she had detected a mild reproach. Clearly her questions had followed a similar course to those asked before, and it seemed Lord Newman had noted the fact that she had fallen into the same trap, that of confusing infection for other, more serious disorders of the bone marrow. Nina spent another five minutes wrapping up the history, eliciting details of previous illnesses and operations, none of which were relevant to the current situation. She asked him briefly about his work, but he was non-committal, describing periods of time in industry, followed by elevation to the House of Lords. He gave little away about himself. She asked about family, and jotted down the fact that he had two children, a son and a daughter, neither of whom he saw very often, but there were no diseases running through the family, nothing hereditary to focus her attention on.

May I examine you now? I'm happy for your wife to stay if you are.

But Linda chose to leave the cubicle, a sense of propriety forbidding her to witness the interaction between doctor and patient, this despite the fact that it was she who had been helping him manage at home over the weeks as he grew increasingly frail, requesting assistance with dressing, climbing the stairs, even when making his way to the toilet in the middle of the night.

Nina closed the curtain after Linda’s departure, made eye contact with Lord Newman, but chose not to ask if there was anything he would like to add. Usually, alone with a patient, she would give the opportunity for him or her to express any concerns that could not be shared with relatives or partners. Nina had learned long ago that all people had secrets.

She delicately picked up his right hand, examined the finger tips, the nails and the palms, felt his pulse at the wrist, felt his pulse at the elbow, noting the force with which the blood was pumped through the artery, and then began to probe around his collar bone and neck. She detected swollen glands, and this confirmed to her the likelihood that he had a disease of the blood which had entered the lymph nodes. She examined his mouth, and noted his excellent dentition. She listened to his heartbeat with her stethoscope, and lingered with her head bowed before his chest as she visualised the subtle sounds of turbulence, vibrations augmented through the diaphragm of her instrument. The lungs sounded reassuringly hollow, but after she had laid him flat on the couch and dipped the side of her hand into the softness of his stomach, she stood up and began to fit the pieces together in her own mind. His liver and spleen were enlarged, the round edges of each organ protruding from under his ribs. Normally, they would have been hidden beneath that bony cage, but due to the disease they had become swollen, detectable to the practised hand. He watched her face as she silently constructed a list of potential diagnoses.

I take it you’ve found my liver and spleen Doctor?

They are both enlarged. Dr Li found the same?

Yes, he did, but those glands that you were feeling up around my neck, I don’t think they were there before. Do you think I should come into hospital?

I think you should, Stephen. I’ll arrange a bed for you. Then we can chase the result of that bone marrow and start any treatment straight away, if necessary.

You think it’s leukaemia as well don’t you?

I really couldn’t say, Stephen, but you have had the one test that will tell us the truth, so in a way there's no point speculating.

Will you be looking after me up on the ward?

Probably not actually. Presuming that Doctor Li’s team continue your care, there won't be much of an opportunity for me to see you. But I'd like to pop in once or twice if I may, to see how you're getting on.

You’re curious then?

I would like to know the diagnosis...but I would also like to know how you're getting on?

She left the cubicle, ushered Linda back in, and took a place at the central station where doctors and nurses filled out their paperwork. There she reviewed the recent blood results, checked that the bone marrow result had not already been reported and released onto the results system (it hadn’t), and wrote down her impressions. For her, during a busy day on call, Lord Newman’s case presented no real challenge. He was not acutely unwell, and required no immediate treatment. She signed her entry, wrote out a drug chart, arranged his transfer to the ward, and was soon distracted by more pressing cases.

Ten days later she emptied her white coat pocket of patient lists and redundant forms, tore them into fragments and inserted the scraps into the narrow horizontal slot of a confidential waste paper bin. She caught sight of Stephen Newman’s name as it passed through her hand and she chastised herself for failing to follow through on her promise to check up on him. It took another four days for her to find the time to ascend to the top floor, where private patients and dignitaries were cared for.

2

Nina’s SHO, Yanni, Hong Kong born but with elocution that suggested an upbringing in south London (it was Peckham), hurried across the ward to warn Nina.

The daughter’s here, Nina, she looks pretty angry.

What's up with her?

Someone told her down in the ED that her mother had cancer, and now we’re telling her she doesn’t.

Well, that’s understandable...but it’s good news...isn’t it?

An eighty-nine year old lady had come to casualty following a collapse, this brought on by what was evidently a long period of starvation. She lived alone, but was visited regularly by her daughter, who was an executive in a management consultancy company, and who was unable to explain why her mother’s body now appeared skeletal. Only on further questioning was it revealed that for over a year most meals had gone half-eaten, some completely untouched. The patient, Vivien, had not mentioned to anyone the fact that food now invariably made her sick...until the collapse led paramedics to her door. The first doctor to assess her in the ED suspected oesophageal cancer, and he had been bold enough to tell Vivien that this was the most likely diagnosis, alone, without waiting for the initial tests to come back,. Her daughter then returned from the car park, and was told the same.

Prepare for the worst... he had advised them.

And now, five days later, following X rays and an endoscopy, the diagnosis had been proved wrong. She simply had a tightening of the valve at the lower end of the gullet which was restricting the passage of food. Starvation had paralysed her immune system, and Nina now planned to commence a course of antibiotics, suspecting a chest infection. She approached the patient’s bed and saw her daughter sitting in a chair, staring vacantly at the silent images on the overhanging entertainment module. The current Secretary of State for Health spoke noiselessly to the uninterested, having secured an opportunity to address every hospitalised patient in the country. Vivien was asleep, and was now wearing nasal cannulae, delivering oxygen gently through her nostrils. Her fingertips were blue, and Nina recognised the signs of an elderly lady who was probably in her last week of life.

She spoke in subdued tones to the daughter,

We should really speak, would you like to follow me to the sister’s office, it’s a lot more private.

Yes, I would, Dr Charan. I really do need an explanation.

Nina cast her eyes around for the responsible nurse, but gave up after twenty seconds or so. She had hoped that the nurse looking after Vivien could have accompanied them, both to dilute the emotion and to provide a witness to any exchanges that might later be used to implicate Nina in any accusations of mismanagement. She led Vivien’s daughter to the edge of the ward, knocked on the sister’s office and hearing no one inside opened the door, having read the combination of the lock that was written in biro on the horizontal part of the frame.

Come in, come in, have this seat.

Vivien’s daughter took a folded piece of paper from her handbag, and Nina saw that a list of questions and complaints had been written on a computer and printed out neatly. Nina prepared herself to make a prolonged defence of other peoples’ mistakes.

There are numerous points I need to make about my mother’s care, Doctor Charan, I really don’t know where to start. Why on earth was she told that she had cancer, on her own, in a busy A&E department? When I turned up, she was distraught. Who could do such a thing?

Mrs Shaw, that was a mistake. I think it was the sign of inexperience, but to be fair I would have probably reached the same conclusion, and I'm actually a specialist in this area. The doctor your mother saw was a junior trainee, but the management and the treatment that he started was perfectly correct. But he did go too far, I don’t think any of us would deny that.

Nina’s honesty was evidently disarming, for Mrs Shaw had nothing to say to that.

But why is she not getting better, and why did it take you four days to start feeding her through that tube?

I know it looks as though there was a delay, but it was important to make the right diagnosis before trying to put tubes in…

But it was four days until she had the camera down...what was going on?

That was my decision, I didn’t think she was up to having such an invasive test, so we relied on an x ray to show us the outline of the oesophagus. In any hospital, that would take 24 hours to arrange. And Vivien was managing to swallow liquid food, so her nutrition was being addressed.

But she looks ten times worse now than when she came in. She’s deteriorating.

This was a common enough observation. Relatives noted a decline in their loved ones’ condition following admission to hospital, but overlooked the fact that the disease had been progressing during the preceding weeks or months. Instead they blamed the care. This confusion annoyed Nina, but she exerted the control and the perspective for which she was well known – for after all, her own irritation paled in relation to the distress and fear that drove Mrs Shaw’s questions.

"She is malnourished, every part of her body is under strain. Her defences are down, and I think it is inevitable that she would develop complications such as infections. She has an infection now, and will need antibiotics for the next week