Double Edged

By Marina Auer

When she answers a call from an old friend, Dr Erin Taylor is catapulted into the drama of decades past.  In 1996, three university students united to investigate the assault of a fellow student, Rina. But Erin and ‘The Furies’, as they called themselves, unwittingly triggered a time bomb. Two decades later, at a reunion lunch, Rina does not arrive. Within hours, Erin is missing as well, fighting for her life.  
Double-Edged:  Past actions and present decisions — her choices will draw blood.
 

 

• Language: English
• Publisher: Kwela
• Release date: Jul 7, 2023
• ISBN: 9780795710773

Marina Auer

Marina Auer is a graduate of UCT Medical School and spent several years working in state hospitals, before moving into private practice. She lives with her family – two teenagers, two cats, one husband – in Hillcrest, KZN. Double Edged is her first novel. 

Book preview

Part 1

Double exposure

Wednesday

__________________________________

Chapter 1

‘They’re ready for you in Theatre 4, Doc,’ a surgical nurse calls through the open doorway. Erin Taylor takes a final sip of coffee before pushing away from the table where a newspaper lies folded over half a headline, Weed out Corrupt—

Late-afternoon sunlight blinks through the window blinds, and from the road the drone of traffic amps up towards rush hour. Erin slips her feet back into her surgical boots and tucks an errant strand of hair beneath a disposable theatre cap.

‘Okay, I’m coming.’ She stretches and sighs. Her colleagues in the doctors’ tearoom look up. One is an anaesthetist, the other an orthopaedic surgeon, both greying white men in their mid-fifties.

‘Take pictures!’ the anaesthetist says.

He has a very dirty mind, that one. His name is Todd Odendaal, but everyone calls him the Toad. The orthopod simply grunts.

‘Of course,’ Erin replies with a half-smile.

The pair watch her walk from the tearoom, surgical scrubs swish-swishing with every step. Erin is one of only two female surgeons here at Rossmed Hillcrest Hospital. The other is an obstetrician/gynaecologist, which the men don’t find as intriguing as Erin’s chosen field.

Rubber soles squeaking as she goes, Erin heads down the seamless vinyl floor to Theatre 4. Waiting there for her, already anaesthetised, is a successful middle-aged businessman. He was a well-known provincial cricketer in his youth and is still a prominent figure in the local community. The man is married, with two children in private school, and currently has a potato stuck up his rectum.

Hence the procedure Dr Erin Taylor, general surgeon, now has to perform: capsicum annuum extraction ab ano est. It’s a pity that Latin is no longer a prerequisite for a medical degree. The words offer a certain gravitas to the condition.

Erin is standing pressed up against the stainless-steel sink, about to scrub, when her pocket vibrates. She digs out the iPhone and glances at its screen. The message is not from a number she recognises. She slips the cell back into her pocket and activates the sensor on the automated tap. Even if the message is from a patient, it will have to wait – Erin has important surgery to perform.

Thirty-four minutes after she entered the room, Erin strips off her disposable gown and latex gloves, and bundles them into the red-bagged surgical waste bin. ‘Thanks, everyone,’ she says to her theatre team.

‘Are we sending it off to the lab?’ the sister asks, inspecting a kidney dish bearing the specimen.

‘No,’ Erin laughs. ‘Straight into the compost.’ She tilts her head towards the waste bin. ‘Oh, wait – a photo first.’

The potato had not come out as smoothly as it might have gone in. What people don’t reckon on, when they’re sticking do-dads up their doo-dahs, is the power of reverse peristalsis. Once that object gets past a certain point, it’s not going to come down again in a hurry. It will be a couple of days before the deep-space explorer is desperate enough to do anything about his (rarely her) uncomfortable condition. Who’s going to rush to the doctor and admit what they’ve done? If it is organic, the object is going to start becoming macerated and covered in slime, and shit. It’s not so easy to get out then.

This one came out piecemeal, with pincers. This one no longer looks like the pristine spuds one buys in Woolworths.

Erin returns to the stainless-steel sink, and scrubs her hands once more.

‘Success?’ the Toad calls out as she passes by the doctors’ tearoom. He’s seated at one of the square dining tables, two empty coffee cups and a copy of Jagter/Hunter magazine open in front of him.

‘Are you still here?’ Erin asks. ‘Have you done any work since I left?’

‘Waiting for bloods,’ Odendaal says with a shrug and the slightest of head tilts at the orthopaedic surgeon sprawled on the room’s only couch. The orthopod grunts, again. He’s a big man who fixes big bones with a big hammer. It’s his case that has been delayed, and probably his fault the lab results Toad’s waiting for were not ordered pre-op. One of the disadvantages of being a specialist is operating with tunnel vision. You focus on the bone that needs fixing. You forget there’s a breathing, bloody body bag lugging that broken bone around.

‘Pictures?’ the Toad demands, stretching out a square-fingered hand.

As Erin starts to pass the anaesthetist her phone, it vibrates again. Another message. She swipes the notification away to get back to the photo stream. The grizzly orthopod ambles over to have a look at what was once an edible tuber – of the Mondial varietal, to be precise; waxy and firm, a good choice for salads. A little too firm for an easy trans-rectal trip.

‘Ugh!’ the Toad pretends to be disgusted. ‘That’s unappetising. You should ask him if he wants it served with sour cream or butter,’ he continues saucily, handing back the cellphone. ‘Come on, I dare you!’

Erin shakes her head. ‘I can’t. His wife is sitting with him in the recovery room right now.’ She pulls off her theatre cap and runs weary fingers along her scalp. ‘She thinks it was a haemorrhoid op.’

Despite their banter, none of this will leave the theatre tearoom. They might know about it, and laugh about it, among themselves, but the bottom line is patient confidentiality is a deeply ingrained habit. Erin unlocks her phone to permanently delete the photo. The message alert pings yet again. This time she opens the app. The first iMessage reads:

Check your emails!

The second:

Let me know when you have!!

And a third:

Call me. x Vanessa

Vanessa? Vanessa Lindstrom? Erin wonders at the unexpected contact. Frowning, she waves goodbye to her colleagues and turns towards the changerooms. Erin’s theatre list is done for the day; after a radical mastectomy and a couple of hernia repairs, the ‘dirty’ case was her last. Dirty not because it ticks the X-rated box, but because the case could expose the theatre environment to harmful bacteria. Anything infected, or involving the large bowel, fits the criterion, and gets scheduled only after the clean cases have been done.

As eager as she is to change out of the grubby blue polycotton scrubs, Erin’s curiosity to check her emails is now too great. She sits down on a wooden bench in the changeroom and scrolls through her Gmail inbox. Nothing out of the ordinary catches her eye. There’s the usual mix of emails from news subscription services, the bank, financial advisors; not many from patients or medical aids. Those go directly to the practice for her secretarial staff to deal with. That must be the email account Vanessa is referring to, Erin thinks, and stands. It is her publicly advertised contact point, after all. And it’s an account she can check only on her laptop in the consulting rooms.

Erin throws her scrubs into the laundry bin, washes her hands again and pulls on her street clothes. Tailored black pants and a pale-blue silk shirt, flat shoes. You don’t spend a day on your feet then wear heels. She glances at the mirror above the basin and grimaces at her reflection. Theatre-cap hair. She scrapes the tresses away from her face into a ponytail. There’s more ash than blonde in them now, she has to admit. At least a theatre cap hides that. Leaning closer to the mirror, Erin runs a finger over the bunched tissue above her left eyebrow. While she had her vision corrected with Lasik in her late twenties, Erin chose to leave this scar untouched. Wearing glasses is a hindrance. Wearing a scar is a reminder.

Looking a little more presentable, she heads out to tackle her last duties of the day. She has to discharge the day cases and check in on Tracey Roberts, her mastectomy patient. At twenty-seven, the poor woman is a decade and a half younger than Erin, and already having to deal with her own mortality.

Erin picks up her iPhone and is about to leave the theatre complex when she hesitates. At the touch of a fingertip Gmail opens again. This time she taps the junk mail folder. And there it is, as blatant as a nosebleed.

From: [e-mail]

Subject: Furies

Erin reads the mail. Then rereads it. No, she says to herself. Not now. She can’t. She won’t. Better excuse? She’s busy. Then, using more elaborate phrases to convey the same message, she dispatches a return email. Done.

Despite being groggy post-op, Ms Roberts still wants reassurance, which Erin cannot offer. An on-site pathologist performed a cryosection on the sentinel node that was excised during the course of the mastectomy. The tissue from this lymph node was frozen, sliced and stained, then examined under a microscope. In mere minutes a diagnosis was reached, in mere minutes the patient’s prognosis proclaimed. The microscope had offered no mercy: the twenty-seven-year-old’s lymph node biopsy indicated spread of the cancer.

The young woman’s skin is wan against the white hospital-issue sheets. ‘I’m sorry,’ Erin says, gently squeezing Tracey Roberts’s hand. ‘We had to remove more lymph tissue in your armpit. Now we need to wait and see what the formal histology shows, as well as genetic markers. We’ll take it one step at a time, Tracey. But we’ll take those steps together, okay?’

The patient gives her surgeon a brave smile. With that bad news carefully delivered, Erin slips her hand from Tracey Roberts’s palm and replaces it with the trigger of the PCA pump. Whenever pressed, the small button attached to the patient-controlled analgesia device administers a tiny bolus of morphine. A timed lock-out mechanism prevents overdosage. And to avoid any addicts siphoning out the opioid for their own use – there’s always one or two floating around among medical personnel – the PCA is like a mini safe, opened only with access codes.

‘I’ll be back in the morning,’ Erin assures her patient, ‘and we’ll discuss our next course of action then. I’ll see you at 07:30.’

Chapter 2

Fifty-six minutes later Erin has completed her rounds and written up all her post-op orders. She is two steps out of the glass door marked ‘EXIT’ when her cellphone rings. Erin recognises the number immediately.

‘So close,’ she groans, eyeing her silver Volvo in the parking lot.

‘Doctor Taylor, are you still in the hospital?’ the theatre manager asks.

‘Yes, Sharon.’ Erin takes a step back through the doors to give truth to her answer. ‘I am. Is there a problem?’ She doesn’t wait for a reply, however. The undercurrent of panic in the call already has her turned back for the stairs. She takes them two at a time.

Erin approaches the sliding doors into the theatre complex before Sharon has even finished making her request.

‘One of the gynaecologists has run into trouble,’ the theatre manager explains. ‘His patient is haemorrhaging and they need surgical assistance in Theatre 6.’

‘I’ll be there in a minute,’ Erin says, entering the changeroom. ‘Have they hooked up the Cell Saver?’ The device scavenges and filters any blood lost during surgery and returns it to the patient as an autologous transfusion. It can be a lifesaver if there’s a delay getting cross-matched blood from the blood bank in Pinetown.

Erin scans the shelves for clean scrubs. There are none except pants, size 3XL. She wears a small, not because she’s petite, but because surgical scrubs are sized for men.

‘Sharon, I need a shirt,’ Erin says to the theatre manager, who is still on the line. She pulls on the baggy bottoms and tightens the drawstring until it fits snugly around her waist.

‘I have one for you in my office.’ Sharon keeps a stash of spare scrubs, knowing the ones in the changerooms are pilfered by night cleaners and ICU staff. ‘And, yes, the theatre team already has the Cell Saver up and running.’

‘Okay, great. I’ll be there now.’

Erin ends the call and pulls on her boots. They’re white, like the ones butchers and abattoir workers wear. She grabs a disposable theatre cap to cover her head, and exits the female changeroom, top half clad only in a sports bra.

Todd Odendaal’s colleague, the orthopaedic surgeon, is entering the male changeroom just as Erin walks out. She smiles at him and adjusts the cap over her hair. The orthopod stops in his tracks. The door swings back and smacks into him. He grunts.

Sharon stands two metres away, ready with the shirt. ‘You really should stop doing that,’ she says with a shake of her head.

‘Theatre 6?’ Erin confirms and dons the shirt.

OT 6 is where Obs & Gynae surgery is performed. To appease the neonatal paediatricians, the room’s thermostat is set six degrees higher than in the other theatres. The paeds’ priority is their newborn patients – especially those that come early and weigh less than a kilogram. But it’s the surgeons who have to stand under the sharp operating lights, dressed in scrubs, gloves and barrier gowns.

Erin glances through the small window that looks into the theatre. It’s like a scene from Saw in there. Above surgical masks, foreheads glisten with sweat and strain.

She turns to the sink to scrub. The requisite two minutes of hand washing feels like a lifetime. Perhaps, in this case, it is. Another two minutes of uncontrolled blood loss in this patient would be lethal. Erin deems her hands clean enough after ninety seconds of scrubbing with Biocide and a double splash of D-Germ alcohol.

With hands surgically prepped, she can touch nothing else now except the sterile gown and gloves laid out for her in theatre. Erin turns her back to the swing door and uses her butt to push it open. Everyone else is too busy keeping the patient alive to hold doors open for a surgeon. She swivels into the operating room.

Tanya, the OT 6 floor nurse, looks up wide-eyed as she retrieves scarlet-soaked swabs from the waste bin. These will be rinsed with saline and the bloody washings also returned to the Cell Saver. Every red blood cell they can salvage is going to be needed here.

Tanya hurries over to tie the back of Erin’s gown. ‘It’s not looking good,’ the nurse whispers.

Erin can see that it’s not looking good. She snaps size 6.5 latex gloves over her hands and approaches the bloodbath. Modern Caesarean sections are relatively straightforward procedures. Any obstetrician will have performed thousands in the course of their training in a South African state hospital. When things start going wrong, however, it happens quickly and catastrophically. The only organ that receives more blood flow than the pregnant uterus is the heart. During pregnancy the arteries are dilated, the veins tortuous and varicose. When the uterus starts to haemorrhage, even an experienced doctor can rapidly become overwhelmed.

While this obstetrician is new to the hospital, he’s not new to obstetrics. Derek Geyser moved to Durban from the Eastern Cape a few months ago. There are whispers that he left the hospital there under a cloud of ill-favour. Erin listens to gossip with only half an ear. She knows better than some how stories can twist in the ever-revolving rumour mill, how a fiction repeated often enough will be taken as fact.

Sidestepping those clutching fingers of memory, Erin turns to the job at hand. There are already four doctors in the operating room: Geyser and his assistant, and two anaesthetists. The obstetric anaesthetist has been joined by Todd Odendaal; Toad is all business now while he helps get up a central line in the patient’s neck. The CVC is a wide-bore intravenous cannula that will enter the internal jugular vein and allow resuscitation fluids to be pumped in at much higher speeds and volumes than would a small peripheral port.

Erin steps up to the operating table to stand opposite the obstetrician. The assistant surgeon shifts to make room for her.

‘Dr Geyser.’ Erin pronounces the name with a guttural throat-clearing G, in the Afrikaans way.

‘Uh, thanks for coming,’ Derek Geyser responds. He can’t quite hide the tremor in his voice, or in his hands.

‘Placenta praevia?’ Erin asks, although Sharon has already informed her of this.

‘Accreta,’ Geyser clarifies, naming the condition of a low-lying placenta having grown too deeply into the uterine wall. The placenta does not detach cleanly as it should after delivery of the baby, and instead causes massive maternal blood loss.

‘You’ve already done the hysterectomy.’ Despite all the blood in the abdomen, Erin can see that the uterus has been removed. And yet the patient is still bleeding. ‘Shall we ligate the internal iliacs?’

Of course they should ligate the arteries that supply blood to the pelvic organs. It is the only way this poor woman – mother of a newborn – is going to make it. But Erin is not the lead surgeon here; she has to defer to the obstetrician’s decision.

‘Ja, thanks,’ Geyser agrees. Erin nods once and gets to work.

You can tell much by looking at a patient’s blood. A large pool of it on the floor is an indication you’re in serious trouble. If the blood is too dark, it suggests there is insufficient oxygenation occurring. And if it’s too light, it means there aren’t enough red cells in circulation. This patient’s blood looks like diluted cherry cordial.

‘She’s going into DIC,’ Erin states, because another thing you can tell just by eyeballing the ooze is how well it’s clotting. And it is clear that this patient has stopped clotting. Disseminated intravascular coagulopathy, a dire diagnosis. She will continue to leak blood from every cut surface – and at this point there are several – until her liver-driven coagulation cascade corrects itself.

‘FDP’s going in,’ Kamithra Bugwandeen, the obstetric anaesthetist, says. She’s got the first bottle of freeze-dried plasma up and is mixing more.

The Toad is looking at Erin over his mask. He gives a minute headshake that communicates volumes. It’s not looking good on their side of the screen either. The patient’s blood pressure is 60/30. And it’s only there with the help of an adrenaline infusion.

Erin looks into the cavity of the woman’s pelvis. The theatre sounds fade. She no longer hears the too-rapid beeping of the ECG or the incessant squawking alarm of the blood-pressure monitor. Her focus is between her fingertips.

She rearranges the large swabs that are packed in the abdominal cavity to keep twisting loops of bowel out of the surgical field. She explores down the pelvic side wall, starting on the patient’s right-hand side. First, she identifies the ureter, which lies unforgivingly close to the vessel she needs to ligate – if she ties that off, the patient will go into acute renal failure. Next, she confirms it’s the internal iliac artery, not the external, that she’s clamping off. A Vicryl tie, similar to fine embroidery thread, is passed underneath and around the artery, secured first with a double knot then two singles.

Once that is done, Erin switches her attention to the vessels on the left. She should be working from the right-hand side of the patient, but Geyser is still in his spot. He should have offered to move. Erin doesn’t say anything, however. The obstetrician is in deep trouble here. It’s probably nothing culpable, unless he went in unprepared: unless cross-matched blood was not ordered pre-op, unless the patient was not told she might require a hysterectomy, or that she might land up in ICU. Or dead. Offering all these warnings pre-operatively is called obtaining informed consent and, if done comprehensively, would scare most people away from any and all surgery for life.

‘Retract here, please,’ Erin asks Geyser to pull up on the Czerny retractor so that she has a better view of the abdominal side wall. The obstetrician’s hands are shaking uncontrollably now. Erin glances up at the man’s face. His forehead is sheathed in sweat. He won’t meet her eyes.

‘I – uh – I need to get …’

‘Take a minute. Have a bathroom break,’ Erin suggests. Geyser steps away from the operating table, peels off his gloves and makes for the doors. ‘I’m swapping sides,’ Erin says. She takes up the position Geyser vacated. With the assistant retracting, she searches for the second artery.

Twenty-four minutes later, Erin’s fingers tie the final knot. With both of the patient’s internal iliac arteries ligated, the blood loss has slowed to a trickle. But it is still a trickle.

Derek Geyser pushes back in through the theatre doors. Instead of donning a new surgical gown and gloves, he hovers.

‘We’ll have to pack and close,’ Erin recommends. ‘That’s all we can do now.’

‘Ja.’ There is still a wobble in Geyser’s voice. ‘And pray,’ he adds, hands clasped.

Erin glances up and sees Todd’s frown. She knows exactly what the cynical anaesthetist is thinking: the patient’s life will be in the hands of the intensive care specialists now, not God’s. She will be taken to ICU, kept sedated and ventilated until her clotting dysfunction is corrected. The ICU team will pour blood and plasma into her, and hope that it doesn’t simply pour straight back out of her.

Erin has been involved in cases like this before. The woman might receive up to thirty units of blood in the process of keeping her alive over the next few days. It’s the equivalent of replacing her entire blood volume several times over, which has its own set of problems. Erin sighs. The next forty-eight hours will be touch and go for this patient.

After closing the skin layer, she steps away from the operating table and peels off her bloodied gloves, then tears the ties on her disposable gown. They join all the wrung-out swabs in the waste bin. The anaesthetists will stabilise the patient, then transfer her to ICU.

‘Here’s a patient sticker, Dr Taylor,’ Tanya offers, holding out a small rectangle of printed paper. It’s the first time Erin sees the new mother’s name and details. Thandeka Mkhize. Twenty-five years old.

She takes the sticker and pushes it into the pocket with her cellphone. Erin dislikes billing patients who are at death’s door. It seems like such an insult to the family. Medicine and money are uncomfortable bedfellows. She’ll get her staff to send the accounts directly to Ms Mkhize’s medical insurance.

Geyser clears his throat. ‘She’s a private patient,’ he informs Erin.

‘A private patient?’

Geyser nods.

That’s a real stuff-up, Erin thinks, but says nothing. The obstetrician looks defeated enough. Private is a euphemism for cash-paying. The patient – Thandeka Mkhize, Erin reminds herself – doesn’t have a medical aid, so she might have saved up only enough money for a private hospital delivery, wanting to avoid the horror of a state-sector labour ward. And now all that money will disappear in the first ten minutes of her stay in ICU. Erin reaches into her pocket for the patient sticker and places it back in the file. She won’t be billing this one. ‘Okay if I leave the transfer to you?’ she asks Geyser.

‘Ja, sure,’ he says, voice muffled by the surgical mask he has not removed.

While still brightly lit, the rest of the theatre complex is deserted. Outside, the sun has disappeared behind a hill on the western horizon. All other elective surgery finished an hour ago, and the post-op patients have been transferred to the wards for overnight care.

Erin returns to the changeroom. The cleaners haven’t swept through yet. There are discarded scrubs and theatre shoes everywhere. Erin groans, takes off her boots – no longer white – and leaves them in the corner with the other soiled footwear. Her dirty scrubs go into the laundry bin. She could pick up the scattered items, but there’s a reason the cleaners will