A Mistake by Carl Shuker (Victoria University Press, 2019), 184 pp., $30
In a 2007 article in the New Yorker, surgeon and health researcher Atul Gawande wrote an account of the medical profession’s evolving approach to mistakes. During surgery and afterwards in ICU, a typical patient will require hundreds of procedures, all of which can result in life-threatening complications if not implemented correctly. As medicine advances and the methods for saving patients become more elaborate and numerous, the risks mount up. Avoiding mistakes is an important issue, given that one relatively small error can lead to potentially fatal consequences.
A study of forty-one thousand trauma patients found that they had 1224 different injury-related diagnoses in 32,261 unique combinations for teams to attend to. That’s like having 32,261 kinds of airplane to land.
There’s a reason he mentions aeroplanes. In 2001, medical specialists at Johns Hopkins Hospital decided to use the aviation industry as a model for addressing the problems Gawande describes. When planes became more technically advanced in the 1930s, the US Army Air Corps realised it could no longer rely on a pilot’s cool head to keep a highly sophisticated aircraft in the air. Planes had become too complex for pilots to operate by memory alone, and one missed step in the operating procedure could lead to a crash. Army test pilots came up with a checklist of steps for takeoff, flight, landing and taxiing. Once the lists were adhered to, accidents were reduced and pilots were able to handle increasingly complicated machines with a lower level of risk.
Reasoning that complexity in medicine could be tackled with the same approach, critical care specialists began devising their own checklists, initially to prevent infections. Once doctors had been persuaded to stop skipping steps, the incidence of infections went right down, preventing injury, death and reducing costs.
There was opposition from doctors at every stage. As Gawande describes it, the initiative
pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity – the right stuff … Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.
This tension, between doctors who possess ‘the right stuff’ – expertise, daring, nerve, flair – and the regulations within which they operate, is at the centre of Carl Shuker’s new novel, A Mistake.
The story opens as Elizabeth Taylor, an experienced and talented surgeon, is examining a young woman who has arrived at a Wellington hospital in a serious condition. When the patient begins to deteriorate she’s rushed to surgery and, as the procedure begins, this ominous exchange takes place between surgeon and nurse:
‘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.’
The checklist sidelined, we’re straight into the surgery, and pretty soon things start to unravel. The initial error morphs into a series of mishaps with escalating consequences for everyone involved. Shuker’s account of the operation is gripping; he lays out the complexities with knowledgeable precision. There’s clearly so much scope for error it will be difficult to establish who was to blame for each problem, and at what stage.
Elizabeth manages the situation as best she can: she has the nerve and the skill and the mental toughness. But the right stuff can only get you so far when something small yet vital has been missed, when things start to fly apart and the mission is catastrophically out of control.
Shuker, a former editor at the British Medical Journal, has an eye for the drama in the material he knows so well. Doctors have some of the best work stories; they deal intimately with human situations, with life and death. They’re engaged in continual battles and yet must maintain professional detachment. When they get it wrong they cop the blame – and they’re always so incredibly tired.
Something more than rich material is needed to shape successful fiction though, and Shuker has this in his kit too: the ability to tell a cracking good story. As the action races along he’s firmly in control. He has the skill and the ruthlessness to deliver the reader a real emotional punch.
There was some echo as I read A Mistake, some resonance I kept trying to define, nearly catching it then losing it again until finally, near the middle of the novel, my ear gave a read-out: Hemingway. There’s a tone reminiscent in passages like this:
She went through her team and she felt good. Richard, Robin, Vladimir, Mei-Lynn. She liked it and they were strong and they had recovered and coped and even excelled.
And this one:
She could see herself in the reflection in the safety glass and she was straight-backed and good and she spoke to herself.
There’s something straight-backed and good, something macho and brave about Elizabeth as she strides the halls battling bureaucracy, pushing away emotion, refusing to be traumatised despite her close encounters with bloodshed, death, suffering, gore. When up against it she turns to home renovation, or drives her stationwagon through eerily empty Wellington streets. She strides into a Morbidity and Mortality meeting and she is noble and precise and she takes no prisoners. She defies men and speaks truth and is strong and she will take one for the team …
After the mistake the hospital management reacts with slow, blunt force. There will be no mercy for Elizabeth, despite the subtlety of the case. Like all doctors, she has to confront mandarins and bureaucrats who don’t understand the nuances of her work. Meanwhile, beyond the misadventure that starts to throw Elizabeth’s life into turmoil, a much larger controversy – and probable mistake – is unfolding, as the government announces its intention to publish league tables of surgeons’ mortality results without foreseeing the negative impact this will have on practitioners and patients.
In keeping with the aviation checklist theme, Shuker’s narrative is interspersed with accounts of the doomed 1986 flight of the space shuttle Challenger, when a miscalculation relating to a tiny part of the craft led to a cascade of failures and the death of all on board.
All explosions ripple out from a single point of ignition. Chaos, like the universe, starts small and expands ever outwards, and chaos is the driving force of A Mistake, a pitiless unravelling that reveals the vulnerability of human systems when they break down.
There’s a clinical orderliness in Shuker’s arrangement of ideas, an uncompromising quality – no soft bedside manner to spare the sensitive reader. Confident in what he knows he says just enough, in narrative so well calibrated he maintains the tension effortlessly. It’s as if he has absorbed Hemingway’s iceberg method, the spare, austere prose in which meaning is implicit. He’s able to convey cruelties, to deliver shocks and evoke the harshness of fate in a manner so deadpan the impact is powerful.
He only loses his clarity and poise, his admirable cool, just briefly, when he takes Elizabeth to Auckland, sin city, and throws her in with colleagues so shallow, decadent and crass that one is wearing a toga. And at one other point, again fleetingly, as Elizabeth sits in a Newtown bar and a line of creative writing blows in on the Wellington wind:
The waiter came and he was a skinny 20-year-old and unknowably beautiful but still there was the air of decline and the threat of age that maybe was just the country and beautiful 20-year-old boys serving gourmet burgers.
In the same scene Elizabeth reflects that a Rotorua girl ‘wouldn’t fit in’ in Wellington – but the cold universe laughs at such provincial distinctions. Really, Rotorua girls fit in no sweat, in Wellington, Auckland, London.
These are minor losses of thrust though, not enough to throw the novel off its relentless, gripping trajectory. Shuker has the right stuff to keep the reader engrossed and shaken to the end. There is complexity within the clarity and an excellent literary paradox in the prose: this is a story about chaos told with consummate, steely control.
CHARLOTTE GRIMSHAW is the author of seven novels and two short story collections. She has been awarded the Sargeson Fellowship and the Katherine Mansfield Prize, been shortlisted for the Asia Pacific Commonwealth Prize, shortlisted twice for the Frank O’Connor International Prize, and won the Montana Fiction Award and Montana Medal. She has been Book Reviewer of the Year, and finalist in the NZ Post Award. Her Metro column won a Qantas Award. Her latest novel, Mazarine (2018), was long-listed for the Acorn Foundation fiction prize at the Ockham New Zealand Book Awards.