In her debut novel, Victorian reconstructive plastic surgeon Dr Neela Janakiramanan shares the story of the dedicated and ambitious Dr Emma Swann, who is about to start a gruelling year as a surgical registrar at a prestigious hospital.

Drawing on her own experiences, Dr Janakiramanan relates her character’s challenges and offers a rare insight into the competitive and exhausting world of surgical training. 

Below is an edited extract of The Registrar, out now.

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.

‘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.

Shit.

‘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.

Shit.

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.

This is an edited extract of THE REGISTRAR by Dr Neela Janakiramanan, Allen & Unwin, RRP $32.99, Available now.