It was seven hours into Suki’s shift when her tech started getting the shakes. They were operating on the prosthetic arm of Mr Baines, Patrick, date of birth 7th April 2053. It should have been a simple ligament print and fix, in and out and sealant sprayed in less than ten minutes, but the tech, Danyll, was lit up with amber warnings and couldn’t seem to steady the scalpel.

She tipped her head gently to open a sub-vocal channel and raised her eyebrow at him. His head tilted in return as he accepted the link.

“You okay?” she asked. “You’ve got a slight tremor.”

He glanced up briefly, then down again to the glowing guidelines projected onto the patient’s arm. “Just fine, Dr Asante,” he said.

Her visual overlay picked up a subtle movement, and zoomed in to a white blush over Danyll’s knuckles where his grip had tightened. It would have been imperceptible to the naked eye.

“You’ve gone amber,” she pressed. The tip of the blade was only moving fractionally, hovering over the patient’s smooth, peachy skin, but it was more than enough for Suki’s VO to flag it up.

“I can see that, thank you,” he said testily. “This is about my twentieth limb today and I haven’t had a break yet. You know how it is.”

She knew all too well. Danyll was a contractor, paid per operation and not by the hour. If she didn’t give him something to quell his tremors it wouldn’t be long before he lit up red as unsafe. She sighed, “You need a shot? The clinic will deduct it from your fees, but it should level you out a bit.”

His eyes met hers. They were a rich brown like polished mahogany, but the whites were flecked with broken pink veins. He was sleep deprived as well. There was nothing she could do about that – stimulants were strictly a two person sign off and she knew she wouldn’t find a spare pharmacist during this busy period.

Danyll lifted the scalpel away from the prone limb, and took a moment to consider. “Sure, go on then,” he replied.

Suki turned to the cubicle’s chem-printer and tapped in a short command. With a gentle hum, a loaded syringe was ejected.

She glanced over to Mr Baines. He was immersed reading something on his VO, his eyes half-glazed and flicking left and right, left and right. Suki pulled up his records on her own VO, and scrolled back through the history. Arm severed at age nineteen in a hover-jet accident. He’d had nearly thirty years of these procedures. No wonder he was so relaxed.

Prosthetics were already cheap enough to produce back in the seventies for it to be unexceptional to replace a limb with a false one rather than try to repair so much as a compound fracture. Now most insurers wouldn’t authorise anything else. Suki’s thoughts strayed to her daughter. My poor Jules. She doesn’t even qualify for this kind of maintenance. She’s been limping for months and they won’t do a thing until she’s outgrown that cheap printout our insurers call a leg.

Regaining her focus, Suki picked up the syringe and turned her back, motioning to Danyll to come to her so the patient wouldn’t notice his tech being injected. She plunged the needle directly into Danyll’s hand, and watched through her VO as he stilled enough to fall back into the green. Satisfied,

she gestured to him to continue the procedure.

The blade smoothly parted the synthetic skin, which Danyll peeled like ripe fruit to reveal the rosy musculature beneath. He located the frayed ligament and prised it up gently with long tweezers. The scalpel hovered, ready to cut it free. A replacement lay waiting in a sterilised dish off to one side.

“Here we go,” he said out loud, and positioned the blade under the taut strand.

And slipped.

Suki’s alerts flashed to red as the scalpel sunk into the limb’s extensor carpi. The artificial muscle burst, releasing a sudden gush of gel and flinging fat, pink globules over the patient’s upper arm and chest.

Now Mr Baines was suddenly alert, and shouting in alarm. Suki quickly doused the slashed prosthesis with sealant spray, gesturing to the patient to calm him. Danyll stood back with his hands raised, the blade still poised between fingers sticky with muscle filler. Suki re-opened the channel to him.

“You’re done,” she said. “I’m blocking your sign in for ten hours. Go home and get some sleep.”

He glared at her for a moment. Realising there was nothing he could do to challenge her authority, he slammed down the scalpel and stormed out.

The patient was also glaring at Suki as he dabbed at the sticky pink goop with the corner of his gown. The spray on his arm was slowly congealing and gave off an acrid smell. “Dr Asante,” he growled, “what the hell is going on? Is he coming back?”

“I’m assigning a new technician to you Mr Baines,” Suki replied. “We’ll have a new muscle printed up for you in no time.”

“Can’t you get on and fix it? These damned technicians are always messing up.”

“I’m sorry,” she explained, “your insurance won’t authorise a surgeon to carry out this kind of routine procedure. You’re covered for the new muscle, but it still has to be fitted by a technician. I can only get involved if there’s a flesh and blood emergency.” Which happens more often than you would like to think, she reflected. I could make you good as new, but instead I spend my time cleaning up after overworked and inexperienced techs because that’s all your employer wants to pay for. And you still have better insurance than me.

Just at that moment, a different type of alert flashed up on Suki’s VO – a page to call the Amberside Hospice. Charlie Hunter was dying.

**

Jules was already tucked in bed by the time Suki arrived home from the clinic. The soft whispers of Musin reading to her drifted down the stairs. Suki slipped off her shoes and followed the sound on tip toe until she stood just outside Jules’ door. Peeking in, the dappled glow of starlight from the ceiling’s screen illuminated her reclining daughter and husband. She didn’t go in, not wishing to disturb them, and listened to Musin speak as Jules gazed up, enraptured as only a child could be at hearing the same story for the hundredth time. Musin’s dark, strong features came to life as he recited from the worn pages of a real book, one Suki had received herself as a child.

“‘Dorothy discovered something shining in a ray of sunshine that fell between the trees’,” he read. “‘She ran to the place and then stopped short, with a little cry of surprise. One of the big trees had been partly chopped through, and standing beside it, with an uplifted axe in his hands, was…’”

“The tin woodman!” cried Jules.

“Yes! ‘…a man made entirely of tin. His head and arms and legs were jointed upon his body, but he stood perfectly motionless, as if he could not stir at all.’”

“Like my leg when it gets stuck?” she asked, rubbing her right knee.

“That’s right,” he replied. “The tin woodman just needed Dorothy to run and get his oil can so he could move again. And soon you’ll have a whole new leg and it won’t get stuck any more.”

“Can’t Mummy run and get me an oil can? Then I could play with everyone again.”

Suki welled up hearing her daughter’s words. She pushed open the door and crossed the room to join them on the bed. As she threw her arms around her daughter Musin smiled warmly at her, but his dark eyes were also filled with dismay.

“I’m sorry I can’t fix your leg right away my little jewel,” Suki said, holding Jules close to her. “You know, you’re growing really fast, so you’ll have a new one before you know it.”

She knew it was a lie. The prosthetic had only been attached a few months before, and had started failing almost immediately. It would probably be a full year before a replacement was authorised.

Musin held his wife’s gaze, and tipped his head to the right. Suki did the same, allowing him to open a sub-vocal channel to her.

“How long were you standing there?” he asked.

“Only a minute. I wanted to listen to you,” she replied.

“You would have thought she would be tired of the Wonderful Wizard of Oz by now.”

“I never was. Besides, I think the tin man makes her feel a little more normal. How is she?”

He smiled faintly. “Fine, I think…”

“But?”

Musin sighed. “But, she fell over again. No more than a scrape, but the other kids are merciless brats. They’re still teasing her.”

Suki stroked her daughter’s unruly hair. She could feel Jules becoming heavy as she drifted towards sleep.

“I’m sorry my love,” she said, “but I have to go out again. It’s Charlie.”

“So soon?” he replied, his forehead creased with concern.

“I’m afraid so. The hospice thinks he only has days left, I have to go and see him.”

“Of course. I’ll make sure Jules gets to sleep. And I’ll speak to her teachers in the morning, see if they can keep a better eye on her.”

Suki made to leave, but turned back to Musin, frowning.

“I just wish…” she started.

“I know,” he replied, cutting her off. “It’s not your fault.”

“If I had the authorisation she could be running around in minutes!”

“But you don’t. All we can do is wait.”

“I’m upset about Charlie too,” she sighed. “I just feel so powerless.” 

“Go see him. I’ll take care of our little jewel. She’s strong, she’ll get through this.”

Jules murmured in her sleep. Suki watched for a moment as etiolated starlight twinkled over her face, then turned to go.

**

The Amberside Hospice had once been refurbished as a hotel, unkindly adorned with slices of red brick and concrete scroll work. Now that facade was crumbling, exposing dull, grey stone beneath, reflecting the dwindling lives of the residents within. Suki picked nervously at the craquelured paint on the iron gate as she waited to be buzzed in.

Charlie Hunter was a former patient, whom she had kept an eye on in the years since his heart transplant. Suki had been a junior back then, and it was the first time she had assisted a surgeon with an internal prosthetic, fusing Charlie’s arteries and veins to the newly printed valves which would keep his blood pumping.

Back then, Charlie was a well-respected architect. But his operation had bankrupted him, and he was forced to live hand to mouth, unable to start up his old business again. Now in his dotage he relied on this state run hospice to care for him.

Suki had grown very fond of the old man and his easy charm. As she walked through the sour-smelling corridors which led to his room she felt her chest tighten at the thought that this may be her last visit.

Charlie was just rousing when the nurse showed Suki into his room. There was no screen to illuminate his crinkled, papery skin, only the weak glow of a bedside lamp. He blinked blearily a few times before recognising her.

“Suki! I hoped you would come and see an old man off!”

“Oh, Charlie,” she sighed, “I came as soon as I could. How are you feeling?”

Charlie chuckled, reaching out to pat Suki’s hand.

“Don’t you worry about me, my dear. There’s no pain. If I put my hand to my chest I can feel my old heart fluttering like a bird with a broken wing. One day soon it will stop, and that will be the end of me.”

“I hoped to be replacing your heart after fifteen years,” Suki said. “At least you’ve gone nearly twenty. But I wish you could go twenty more.”

“Well, I don’t want another twenty years of this, even if I had the money for a new heart. It’s my time now. I’ll miss Jules growing up though. How is she?”

“She’s seven, and a delightful handful. I left Musin reading her the Wonderful Wizard of Oz again. She fancies herself as a tin woodman.”

“Ha! Tell her that role is taken!” Charlie took Suki’s hand and placed it on his chest. Suki could feel his heart’s arrhythmic beat. “That story has a sad ending though,” he continued. “The tin man is given a new heart by a wonderful doctor, but now that heart is broken, and she hasn’t brought him so much as a sticking plaster to patch it together again.”

Suki looked away, ashamed. “That’s not fair, Charlie. You know I’d give you a new heart in a second if I could.”

But Charlie was grinning. “Oh, you know I’m just teasing, Suki,” he said. “Besides, I have a little confession to make.” 

“What do you mean?” Suki said, confused.

“I may have had a little help keeping this old thing pumping for an extra five years.” He leaned over to her and continued in a conspiratorial whisper, “Look in the drawer, little blue box in the corner.”

Suki pulled the drawer open and fished out a small container. She opened it, and gasped. “Charlie! These are illegal!”

“They’re life-saving,” he snapped. “Those pills have been laying down fresh layers of polymer for years. They’ve stopped my heart wearing thin before I was ready. This is my sticking plaster, and the tin man has lived for another few chapters, enough to finish his story the way he wanted.”

“Why didn’t you tell me you were taking these?”

“I didn’t know how you’d react, Suki. If you’d reported it – well, it’s too late for that now. I stopped taking them a while ago. I’m done with all this.”

“Oh, Charlie. Of course I wouldn’t have reported you. I might have tried to stop you though, you have no idea what the side effects could be.”

“Rubbish. Aside from my heart wearing out I’m as healthy as a horse. It’s only illegal because it works too well. The biotech companies, the insurers, they’re all in this together. If you don’t have good insurance you don’t get good maintenance, you know that. You spend all your money trying to get a bespoke printout from your insurer’s own manufacturer because they won’t let you install a generic design. They certainly won’t let you take pills that target degrading areas because heaven help if your lungs or your liver lasted a few years longer, it would cut into the dividends.” He paused, then continued quietly again, “Half the residents in here would be dead already if it wasn’t for the black market.”

Suki looked at him thoughtfully. She knew unlicensed biotech was out there, but she hadn’t known that her old friend Charlie was using it under her nose, despite her speciality. Maybe black market technology was better than the insurance companies made out? Perhaps she had been naive. A dangerous thought occurred to her.

“You know, Jules has been having real problems with her new leg. It will be the best part of a year before she’s scanned for a new one.” She looked at her friend questioningly. As he met her gaze his face creased into a beaming smile.

“I thought you’d never ask,” he said. “Think of this as an old man’s parting gift. There’s a nurse here, Akim. Tell him I sent you, he’ll tell you where to find our printer. I don’t know who she is. But she can print you just about anything. Parts, whole prostheses if you really need it. And she’s good. You could have Jules running around again and nobody would be any the wiser.”

**

Leaving Charlie was hard, but Suki took some comfort that he seemed to be at peace with his fate.

She agonised, but the next day she followed Akim’s directions to a run-down industrial estate, and found the unit he had told her about, producing printed toys and colourful tchotchkes for export. She was taken through a maze of racks stacked high with boxes, to a back office which was quiet and clean.

To Suki’s surprise, the printer was a young woman. She had trained with one of the large biotechs, but spent most of her time modifying designs so they couldn’t be copied and used on the street. When she left, sickened by the way such simple but life changing technology was being restricted, she knew what to look for and how to reproduce the company’s patented products and formulae. 

They spent a long time conversing. Suki was impressed by the printer’s altruism. Her underground business was heavily subsidised by her legitimate one. She wasn’t trying to exploit a desperate market, but to help ease the plight of so many who had fallen through society’s cracks. She was an experienced tech and fitted parts for customers herself, but her eyes lit up when she discovered Suki was a prosthetic surgeon.

When Suki left, clutching a precious parcel of ligaments and tendons for Jules’ leg, she knew it wouldn’t be long before she returned.

**

At home, Suki found Jules playing with little figures Musin had made for her, marching them back and forth across the carpet. Jules’ leg was stretched out in front of her, locked straight.

Suki helped her up from the floor, and pulled her into a crushing hug.

“Hi, my little jewel,” she said. “Look.” She held the package up so Jules could see the fresh polymer strands floating in sterilised gel. Tears welled in her eyes as her daughter tentatively prodded at the bag.

“What is it?” Jules asked.

Suki replied, “Mummy has brought you an oil can.”

Ida Keogh is a new writer and an avid devourer of dystopian and speculative fiction. She works as a barrister in London chambers specialising in employment and regulatory law, with a particular interest in the medical profession. Her regular contact with practitioners and NHS institutions provides her with a unique insight into the daily challenges facing our modern healthcare system. 

This story was shortlisted for Writing the Future, the world’s largest health short story prize, which aims to bring together those working in health and healthcare with creative writers to think differently about the future and its implications for today. It’s run by Kaleidoscope, a social enterprise set up to bring people together to improve health and care.

Read about the judging process in this BMJ Opinion piece by Richard Smith, one of the judges.