You Go to My Head Part 4:
Rejection Slip by Sevenpercent for J. Baillier
Starting note from 7Percent: This started life as an homage to BaillierJ's series, in honour of over a year of wonderful co-authorship where she allowed me to bask in her sunshine (I am the moon to her sun) and her birthday. After some pertinent tweakery, she decided to incorporate this into the series as an official part – what a compliment!
Response note from J. Baillier: It's difficult to try to translate ecstatic flailing into a reasonable-sounding note. Four words: best birthday present ever. These are definitely my boys on these pages, and the image of the going to [spoiler redacted] gives me a nice sort of arrhythmia. It's uncanny to get to read your own story series without knowing in advance what's going to happen next and I have no idea how Seven did this – emulated the slice-of-medical-life atmosphere of the series without having lived said medical life. If anything, this proves that a) she is a bloody genius and b) there is at least one person in the world who not only listens to my incoherent post-call ramblings... but actually takes notes.
When John gets home from being on call, he is still pumped up with adrenaline. Taking the extra shift had been a favour to a colleague who had called in sick with a migraine, and John really didn't mind – well, at least not much. Monday nights tend to be a busy cluster of bread-and-butter cases and he would often turn down offers of Monday extra shifts on principle. John preferred Friday nights or Saturdays: the 'big night out' mayhem of London always had more appeal in terms of trauma in particular. On one of those he'd usually get some action in the A&E, perhaps even something that would require serious time in an OR. So, when his colleague passed the baton to him in the afternoon, he'd texted Sherlock that he'd just stay at the hospital and catch up on paper work before starting the 2100 to 0800 shift he'd agreed to take over. During early evening he kept an eye on the OR lists and by nine pm he'd been climbing the walls, worried that he'd spend the whole twelve hours staring at the ceiling, twiddling his thumbs with little to do. When he's on call, he never sleeps properly anymore; maybe that's because he's gotten used to having a six-foot-tall bump in the bed next to him these days.
On call is becoming something he does less and less, partly because the juniors are eager to do the busier ones and his time with Sherlock is already squeezed by their long work hours. Gone are the days when he'd happily worked through a whole day, and then done a night on call. The older he gets, the more sleep deprivation annoys him. It can take a whole day to recover anything resembling a normal circadian rhythm, and he is generally grumpy as hell as a result. With two doctors in the relationship, life was never going to be easy, but with Sherlock, the stakes were raised to a whole new level of challenge. When Sherlock does his plentiful call shifts – often containing long emergency operations in the middle of the night assisting juniors and then having to work the next day – they never seem to bother him, but then, he seems able to cope with sleep patterns that baffle neurotypicals. What he cannot, will not— and probably doesn't even know how to – deal with, is a grumpy John. Sherlock's mercurial moods need to be managed with patience and love, both of which can be in short supply when John has been kept up all night caught between the medical equivalent of a rock and a hard place. At least Sherlock lets him crawl into bed and stay there post-call nowadays without demanding to be entertained.
Call becomes easier with experience but on the one hand, as a senior he is often called by nervous juniors or A&E doctors who seem to think that an anaesthetist is able to make serious decisions over the phone about a rebound patient with life-threatening complications from recent cardiac surgery. On the other hand, anaesthesia and other juniors looking up to John is at least marginally better than some of the senior surgeons dismissing anaesthetists as little more than janitors in the OR. He's either a clipboard toting administrator with no medical clout, or junior doctors expect him to be an expert in every single medical specialism for which he is the Clinical Director. He's damned if he is, damned if he isn't.
That said, now that John is doing more and more managerial stuff, it does feel good to get back in the OR occasionally. That's why he'd been hoping for something a little more interesting during call than the elective surgeries that had been filling his sparse clinical time these days. There are times when he seriously misses being a junior anaesthetist – everything was still new and exciting. Thankfully, he'd got to experience such deja vu in spades last night, which compensates for losing some precious time off.
Of course, the principal reason why that free time is so important is currently ignoring him. Sherlock is stretched out on the black leather sofa. He's wearing his black silk pyjamas and black cashmere dressing gown. John calls it his camouflage – if Sherlock turns his face toward the back of the sofa, he blends almost perfectly into the background. He'd barely opened an eye when John came in, but that doesn't curb John's enthusiasm as he bounces into the kitchen. For once, he is so wired that he can't crawl into a shower and head for bed right away, as he normally does after a night at the hospital.
As he pulls out of the cupboard two mugs, fills the kettle and rummages for tea bags at the speed of light, he calls out, "You won't believe what happened last night."
There is a grunt from the general direction of the sofa, which John can barely hear over the sound of the kettle coming to a boil.
Delivering a cup of tea to the glass coffee table in front of the recumbent form, John launches into his story. "I had awesome luck – a brilliant case came in, high risk stuff – you'd had loved it. Emergency craniotomy for a brain aneurysm clipping; you 'd have bad-assed your way through it, no problem." A challenging and fascinating case for the operative doctors naturally means a tragedy for the patient so John does feel a pang of guilt describing these things in such excited terms, but on the other hand he likes to think that enthusiasm and interest equal high work motivation and that's what leads to quality results. It's that spark that helps doctors withstand the tough lifestyle that comes with the long hours and having to be on call.
Sherlock shifts on the sofa; John's declaration has achieved the opening of those amazing blue-grey eyes. They are now in a full-on glare, followed by a sniff. "Who was on duty?"
"Lucky for me, two of my favourite anaesthetic nurses and Jake the King of scrub nurses is back from his gap year. We had a ball."
"I meant the surgeon, not the supporting cast." He waves his hand dismissively and closes his eyes again.
"Anderson."
Sherlock snorts. "And the patient actually survived? How unusual…"
"You're just jealous of our five hours of high octane medicine. The intubation in A&E was a bitch, though – bunch of people running around getting what I need and then when I actually got on with it they scampered. How do they not realise that's the moment when I do actually need the assistance?"
Sherlock replies with a dismissive hum.
"They'd only just reached the circle of Willis when the damn aneurysm sack ruptures, and we had to scramble like hell. They had to put in a temporary clip three times. On top of everything, you wouldn't have believed the amount of pee the mannitol wrung out so the at five this morning, I had to put in the central life with very little stuff to fill the jugular vein and help visualise it. Thankfully I aced it, showing the new junior how to do it with the head in neutral position with low venous fill. Nothing like having an audience of awestruck juniors to do the ego a bit of good." Out of the two of them, Sherlock is most certainly the showoff, of course, but John is not immune to how good it feels to be reminded that he's still got what it takes. Not even senior consultants are strangers to feeling apprehensive and unconfident when faced with something they haven't done in a long time.
Sherlock sits up and takes a long sip of tea while John describes the moment of the aneurysm bursting in full gory technicolour.
Sherlock sighs, puts the mug down and slumps back down onto the sofa, closing his eyes again. He mutters. "So, you're delighted at having been back in the saddle, then?" Sherlock rarely bothers with such small talk, not to mention reassuring John. He seems to be in a strange mood.
John smirks. "Yeah. I shouldn't be grinning at the patient's bad luck, but there was a bit of me that rejoiced when the radiologist said no way could it be coiled. I think Anderson had already decided to go in, though, since there was a significant midline shift." If the blood already escaped through the bleeding aneurysm presses severely down on brain tissue, it needs to be evacuated and the pressure inside the skull relieved.
"Did they replace the lambeau?" Sherlock asks, signaling that he's considering the same thing. If the brain swelling remains severe at the end of the operation, the surgeon sometimes opts out of replacing the removed piece of cranial bone immediately, which gives the swelling some space.
"Nope. Not a very good prognosis altogether, even if they did manage to clip the damned thing."
"Obviously not," Sherlock mutters.
"You know how I hate getting back into the swing of things after a holiday. Just what I needed—no time for any nerves to set in, it was totally battle stations," John reminisces while swallowing down half his tea in one gulp. He considers a glass of wine to help himself wind down – what does it matter if it's only 10 am if yesterday never really ended for him?
Their holiday had taken them to the Seychelles for two weeks of sun and relaxation. It had certainly re-charged John's batteries, even if he had spent more time there without Sherlock's presence than he would have preferred. Sherlock had spent most of his time underwater, going out at least twice a day with the dive boat, with the occasional night dive thrown in for good measure. Sherlock is definitely not good at just kicking back and enjoying a lazy time by the pool, which, knowing him, is hardly surprising.
They'd spent the first four days of holiday arguing about it. John had tried to appeal to Sherlock's scientific common sense to tone down the manic schedule: "Diving is putting yet more stress on your physical health you know. Human bodies aren't evolved to deal with that kind of pressure and weird oxygen mixes."
John kept using the hotel's wi-fi to drag up article after article about the side effects – from exposing Sherlock to breathing air under pressure as well as the physical pressure gradients that would increase peripheral vasoconstriction, raise the volume of blood in his heart, enlarge all four chambers and boost cardiac output by 30 percent. "Holidays should lower your blood pressure, not increase it."
"You're one to talk about side-effects", Sherlock had snorted. "Isn't there quite a bit of data about anaesthetists' long-term exposure to halogenated ether derivatives causing cognitive impairment?"
Undaunted, John had then trotted out how scuba diving decreased activity of the sympathetic nervous system, leading to a concentration of noradrenaline in Sherlock's blood plasma, making his kidneys secrete more sodium and making him have to urinate more often. "If you didn't go diving so often, I might get a good night's sleep out here; instead, you're up and down like a bloody yo-yo all night traipsing off to the loo."
He'd actually had to put hands on hips and glare at Sherlock as he described oxygen toxicity from breathing hyperoxic gas mixes. "You're a bloody doctor! You know the risks of air embolism and that the safety limits in diving tables are based on are not flawless."
"I'm not using some archaic table, I have a computer," Sherlock had declared snootily and wiggled his raised wrist, to which a watch-like device was still strapped. "That reminds me, I have to rinse this so the salt doesn't stick in."
"You're not listening to me, not really," John had told him, blocking his way to the en suite.
"You don't understand," Sherlock had complained, raising his hands in exasperation.
That much was true. The most John ever did was snorkel along the surface since he didn't really like swimming in the ocean all that much. He had signed up for a try dive on their last holiday , which had taught him that the diving mask made him feel claustrophobic and the snorkel reminded him uncomfortably of intubation equipment and the whole thing just felt so risky that he couldn't imagine being able to focus on anything else than staying alive while doing it.
He had tried to be tolerant because clearly Sherlock loved diving and John was glad to see him to positively keyed-up and happy, but after a few days he had to admit to himself how much it annoyed him that Sherlock seemed to want to spend a lot of time away from him off in a motorboat miles from the resort.
"So, explain it to me. What's so bloody special that it is more important than us spending time together?"
Sherlock hadn't replied right about, but he had seemed to be deep in thought for the rest of the afternoon.
Before dinner, he finally managed to put it into words while John was sipping a proper rum punch as they were watching the sun go down. Sherlock's drink had no alcohol in it because he was planning a night dive.
"It's the most alien environment I have ever experienced, or am likely to experience. For all of the reasons you've described, the physical sense of being under water, breathing, is like being perpetually poised on the fight or flight knife edge. It's terrifying on one level, exhilarating on another. The effect of it is so overwhelming in a good way that it makes every sensation multiply. Colours are brighter. Fish are just astounding. It's... intense enough that it helps me focus and relax and forget about the pointless things that distract me at other times. The sensation…" He struggled to find words. "…I'd love to be able to conduct underwater cognitive studies, MRI scans, and blood chemistry work to see what is really happening. By the time one gets to the surface, the physical exhaustion is heavier than logic should dictate." He shrugged, "It's like chasing a mirage, trying to describe it. But I know what I feel." He had looked away from the setting sun and down into the dark water lapping against the wooden pillars holding the villa above the sea. "It's almost as good as the first time you said that you loved me—incomprehensible, terrifying and yet wonderful, all at the same time."
This is what John loves the most about Sherlock – there's never a dull moment and the unexpected should always be expected. Most would describe Sherlock as unemotional, cold even, when in reality he is just very wary of showing such things, lest he get misunderstood and rejected.
There was no need to continue the conversation. John's anger had dissipated completely and replaced with an overwhelming impulse to kiss Sherlock until he was gasping for air. What happened after that had been enough to make them miss both their dinner reservation and for Sherlock miss the boat for the night dive.
As the cherry on top, John managed thereafter to coax Sherlock into enough down time on the overwater villa's veranda to actually relax. Instead of his usual nervous exhaustion from the physical and mental challenges of dealing with reef sharks, drift currents, coral scrapes and headaches that came with scuba diving, Sherlock returned to the UK with freckles in places that the English sun had never reached.
Once back home, John returned immediately to work but Sherlock had tacked on some research leave, so he wouldn't be back at work for another two days.
Not that there was much sign of any research work being done.
While John had rushed straight back into the fray, by all appearances Sherlock had been glued to the sofa and there had been precious little evidence of any academic activity. At first, John chalked it up to post-holiday blues, complicated by the lack of a schedule. Not that Sherlock ever used his research leave the way most others would: the hyperactivity that characterised his work came to a screeching halt and he procrastinated like mad, not putting any energy into it until the last possible moment. He claimed that final submission dates motivated him the same way as a cranial trauma did. "The closer to dead, the better. That's why the term deadline is so brilliant."
"So, how was your day?" John asks tentatively, suddenly interested in his tea. He racks his brain to try to remember whether there was a deadline for this latest article.
There is no answer.
"Sherlock?"
Silence grows. John looks around the flat. On the glass and chrome desk there is no sign of the usual chaos of papers that erupts when Sherlock is at work. The two laptops that Sherlock usually uses simultaneously are closed; the cabled array of the two side-by-side eye wateringly expensive AOC Agon AG271QG ultra HD monitors are dark.
He purses his lips, looking back at sofa. "Have you hit a bit of writer's block?"
Sherlock doesn't even open an eye to acknowledge the question.
John suddenly remembers that Sherlock has been writing up the results of the first two years' worth of his clinical cases at King's College Hospital using the shunt he'd invented as a registrar. It was important to get the evidence of its success out there in the authoritative journals, so hospitals wanting to use it would have evidential logic on their side. A very promising case study article on a patient's history with the new valve had already been submitted to a journal a month ago.
John decides that this degree of lassitude is unusual, even by Sherlock's standards. As he watches the man languishing on the sofa, John realises that he's still wearing the same pyjamas that he was when John last saw him roughly twenty-six hours ago. He's clearly shaved and showered, but there is little sign of any other activity. Come to think of it, there is no pile of dirty dishes in the sink or take-away boxes in the bin where he'd deposited the tea bags. He wonders if Sherlock has eaten a single bite.
A diagnosis now offers itself: sulking. Perhaps something out of the ordinary has happened and discouraged him. John can't think of anything, until he starts wondering how long it's been since the previous article had been sent in. Peer review of that should have taken weeks, so it's too early… OH.
"Have you heard back from the BJNS*?"
Sherlock scowls, without opening his eyes.
"And….?"
The shoulders slump, bare toes curl and frown lines deepen. "Rejected. Hasn't even been passed for peer review."
"Did the editor explain why?"
"He's an idiot."
John doesn't try to hide his smile. "I don't think that was his explanation. He would have told you why – maybe you forgot to format it to match their house style."
"I deleted the email without reading the rest of it."
John looks down at the floor and rubs his forehead. "So, let me guess; is this the first time you've ever had an article rejected?"
Sherlock's eyes snap open. "Why does that matter? The editor is not a specialist. I've always managed to convince colleagues to see my point of view, so his decision to not even pass it for peer review is just mean and spiteful."
John pushes Sherlock's feet away from the end of the sofa so he can sit down. "You do know that nearly 80 percent of all articles submitted to quality medical journals are rejected."
"Not mine."
"And almost ninety percent of all articles that actually make it to publication in serious medical journals get sent back at least once during the peer review phase."
"It's never happened to me before."
"Well, even being the exception that proves the rule in the past doesn't always hold true for the future. You've published way more than most consultants your age. Maybe they've just decided that you're no longer the 'boy wonder' you used to be."
Sherlock sits up; the expression on his face betrays just how affronted he really is. "Boy wonder — is that what you think I am?" Then he looks away. "Or, rather what I was but am no longer."
Realisation hits John. This must be what is really upsetting Sherlock — a sense that this rejection means something serious. Behind the bravado surgeon and the arrogance of his extraordinary skills lies a very fragile ego. His social blunders have been leniently ignored due to his extraordinary skills and genius – losing that status of being a special case maybe causing him to fear for his position even if he has improved a lot on that front. He now gets somewhat along with most colleagues and the tidal wave of complaints from patients and their relatives regarding his bedside manner had diminished into a rivulet.
Gently, John says, "You will always be wonderful in my eyes – you were that the first time I clapped eyes on you, that's what you are now and ever shall be."
Sherlock flops his head back down on the arm rest. "I'm done with publishing articles. I'd rather just do the work than waste time writing about it. It's such a fag trying to get the data from other surgeons using the shunt, and without a significant quantity of participants involved to get critical mass- well, I'm not really surprised that the article got turned down. I just don't have the time or the interest to do all the wretched leg work involved in this sort of lark."
"You're the one who told me that if I didn't get off my arse and try to publish something that I wouldn't even get a footnote under my name in medical history. You're going to get a whole bloody paragraph thanks to that shunt of yours. Knowing you, there will be whole pages to follow."
Maybe that's yet another facet of the problem. Being so successful early in one's career does heap the pressure onto Sherlock's shoulders. Now that he knows the man so intimately and can look through that arrogance, John knows that confidence can be as brittle as spun sugar. He worries that the younger man lacks the emotional resilience to shrug off an academic setback like this.
"It would serve them right if I got Mycroft involved. He might be willing to put his minions to work gathering the data."
John shakes his head. "Not a good idea. Not if you want to keep your royalties from Medtronic flowing and avoid a lawsuit." A frown creases his brow. "Actually, that raises a point. Why didn't you go to Meyer-Hessen in the first place; family connections and all that?"
Sherlock snorts. "What, and make the evil overlord even more rich, smug and self-satisfied? Not ever going to happen. No, I'll just find a different way to destroy the reputation of that paper-pushing idiot editor."
John is aware that the editor in chief of BJNS is a God-like figure in his field. He's a professor in Liverpool, a regional advisor to the Royal College of Surgeons, a past Secretary of the Society of British Neurological Surgeons for four years, and an Advisor to NICE and the Department of Health. He's also a Cambridge graduate, just like Sherlock, and Sherlock had been sniffy about that even before he got rejected: "Pembroke man. Says it all." John had found it rather predictable that Sherlock had gone to Kings College at Cambridge. All six feet of posh would have fitted in there perfectly.
"Sherlock, before you unleash your inner hound of hell and ruin your reputation forever with the BJNS and half the medical profession of Britain, why not do what every other medical professional does?"
"What's that?" Wary, as if he suspects some form of appeasement is on its way.
"Go find another journal. Hawk your paper around. Over half of all published articles have been rejected at least once by other journals before they finally make it into print. The JNS has a rejection rate of like 95%; others will be less picky. Why not try the JNSPeds?**"
"Why should I settle for an inferior publication? Just think if our patients did that. 'Excuse me, Doctor Holmes, but I've come to you because none of the really good surgeons were available, so I will have to settle for your level of mediocrity.'
John wants to treat this like an adult conversation, but exhaustion always makes him impatient and a part of him just wants to tell Sherlock to get over himself. He reminds himself yet again that his lover has not had the easiest of times in the medical profession. Having to navigate the petty politics and competitive one-up-manship of surgical practice is not easy for normal people, let alone neuroatypicals. Add in a genius brain with the social skills of a ten year old and Sherlock was always going to feel the bumps and jolts that accompany a brain surgeon's career more than most.
The ping of a text message makes John grab his phone from the side table. Saved by the bell. A quick scan gives him the excuse he is seeking. "Sorry to interrupt this rant, but Martha wants to know if it's okay for our new Account Manager to drop by this morning rather than this afternoon."
Sherlock just waves a desultory hand. "Whenever. It doesn't matter."
John tries to keep his temper under control. When Sherlock gets into a stop, it is almost impossible to break the mood. The private concierge firm that Sherlock uses has the quaint name of Mrs Hudson, but it is run by a powerhouse of a lady who had been John's predecessor in the Clinical Director post. It surprised no one who knew her that Martha Hudson was hardly going to rest on her laurels during retirement. The service her young company provided had been tailored to the needs of people Martha had once been herself – busy, high-powered professionals: doctors, lawyers, and businessmen.
Unsurprisingly, Sherlock has not been an easy client to look after, since he has little interest and patience for financial affairs and organising their household. The firm does all that for them – from organising their Ocado grocery order supplemented by the occasional foray to Fortnum & Mason to marshalling their laundry and the flat cleaning service, but being efficient at it does require Sherlock and John to sit down with their assigned Manager to sort out the details. The Manager also pays their bills and organises their diary. Well, she organises Sherlock mostly because he's the one who gets most of the invites to medical events, conferences and the like. She tries to organise it, at least – the previous one had just quit so that is why a new introduction is due.
The service had actually been a birthday present from Sherlock to John last year. The card had said: "You moan that because I am inept you get lumbered with all the housework and managing me, so this is my way of freeing up your free time — to spend more of it with me." The best presents to give are ones you want yourself.
John shuddered to think what the service cost, but had agreed that both of them were so damned busy that there was a risk that they would have ended up starving or naked if something didn't change. Knowing the person who ran the company must have been what sold the idea to Sherlock – John is certain he would never have been willing to hire some random stranger to invade their privacy.
"Martha mentioned that the new Manager will bring our suits for tonight," John says. He needs to get a move on with showering and sleeping if he wants enough of it before they have to leave the flat.
"Not going."
"That's absurd. Just because you got that rejection letter, you're freaking out."
"The BJNS editor is going to be there."
"So is Medtronic. They've agreed to sponsor the table, thanks to you. John Steadman is hosting. Bad form not to show up."
It is the annual charity dinner for Great Ormond Street Hospital. Because Sherlock's shunt had been first designed for paediatric use, his reputation is mostly in that area. Great Ormond would probably have jumped at the chance of employing him but he'd stayed at Kings because he didn't want to be pigeon-holed into only doing paediatric surgery, not this early in his career. Medtronic** had beaten the offers of the other medical technology and Big Pharma firms to get their hands on something that was demonstrably better at avoiding the complications of draining excess cerebrospinal fluids away from the brain and into the abdominal cavity. Together with their catheters, the new device was being used more and more, and Medtronic had paid the development costs of producing the adult version. Sherlock's reputation had risen fast after that — almost as fast as his bank balance. John knows that the royalties would allow them to buy their own posh flat with all mod cons, but they like their current rental unit. One flat a floor below had sold for over £3 million last month, if the guy on the security desk was to be believed.
This charity dinner is one that John really wants to attend. Not just because the brightest stars in the world of paediatrics will be there, but because he really believes in the work of the Great Ormond Street Hospital. Totally devoted to children when it opened with ten beds in 1852, it is in the process of updating all of its buildings and services with a whole complex, right in the centre of London. The corporate sector has been generous, but the community of parents, former patients and medical professionals have all done more than their share of the required fundraising.
"Whether I am there or not is irrelevant; Medtronic's money for the table is already paid."
John's glare is delivered with what he hopes is sufficient annoyance to penetrate the sulk. "Tonight isn't all about you. It's about getting others in the room to cough up more for a very good cause. So, we are going."
"Go without me."
"No. Not this time. You have sweet-talked me into attending just about every one of your award ceremonies and other big dinners – so much so that I am beginning to feel like arm-candy. This time you can come because I want you there."
Sherlock had opened his eyes again at the phrase 'arm-candy'. "Is that what you think I think of you? As some sort of trophy?"
John laughs. "It works both ways. Me walking into a room and watching half of the people there ogling you is kind of a turn on. So, we are going tonight."
-o-0-o-0-o-0-o-0-o-0-o-
When John hands his coat to the cloakroom clerk at the Dorchester Hotel Ballroom, he turns to watch Sherlock taking off his cashmere coat. What is revealed always makes him smile – Sherlock in a black dinner jacket is a sight to behold. This one is tailor-made, cost the earth and the moon, and is cut in a way that emphasises his excellent posture, the broad shoulders tapering to a bum the sight of which make John feel positively possessive.
They join a queue of guests meandering from the anteroom to the ballroom. This is the part that Sherlock loathes, so he lets John do the "pressing of the flesh" and the "working the room" stuff. They are introduced to a glittering collection of medical professionals and celebrities who have been steering the latest funding drive. Every so often, John murmurs to Sherlock to stop looking so bored.
The GOSH patron Lady Estelle Wolfson is at the end of the receiving line. For a seventy-year old who married one of the wealthiest men in Britain just a decade before he died, she looks every inch the celebrity model she had once been — tall, elegant and immaculately dressed. John is familiar with her reputation in the charity circles — who isn't? Apart from Wolfson colleges at both Oxford and Cambridge, the family trust is the largest donor to University College London, where John had done his medical training. Rumour has it that the Wolfson Foundation had been donating over £300 million every year to worthy causes even before her husband died, and she has now taken the reins and handles the Foundation as if she had been born to it. Her real value to Great Ormond Street is that she knows absolutely everyone worth knowing in the world of philanthropy.
All that is very interesting, because she clearly knows Sherlock; her eyes light up as the pair of them reach the end of the meet-and-greet queue.
As she takes Sherlock's hand in both of hers, she is positively beaming. "There you are. I saw your name on the guest list. How are you, Sherlock?"
"Fine." He extracts his hand and turns to John. "May I introduce my partner, Doctor John Watson?"
A pair of lively eyes scan him up and down, and then her laugh lines deepen. "Mycroft told me you had, at last, found someone. Doctor Watson, forgive me my ignorance, but are you in neurosurgery as well?"
Before John gets a word in, Sherlock speaks up. "John is an anaesthesiologist, and the Clinical Director of Surgical Services at King's."
"Is that so? Then again, you would have had my congratulations and also my respect even without such an impressive position; anyone who can deal with this man deserves a medal."
He hears the tease in her voice, and wonders what her connection to Sherlock is, since her comment seems to stem from experience. Plus, she is on a first-name basis with Sherlock's brother.
"Stella…" there is a baritone warning rumbled beside him. "Don't embarrass me."
"Heaven forbid that I should tell your partner about the time you surprised my guests by appearing naked."
John gulps.
Sherlock rolls his eyes. "I was four at the time."
Ah, a family friend then, and before she married into such amazing wealth. "Enchanted, my lady, do tell me more," John says mischievously.
She smiles but shakes her head. "I am not going to have time tonight to do anything more than visit each table to do the hostess thing, so let me say this now: Sherlock, I want to thank you personally for your contribution. 10% of your royalties for life; that is a generous gift from such a young man. So, Doctor Watson, do your best to keep him going for a long and healthy life, so GOSH can benefit."
"I'll do my best, ma'am."
As they move on into the ballroom to consult the table plan, John leans in to say quietly, "Ten percent? What's that worth these days?"
Sherlock shrugs. "I don't know, or care. It all goes into some account somewhere, invested and managed by people who have the time and inclination to care. What matters is that it will be put to good use in helping patients."
"Your ProCore valve already does that. 40% of traditional shunts fail within 2 years and 98% have failed within 10 years. Yours won't. That saves lives and spares folks from reoperations."
The room is dark, with tables dramatically lit by spotlights from the ceiling; the statuesque flower arrangements in the centre of each table are a stunning piece of floral art. The effect is hugely glamorous, and fitting more for an Oscar ceremony than the usual sort of charity function. John has a momentary pang of concern that money which should be spent on sick children might have been used to pay for things like the black silk draped ceiling with tiny fairy lights making it look like they are standing under the stars.
He sighs as Sherlock bolts across the floor, weaving his way through the tables set for ten, towards the centre of the room. How he manages to slither through crowds of tuxedoed men and women in long evening gowns without causing so much as a ruffled feather is something that John has never managed to duplicate.
When he finally catches up, Sherlock is leaning over table E, scanning the placement of table cards showing people where they are sitting. He suddenly swoops in, grabs two cards and moves around the table to swap them for two there, handing John those. "Put them where ours were. I'm not sitting next to some boring idiots all night."
John gives him a warning glare, but does as he's told, managing to sort it just in time as more guests start arriving at the table. The first couple to the table is led by a middle-aged man John recognises, but he doesn't know the woman on his arm. He has in tow another two sets of couples, both of whom are looking around the decorated ballroom with pleasure.
"Sherlock! Hello, John, delighted to see you again. Let me finally introduce you to my wife."
Sherlock straightens up just as John manages to get the other name cards in the right place – Mr and Mrs James Keene. He steps back to Sherlock's side.
"This is my wife, Evelyn; Evelyn, this is Doctor Sherlock Holmes, the young man I have told you so much about."
She smiles a welcome that is generous and just a tad curious. "I am delighted to make your acquaintance, Doctor Holmes. I've learned that your invention is just marvellous. And, Doctor Watson, I owe you a special thanks for keeping John happy at that rugby last year; I really can't abide the sport, but for once he came home happy that he'd found someone to share the box who was actually interested in the game"
John Steadman is the head of the UK offices of Medtronic. A neurologist by training, he had been introduced to John last year, before it had become general knowledge that he and Sherlock were together. A Mancunian with what he confessed was a low tolerance for the usual kind of glad-handing that took place at functions like these, Steadman and he had, indeed, enjoyed talking rugby at a corporate hospitality function at Twickenham last year. While they had delighted in watching the Barbarians being thrashed by the New Zealand All-Blacks, Sherlock had been bored witless, barely looking up when the Kiwi Fly Half Dan Carter scored an astonishing try.
More introductions happen in a flurry of handshakes, as other people join the table. Sherlock introduces John, this time not as his partner but by his job title, and John relaxes a bit. These are professional peers — important medical contacts, but not friends to whom their personal relationship should matter.
Within moments, John realises that not only had Medtronic sponsored the table; they've brought in the big guns from the rest of the world-wide company, too. In rapid order, he is introduced to the Executive Vice President, James Keene—an American who is responsible for the Restorative Therapies Group which covers neurological treatment equipment such as Sherlock's shunt—and his wife. Then Rob van Hoek, Executive Vice President for the EMEA Region for the whole company, and his girl-friend, a charming blonde Dutch woman who might be half his age.
Because he had known that the table tonight would be a Medtronic sponsorship, John had done a bit of research. To him, it used to be just a brand name on the side of equipment he used every day. Until this afternoon, the size and scale of the business had not properly sunk in. Employing nearly 90,000 staff in over a hundred companies, it is a multibillion dollar business.
Finally, a solitary man approaches the table, and thanks to the web browsing John had done while Sherlock was getting dressed that this is none other than the BJNS editor.
Sherlock deliberately turns away from the man to engage in a conversation which John is quite certain is happening in fluent Dutch. While the other men around the table are busy getting their wives settled in chairs, the editor, dressed in a slightly ill-fitting dinner jacket, hesitates. Perhaps he's unsure of where he has been allocated a seat, or simply just intimidated in the face of a lot of people he doesn't know.
John decides to come to his rescue. "Professor McEnery, I'm John Watson. I think you're seated between Mrs. Steadman and Rob van Hoek. Let me introduce you."
As he walks past Sherlock, John tries to catch his eye, but fails. He tries to hide his smirk. While others might read many things in his behaviour as arrogance, John knows that avoidance is more likely to be the explanation. He's certain that Sherlock will not raise the topic of his rejection slip – he must be quite embarrassed, still.
A red jacketed MC announces, "Ladies and Gentlemen, I want to welcome you all to this evening, and ask you now to take your seats for a brief introduction by the Patron of the Great Ormond Street Hospital, Lady Estelle Wolfson."
John manages to get back to his seat just as a master of ceremonies starts the formal proceedings. Sherlock is already seated, and still in an earnest conversation in Dutch with van Hoek. On second thought, John wonders if anything discussed in Dutch just sounds serious; for all he knows they could be discussing the weather.
While the tall, elegant woman climbs the steps to the small stage, John glances at the menu card in front of him. There are canapes, followed by a choice of starters: a goat's cheese tart with roasted beetroot and sour cream, or scallops served with black butter and chorizo crumbs. The mains offer a choice of Welsh lamb (served 'pink', according to the card), Wild Arctic Char fillets in a Scandinavian dill sauce or a porcini risotto. Ever one to contemplate the sweets, John is torn between a pavlova with cloudberries or an apple pie made with something called quark (a soft cheese-like mild product favoured in Sweden and Finland, the menu informs) accompanied by something called Appleaud, a liqueur from apples in the Åland islands which has 'a pleasant fragrance, a nice golden colour and an enticing taste of apples'. The choices make his stomach rumble in anticipation; it's been ages since breakfast and he'd slept through lunchtime.
A waiter has appeared, and is distributing a full champagne glass to each place setting. There is a soft tap at the microphone which makes John look up.
Wolfson now has the mic. "Those of you who are hungry are probably more interested in the menu choices than what I have to say, so I promise to be brief. First of all, I must thank the owners of the Dorchester Hotel for donating this venue and the meal tonight, so that GOSH can say thank you properly without diverting any of its fundraising proceeds. This is an extraordinary generosity that is truly appreciated. Those of you who are regular participants in GOSH's work will know that it needs no introduction. For over a hundred and sixty-five years, London's children have benefitted by having a world-class medical facility on their doorstep. For those of you who have been invited here as guests and for whom Great Ormond Street is something of an unknown, I'm sure your table company will gladly tell you more about the work of this amazing hospital and not let you leave the room before your wallets have been emptied."
There is a ripple of knowing laughter that runs through the ballroom.
"For those of you who would like to know more about the charity: on the table in front of you, you will find a small brochure of the history and successes of this amazing hospital. I insist that you all take one home tonight, and pass it on to someone who has not donated yet. You shall all be my missionaries."
"On the video screen behind me, throughout the meal there will be some of the stories, the evidence if you will of how the generosity of our donors has made and is making a difference to the lives of children not just here in London but all over the world. I am talking, of course, of the research and development of novel medical techniques that have started here, and gone on to change the world of paediatrics and surgery across the globe. For those of you who get bored by the medical conversations going on at the table, you can listen into the narratives by using the hashtag #OhMyGOSHDinner."
The hashtag flashed up on the video screen behind her.
"As the evening progresses, we would all be delighted to hear from the tables when you have an important announcement to make, which I can only hope is to the benefit of this wonderful charity."
"In the centre of each of your tables is a rather fetching floral art creation donated by GE Healthcare. The florist doesn't have a website, but you will find more of his creations on Instagram. I am reliably informed by my granddaughter that they are the cutting edge of cool with Kate Moss on speed dial, and their clients include Gucci and the McCartney family. I am afraid that I gave the owner and namesake, Darren Yang, one of the most challenging briefs he's ever had to deal with. The distinctive feature is that each table has an item in their arrangement that has helped Great Ormond Street Hospital save the lives of children over the past year. For the men and women who have designed those procedures or equipment, this evening is our chance to say thank you."
She scans the length of the ballroom. "Ah, I can see that the waiters have delivered to each of you a contribution from Berry Brothers & Rudd, a glass of Dom Perignon 2009. Can I ask you to raise your glasses please and join me in a toast to Great Ormond Street Hospital?"
John lifts his glass, and Sherlock does the same, casting an eye at him. Whatever his conversation had been about with the Dutchman, it seems to have restored his good mood.
"To Great Ormond Street Hospital," his baritone joins those of the rest of the audience and then there is silence as the champagne is tasted. John's nose registers wafting scents of both fresh lemon and wild cherry, and the taste is fresh with an intriguing level of spice and just the faintest tinge of toasted bread.
Sherlock smiles at his glass. "Pure infanticide."
John almost flinches; that is most certainly not a particularly appropriate a word for a paediatric gathering. Undeterred, Sherlock continues: "What I mean is that while this is moderately delicious now, it's still in its infancy. The product of an idyllic harvest, it will be truly stunning in another ten years."
Lady Estelle is quick to dampen down the small ripples of conversation that had started up. "Finally, I would like you all to show your appreciation for the life-saving work that the hospital does, together with our thanks to the medical professionals gathered here. Please join me in a round of applause."
The clapping is sustained and loud, with genuine feeling behind it.
"And now – let's eat," Wolfson announces and there is an eruption of conversation again.
Sitting next to John on his right is a woman with long straight brown hair which is complemented by the rich brown damask gown she is wearing. He introduces himself, and discovers that Nicola Symonds is the deputy CEO of the Great Ormond Street Hospital in charge of Operations. Running not one but two clinical divisions, she is also head of the Estates and Facilities service. She's only been in the job for sixteen months, having joined the ranks of Great Ormond Street from the NHS Imperial College Trust, where she'd been the boss of Operations and Performance.
John's mind boggles at the size and scope of her job. Compared to him, her job is like running the whole country instead of one service in a small market town. He is a little in awe, but she is so lively and approachable that they soon get talking about the trials and tribulations of medical management.
She grins, "Give me non-medical staff any day – they can actually be managed. Surgeons are the worst, more challenging than herding a wheelbarrow load of frogs." She divulges that it really doesn't help that her own background is in non-surgical paediatrics.
From prima donnas in the nursing area, drama queen surgeons and juniors utterly unfit for surgical work, the two of them swap war stories over the first course (he'd chosen the scallops and a glass of premier cru Sancerre to go with it). Names are, of course, changed or never mentioned to ensure that collegial etiquette is observed.
Sherlock is still knee deep in Dutch with the Medtronic Senior VP. He has only pecked at his goat's cheese tart and has now abandoned his fork.
When the plates are whisked away and there is a momentary lull in the conversation, Nicola asks John to introduce her to Sherlock, and he obliges.
"Please refrain from calling me Doctor Holmes – that always makes me look around to see if my father is in the room. It's Sherlock," he says while extending his hand.
John smiles; Sherlock can be agreeable and well-behaved, if he thinks it worth his effort. So, why has he turned on the charm tonight after being in such a foul mood mere hours before?
"I had the pleasure of being at the seminar you participated in at GOSH last September," Symonds tells Sherlock, "Your video of the corpus calloscotomy, complicated by slit ventricle syndrome – I'd never seen such a procedure before. The resection was impressive enough but the VPS*** was just amazing. I have been informed that doing it freehand as you did, with direct visualisation in the peritoneal space, is most impressive. But, given that the thing hanging up here in front of us…" she gestures to the shunt valve artfully ensconced between a deep purple canna lily and a bamboo shoot, "…why didn't you use one of your own ProCores?"
"The guidelines state that fixed valves like the Medtronic CoreDelta should be used in patients with a history of epilepsy. Given that the resection was designed to ameliorate the patient's atonic seizures, the fixed pressure version was more appropriate. After all, the patient's drop attacks had disrupted the functioning of his original shunts, leading to the slit ventricle syndrome in the first place. If only we could move on to a properly smart shunt that was robust enough to withstand the shocks of a seizure, then patients could really thrive without needing such tricks."
The calloscotomy had not been done at King's College – Sherlock had been granted a few days' leave to do the work at Great Ormond Street because it was part of the Kings Health Partners, and one of four centres of the NHS's Children's Epilepsy Surgery Service (CESS). All John knows about the case he'd heard from Sherlock. That video had been impressive.
Nicola smiles and nods, "Well, that smart shunt has been a dream for almost thirty years. Maybe we will look back on tonight as the real start on it finally becoming a reality."
Sherlock frowns a bit, as if trying to understand something. "Why would tonight be noteworthy?"
She looks a little surprised, but then on Sherlock's right, Rob Van Hoek speaks up. "Miss Symonds; I think that is my cue." He gets up and walks to the little spot-lit stage, where he takes a pen from his pocket and taps it firmly on the side of his champagne glass to get the attention of the other party attendees.
The master of ceremonies offers him the microphone. The conversations in the room dampen down and then silence falls.
"Good evening. I'm Rob van Hoek from Medtronic. It falls to me to make an announcement that is known only to select members of one particular table. When we became aware that Doctor Sherlock Holmes had donated a percentage of his royalties to the hospital we are honouring here, I took a proposal to the main Medtronic board. It is somewhat embarrassing that the latest phase two developments at GOSH are named the Premier Inn Clinical Building and the Mittal Children's Medical Centre. If the world leader in medical equipment cannot compete with the likes of a hotel chain and a steel family, then we should be ashamed of ourselves. So, we have agreed to sponsor the new Paediatric Neurosurgery Research Unit at GOSH, a £45 million contribution over the next three years. Alongside its clinical work, the new centre has the specific objective to design, build and test a new, smart ventriculo-peritoneal shunt that will adapt to changing patient physiology and withstand much more than the old equipment."
Nicola Symonds starts clapping, and the rest of the hall joins in.
Van Hoek holds his hands out in a dampening motion. "I am not finished. Please… As the first step, we will be issuing a press release on Monday announcing a new post-market clinical study to evaluate the current ProCoreValve shunt in everyday clinical practice. It's a multicentre study to evaluate longer-term performance of what we believe will be the next generation of adjustable shunts that should transform the treatment of hydrocephalus. We hope to recruit 600 patients across 35 sites in Europe, to test the ProCoreValve's outcomes including all-cause mortality at thirty days all the way out to five years post-surgery. We think the findings will prove crucial to the next design stage. So, if your hospital is approached, please do join in."
Another round of polite applause escorts van Hoek back to their table. Before he has retaken his seat, he turns to Sherlock. "And, of course, we will want you, Doctor Holmes, to play a major part in that project. As a matter of fact, we would very much like you to be in clinical charge of it."
Sherlock looks stunned. Blinking rapidly for a few seconds, he manages to stutter, "Um… that's… ah, rather generous of you."
The rest of the evening passes in a haze of fine wine, good food and sparkling conversation, even if Sherlock seems rather shell-shocked. John can't keep the grin off his face, and Sherlock mirrors it with his own.
-o-0-o-0-o-0-o-0-o-0-o-
They are in the cloakroom queue, when someone calls out for Doctor Holmes.
They both turn to see Professor McEnery, the BJNS editor, coming up behind them. Caught in the queue, there is no escape.
John feels Sherlock stiffening beside him.
The bluff Liverpudlian is beaming a smile. "So, now you know why I had to turn down your article. There will be an announcement in the next issue about Medtronic's multicentre study. I was sworn to secrecy not to tell you why your case study had been rejected. I look forward to seeing your name alongside that of the other participating surgeons when the data starts coming through. No hard feelings?"
John looks away to conceal his smirk as Sherlock regards the man graciously. "Of course not; whatever gave you that idea?"
––– The End –––
Author's Notes:
*BJNS = British Journal of Neurosurgery. JNSPeds is an American publication: Journal of Neurosurgery: Pediatric.
**Medtronic actually exists, and if Sherlock's invention was real, they should be keen to back it as the first step on the route to a smart shunt. It would be so wonderful a medical step forward that hundreds of thousands of patients and their carers would jump for joy. If you would like to know more about the pursuit a smart shunt, check out . .gov/pmc/articles/PMC3642745/
***GOSH is real. Great Ormond Street Hospital depends on its fundraising charity to bring medical services and world class research to Britain's sick children. The dinner is fictitious, but anyone who liked this story is encouraged to give, at . ?appeal=DMC0917A&gclid=CjwKCAjwmK3OBRBKEiwAOL6t1D9Vlnl-PU4Z2yxQtpro1zUVDz0gJmb8aTc70YzzZzlnMPcvvKXkpxoCmRcQAvD_BwE J_Baillier would approve! [Note from J. Baillier: she does approve, though when it comes to funding medicine I believe that funding should all come from governmental sources although that is most often not possible since those funds are limited. This is the sort of brainwashing one gets as a Scandinavian...]
****VPS is ventriculo-peritoneal shunting – a procedure in which a route is created from the brain ventricles for cerebrospinal fluid to drain into the abdomen to keep intracranial pressure from rising if its normal flow is not working properly.
The corpus calloscotomy is not a particularly difficult operation; it cuts the communication between the brain's two hemispheres and ameliorates the effects of atonic epilepsy (the so-called drop fits). I have a friend whose grandson has had this operation (not the shunt) at Great Ormond Street Hospital and he has made a good recovery, with much reduced seizure activity.
Publishing medical research is a daunting prospect. There are 5,633 journals are currently indexed in MEDLINE5. Choosing one can seem a daunting and imposing task. In addition, many manuscripts are rejected by the editors before they ever make it to peer review, simply because the research does not fit the aim and scope of the journal.
Large, international publishers such as Elsevier, Springer, and Taylor and Francis, offer journal finders, which let authors match manuscript criteria to journal criteria, helping to streamline the process. In addition, there are independent databases such as JournalGuide and open-access publishers such as BioMed Central, which help guide authors in selecting from a broader range of journals. Sherlock could have benefited from such services to find out where best to send his article.
Nowadays, one manuscript has to abide by a number of different guidelines, for different purposes. For example, manuscripts for publication in medical journals need to follow the ICMJE Uniform Requirements for Manuscripts16, to ensure, amongst others, that authors fulfil authorship criteria. If the manuscript reports on a clinical study, then more guidelines are used, depending on what kind of study it was – for example, CONSORT for randomised controlled trials, CONSORT extensions for equivalence or non-inferiority trials, STROBE for observational studies, ARRIVE for animal preclinical studies17. If the project it was sponsored by industry, suddenly the Good Publication Practice 3 guidelines come into play as well. If it is a case report, then CARE guidelines can be used; if a systematic review, then PRISMA17 is used. But, that is not all: the journals own guidelines then have to be followed: author guidelines, manuscript templates, statistics guidelines and so on. In this way, for example, an industry-sponsored, randomised controlled, non-inferiority trial for publication can follow 5 or more sets of guidelines – overwhelming for anyone wanting to publish.