Chapter 8: Rehabilitation

David wakes-up first. He does not move and he admires the beautiful woman lying in bed on his left. He studies her face totally relaxed in her sleep, he listens to her heartbeat, watches her chest rises & falls with the rhythm of her heart. He feels so happy & so whole. Suddenly, she starts to stir and her heart starts to pound frantically in her chest. Her face starts to contortion with pain, she starts to shake then she screams and opens her eyes suddenly.

"Julia, it's OK. It's me. You are safe. Nobody is hurting you. I am here. I am protecting you. I will never let anything bad happen to you. Julia, look at me, love. Look at me, breath in, breath out and count with me slowly: 1, 2, 3, 4, 5,… ". And he takes her in his arms and hugs her tightly. Rocking her in his arms like he would do with one of his children and pampering feather kisses on her cheeks, temples, forehead,..

Julia calms down slowly and sighs heavily.

David hesitantly says: "Julia, I think you need some help to deal with some Post Traumatic Stress due to St Matthews & Thornton Circus. You have been through a lot in a very short time period, love".

"Yes, you are right". She pauses.

"I am getting some help since I woke up from the coma to deal with the psychological effects of a long period in the coma and I am also facing survivor's guilt. I have met some other St Matthew's survivors and we had some "group therapy", it helped us all a lot. I have a meeting planned with Kim's parents next week, it will help me to finalize my grief process. Kim was in my team for several years and we had a good relationship. I miss her every day". She pauses and sighs heavily.

"I also have some symptoms of PTSD, mainly nightmares and an overall anxiety. I will continue these sessions with that psychotherapist. We agreed I do not need medication. I am following "Cognitive Processing Therapy" which is a 12-week treatment with weekly sessions of 60-90 minutes. At first, I am talking about the traumatic event with my therapist and how my thoughts related to it have affected my life. Then I write in detail about what happened. This process helps me examine how to think about my trauma and figure out new ways to live with it. We have agreed to use this technique as I like to write things out, my past as a barrister is never far away. Finally, I will get some additional psychological follow-up at the reeducation center, specifically to deal with the amputation".

Julia and David are getting ready and they go together to the reeducation center. David has insisted to come with her for the first day to listen to all the explanations & see how he can support her best. They arrive and Julia is walking proudly with one single crutch.

The Head Doctor in charge of Julia's reeducation welcome her at the main entrance and David introduce himself as Julia's partner. The doctor compliments him to be there and David replies this is totally normal to be here and supports Julia. He also says he wants to be an active part in Julia's recovery process, learn how he can help her to work at home and if he can eventually learn some massages to speed up her recovery & reduces any potential pain.

The doctor starts with some "basics". Immediately after the amputation, priority has been given to your recovery and the healing of your stump, two essential steps before starting rehabilitation and being fitted. To start rehabilitation: you should not (or almost) no longer feel pain in your stump, your stump must be able to support a load, the edema should have subsided and stabilized and you should be able to move your stump as much as possible in all directions. From what your doctor told me, you are ticking all the "boxes" and we can therefore start".

Julia nods.

"Whilst you were at the hospital, the doctors have asked you to do some movements exercises, some exercises to build back your muscles (torso, arms & legs) to prepare your body for rehabilitation. You have also strained your stump. These exercises prevent stiffening of muscles and joints. Also familiarize yourself with movement patterns that your amputated leg is not used to"

"Today, we are going to work on the so-called prosthesis that you will wear between 3 to 6 months. At the end of this period, we will manufacture your final prosthesis. First, we will show you how to wear the prosthesis, without hurting yourself, to stand straight and put some weight on it and then how to walk with it."

"What are the other activities you would like to be able to do, Miss Montague?"

"I am a keen horse-rider since I am 6 years old and a keen swimmer". She pauses then says tentatively: "I also would like to learn some self-defense movements, so I suppose this will require to be able to compensate my right side with my left side"

David looks at her very surprised.

"Julia, do you want to learn self-defense?"

"Yes, I do"

"With whom?"

"Preferably you David, with the help of the doctors and physiotherapists here to assist you and avoid to hurt myself with the prosthesis".

"Alright love, I will be very happy to do that and I think this is a brilliant idea to help you with your self-confidence".

The doctor nods. "Indeed, this is a very good idea Miss Montague"

"Do you have any other goal? Short-term or longer term?"

"Well, obviously my main goal is to walk as soon as possible with a prosthesis and without a crutch and I also want to be able to dance the New Year's Eve ball with David"

"Very well, this is definitely achievable, especially with your overall good shape & your strong determination"

"Thank you. I am also running my campaign from London at the moment, but I need to be able to go on tour in the UK & visit people in other cities. I don't want to give the impression that I am weak and that I am not fit to be Prime Minister. I have fought all my life to get there and I won't let anything or anyone get in my way!"

"Very well, I fully understand that and that means we will have to work on your ability to stand for some period of time"

The doctor hesitates but then asks carefully: "We also do silicone cosmesis and I was wondering if you would be interested for the scars on your hands, we could try scarring restoration. We have the capacity and skills to produce high-quality cosmetic covers that will make a positive difference to your daily life".

"I will consider it, but this is not my priority. My priority is to walk with a prosthesis and no help"

"Let's go back to your prosthesis. As you know, a prosthesis replaces your missing limb and is made up of several components depending on your level of amputation. The socket forms the interface between the stump and the prosthetic components. It has a significant impact on your comfort and the functionality of the prosthesis. Adapters and connecting elements allow the different prosthetic components to be assembled together. Once the shape of the socket has been validated after several tests and the prosthetic components selected, the orthopedic technician assembles the various elements and adjusts the alignment according to the examination results and the alignment guidelines in force. When the prosthesis is fitted, it makes additional connections with technical equipment to adapt the prosthesis to your profile. You can then take the first steps with your new prosthesis".

"Do you have any question so far?"

"No"

"As I said, we will start with a Trial prosthesis which allows you to quickly practice wearing and using a prosthesis. This step is necessary because it contributes to good healing of the stump and promotes its shaping. This phase also makes it possible to try and validate the prosthetic components so that the prosthesis best meets your needs. When the stump is stabilized and the tests are completed, your orthopedic technician then manufactures the definitive prosthesis, perfectly adopted"

"The doctors at the hospital have taken the imprint of your stump, so we have already prepared a Trial prosthesis that we can try this morning, if you feel ready"

"I am more than ready" says Julia, beaming.

"Perfect, than this afternoon you will try to put the trial prosthesis on yourself for the 1st time after we have potentially done some adjustments to it, after the 1st try this morning. You will meet the physiotherapist to show you some movements to do at home to continue to improve your mobility and also some massages you or David can do. Finally, you will meet the psychologist"

The trial prosthesis try is a bit mitigated as Julia experiences some pain. The doctors & technicians are re-assuring and are working on the adjustments during the rest of the morning & lunchtime.

David and Julia are having lunch together.

"David, I am really happy that you are here with me today. It means a lot to me. Thank you"

"Julia, this is totally normal for me being here today. It is an important day in your rehabilitation process and I want to share this moment with you, show you my support and see how I can support you even more, moving forward"

"I am not used to that, you know. Roger has never supported me"

"And what about your parents?"

"My father has always been very supportive, my mum as well but she was worried for me all the time as well - about my very long hours of work, the impact on my health & my personal life".

"I have discussed a lot with your mum whilst you were in the coma. She loves you very much and she is deeply worried about you, but also she respects your choices and she is trying to show her support as much as she can"

"I know"

"OK, so are you ready for the afternoon?"

"Not fully. I think I need a hug and a proper kiss from my lovely boyfriend to give me more courage"

"Boyfriend? Are we not too old to use that word?"

"I don't know.. I like it.."

"OK for boyfriend then.. for the moment"

Julia is puzzled but doesn't reply.

"Hello, I am Charles, your physiotherapist. I am very honored to meet you Miss Montague"

"Hello Charles, nice to meet you"

"And you must be the famous David Budd?"

"Err.. yes, nice to meet you Charles"

"Charles, at the moment, David & I have not made our relationship public, so I count on your total discretion, please"

"Don't worry Miss Montague, your team has requested the staff to sign very strict NDA & we would lose our job if we were to talk to the press and I admire you so much, I would never do anything that could be prejudicial to you or David"

"OK, thank you"

"So let's start!"

Charles show them several movements that Julia can practice as much as possible at home and then shows them some massages she or David can do easily. He also hands them out some print-outs to help them to memorize all the movements.

The second session to try on the Trial Prosthesis is going much better than the one in the morning. The adjustments make a huge difference and Julia manages to put it on at the third attempt. The doctors & David are very impressed.

Julia is tired but quite positive about her day. Then they meet the psychologist.

"Hello Miss Montague, I am Devon"

"Nice to meet you Devon. Please, you can call me Julia"

"And you must be David?"

"Indeed, nice to meet you Devon".

"David, this is great of you to be here today to support Julia"

"This is normal to me, I want to support her the best I can"

"Great, let's start with some global information about the psychological impacts of amputation and then, if you agree, I would like to talk to each of you separately for a while"

They both nod positively, so the doctor continues.

"Amputation confronts the person with the immense difficulty of coping with the psychological shock caused by the amputation itself, by the alteration of the self-image that it constitutes, and the consequences which result from it. Amputation is to say a disability which is no longer recoverable, but only compensable. Without being able to keep his whole body, the subject considers himself devastated. Mourning will therefore be necessary in order to gradually recognize that, even deprived of a part of his body, the subject remains a living whole. The culmination of this work of mourning what we were before and accepting what we are now will thus allow the development of a new body image. This work of mourning will be carried out gradually, in stages"

"Do you have any question so far?"

"No"

"According to the Kübler-Ross model, there are schematically five stages between the announcement or discovery of the amputation and its acceptance.

The 1st stage is "denial": the patient who has just had an amputation can't accept reality, but this stage is usually short-lived"

"I did not feel that way. It was a massive shock when I woke-up from the coma but I saw the stump immediately as it was almost healed completely. I cried a lot"

"The 2nd stage is "aggression and revolt": the revolt is of course about the injustice of amputation, but all areas of thought or activity can be affected, and the slightest annoyance, even unrelated to health, can lead to unusual reactions"

"My first reaction was to push David away. Despite the deep love I feel for him"

"The 3rd stage is "bargaining": at this point, the amputee begins to come to grips with his new situation, but will only accept part of the reality, and often only that which he thinks will allow him to live "almost as before". The amputee often refuses to follow the advice of the healthcare team or family, or refuses part of the treatment, on the pretext of uncertainty about how to react to the amputation"

"Mmmm not sure I have been through that one. Bargaining is not really compatible with my temper"

"The 4th stage is "depression": it is not a depression in the psychiatric sense of the term where there is loss of interests, absence of pleasure, absence of project, appetite disorder, sleep disorder, loss of self-esteem, feeling of "way." dead end ", suicidal thoughts, etc. It is rather a bitterness (that is to say a resentment mixed with sadness caused by the observation of the definitive loss of something) with which is associated a question as to how the amputation can be integrated into the everyday life. It is therefore a phase of "depression" in the sense of "reduction of psychological pressure", with self-reflection and the hope of integrating amputation into everyday life. At this stage, information on amputation, fitting, etc. is well perceived because the initial defense mechanisms of aggression have been gradually replaced by a bearable psychological context allowing constructive thought mechanisms. The amputee is often silent, attentive, even meditative, sometimes also dubious, but the emotional load, which is less strong, allows listening and understanding of new principles of life. Information also allows the amputee subject to express his subjective experience, which is particularly important in order to be able to mourn what we were "before" and consider accepting themselves as they are "now".

"I think I must be there"

"We will see, we will discuss together is a few minutes"

"The 5th & last stage is "Acceptance": this process of active acceptance goes through the complete disappearance of the feeling of inferiority and dependence, by the conviction of the possibility of a new way of life, by the development of a new amputated self-image, by the observation the ability to take charge of oneself. This active acceptance is also called "Knowing how to be". However, it should be noted that active acceptance is not a definitive step, and that its maintenance sometimes requires significant efforts for the amputee and his entourage, especially during the inevitable hazards of life, professional, family, or other"

David leaves the room to grab some coffee. Julia stays with Devon.

"How do you feel today Julia?"

Julia hesitates. There is a pregnant pause.

Then she bursts out: "I am terrified".

"Thank you for sharing this with me, Julia. Can you, please, specify what are you afraid of exactly?"

"My biggest fear is that David leaves me. Because he realizes I am a disabled old woman with a bad temper. I am scared he gets back together with his soon-to-be ex-wife. I am not used to feel that way. I have been an independent woman all my life, I did not need a man to make me happy and now if David and I spend one night apart, I don't sleep well and I misses him. He makes me feel safe, at peace and whole"

"I am also scared I will never manage to walk on my own again and that being amputated will stop me to have a baby with David"

"Why would that stop you?"

"I have always doubted my ability to be a good mother. And since the amputation, that fear is worse than ever. I am scared not to be able to look after the baby properly, to carry the baby and later to run after the infant in case of any danger arises for example"

"Do you want to have a child with David?"

"Yes, I really do. David is a wonderful father to his 2 kids and he is giving me the desire to be a mother, for the first time in my life, even if I am scared it will be too late, due to my age"

"We will work on that together as well then, if you agree"

"Yes, please, that will definitely help me"

"Now moving on to more work-related question. Are you scared about the election?"

"No, I have prepared myself all my life for that goal. I am not scared"

"And are you scared to do a public speech?"

"Well, I have always enjoyed to do public speeches, so not really. The first one will be a bit stressful, I suppose. But I will manage"

"As we discussed earlier, amputation is lowering your self-esteem & self-confidence. In your case, it does not seem to be the case for things related to your work, position & running for PM campaign. It seems to be very oriented towards your love life and your emotions"

"I think you are still seeing the psychotherapist from the hospital regarding post-coma trauma, survivor's guilt and PTSD which causes general anxiety & nightmares"

"That is correct"

"OK, so what we suggest, having discussed this with the Head Doctor this morning as well, is that in the morning you do physical exercises with the prosthesis, then we talk for a bit. Than you have your lunch with David, I think he insisted to eat with you every day"

"Yes"

"In the afternoon, you will start with your physio appointment, then physical exercises again, then we finish the day with another discussion"

Julia nods then leaves the room and David comes back.

"How do you feel today, David?"

"I am very worried about Julia's recovery but also very hopeful & positive to see she is such in good hands here"

"Why do you worry so much about her? Do you feel guilty about what happened to her?"

"I love her and I want her to be happy. Yes, I still feel guilty about not being able to avoid that bomb to blow her up and shatter her leg"

« Do you speak about having a baby together? »

"Well, I mentioned it several times but I do not want her to feel pressured. I know she is thinking about it, but it seems to stress her out"

"It is indeed, do you know why"

"Well, I suppose she doubts her ability to be a good mother because she sets high standards in everything she does"

"I have been informed that you were seeing one of my colleague regarding PTSD issues"

"Yes, I do"

"How is it going?'

'I know it is a long road ahead, but I am slowly getting better. The medication also helps and I know I will not hurt Julia anymore"

"Did you hurt Julia?" David explained what happened that night at the Blackwood, before St Matthews..

"Do you know how Julia feels about it?"

"Julia has been supportive, she said straight away she knew I did not want to hurt her and that I needed to get help. She has been able to see through it and see me for who I really am. I don't think she is still thinking about it, even if I am still struggling to forgive myself"

"OK, I will make sure we treat that topic during my sessions with her"

"Thank you Devon"

Julia is progressing every day with the prosthesis and with the psychological sessions.

One evening, David calls Vicky and he laughs with her on the phone.

Julia sees red and asks him angrily: "Do you still love her David? If yes, you can leave and get back together!" David snaps back at her and shouts: « Oh stop this Julia! I am divorcing from Vicky. We will be finally divorced in March. We have a good co-parents relationship and are finally able to have a light conversation and laugh together. She will always have a special place in my heart as we have spent 12 years together and she is the mother of my children but I am in a romantic relationship with you Julia, I live with you, I love you and I want to spend the rest of my life with you. I. Love. You. Never doubt that again"

"I promise. I am sorry. My rehabilitation is work in progress and it brings back my insecurities. Thank you David for finding the words to re-assure me. I love you too."

Julia finally decides to try the silicone treatment on one of her hands. It will strengthen her self-confidence even more. After 2 difficult weeks and lots of ups & downs, one day, David arrives at the reeducation center to have their daily lunch and Julia walks towards him alone, without any help & all smiles. He runs towards her, outstretches his arms to reach her quicker, they cuddle and cry at the same time. That night they make love passionately several times to celebrate that victory.