Even the act of blinking seems to be in slow motion as I wait for my gown to be tied. Fender, like most neurosurgeons, does not indulge in small talk, and for that I am grateful. I have offered to assist him out of curiosity; a large aneurysm of the carotid artery apparent on the patient's MRI, pushing on the optic nerve and causing a loss of vision in one eye. I should not still be here, in the middle of the night, hungry and sleep deprived, but I could not help myself. Staring at the angiogram, my interest was piqued. I have never seen a presentation like this before so, despite my exhaustion, despite the fact I must be back at Imperial in less than eight hours, it is a opportunity I cannot refuse. Besides, Fender has an impressive list of achievements, and a reputation for efficiency, so I remind myself that I must never turn down an opportunity to learn something new.
As the resident drills the holes to open the skull, I hold my breath; a technique that I've often found useful to trick the brain into alertness. The electric saw screeches through bone, the skull flap is removed and I watch, fascinated, as the underlying dura is cut and folded carefully back.
The brain is now exposed, the complex network of blood vessels and fluid that covers its surface giving it a golden shimmer beneath the powerful theatre lights. But sheen or no sheen, the patient's brain must be manipulated into place, pushed about in order to provide better exposure of the procedure site. An hour goes past. More drilling, more pushing, and a great deal of cursing under his breath but, finally, Fender obtains the required clarity of view. There before us is a big, bulging aneurysm, right at the juncture of the carotid and the ophthalmic arteries.
I stifle a yawn, squeezing my eyes shut tightly, and opening them again widely, desperate to stay alert as he places two cords around the carotid. His technique seems sound but hardly deserving of his reputation as a brilliant innovator. I sense an awkwardness, an almost imperceptible decline in dexterity, in movements that should be inherently crisp and precise. Perhaps it is his age, his eyesight, or his hand/eye coordination; either way, the wobble is subtle but it's there. Observing him, I do approve of one thing in particular though; Fender works in silence. No sporting commentary, no oneupmanship, nothing inappropriate, just the intense concentration required for the successful execution of surgery.
"Better to be safe than sorry." Fender says, with a sort of forced bonhomie, snatching a glance in my direction before taking a silver aneurysm clip and slipping it in behind the offending bulge.
I grip the suction tip and lean closer, anticipating what might happen next, waiting for him to release the clip slowly, allowing the two prongs to cinch closed over the neck of the aneurysm. He seems to hesitate and I inhale sharply, my reflexes causing me to suck as much oxygen as I can into my lungs. I hear Fender gasp, and swear loudly and, before me, the entire brain pan suddenly fills with blood. Both the resident and I are galvanised into action, suctioning furiously, but the sheer volume of blood means we simply can't keep up. Frantically, I tear the suction tip off and the resident follows suit, our hoses flailing hopelessly in the bloody opening, unable to make any headway. We can no longer even see the brain, and I stare in abject horror as blood begins to spill up, and over the edges of the skull.
"One hundred and ten over sixty five. Ninety over fifty…" A nurse cries out.
I wait for Fender to act but, to my horror he is frozen and immobile, as if he is deep in thought, as if he has time to contemplate his next action, the leisure to consider his subsequent response. Around me, nurses scramble, squeezing bags of blood into the young man on the table but to no avail, his blood loss is simply too great. I'd read his chart, his birth year the same as mine, half the age of the surgical lead, half the age of the man who, in such a critical moment, does not appear to know what to do.
"Seventy over forty…"
I've experienced bleeds like this; in the abdomen you can simply compress the bleeding vessel or place clamps appropriately but, in the brain, these techniques are simply not an option. We are all thinking the same thing: Fender needs to act or this man will die.
"Fifty five over zero…"
"Do something! Please!" The young registrar exclaims, his face inches from mine.
"We've lost him. Blood pressure unmeasurable." The anaesthetist calls out.
Loudly and firmly, almost as a reprimand, I say Fender's name. The situation calls for assurance, a boldness that has apparently deserted him, a willingness to attempt everything until there is nothing left to try. But, instead, he stands motionless when every second counts. And that is when I feel the surge. It is only faint but I know it to be adrenaline, the hyper focus and clarity that descends when there is no one else standing between life and death but you. I slip my hands below the surface of the pooling blood and begin feeling about. Somehow, I manage not only to locate the carotids but to tie them off, proximal to the bleed. Almost instantly, the suction begins to work and the registrar lets out a string of vehement expletives under his breath.
I nod at him as the furore around me calms. His eyes are fixed in horror, watery and wide. As the nurse calls out the rising numbers, I glance across at Fender cautiously, before beginning to examine the site more closely.
"There was a second aneurysm hiding behind the first one," I tell him calmly.
Wordlessly, he takes a step forward and clears his throat, authoritatively. Without missing a beat, he requests a second silver clip and I observe him intently as he carefully places it into position. His hands are not quite as steady as they ought to be, but his demeanour seems calm as he finally removes the carotid ligatures. I can't help but wonder what happened to him, what caused that momentary, but potentially fatal, inertia. Did he freeze out of fear? Or did he believe that there was nothing further he could do? God forbid that it was the amount of blood loss that caused his hesitation. A negative reaction to the sight of blood was a surgeon's worst nightmare and I couldn't imagine what either situation would feel like, or which might be worse: to experience haemophobia for the first time, or simply to have lost one's nerve at the worst possible moment?
"Close up, will you." I hear him bark at the registrar before, without another word, he turns and strides from theatre, like a grandee leaving a coronation.
His departure sees the room descend once more into quiet; a self-conscious, uncomfortable soundlessness, punctuated only by electronic reverberation, where no one attempts eye contact, and only the most essential of communication breaks the silence.
"Well done," the anaesthetist says to me, over an hour later, as we find ourselves vying for the same non-existent, four o'clock-in-the-morning taxi. "I didn't think we'd get that one back."
It's cold and his breath condenses in the air as he speaks. I am in no mood for conversation, however, and I pull my scarf up beneath my ears, failing even to glance in his direction as I edge closer toward the kerb.
"Yes." I growl, as I step in front of him to hail the approaching black cab. "I had no intention of having my name associated with a completely avoidable exsanguination."
On the short drive home, staring vacantly out at the almost deserted streets, I wonder how much longer I can keep this up. I am constantly tired, yet sleep often eludes me. And it's not a regular tiredness, it is weighty, all-encompassing and utterly depleting, my mind wandering frequently and my temper often short. I'm familiar with this level of sleep deprivation, but nothing could prepare me for how badly I long to spend the night with Louisa, to wake feeling the warmth of her body, as hot as a furnace as she curls up in the small of my back. But it seems, frustratingly, never to eventuate. Our schedules are so ill-matched, and for the last few weeks, since she recovered, we have passed like proverbial ships in the night. All I can do is to gaze after her longingly as she kisses me hurriedly goodbye; inevitably late, and running, in order not to miss her bus.
My need for her has become a dull ache. Physically, our separation is miserable enough but to be cleaved from her joyousness feels so inordinately dispiriting. I miss that sense of closeness; of watching her wake up, of sharing a meal or our relaxing Sunday walks. I miss the comfort, the reassurance of her attention, her inexplicable interest in my day; after tolerating endless hours of idiotic and obstructive behaviour, coming home to her warmth and energy is somehow so sustaining. I miss the peace that descends after we make love, a tranquility, a contentment, a state of relaxation I've never known before. Even as well practiced as I am at burying feelings, and at surmounting physical need, I find myself tested almost beyond my capacity for endurance. But, it is my responsibility to sort out this appalling mess and that is what I mean to do.
Feebly, I barely manage to keep my composure when she asks, somewhat plaintively, how much longer this state of unwilling sequestration will last between us. The tone of her enquiry surprises me. She always seems so self-contained, her life so full of popular culture and endless distractions, and I am taken aback. The best solution seems to be to downplay her fears, even disparaging them somewhat ingenuously, by telling her it it simply can't be helped. I find myself snatching furtive glances as I speak, she is more beautiful than ever, and with every word I utter I am fully cognisant of the fact that I attempt to convince myself as much I attempt to convince Louisa that this purgatory will soon be over.
The strain on my resolute self is compounded. I love her even more for smiling sympathetically when I explain why I must arrive so early, and stay so late, why I need to monitor post op patients, some of who are in ICU and require a lot of careful management. I love her intensely for nodding, and squeezing my hand, as I outline the requirements of outpatients, and rounds, and how as well as covering emergencies, I am still mopping up electives at St. Mary's, and running the new clinic, and building my list at Imperial. I love her so much it hurts for the way she gazes at me, her eyes so clear and calm, when I point out, slightly pompously, that post-op clinics still have to be shoehorned in somewhere. I can barely control my urge to embrace her simply due to the way she bites her lip with such forbearance as I lament how the whole carefully planned schedule is rendered impossible when I have emergency cases that can't be transported elsewhere for treatment.
And so I slip into the flat just as the little brass carriage clock marks five o'clock, chiming with it's usual melodic delicacy. I pause at the bedroom door as I pass but, despite not being able to see anything in the darkness that shrouds the room, I cannot seem to stride stoically past. Selfishly, I have a desperate desire to slip in beside her, to hear her murmur an encouraging greeting in that sleepy, welcoming voice. My abdominals clench just recalling her softness, the scent of her hair, the way her skin feels beneath my hands. But even in my confused and enervated state, logic suggests that it's Monday, the only day of the week when she too has an early start. Reason reminds me that I'm being self-centred, that my need for gratification shows a self-interest and a lack of consideration that reflects rather poorly on my character. Swallowing hard, I force myself to the spare room, again, discarding my clothing despondently over a chair before crawling beneath the covers, bone weary and exhausted.
I think about her education as I drift off to sleep, the aptly named 'Liberal Arts'. Assignments and essays and dissertations seem to form a large part of her coursework now and it's a concept I don't really understand. The few lecturers she does have, she addresses by their first names, a situation I find quite extraordinary when compared to the rigidly hierarchal world of a medical school. I can't help but have a faint mistrust of her tutors' motives too, since meeting for coffee seems to have become an acceptable and rather frequent substitute for lessons, a situation I find disconcerting, completely infuriating and utterly unprofessional. He'd even had the temerity to call her at home once, on some flimsy pretext, a change of venue or time allocation or something similarly vague, confirming my suspicions that the organisation is simply a shambles.
"You know, I've been thinking…" she'd said, as she lay on the sofa, still recovering from her severe bout of influenza. "And, well…it might be quite good to have my name on your answer phone message too, actually…since I live here now. What do you think?"
Even through the perpetual fog I find myself shrouded in, I'd felt a familiar stirring, that odd mixture of gratitude, fear and disbelief I experience whenever I allow myself to hope that she might stay with me forever. It was ostensibly a reasonable request. Whichever way I looked at it, the benefits of agreeing far outweighed the negatives, and it dawned on me then, too, that I no longer cared who knew that Louisa was living here with me now.
"Umm, yes…" I said, glancing at her cautiously. "That seems…"
"And I don't mean to be rude or anything," she'd interrupted quickly and slightly breathlessly, "but, since you're changing it…is there any chance you could make it, umm, I don't know….perhaps just a little bit…friendlier?"
I frowned at her.
"Friendlier?"
"Yes Martin. Friendlier." She'd replied, sounding suddenly irritated. "I don't want people to be scared off when they ring me and get the answer phone message."
"Scared?" I replied, perhaps a little derisively. "What people? And why on earth would they be scared?"
"Because, Martin, you sound ferocious."
"To whom?" I'd demanded.
"To anyone that rings, anyone who's not, I don't know…used to you I suppose…"
"Such as?" I asked again, now keen to know just what sort of people she expected to call, and why they would be so faint hearted as to be intimidated by a perfectly reasonable, clear and succinct answer phone message.
"Lots of people really…my friends…people from college…"
She'd stared back at me, jaw clenched, and I recognised her expression as her eyes flashed; that teenage blend of shame and defiance, challenging me to remonstrate with her, to dare to object.
"Right, yes, I'll change it." I assured her quickly but I still hadn't done it as yet.
With a dull mind, I'd added it to my ever growing list of things to do. Somehow I was managing to maintain my sharpness in my work but, peripherally, my attention to detail was certainly slipping. Even more alarming, as I slunk up the stairs after my last middle-of-the-night emergency, I'd sworn I'd seen a cat in the hallway. Incensed, and about to pound on the door of the rule-flouting neighbour, it had dawned on me, fortunately, that perhaps I was actually seeing things, split second hallucinations that were solely the result of sleep deprivation. As anathema as it was to admit it, even to myself, I was so tired that even twenty four on the Epworth scale was an inadequate measure. And the inevitable consequences were, too, that I was not only well behind in the reading required to keep me current, but also in my personal administration and book keeping. My car required an MOT, Alan Leslie had several important documents awaiting my signature, and an horologist of my acquaintance had recommended an importer fellow in Hatton Gardens that I'd already had to cancel twice having rather optimistically made afternoon appointments.
Admitting to fatigue has always been seen as a weakness in my profession, a fault in one's temperament that will bring only disgrace. Long shifts, high pressure, stress and the ever-present spectre of patient deaths are seen as merely a right of passage that every surgeon must undertake, the means to an end, sorting the wheat from the chaff, the men from the boys. The truth is, when I was a registrar, I'd never minded working long hours. On call, sleep-ins, on duty overnight, it never mattered to me. Day shift is frantically busy but, at night, the pace is less frenetic; most of your patients are asleep, and emergent cases are often dynamic, and as stimulating as they are complex. Perhaps though, even after such a short time as a consultant, I have just become complacent, insipid and soft. Through a veil of exhaustion an idea now disturbs me: I have always identified myself by my vocation but, suddenly, terrifyingly, that seems not enough. A dull ache takes up residence behind my eyes, almost an omen, a portent, a threat.
Though the hours might pass rapidly, the days became indistinct and the weeks are a blur. I'd glanced at the date on my watch as I emerged out into the daylight, momentarily at a loss as to where I was meant to go next, and feeling a spark of excitement when I realised that the answer was actually home. I'd finally collected the post, slipping it into my briefcase as the world swam around me, a sensation akin to jet lag, unpleasant and unwelcome. Desperate for exercise, I'd decided to walk home, pushing my way through the throngs of dawdling pedestrians, filling my lungs with cold, carbon monoxide-infused air, holding my breath, and then exhaling emphatically. Fill the chest and hold it in, twenty strides until my lungs burn, and the closer I get to the flat, the more it seems to drive my desperation. I need to see Louisa, to get home to her, to touch her before she boards her bus.
When I stumble through the front door, she is standing at the kitchen table, stuffing folders into her bag, dressed for the cold, an impish, new, Pom-Pom hat pulled down over her brow. A smile spreads across her face as she looks up from her task
"Martin!" She says enthusiastically, dropping her bag and throwing her arms rather emphatically around my neck.
I feel her mouth against mine; warm, soft and ambrosial, and I stand, depleted and vacuous, as she kisses me, the sweetest thing I've ever tasted. I close my eyes and the room begins to spin
"My bus is in a minute though…" she says despairingly, as I endeavour to put my arms around her. My limbs feel heavy, and leaden, and impossibly weak.
"Yes…of course." I reply, holding her for the briefest of moments before stepping reluctantly backwards. "I…umm…I have something for you…"
Snapping open my briefcase, I hand over her mail, a creased and gaudy postcard, depicting tanned young men in minuscule bathing costumes, lined up on a sandy beach. Whoever it is from, its arrival seems to delight Louisa exponentially and she utters a shriek of excitement, snatching it enthusiastically from my hand without even glancing at the picture. I watch her as she reads it, equal parts touched and perplexed by the wonderment she apparently experiences; her loveliness, her joyfulness utterly remarkable, and completely bewitching. If there is a more desirable woman in the whole of the world at this moment, I simply can't envisage her.
The warmth of her, the pressure of her touch, the silkiness of her mouth, it stays me, and the feeling is visceral. I snatch a glance at the sofa, and the idea of it causes my heart to run like a piston. I want her so very badly now, despite an almost overwhelming exhaustion smothering me, weighing me down like an old fashioned diving suit. I'm not even ashamed of how primal my need is, reaching up to touch her face, hoping that I might distract her.
"It's from Libby!" She squeaks, but I'm no longer paying attention.
In my mind, Louisa straddles my lap; it's all I can think about, as my carotid pulse begins to hammer in my ear. It's been an eternity and I'm as overwound as the spring in a mistreated clock. While my imagination is hijacked by texture and taste, while I'm already light-headed and my breathing is shallow, I struggle to focus on anything else. Eventually, her voice forces itself through the haze of lust that envelops me, and my arm drops down dead at my side as violently if I'd had a brachial plexus block. She'd shrieked, you see, and I'd regained enough composure to see that her eyes were shining, her face split in half by an ecstatic grin.
At first I am confused. I thought I'd listened well enough, I thought I'd understood her and that her wish was to spend Christmas with me. And hadn't I agreed, in principle, too, assuring her that I would do my best to try and secure at least part of the day off to ensure that? But now my mouth falls open and I stare back at her aghast. It dawns on me then that I just don't understand her at all and I probably never will. And then it hits me, the sheer inevitability of it all, the resignation that something more exciting was always going to come along and supplant me. To my shame, tears almost prick in my eyes as she hugs herself in apparent glee, waiting for my response as if I could possibly determine what it is she wants me to say.
"Oh my god, Martin!" She cries out, apparently delirious with happiness. "She's only gone and invited me to Sydney for Christmas."
