I had set my alarm for half past five, earlier than usual, but I wanted to ensure that I was completely prepared. From the first time we'd met, Bernard Newton had instilled into me the crucial importance to a surgeon of preparation, practice, and pre-emptive visualisation. Every physical action, every thought process and every decision made must become second nature, he had repeated to me, ad nauseum until it, too, had become my mantra. As he had so frequently pointed out, a split second's indecision can result in the loss of a life so we, as surgical practitioners, must become experts in pattern recognition, and operate using not just all of our senses but our intuition as well, proceedIng confidently without the need to analyse each step or reduce decision making into its components.
He had been a rigorous but fair tutor, with exacting standards that I had strived ferociously to exceed. To this end, I had spent the previous evening organising my thoughts and conducting my own methods of ensuring my own preparedness for the task ahead. As much as I know how to perform this operation intellectually, I must feel it; acting it out, using all of my somatosensory memory to augment my knowledge and skill.
As I sat in the reassuring tranquility of my living room, I undertook a complex process of imagining and reviewing the relevant anatomy, three dimensionally, and thinking about the key physical landmarks, and their influence on each step of the procedure. Then I recalled my perceptions, my sense of contact with these an anatomical structures; the weight, the muscle tension, and the sense of space and timing. Finally, I ran through every step of the procedure, ensuring I had all the relevant information on hand, and that I had anticipated any difficulties or unexpected discoveries, and have formulated an alternative surgical plan should any of these alternatives occur.
Unusually, today I will be completing the procedure from start to finish without a consultant alongside me, however, while Bernard will not be scrubbed, he will be in the building. It is the first of a number of these elective surgeries that I will be undertaking over the next few weeks as part of my final assessment, and in the lead up to my FRCS examinations. I believe I am as well prepared as it is possible to be and, by half past six, I am climbing into a taxi, focused and feeling remarkably self-assured, despite the weariness which seems to be intrinsic to me of late. My relief in discovering the only silent minicab owner in the city as my driver for the morning seems like a positive omen and I focus on my breathing as we make the short journey to St Mary's.
After spending some time in the consulting area, and re-reading the patient notes, I have a brief but reassuring conversation with Bernard, and we make our way down to the ward to speak to the patient. I am feeling quite buoyant until, for some reason, the patient in question is nowhere to be found. The Admissions nurse helpfully informs us that he has already been summoned to the Operating Suite. Puzzled, Bernard instructs me to head to theatre and start scrubbing up, while he sorts out the not insignificant issue of our disappearing patient.
I change into my scrubs and head, as instructed, for theatre. As I pass through the Admissions area of the Operating Suite I notice the anaesthetist rostered on to my team and, as he sees me, he gestures at me to wait.
"Ellingham." He says and his voice is agitated. "The patient's daughter has informed the Admitting Nurse that the patient is AB negative. I've reviewed the notes and there's no record of this, or that a group and crossmatch blood test been ordered."
I stare at him in disbelief. A very rare blood group and yet no tests have been done on the patient to confirm this, or ensure availability of appropriate blood products.
"Have you spoken to The Path Lab?" I ask quietly.
"Yes, of course, and they're saying no chance of seeing the results in under two hours. In fact, the rarity may mean up to four hours plus if blood needs to be couriered in."
"How was this overlooked? Was it not mentioned in pre-admissions?"
"The daughter attended, and she is adamant she told the Surgical Registrar. She says she even took notes so she could keep her family up to date."
I let out a long growl of frustration. It's fortuitous that I am holding nothing in my hand because my urge to throw something is overwhelming.
"We've no choice then." I say to him. "Cancel the procedure until we have a guarantee that the blood is on site."
As I stride towards theatre, I hear my heartbeat thumping in my ears and I realise that my fists are clenched in rage. After taking a moment to compose myself, I locate the Anaesthetia nurse and ask her to inform the charge nurse and the scrub team of the cancellation. I don't even want to think about the cost of the consumables and time the sterilisation unit have utilised, just in the preparation of the instruments alone.
Making my way back up to the Consultants rooms, I again seek out Bernard and ask him about the inevitable incident report both the Anaesthetist and I will both now have to complete. He gives an incredulous laugh and shakes his head at me but seems cheerfully unconcerned and, for some reason, his laissez-faire attitude makes me feel even more aggravated than before. I shower and change back into my street clothes and, as I perch on my desk and reattach my cuff links, I feel an overpowering sense of frustration and discontentment. Half an hour later, I drop my report on his secretary's desk and enquire of his whereabouts, only to be told that he has left for the day. I stare at her for a moment, considering my position. I realise that exhaustion and anger are distorting my thought process but I am beyond caring. Coldly, I inform her that I am also about to depart for the day and I am not contactable. I turn to walk away and I hear her call after me but I am finally unable to hide my complete contempt for her, the incompetent staff I am forced to deal with on a daily basis and every unutterable bastard that has conspired to make my life the miserable and blighted existence it has somehow always seemed to be. Without even a backward glance, I march towards the exit, not having thought any further ahead than the incandescent rage I feel at my thwarted efforts, and my absolute need to remove myself from the hospital environment as a matter of urgency.
As I emerged into the sunlight, it suddenly dawns on me that, if I could manage to get hold of her, there is a chance I could still take Auntie Joan out for lunch. I hadn't heard from her since our earlier fraught conversation and, despite doing my best to push it from my mind, I was still feeling regret at that unhappy outcome. I knew, despite how I'd disappointed her, that she had still come up to London because I'd had an awkward conversation with Ruth earlier in the week, when she'd phoned me and asked for a lunch venue recommendation. I'm not sure why she expected that I would be able to oblige but I suppose, only having recently moved back to the city herself, she might not be in a position to make any suggestions. Somewhat fortuitously, a few months earlier I'd had a very satisfactory experience at a Japanese restaurant in Pimlico, where I had spent a fascinating evening with colleagues from the University of Tokyo hospital. It had been edifying in many levels, both medical and cultural, and I had learned much of interest including the levels of freshness and hygiene expected from food preparation in Japan. The sushi chef had been required to train in his craft for almost as long as I had been in medicine and I watched his knife technique, as he prepared an array of superior quality fish, with undisguised admiration.
I hastened for home and, as soon as I was back inside my flat, I placed a call to Ruth's number and, much to my relief, Auntie Joan picked up the call. She had been the closest thing to a mother to me when I was a child and, for that, I cared deeply for her. However, that didn't mean that I didn't find her to be one of the most stubborn and infuriating human beings to ever walk the earth. Our irregular phone calls usually ended in uncomfortable silence- I am not a natural conversationalist, I understand that, but I am never quite sure what she wants me to actually say. I can't imagine that she is interested in my work so I'm not entirely sure what it is that wants to hear. These days, I'm always conscious of her understated irritation with me, and her frustration at my inability to make idle chit chat. I am bewildered and so the safest thing I find is to avoid speaking to her which only seems to make things worse. For this visit though, I am cognisant of the fact that she feels that I have let her down and I want to address that. I will do my best to be forthcoming, and converse on subjects within my area of expertise.
When she answers the telephone, and realises it is me, I inform her that I am now in a position to have lunch with her. My pronouncement is met with silence; I'm not sure why I expected her to sound pleased but that's not the impression she gives me. In order to further mollify her, I offer to collect her from Ruth's flat in Grosvenor Rd, and drive us both to lunch. She informs me that Ruth had made a booking for one o'clock, based on my recommendation and, though I sensed she was grateful to now not have to navigate public transport, I didn't sense any pleasure in the fact I was now able to join her. Let me be quite clear that I'm quite accustomed to this sort of situation. I know I am a difficult person and I have long since abandoned any ideas of being anyone's choice of companion. However, Auntie Joan is the only person I know that has ever seemed to take any pleasure from an association with me so it does make me feel slightly discomfited that even she doesn't seem happy that I'm able to join her. I wrack my brain and it occurs to me that perhaps the upset of my last visit to Cornwall, and witnessing Edith's appalling behaviour, has affected her more deeply than I'd imagined. It was, after all, very distasteful. However, the last evening Auntie Joan and I had spent together at the farm, after I'd deposited that procacious whirlwind of a child into the care of her new guardian, had seemed pleasant and comfortable so I was at a bit of a loss as to why exactly Joan seemed so off with me now. It was feasible that, just because I'd never given Edith a second thought, it didn't actually mean she hadn't rather upset Joan, and it probably had been remiss of me not to have subsequently visited her on the farm. But, what was done was done and I'd just have to live with that.
When I reached Pimlico, and got out to open the car door for her I was, initially, quite relieved to discover that Joan did in fact seem pleased to see me. I was, however, somewhat embarrassed to have to stand on the pavement while she hugged me and then, when she inspected me from head to toe, like some sort of prize pig. She even poked me in the kidneys with a rheumaticky finger and pronounced me 'lean', before informing me that I had grown handsomely. At least the lean part was true, and I watched her as she'd beamed up at me, her eyes still so bright and her expression shrewd; I was, however, disturbed to observe that she had put on a significant amount of weight; at a glance I could tell that her BMI was outside healthy guidelines for her age and sex, and I would try and talk to her about that over lunch.
All in all, and especially after the extreme frustrations of the morning, I was rather happy to see her again and I was greatly looking forward to a quiet, pleasant meal with the added benefit of lean protein and fresh ingredient prepared with surgical precision and exemplary hygiene. I especially wanted to make sure she was managing the farm alone, and that she was coping financially; I had my concerns about her situation and I sensed that, like her weight gain, it would not be an easy topic to broach.
We chatted amiably for the duration of the drive. Though reluctant to initiate it in conversation, I suppose I am always most comfortable when talking about my work and, to her credit, Joan has always been my most staunch supporter, and has always indicated to me that she is proud of my achievements. In that way, she stands alone in my family and for this reason I will always be grateful to her; throughout my life she has been the one and only constant I have been able to rely on. In view of how ghastly my parents were, I was very lucky to have her.
Miraculously I find a parking space and we make the short walk to the restaurant, side by side, in my preferred version of conversation; she is talking animatedly about the immense changes she has seen in the city since last she visited, and I am listening. I hold the door open for her and she passes in front of me. I seem to tower over her. Could she have shrunk that much? Osteoporosis crosses my mind and I add it to the list of topics I feel I must address with her.
The young and exceptionally polite Maitre D' shows us to our table. As I follow behind my aunt I notice with wry amusement that she still maintains her great fondness for shapeless garments and handmade cardigans. Firstly, I'm relieved that we're not seated in the sunken area where one is required to remove ones shoes; obtaining access to which might also provide a challenge for my stiffly-gaited lunch companion, while I also suspect that that sitting on the floor might be just a trifle too much culture for my countrified, traditionalist aunt. As we are shown to our booth I am pleased to see that it is secluded and private, but, abruptly, I feel my relief and good humour evaporate as our table is clearly set for three. In an instant, I feel an overwhelming flash of frustration and, dare I say it, resentment.
I wait for Joan to be seated and then I lower myself into the place opposite her. Ostensibly, she fusses with her napkin but, when she is finally brave enough to meet my gaze, I raise one eyebrow and she knows immediately what I mean. I see her shift in her seat and I allow myself to feel a tiny amount of righteousness as I sense her unease.
"Don't look at me like that, Marty, it's you that's the third wheel today" she says somewhat defensively.
I stare back at her, aghast.
"Well, thanks for that Auntie Joan, I've just driven an hour round trip to get you but that's fine. I'll happily leave, shall I, so I'm not in the way?"
If I now sound churlish, I no longer care. So far it's been a difficult, disappointing and frustrating day and, now, I'm assailed by the horrifying thought that I will be forced to share our time together with another of the old crones Auntie Joan tends to collect; a long-forgotten school friend, a favourite old teacher or maybe her childhood nanny; smelling of lavender and mothballs, with a whiskery chin and loose dentures. Or worse still, some ancient paramour, in a shiny, worn suit, dribbling his meal down his moth-eaten, hand knitted tie, and speaking endlessly of cricket and immigration, and waxing lyrical about his halcyon days.
I had begun to work myself up somewhat now and I feel my disappointment turning to anger. I'm struggling to maintain my composure as frustration, disappointment and exhaustion begin to render me unreasonable.
"Honestly, Auntie Joan, couldn't it have just been us? We've things to discuss for goodness sake! Please tell me it's not one of the dreadful old biddies from your reunion!"
She stares at me defiantly.
"Marty, it would have been just us, as you say, except that you took forever to reply to my message, only to then tell me you couldn't possibly attend. By that time, I'd imagined myself sitting here at lunch, very much alone." She replied loudly and indignantly. "That may be your idea of a birthday treat but it is most definitely not mine."
My heart sank. Personally, I had no interest in the childish commemoration of birth dates but I was aware that many people did, and Auntie Joan was definitely in the birthday celebration demographic. Was that why she seemed cross with me? The thought was utterly ridiculous and, in view of my current level of fatigue and overextension, I couldn't help but feel aggrieved then, and I knew that the tone of my voice was edging toward icy vitriol as my feelings threatened to boil over.
"If you want to know, Auntie Joan, I have had a hellish month and I've barely been at home at all. It's only due to yet another extremely stressful, unmitigated disaster, and the incompetence of a miserable collection of utter morons, that I could in fact join you today. Just so you are clear, as soon as I was aware of my availability today, I prioritised our lunch over everything else. But, by all means, tell me I'm the unwanted third wheel."
I folded my arms and stared at her, struggling to contain my burgeoning resentment. Why, whenever I tried to do the right thing, did I end up in yet another situation of conflict and discontent. In an explosion of frustration, I threw my napkin down onto the table petulantly.
"I need the lavatory." I said coldly and, glaring at her, I stood up and strode away.
The space itself was small and dominated by a large wall hanging of a koi carp. I recalled with relief the high standards of sanitation; impressed by the spotless cleanliness and how well appointed it was, with quality unscented liquid soap and a generous supply of soft cotton hand towels.
Forcing myself to stare at my own reflection, I inhaled and exhaled deeply for several breaths until I felt the tension start to lift from my shoulders, and I noticed my colour in my face return to normal. I must take whatever time needed to regain my equilibrium.
"Good god, Ellingham, you faced worse on a daily basis when you were eight years old and you behaved with more decorum." I thought to myself. "What happened to your famous composure? Where's your dignity, man?"
I lifted my chin and reached up to adjust my tie.
"Inviolable hmmm? And yet behaving like a baby at the first setback. Are you really that pathetic?"
I rolled my shoulders over and, flexing my fists, I felt the tension begin to ebb away. Feeling my heart slow, and noting the gentle, rhythmic rise and fall of my chest calmed me even further and, despite feeling so drained, I reassured myself that I would get my emotions under control and I could regain my former sanguine state. In fact, there was actually no question, I must.
I had made up my mind that I would stay at lunch just long enough to sample the sashimi of the day and then I would leave Auntie Joan and her guest to whatever delights their afternoon afforded. If I paid for both lunch and a taxi to return them from whence they came, I would feel like I had discharged my responsibilities without being churlish, and I would still have sufficient time in the afternoon to spend in my own company, perhaps even take some much needed exercise. It seems to me like an acceptable solution that was surely better for everyone.
Squaring my shoulders and standing as tall as I could manage, I observed with satisfaction as my face assumed its usual practiced expression of haughty and untroubled self reliance. After a moment, I burst through the door and, even if at that moment I didn't exactly feel it, I marched back out into the restaurant, content that I looked every inch the confident and charismatic surgeon.
In retrospect, the next few moments seem disjointed and confused but, as I approached our table, I was indistinctly aware that my Aunt's guest had arrived. Before I had the chance to think, I suddenly felt an alarming falling sensation, like the half-asleep hallucination known as the hypnic jerk, or the disconcerting affect of aeroplane turbulence, as the rapid drop in altitude wrenches your breath from your body.
I stood like a statue, momentarily transfixed, willing myself to look away with every shred of mental strength that I had remaining, and yet I failed dismally. Momentarily stunned, there I remained for what seemed like forever, my famously steady hands clasped behind my back so that I could control their worrying tremble.
I finally reclaimed my equilibrium, daring to take a step forward, and that is when she noticed me. Immediately, a sweetly nervous smile spread across her face and she was somehow lit from within. Disconcertingly, I felt my own sense of heat; emanating from my lower abdomen and radiating throughout my body, culminating in a flush that burned across my face. If I felt appalled at my reaction, it didn't matter because, by God, she was so utterly breathtaking I couldn't make myself look away.
When she spoke, her voice was soft and gentle but, somehow, it still felt like a blow to my solar plexus, and, again, all the breath was drained from my body and I was left with merely the thundering sound of my racing heart.
"Hello, Martin." She said tentatively, and it was then that I knew for absolute certain.