Saturday. Part 11

Henry says to Jay, Ts there blood around?'

Gita Syal answers, 'Plenty in the fridge.'

Ts the patient haemodynamically stable?'

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'Blood pressure and pulse are OK. And pre-op bloods are fine, airway pressure's fine/ Jay says. 'We're ready to roll, boss.'

Perowne takes a look at Baxter's head to make sure Rodney has shaved him in exactly the right place. The laceration is straight and clean - a wall, a skirting board, a stone-floor landing rather than the grit and filth you see in wounds after a road traffic accident - and has been sewn up by A and E. Even without touching, he can see that the top of his patient's head has an area of boggy swelling - blood is collecting between the bone and the scalp.

Satisfied with the registrar's work, he says to him as he leaves, 'Take the sutures out while I scrub up.' Henry pauses in the corner to choose some piano music. He decides on the 'Goldberg' Variations. He has four recordings here, and selects not the showy, unorthodoxies of Glenn Gould, but Angela Hewitt's wise and silky playing which includes all the repeats.

Less than five minutes later, in long disposable gown, gloves and mask, he's back at the table. He nods at Gita to start the CD player. From the stainless-steel trolley Emily has positioned at his side, he takes a sponge on a clamp and dips it in a bowl of Betadine solution. The tender, wistful Aria begins to unfold and spread, hesitantly it seems at first, and makes the theatre seem even more s.p.a.cious. At the very first stroke of sunflower yellow on pale skin, a familiar content edness settles on Henry; it's the pleasure of knowing precisely what he's doing, of seeing the instruments arrayed on the trolley, of being with his firm in the m.u.f.fled quiet of the theatre, the murmur of the air filtration, the sharper hiss of oxygen pa.s.sing into the mask taped to Baxter's face out of sight under the drapes, the clarity of the overhead lights. It's a reminder from childhood of the closed fascination of a board game.

He sets down the brush and says quietly, 'Local.'

Emily pa.s.ses him the hypodermic she has prepared. Quickly he injects in several places under skin, along the line 250.

of the laceration and beyond. It's riot strictly necessary, but the adrenaline in the lignocaine helps reduce the bleeding. At each location the scalp immediately swells into b.u.mps. He sets down the hypodermic and opens his hand. He doesn't have to ask - Emily places within his grasp the nicely weighted skin knife. With it he extends the laceration by several inches, and deepens it. Rodney is close at his side with the bipolar cauteriser, closing off the bleeding points in two or three places. At each contact there is a bleep, and a thin trail of greyish smoke rises with a sharp odour of singed flesh. Despite his bulk, Rodney cleverly avoids crowding his consultant's s.p.a.ce and applies the small blue Raney clips that pinch tightly on the parted skin and close off the blood supply.

Perowne asks for the first of the big self-retaining retractors and sets it in place. He lets Rodney attach the second and now the long incision is stretched apart like a wide-open mouth to reveal the skull and all the damage.

The fracture runs fairly straight. Blood, altered blood, is rising up through it. Once Rodney has washed out the area with saline and wiped it, they can see the crack in the bone is about two millimetres wide - it looks like an earthquake fissure seen from the air, or a crack in a dry riverbed. The depressed fracture in the centre has two segments of bone at a tilt with three other finer cracks radiating from them. There'll be no need to drill a burr hole. Perowne will be able to slip the cutting saw into the larger fissure.

Emily presents the craniotome, but he doesn't like the look of the footpiece - it seems a little skewed. Joan hurries into the prep room and comes back with another. It's satisfactory, and while she unpacks it from the sterile wrapping and fits it, he says to Rodney, 'We'll turn a free flap around the depressed fracture so that we've got full control of the sinus.'

It's said that no one opens up faster than Henry Perowne. Now he goes even more quickly than usual because there's no danger of damaging the dura - the clot is pressing down on it, pushing it away from the skull. Although Rodney leans 251.

in with a Dakin's syringe to douse the cutting edge with saline solution, the smell of singed bone fills the theatre. It's a smell Henry sometimes finds clinging to the folds of his clothes when he undresses at the end of a long day. It's impossible to speak over the high-pitched whine of the craniotome. With his eyes he indicates to Rodney that he should observe closely. Exceptional care is needed now as he guides the saw across the midline. He slows, and tills the footpiece of the drill upwards - otherwise there's a danger that it will catch and tear the sinus. It's a wonder brains come to any harm at all outside an operating theatre1 when they're encased so thickly in bone. At last Perowne has cut round a complete oval shape behind the crown of Baxter's head. Before he lifts the flap he examines the fragments of the depressed fracture. He asks for a Watson Cheyne dissector and levers them gently up. They come away easily and he puts them into the kidney bowl of Betadine that Emily offers.

Now, using the same dissector, he lifts the whole free flap away from the skull, a large piece of bone like a segment of coconut, and lays it in the bowl with the other bits. The clot is in full view, red of such darkness it is almost black, and of the consistency of recently set jam. Or, as Perowne sometimes thinks, like a placenta. But round the edges of the clot, blood is flowing freely now that the pressure of the bone flap has been relieved. It pours from the back of Baxter's head, over the surgical drapes and onto the floor.

'Elevate the head of the table. Give me as much as you can,' Henry calls to Jay. If the bleed is higher than the heart, the blood will flow less copiously. The table rises, and Henry and Rodney step back in quickly through the blood at their feet and, working together, use a sucker and an Adson elevator to remove the clot. They irrigate the area with saline and at last get a glimpse of the tear, about quarter of an inch long, in the sinus. The bone flap was well placed - the damage is right in the centre of the exposure. The welling blood 252.

immediately obscures their view again. An edge of bone from the depressed fragment must have pierced the vessel. While Rodney holds the sucker in place, Perowne takes a strip of Surgicel and lays it over the tear, places a swab on top and indicates to Rodney to press down with his finger.

Henry asks Jay, 'How much blood have we lost?'

He hears Jay ask Joan how much irrigation has been used. Together they make the calculation.

Two point five litres,' the anaesthetist says quietly.

Perowne is about to ask for the periostal elevator, but FmiU" is already placing it in his hands, fie finds an area of exposed but undamaged skull, and with the elevator - a kind of sc.r.a.per - harvests two long pieces of pericranium, the fibrous membrane that covers the bone. Rodney lifts the swab, and is about to lift also the Surgicel from the tear, but Perowne shakes his head. A clot might be already forming and he doesn't want to disturb it. He gently lays the strip of pericranium over the Surgicel, and adds a second layer of Surgicel and the second strip of pericranium, and places a new swab on top. Then Rodney's finger. Perowne rinses out the area again with saline and waits. The opaque milky bluish dura remains clear. The bleeding has stopped.

But they can't begin to close up yet. Perowne takes a scalpel and makes a small incision in the dura, parts it a little and peers inside. The surface of Baxter's brain is indeed covered with a clot, much smaller than the first. He extends the incision and Rodney tucks back the dura with stay sutures. Perowne is pleased with the speed of his junior registrar's work. Rodney uses the Adson to lift out the congealed blood. They wash out with saline, sucker the mix away and wait to see if the bleeding continues - Perowne suspects that one of the nearby arachnoid granulations could be a source. There's nothing, but he doesn't close up just yet. He prefers to wait a few minutes, just to be sure.

In this lull, Rodney goes over to a table by the prep room door and sits down to drink a bottle of water. Emily is busy 253.

with the instrument tray, Joan is dealing with the wide pool of blood on the floor.

Jay breaks off a murmured conversation with his registrar to say to Perowne, 'We're fine over here.'

Henry remains at the head of the table. Though he's been conscious of the music, only now does he give it his full attention again. Well over an hour has pa.s.sed, and Hewitt is already at the final Variation, the Quodlibet - uproarious and jokey, raunchy even, with its echoes of peasant songs of food and s.e.x. The last exultant chords fade away, a few seconds' silence, then the Aria returns, identical on the page, but changed by all the variations that have come before, still tender, but resigned too, and sadder, the piano notes floating in from a distance, as though from another world, and only slowly swelling. He's looking down at a portion of Baxter's brain. He can easily convince himself that it's familiar territory, a kind of homeland, with its low hills and enfolded valleys of the sulci, each with a name and imputed function, as known to him as his own house. Just to the left of the midline, running laterally away out of sight under the bone, is the motor strip. Behind it, running parallel, is the sensory strip. So easy to damage, with such terrible, lifelong consequences. How much time he has spent making routes to avoid these areas, like bad neighbourhoods in an American city. And this familiarity numbs him daily to the extent of his ignorance, and of the general ignorance. For all the recent advances, it's still not known how this well-protected one kilogram or so of cells actually encodes information, how it holds experiences, memories, dreams and intentions. He doesn't doubt that in years to come, the coding mechanism will be known, though it might not be in his lifetime. Just like the digital codes of replicating life held within DNA, the brain's fundamental secret will be laid open one day. But even when it has, the wonder will remain, that mere wet stuff can make this bright inward cinema of thought, of sight and sound and touch bound into a vivid illusion of an instan 254.

taneous present, with a self, another brightly wrought illusion, hovering like a ghost at its centre. Could it ever be explained, how matter becomes conscious? He can't begin to imagine a satisfactory account, but he knows it will come, the secret will be revealed - over decades, as long as the scientists and the inst.i.tutions remain in place, the explanations will refine themselves into an irrefutable truth about consciousness. It's already happening, the work is being done in laboratories not far from this theatre, and the journey will be completed, Henry's certain of it. That's the only kind of faith he has. There's grandeur in this view of life.

No one else in the theatre knows the hopeless condition of this particular brain. The motor strip he's looking at now is already compromised by disease, most likely by deterioration in the caudate and putamen, deep in the centre of the brain. Henry places his finger on the surface of Baxter's cortex. He sometimes touches a brain at the beginning of a tumour operation, testing the consistency. What a wonderful fairy tale, how understandable and human it was, the dream of the healing touch. If it could simply be achieved with the caress of a forefinger, he'd do it now. But the limits of the art, of neurosurgery as it stands today, are plain enough: faced with these unknown codes, this dense and brilliant circuitry, he and his colleagues offer only brilliant plumbing.

Baxter's unmendable brain, exposed under the bright theatre lights, has remained stainless for several minutes - there's no sign of any bleeding from the arachnoid granulation.

Perowne nods at Rodney. 'It's looking fine. You can close up.'

Because he's pleased with him, and wants him to feel better about the evening, Perowne lets his registrar take the lead. Rodney sews up the dura with purple thread - 3-o Vicryl - and inserts the extradural drain. He replaces the bone flap, along with the two broken pieces from the depressed fracture. Then he drills the skull to screw in place the t.i.tanium plates that hold the bone secure. This part of Baxter's skull 255.

now resembles crazy paving, or a broken china doll's head clumsily repaired. Rodney inserts the subgaleal drain and then sets about sewing the skin of the scalp with 2-o Vicryl and punching in the skin staples. Perowne gets Gita to put on Barber's 'Adagio for Strings'. It's been played to death on the radio these past years, but Henry sometimes likes it in the final stages of an operation. This languorous, meditative music suggests a long labour coming to an end at last.

Rodney puts chlorhexadine on and around the wound and applies a small dressing. It's at this point that Henry takes over - he prefers to do the head dressing himself. He releases one by one the pins of the head clamp. He takes three opened out large gauze swabs and places them flat on Baxter's head. Around the head he lays two gauze swabs left long. Holding the five swabs in place with his left hand, he begins to wind a long crepe bandage around Baxter's head while supporting it against his waist. It's technically and physically difficult, avoiding the two drains and preventing the head from dropping down. When at last the head bandage is in place and secured, everyone in the theatre, the whole firm, converges on Baxter - this is the stage at which the patient's ident.i.ty is restored, when a small area of violently revealed brain is returned to the possession of the entire person. This unwrapping of the patient marks a return to life, and if he hadn't seen it many hundred times before, Henry feels he could almost mistake it for tenderness. While Emily and Joan are carefully pulling away the surgical drapes from around Baxter's chest and legs, Rodney makes sure the tubes, leads and drains are not dislodged. Gita is removing the pads taped over the patient's eyes. Jay is detaching the inflatable warming blanket from around Baxter's legs. Henry stands at the end of the table, cradling the head in his hands. The helpless body is revealed in a hospital gown and looks small on the table. The meditative, falling line of the orchestral strings seems to be addressed to Baxter alone. Joan pulls a cover over him. Taking care not to tangle the extradural and subgaleal drains, 256.

they turn Baxter onto his back. Rodney slots a padded horseshoe into the end of the table and Henry rests Baxter's head on it.

Jay says, 'You want me to keep him sedated overnight?' 'No/ Henry says. 'Let's wake him up now.' The anaesthetist will ease Baxter - simply by the withdrawal of drugs - into taking over his own breathing from the ventilator. To monitor the transition, Strauss holds in the palm of his hand a little black sac, the reservoir bag, through which Baxter's breathing will pa.s.s. Jay prefers to trust to his sense of touch rather than the electronic array on the anaesthetic machine. Perowne pulls off his latex gloves and ritually pings them across the room towards the bin. They go in - always a good sign.

He takes off his gown and stuffs that into the bin too, then, still in his hat, goes down the corridor to find a form to do his op note on. At the desk, he finds the two policemen waiting, and tells them that Baxter will be transferred within ten minutes to the intensive care unit. By the time he gets back, there's a different atmosphere in the theatre. Country and Western music - Jay's taste - has replaced Samuel Barber. Emmylou Harris is singing 'Boulder to Birmingham'. Emily and Joan are discussing a friend's wedding as they clean up the theatre - on the night shift this dull task falls to the scrub nurses. The two anaesthetists and Rodney Browne are talking about offset mortgages and interest rates as they make the final preparations for the patient to be transferred to intensive care. Baxter lies peacefully on his back showing no signs of consciousness yet. Henry grabs a chair and starts his notes. In the name s.p.a.ce he writes 'known as Baxter', and in the date of birth, 'est. age plus/minus 25'. All the other personal details he has to leave blank.

'You've got to shop around,' Jay is telling Gita and Rodney. 'You're in a buyer's market.'

'It's a spray-on tan,' Joan says to Emily. 'She's not allowed in the sun because she gets basal cell carcinomas. Now she's 257.

gone bright orange, face, hands, everything, and the wedding's on Sat.u.r.day/ The chatter is soothing to Henry as he quickly writes, 'ext/subdural, sup sag sinus repair, pt p.r.o.ne, head elevated & in pins, wound extended/retracted, free bone flap turned . . .'

For the past two hours he's been in a dream of absorption that has dissolved all sense of time, and all awareness of the other parts of his life. Even his awareness of his own existence has vanished. He's been delivered into a pure present, free of the weight of the past or any anxieties about the future. In retrospect, though never at the time, it feels like profound happiness. It's a little like s.e.x, in that he feels himself in another medium, but it's less obviously pleasurable, and clearly not sensual. This state of mind brings a contentment he never finds with any pa.s.sive form of entertainment. Books, cinema, even music can't bring him to this. Working with others is one part of it, but it's not all. This benevolent dissociation seems to require difficulty, prolonged demands on concentration and skills, pressure, problems to be solved, even danger. He feels calm, and s.p.a.cious, fully qualified to exist. It's a feeling of clarified emptiness, of deep, muted joy. Back at work and, lovemaking and Theo's song aside, he's happier than at any other point on his day off, his valuable Sat.u.r.day. There must, he concludes as he stands to leave the theatre, be something wrong with him.

He takes the lift one floor down and goes along a polished, dim corridor to the neurological ward where he makes himself known to the nurse on duty. Then he walks in, and pauses outside a four-bed room to look through the gla.s.s. Seeing a reading light on above the nearest bed, he opens the door quietly and goes in. She's sitting up writing in a notebook with a pink plastic cover. As Henry sits down by her bed and before she has time to close her book, he notices that she's drawn for the dot of each 'i' a meticulous heart.

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She gives him a sleepy welcoming smile. His voice is barely above a whisper.

'Can't sleep?'

They gave me a pill, but I can't stop my mind.'

'I get that too. In fact, I had it last night. I was pa.s.sing by, so - a good time to tell you myself. The operation went really well.'

With her fine dark skin, her round and lovely face, and the thick crepe bandage that he wound round her head yesterday afternoon, she has a dignified, sepulchral look. An African queen. She wriggles clown the bed and ptiMs the covers round her shoulders, like a child preparing to hear a familiar bedtime story. She hugs her notebook to her chest.

'Did you get it all out like you said?'

'It came out like a dream. It rolled out. Every last bit.'

'What's that word you said before, about how it's going to go?'

He's intrigued. Her change in manner, her communicative warmth, the abandonment of the hard street talk, can't simply be down to her medication, or tiredness. The area he was operating in, the vermis, has no bearing on emotional function.

'Prognosis,' he tells her.

'Right. So doctor, what's the prognosis?'

'Excellent. Your chances of a total recovery are 100 per cent.'

She shrugs herself deeper into the bed covers. The love hearing you say that. Do it again.'

He obliges, making his voice as sonorous and authoritative as he can. He's decided that whatever's changed in Andrea Chapman's life is written down in her notebook. He taps its cover with a finger.

'What do you like to write about?'

'It's a secret,' she says quickly. But her eyes are bright, and her lips part as if she's about to speak. Then she changes her mind and clamps them shut and with a mischievous look stares past him at the ceiling. She's dying to tell.

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He says, 'I'm very good at secrets. You have to be when you're a doctor.'

'You tell no one, right?'

'Right/ 'You solemnly promise on the Bible?'

'I promise to tell no one.'

'It's this. Right? I've derided. I'm going to be a doctor.'

'Brilliant.'

'A surgeon. A brain surgeon.'

'Even better. But get used to calling yourself a neurosurgeon.' 'Right. A neurosurgeon. Everybody, stand back! I'm going to be a neurosurgeon.'

No one will ever know how many real or imagined medical careers are launched in childhood during a postoperative daze. Over the years, a few kids have divulged such an ambition to Henry Perowne on his rounds, but no one has quite burned with it the way Andrea Chapman does now. She's too excited to lie covered up. She struggles up the bed, plants her elbow on the mattress, and as best she can with her drain still in place, rests her head on her hand. Her gaze is lowered, and she's thinking carefully before asking her question.

'Have you just been doing an operation?'

'Yes. A man fell down stairs and whacked his head.'

But it's not the patient she's interested in. 'Was Dr Browne there?'

'Yes, he was.'

Finally. She looks up at Henry with an expression of pleading honesty. They are at the heart of her secret.

'Isn't he just a wonderful doctor?'

'Oh, he's very good. The best. You like him, do you?'

Unable to speak, she nods, and he waits a good while.

'You're in love with him.'

At the utterance of the sacred words she flinches, then quickly checks his face for mockery. She finds him impenetrably grave.

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He says delicately, 'You don't think he's a little old for you?'

'I'm fourteen,' she protests. 'Rodney's only thirty-one. And the thing is this . . .'

She's sitting up now, still pressing her pink book to her chest, joyous to be addressing at last the only true subject.

'. . . he comes and sits where you are, and says to me about how if 1 want to be a doctor I need to get serious about studying and that, and stop clubbing and that, and he doesn't even know what's happening between us. It's happening without him. He's got no idea! I mean, he's older than me, he's this important surgeon and everything, but he's so innocentV She outlines her plans. As soon as she's qualified as a consultant - in twenty-five years' time, by Henry's private calculation - she'll be joining Rodney in Guyana to help him run his clinic. After a further five minutes of Rodney, Perowne rises to leave. When he reaches the door she says, 'Do you remember you said like you'd make a video of my operation?'

'Yes.'

'Can I see it?'

'I suppose so. But are you really sure you want to?'

'Oh my G.o.d. I'm going to be a neurosurgeon, remember? I really need to watch it. I want to see right inside my head. Then I'm going to have to show it to Rodney.'

On his way out, Perowne lets the nurse know that Andrea is awake and lively, then he takes the lift up to the third floor again and walks back down the long corridor that runs behind the neurosurgery suite and brings him by the main entrance to intensive care. In soothing gloom he goes along the broad avenue of beds with their watchful machines and winking coloured lights. He's reminded of neon signs in a deserted street - the big room has the ephemeral tranquillity of a city just before dawn. At the desk he finds the nurse in charge, Brian Reid, a Geordie, busy filling out forms, and learns that 261.

all Baxter's signs are good, that he's come round and is dozing. Reid nods significantly towards the two policemen sitting in the shadows near Baxter's bed. Perowne was intending to walk home as soon as he was satisfied his patient was stable, but as he comes away from the desk, he finds himself going across. At his approach the constables, bored or half asleep, get to their feet and politely explain that they'll wait outside in the corridor.

Baxter is lying on his back, arms straight at his sides, hooked up to all the systems, breathing easily though his nose. There's no tremor in the hands, Perowne notices. Sleej: is the only reprieve. Sleep and death. The head bandage doesn't enn.o.ble Baxter the way it did Andrea. With his heavy stubble and dark swelling under the eyes he looks like a fighter laid out by a killer punch, or an exhausted chef, kipping in the storeroom between shifts. Sleep has relaxed his jaw and softened the simian effect of a muzzle. The forehead has loosened its habitual frown against the outrageous injustice of his condition, and gained him some clarity in repose.

Perowne brings a chair over and sits down. A patient at the far end of the room calls out, perhaps in her sleep, a sharp cry of astonishment repeated three times. Without turning, he's aware of the nurse going towards her. Perowne looks at his watch. Three thirty. He knows he should be going, that he must not fall asleep in the chair. But now he's here, almost by accident, he has to stay a while, and he won't doze off because he's feeling too many things, he's alive to too many contradictory impulses. His thoughts have a.s.sumed a sinuous, snaking quality, driven by the same undulating power that's making the s.p.a.ce in the long room ripple, as well as the floor beneath his chair. Feelings have become in this respect like light itself - wavelike, as they used to say in his physics cla.s.s. He needs to stay here and, in his usual manner, break them down into their components, the quanta, and find all the distal and proximal causes; only then will he know what to do, what's right. He slips his hand around Baxter's 262.

wrist and feels for his pulse. It's quite unnecessary because the monitor's showing a reading in bright blue numerals - sixty-five beats per minute. He does it because he wants to. It was one of the first things he learned to do as a student. Simple, a matter of primal contact, rea.s.suring to the patient - so long as it's done with unfaltering authority. Count the beats, those soft footfalls, over fifteen seconds, then multiply by four. The nurse is still up at the far end of the ward. The constables in the corridor are just visible through a window in the unit's swing doors. Far more than a quarter of a minute pa.s.ses. In effect, he's holding Baxter's hand while he attempts to sift and order his thoughts and decide precisely what should be done.

Rosalind has left a lamp on in the bedroom, by the sofa, under the mirror; the dimmer switch is turned low and the bulb gives less light than a candle. She's lying curled on her side, with the covers bunched against her stomach, and the pillows discarded on the floor - sure signs of troubled sleep. He watches her from the foot of the bed for a minute or so, waiting to see if he disturbed her as he came in. She looks young - her hair has fallen forwards across her face, giving her a carefree, dissolute air. He goes to the bathroom and undresses in semi-darkness because he doesn't want to see himself in the mirror - the sight of his haggard face could set him off on a meditation about ageing, which would poison his sleep. He takes a shower to wash away the sweat of concentration and all traces of the hospital - he imagines fine bone dust from Baxter's skull lodged in the pores of his forehead - and soaps himself vigorously. As he's drying he notices that even in poor light, the bruise on his chest is visible and appears to have spread, like a stain in a cloth. It hurts less though when he touches it. It feels like a distant memory now, months ago, when he took that blow and felt the sharp ridge of a shock wave run through his body. More insult than pain. Perhaps he should turn the light on after all and examine it.

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But he goes into the bedroom, still with his towel, and switches off the lamp. One shutter stands ajar by an inch, casting a blurred rod of soft white light across the floor and up the facing wall. He doesn't trouble himself with closing the shutter - total darkness, sense deprivation, might activate his thoughts. Better to stare at something, and hope to feel his eyelids grow heavy. Already, his tiredness seems fragile, or unreliable, like a pain that comes and goes. He needs to nurture it, and avoid thoughts at all costs. Standing on his side of the bed, he hesitates; there's enough light to see that Rosalind has taken all the covers, and has knotted them under her and against her chest. Pulling them free is bound to wake her, but it's too cold to sleep without them. He fetches from the bathroom two heavy towelling dressing gowns to use as blankets. She's sure to roll over soon, and then he'll take his share.

But as he's getting into bed, she puts her hand on his arm and whispers, 'I kept dreaming it was you. Now it really is.'

She lifts the covers and lets him enter the tent of her warmth. Her skin is hot, his is cool. They lie on their sides, face to face. He can barely see her, but her eyes show two points of light, gathered from the tip of the white bar rising on the wall behind him. He puts his arms around her and as she moves closer into him, he kisses her head.