Saturday (30 page)

Perowne pushes a way through the small knot of people. When he reaches the first door the guards, Mitch and Tony, both West Indian, recognise him and let him through.

‘How's it going?'

Tony, whose wife died of breast cancer last year and who's thinking of training as a paramedic, says, ‘Quiet, you know, relative like.'

‘Yeah,' Mitch says. ‘We just got the quiet riot tonight.'

Both men chuckle and Mitch adds, ‘Now Mr Perowne, all the wise surgeons got the flu.'

‘I'm truly unwise,' Henry says. ‘There's an extradural.'

‘We seen him.'

‘Yeah. You better get up there, Mr Perowne.'

But instead of going straight ahead to the main lifts, he makes a quick detour through the waiting area towards the treatment rooms, just in case Jay or Rodney while waiting has come down for another case. The public benches are quiet, but the long room has a battered, exhausted look, as though at the end of a successful party. The air is humid and sweet. There are drinks cans on the floor, and someone's sock among the chocolate bar wrappers from the vending machines. A girl has an arm round her boyfriend who's slumped forward, head between his knees. An old lady wearing a fixed, faint smile waits patiently with her crutches resting on her lap. There are one or two others staring at the floor, and someone stretched out full length, asleep on a bench, head covered by a coat. Perowne walks past the treatment cubicles to the crash room where a team is working on a man who's bleeding heavily from his neck. Outside, in the majors' area, by the staff base, he sees Fares, the on-duty A and E registrar whom he spoke to on the phone.

As Perowne approaches, Fares says, ‘Oh right. That friend you phoned about. We've cleared cervical-spine. The CT scan showed a bilateral extradural with a probable depressed fracture. He dropped a couple of points so we called in a crash induction. They took him upstairs half an hour ago.'

An X-ray of the neck – the first investigative measure – suggests there'll be no complications with Baxter's breathing. His level of consciousness as measured by the Glasgow Coma Score has fallen – not a good sign. An anaesthetist – probably
Jay's registrar – was called down to prepare him for emergency surgery which will have involved, among other things, emptying Baxter's stomach.

‘What's his score now?'

‘Eleven down from thirteen when he came in.'

Someone calls Fares's name from the crash room, and by way of excusing himself he says as he leaves, ‘Bottle fight in a bus queue. And oh yeah. Mr Perowne. Two policemen went up with your friend.'

 

Perowne takes the lift up to the third floor. As soon as he steps out into the broad area that gives onto the double doors of the neurosurgical suite, he feels better. Home from home. Though things sometimes go wrong, he can control outcomes here, he has resources, controlled conditions. The doors are locked. Peering through the glass he can see no one about. Rather than ring the bell, he takes a long route down a corridor that will bring him through intensive care. He likes it here late at night – the muted light, the expansive, vigilant silence, the solemn calm of the few night staff. He goes down the wide space between the beds, among winking lights and the steady bleeps of the monitors. None of these patients is his. Now that Andrea Chapman has been moved out, all the people on yesterday's list are back in their wards. That's satisfying. In the marshalling area outside the ICU, the space looks unnaturally empty. The usual clutter of trolleys has been removed – tomorrow they'll be back, and all the bustle, the constantly ringing phones, the minor irritation with the porters. Rather than call Rodney or Jay out of the theatre, and to save time, he goes straight to the changing room.

He taps a code in the number lock, and steps into a cramped and homely squalor, a particularly masculine kind of pigsty suggestive of several dozen delinquent boys far from home. He uses a key to open his locker and starts to undress hurriedly. Lily Perowne would have been horrified – scattered
across the floor are discarded scrubs, some clean, some used, along with the plastic bags they came in, and trainers, a towel, an old sweater, a pair of jeans; on the tops of the lockers, empty Coke cans, an ancient tennis-racket press, two unrelated sections of a fly-fishing rod that have been lying there for months. On the wall a peevish computer-printed notice asks, Is it possible to discard towels and greens in the appropriate manner? Some wag has written ‘no' underneath. Another more official sign advises, Don't take risks with your valuables. There used to be a sign on the lavatory door saying, Please Raise the Seat. Now there's one saying, in resignation, To complain about the state of the lavatory dial extension 4040. A prospective surgical patient would not feel reassured by the racks of white clogs, stained with yellow, red and brown, with dried hard little friezes of gore, and the faded, clumsily inscribed Biro names or initials. It can be vexing, to be in a hurry and not find a matching pair. Henry keeps his own in his locker. He takes his scrubs, tops and bottoms, from the ‘large' pile and pulls them on, and makes a point of binning the plastic bag. Despite the chaos around him, these actions calm him, like mental exercises before a chess game. At the door he takes a disposable surgical cap from a pile and secures it behind his head as he goes along the empty corridor.

He enters the theatre by way of the anaesthetic room. Waiting for him, sitting by their machine, are Jay Strauss and his registrar, Gita Syal. Round the table are Emily, the scrub nurse, Joan, the runner, and Rodney – looking like a man about to be tortured. Perowne knows from experience how wretched a registrar feels when his consultant has to come out, even when it's an obvious necessity. In this case it hasn't even been Rodney's decision. Jay Strauss has pulled rank. Rodney's bound to feel that Jay has grassed him up. On the table, obscured by surgical drapes, is Baxter, lying face down. All that's visible of him is the wide area of his head shaved to the rear of the vertex, the crown. Once a patient is draped
up, the sense of a personality, an individual in the theatre, disappears. Such is the power of the visual sense. All that remains is the little patch of head, the field of operation.

There's an air in the room of boredom, of small talk exhausted. Or perhaps Jay has been holding forth on the necessity of the coming war. Rodney will have been reluctant to voice his pacifist views for fear of being taken apart.

Jay says, ‘Twenty-five minutes. That's pretty good, chief.'

Henry raises a hand in greeting, then gestures at the young registrar to accompany him to the light box where Baxter's scans are on display. On one sheet, sixteen images, sixteen bacon slices through Baxter's brain. The clot, trapped between the skull and its tough membranous inner lining, the dura, sits across the midline, the division between the two hemispheres of the brain. It's two inches or so below the vertex and is large, almost perfectly round, and shows pure white on the scan, with telltale precise margins. The fracture is clearly visible too, seven inches long, running at right angles to the midline. In its centre, sitting right on that midline, is shattered bone, where the skull has partially caved in. Right below that depressed fracture, vulnerable to the sharp edges of displaced bone tilted like tectonic plates, runs a major blood vessel, the superior sagittal sinus. It extends along the fold – the falx – where the two hemispheres meet, and it's the major vein draining blood away from the brain. It sits snugly in the groove formed where the dura wraps separately round each hemisphere. Several hundred millilitres per minute flow through the sinus and it's possible for a surgeon to tear it while lifting the broken bone. So much blood escapes, you can't see to make a repair. This is when a year-two registrar can panic. And this is why Jay Strauss has called Henry.

While he's looking at the scans, Perowne says to Rodney, ‘Tell me about the patient.'

Rodney clears his throat. His tongue sounds thick and heavy. ‘Male, in his twenties, fell downstairs about three hours
ago. He was drowsy in casualty, with a Glasgow Coma Score of thirteen dropping to eleven. Skull lacerations, no other injury recorded. Normal C-spine X-ray. They did a scan, ordered a crash induction and sent him straight up.'

Perowne glances over his shoulder at the monitors on the anaesthetic machine. Baxter's pulse shows eighty-five and blood pressure one hundred and thirty over ninety-four.

‘And the scan?'

Rodney hesitates, perhaps wondering if there's a catch, something he didn't notice that could compound his humiliation. He's a big lad, occasionally and touchingly homesick for Guyana where he has ambitions to set up a head injury unit one day. He once had hopes of playing rugby for a serious team until medicine and neurosurgery took him over. He has a friendly, intelligent face, and the word is that women adore him and he puts himself about. Perowne suspects he'll turn out well.

‘It's a midline depressed fracture, both extradural and –' Rodney points to an image higher up the sheet and a small white mass shaped like a comma – ‘subdural too.'

He's seen the only slightly unusual feature, a clot below the dura as well as the larger one above it.

‘Good,' Perowne murmurs, and with that one word Rodney's evening is rescued. There is, however, a third abnormality the registrar will not have noticed. As medicine progresses, certain diagnostic tricks fall into disuse among the younger doctors. In a frame further up the sheet, Baxter's caudate on both sides of the brain lacks the usual convexity, the normal healthy bulge into the anterior horn of the lateral ventricles. Before DNA testing, this shrinking was a useful confirmation of Huntington's Disease. Henry never doubted he was right, but the physical evidence confers its own bleak satisfaction.

Henry says to Jay, ‘Is there blood around?'

Gita Syal answers, ‘Plenty in the fridge.'

‘Is the patient haemodynamically stable?'

‘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 spacious. At the very first stroke of sunflower yellow on pale skin, a familiar contentedness 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 muffled quiet of the theatre, the murmur of the air filtration, the sharper hiss of oxygen passing 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 passes him the hypodermic she has prepared. Quickly he injects in several places under skin, along the line
of the laceration and beyond. It's not strictly necessary, but the adrenaline in the lignocaine helps reduce the bleeding. At each location the scalp immediately swells into bumps. 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 space 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
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 tilts 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 theatre 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.