by Sarah Hall
More difficult was encouraging Christopher to use the first person singular, to begin to ask, ‘Who am I?’ and understand, ‘I am me.’ Progress in this area was painfully slow. Christopher believed himself to be somehow joined with the commune, and could not identify the single entity of himself, at least not consciously. Encouraging him to say ‘I’ instead of ‘we’ created high levels of anxiety – he often shouted, ‘But we aren’t alone,’ and would scratch at his arms or hit his head. His fear of individuation was profound and induced panic and upset. It was as if he felt I was trying to convince him that he was becoming a new person, unknown, a stranger to himself, rather than acknowledging his existing state. I would often find myself embracing him in order to calm him down. As an intermediate stage, I began to get him to use his name to describe himself, thereby gradually demarcating his identity. ‘How’s Christopher today?’ I would ask. ‘Christopher watched Batman last night,’ he would reply.
A breakthrough came during a project to replicate the snail farm. I was keen to have Christopher teach me how the process of detoxifying worked and thereby demonstrate his unusual skills. As Christopher was punching holes in the lid of the margarine box, I asked, ‘Where will we get the snails from?’ ‘I can always find them hiding under leaves,’ he told me. The moment passed without his noticing the self-referencing language, but it had a remarkable effect. In the following session his mood levelled, he became emotionally consistent and he was able to use the personal pronoun with greater ease. My own reaction to this breakthrough was to feel immense satisfaction, and I struggled to maintain my composure.
Outcome and updated formulation
Though seemingly physically healthy and responding well to psychological treatment, Christopher was found unconscious in his room in the foster carer’s home on 25.01.2013. There was no sign of violence or sickness. He was pronounced dead after two hours of attempted resuscitation. Post mortem results were inconclusive, showing no sign of illness, trauma, or suicide. While the initial formulation was not incorrect, it is possible there was an underestimation of the strength of Christopher’s attachment to the collective – one must leave room for the inexplicable. Due to the rare nature of the presenting case it was always my intention to publish it as a paper in the Journal of Contemporary Child Psychotherapy and I felt that the tragic outcome should not deflect me from this intention. On reflection, perhaps treatment proceeded too rapidly and a full range of risk-influencing factors were not identified and taken into account. The case is currently being reviewed as part of an ongoing Severe Untoward Incident investigation.
On a personal note, working with Christopher, though fascinating, was also extremely challenging and disturbing. At times I felt particularly angry towards his mother, my supervisor, and even my own limitations in helping him. I began to question my own boundaries. I wondered whether this was ultimately influenced by my childlessness, a state that I had until then believed myself to be reconciled with, and feelings of attachment to Christopher. I found his sudden death extremely confusing and could not come to terms with it. I spent weeks researching medical journals, looking for reasons he might have passed away, and I also made several visits to the K-town commune, but was never allowed inside, and on the last visit there was an altercation. I have since restarted my own personal therapy. Christopher’s was my final case. I was granted six months’ leave of absence from work, and following this I made the decision to retire permanently from practice.
· Theatre 6 ·
You are dreaming of geese, of all things. Geese in a field by a river. Grey geese, like the ones you pass on the cycle ride to and from the hospital. There are thousands, covering the grass. The geese have their heads raised, but their wings are splayed and crooked on the ground, as if broken. In the dream, you cycle very carefully through them, only just missing the tips of their feathers, the bicycle wobbling and tilting. The sound they make as you ride past is unholy, a sawing cry.
When your bleep goes it is ear-splittingly loud, thanks to its new battery. Geese, you think, as you come round. You reach over, fumble and drop the device, sit up and retrieve it from the floor. The on-call room is never dark enough, even with your eye-mask. White standby light from the computer flares slowly. The clock numerals on the wall opposite are faintly luminous.
Four a.m. You recognize the number on the bleep display. A & E. This is how it usually begins. You go to the phone on the wall, call the number. It takes a while for anyone to answer. The gynae registrar picks up. You recognize her voice, but can’t for a moment think of her name.
Hi, I’m booking someone on the theatre list, she says. We need to get her up there now.
Yes, OK, you say.
Pregnant female, twenty-nine, foetal distress. Approximately twenty weeks. The mother is very unwell, probably started miscarrying a week ago. She was told by her GP to wait it out, you know.
Her voice is quiet, the tone uncomfortable, or annoyed, you can’t tell which. Annoyed, you decide. There’s a pause – and you can hear noises in the background, the flurry of activity in the emergency department, alarms, bustle, raised voices. Then the registrar says:
Blood pressure is a hundred over sixty, heart rate one thirty, temperature thirty-nine, maintaining sats. We’re resuscitating. I’ve given her two litres of Hartmann’s, and Tazocin. She’s septic.
The last filaments of sleep disperse, and now you are alert.
She’ll need more, you say. What IV access have you got?
I’ve got one eighteen-gauge in the antecubital fossa. She’s quite difficult.
I’ll come down, you say.
Yep.
The line goes dead.
You bleep the Operating Department Practitioner, Karen, who rings back immediately. You tell her to get everything together – someone’s coming up.
What have we got, she asks.
Distressed pregnancy. Twenty weeks.
Right-o. Want me to notify the night officer or ask for a recorder?
You think for a moment. You have not yet seen the patient and the gynae registrar did not mention anything untoward. Karen is good, thorough, discreet. You’ve worked well together in the past.
No, you say. Leave it. Who’s around up there?
Robin. And Jim.
Can you send Jim on a break?
I’ll try.
*
The walk to A & E takes five minutes. The corridors glimmer dully underfoot and are empty mostly; you pass a porter and a woman sweeping the floors, Cley and Winterton wards. You pass the chapel. The lights are low; the small electric candles and crucifix on the altar are always lit. Above the doorway a sign reads Life Is Sacred. Sometimes you go into the chapel to sit, but not tonight. You focus on the forthcoming procedure. It will not be your decision, of course, the surgeon will prioritize, but you will be complicit – the entire team will be. Since the new legislation came in two years ago, the hospital has been fined several times, and a review is underway. You’ve already filled out several reports this year, and you’ve received a disciplinary letter, which, you are assured by several of your consultants, is simply a formality and can be disregarded. Among some, such a letter is a badge of honour. You are uncomfortably aware, though, that in other hospitals medics have been charged and struck off; their names listed on the back pages of the journals. One or two have even been attacked in the street.
You key in the code, push open the door of A & E and walk through the bays. There’s the usual racket and pace, machines beeping, staff in motion – managed disorder. A bloody-faced drunk lolls on the edge of a gurney shouting obscenities. You wash your hands, ask a nurse where the theatre patient is. He gestures to a bed. The curtains are partially open but the woman is alone. Most of the staff seem to be attending a car crash victim at the far end of the room, where there is debris strewn on the floor, the residue of a shirt, a pair of cut-open jeans. The gynae reg has disappeared.
The pregnant woman is lying on her side, eyes closed, deathly pal
e and sweating profusely; the mound under the gown is wet. She has a hand tucked across her lower abdomen. There’s a receptacle next to her on the bed into which she has vomited. You check the pressure bag is pushing fluids and read her chart notes. She opens her eyes, lifts her head, and looks up at you.
I’m Dr Rosinski, you say. I’m the anaesthetist registrar. I’m going to put another cannula in you, before we take you to theatre, is that OK?
With effort, the woman nods. Her head falls back on the pillow. You take gloves from a box on the wall, select a sixteen-gauge cannula. You tourniquet, tap and brush the forearm, find the cephalic vein and swab the skin with a steri-wipe.
Sharp scratch, you say.
The needle slides in. She doesn’t flinch. She looks up at you. Her cheeks and chest are garishly flushed against the pallor.
I don’t want – she whispers. Please, don’t let me –
She is trembling and cannot say it. You can see fear in her eyes, under the disorientation of illness and shock, fear that used to be selfless, but is now for herself as well as for the baby. Such cases are common enough not to make the newspapers anymore.
I know, you say, gently. It’ll be OK.
You can’t really say more. What could you say? Our surgeons are excellent. Our maternal mortality rates are among the lowest in the country. We don’t all believe in the Hunter foetal care plan. You finish cannulating. You take a blood culture and gas, complete the anaesthetic assessment, tape over her rings, then find a nurse and a porter to help wheel the bed. On the way to theatre the patient vomits again. The sheet underneath her is stained and her breathing has become more laboured.
Don’t worry, the nurse says, daddy is on his way, I’m sure. And the baby will be just fine.
Inane, soothing and a lie. Or perhaps the nurse is simply playing her part; it is hard to know sometimes. You wonder – if everybody acts with duplicity, do they arrive at a kind of truth? But you say nothing, certainly not the obvious. That the patient is beyond such things now. That if the products of conception are not evacuated fast, the infection could become fatal. Products of conception is not a permitted term anymore. Nor septic abortion. There is a new language, which must be written, if not spoken. Pre-birth crisis. Unsalvageable uterine life. You’ve seen this level of disintervention before – the extraordinary bleeding and blossoming of bacteria, which amounts to neglect. God’s Jurisdiction, is how the prime minister described it in his speech to parliament. He is a great orator, they say, the best for decades.
The woman is crying softly. You would like to give her something more, ketamine, temazepam, but the options have been limited. If on the drug chart it appears you are disregarding the baby’s health, even at this stage, it will look bad. At the lifts you thank the nurse and say you and the porter can manage the rest of the way. The nurse smiles, reaches into her pocket and takes out a small silver disc, on which there is an embossed angel. You’ve seen these items on sale in the hospital gift shop – twenty pence each – they’re found all over the wards and in the chapel’s votive plates. The nurse presses the icon into the hand of the patient.
Thank you, you say. I’ll have to take it off her before surgery, but I’ll put it somewhere safe.
You press the button and the lift doors close.
*
In the Anaesthetics Room Karen has thoughtfully brought you a cup of tea. It’s lukewarm. There’s no time – you take two sips and bin it. You wash your hands. You and Karen transfer the patient to the table. You check the ID band again, position her head and neck so she is taking the morning air. You give her 100 per cent oxygen, push the milky hypnotic, and paralyse. After sixty seconds you remove the mask, Karen hands you the laryngoscope, you view the cords, and intubate. You scrub your arms, to the elbow. You place a central line as swiftly and smoothly as you ever have. Then you wheel her into Theatre 6 and attach her to the ventilator. They are all waiting, masked and gowned. The gynae reg has scrubbed in; she nods to you. Dr Malhotra – now you remember her name. She was there last year, during the Hannah Lehrer surgery, which is now the Hannah Lehrer case. You do not recognize the consultant. He introduces himself.
Hello. I’m Mr Desai.
You introduce yourself, Karen and the support worker do the same, the nurses. The WHO checklist is repeated. You adjust the table upwards, and the patient is positioned.
Are we without a night officer? the surgeon asks.
I believe so, you say.
You catch Karen’s eye for the briefest moment before she looks away.
And are we recording?
No. Our tech is on a break.
OK then, let’s get going, Mr Desai says; his tone light, almost sing-song.
He steps towards the table.
May I have your permission to disinfect? he asks, peering at you above his glasses and mask.
He is politer than most consultants, the politeness of absolute confidence, perhaps. Drapes are being placed around the patient.
Please go ahead, you say.
As the surgeon sterilizes, he glances at you again and says:
It’s a nice bike.
Excuse me, you reply, thinking you’ve misheard.
Your Peloton. It’s a nice bike. I used to have one. I saw you putting it into the rack yesterday evening.
Oh, right.
Cycle in every day?
Yes. Most days. I live in Chesterton.
Ah, good for you. I would, but I live too far out now. My wife likes to be in the countryside. Which way do you come in?
Along the river. Past the crem.
Ah, beautiful, he says. Of course, that’s the best way to come. Reminders.
He then asks, as courteously, for permission to begin. There are no ciphers and codes by which to discuss politics or protocol, perhaps these things are discussed without you realizing it, perhaps you even discuss them without realizing it. You monitor the anaesthetic machine, push intravenous antibiotics. Four litres of fluid. You start colloids, administer little boluses of metaraminol. The surgeon evacuates quickly, pronounces its time of death and notes its sex, which is a legal requirement. The drapes are soaked, dark. The patient’s legs are lowered. Her blood pressure drops to sixty over thirty and sticks there – you have a sweaty few minutes getting it back up. You give her more fluids, noradrenalin, and begin a blood transfusion.
She’s not enjoying this at all, you say.
A laparotomy kit is brought forward. The initial cut is vast. The surgeon and registrar converse calmly as they operate. They attempt to save, and then remove the woman’s uterus. Finally, Mr Desai steps back, and Dr Malhotra closes, as carefully as stitching the hem of a wedding gown. You and Karen wheel the patient into recovery. She is extremely pale, but alive. She is lucky, though under what order of providence you could not say.
The anaesthetist for the next shift arrives and begins the handover. You tell him about the night’s procedure.
Christ. Glad I missed that hot potato, he says. Another letter, right?
You shrug. You pass on the theatre list for the day – a ureteric stent, a bowel obstruction, revision of breast augmentation, nothing complicated. You are supposed to complete the requisite paperwork immediately and file a report to the Department for the Protection of Unborn Children, but instead you change out of your scrubs, go to the bike racks and head home. You’ve done your duty, enough.
The morning is clear, a few high clouds banking on the horizon. Dawn has come and gone, but it still feels fresh and damp and clean. You cycle through the hospital grounds, past the crematorium and across a small park, then along the river. The field is empty. The grass glistens under the wheels of your bike. When you look up there is a long dark vee of birds in the sky, migrating south.
· Wilderness ·
They climbed up the beach and onto the old railway tracks that ran round the headland. The tracks were overgrown and rust-wrecked, though the Outeniqua Choo Tjoe had been defunct less than a decade. Loose stones had fallen from th
e cliffs, landing in the cooked bitumen between pilings, and sticking there as the tar congealed. The three of them walked in a row, stepping on the broken laths, a few paces apart – Zachary leading, Joe next, then Becca. Above them was a grey Southern Cape sky that looked, Becca thought, entirely exportable to England. Down below, a big, upset sea – Cape sea, with Antarctic muscle behind it. They walked with heads down, their anoraks crackling. After a while, conversation got up about fears and phobias. Heights. Needles. Being shot in the back of the head in the cinema. Clowns’ mouths.
Clowns’ mouths?
Joe snorted. He paused a moment on the track, so Becca had to stop too, then carried on.
Don’t you mean just clowns, Zach? The whole clown entity is considered pretty sinister.
I do not, mate, Zachary said. I mean exactly their mouths. Their lipsticky mouths. Like giant red vaginas.
Joe snorted again, the snort of the incredulous. Becca said nothing. She had been saying nothing most of the morning. Zachary mustn’t have seen many vaginas, she thought, though his wife was extremely beautiful, in a strange Martian way. Lizette was an ex-Boden model, who’d gone religious after pushing out two of Zach’s kids. She had long black hair down to her backside, upholstered lips and hipbones that jutted out of her jeans like scaffolding. She’d made Becca feel inelegant and very uncomfortable when they’d met the day before, though there was also a weird mental crackle off her.
Zachary himself was tall and fat. The kind of solid torso fat a man prefers to call barrel – barrel-chested or barrel-bellied, conjuring images of leopard-clad circus strongmen or Saxons. How he’d gotten Lizette to say yes, Becca couldn’t guess. Ace in bed, maybe. Or a good sense of humour, though so far Zachary’s prevailing mood was melancholia bordering on despair. There seemed to be a perpetual argument going on between the couple – she nagging him to take off his raggedy woollen hat, which he never did, or fix his strained-against belt, or not slurp his beer; sarcasm circling around everything he said to her, mocking her accent or her lack of intellect. It was painful. Their house, where Becca and Joe were staying for a few days, was ramshackle for the poshed-up Garden Route. Zach and Lizette lived in the hills, which was half the price of living on the beach in Wilderness, apparently. She’d decorated the living room in vivid Mexican greens and attempted some Gauguinesque nudey murals on one wall. The women’s breasts were asymmetrical, more like Picasso.
