by David Ellis
“Thank you, doctor.” He paused briefly to look at his notes. “Am I right in thinking this was your first day on the Coronary Care Unit?”
“That is correct, sir.”
“So you might not perhaps have been fully aware of procedures for treating certain cardiac conditions?”
“Yes, I suppose that is true, which is why I phoned to speak with my senior registrar, Dr Odulele.”
“Quite. Tell me, doctor, do you think starting the new drug – the amiodarone – any earlier might have made any difference to the outcome?”
“To be honest, sir, I don’t think so. Mr Williams did have extensive damage to his heart…”
A man suddenly stood up from the public area of the coroner’s court; Emma recognised him as Mr Williams’s partner. He started shouting and pointing his finger at her: “You’re lying, you bitch. You killed him! If you’d treated him sooner he’d still be alive! You killed him!” He was persuaded to sit down by people either side of him.
“Thank you, doctor,” said the coroner. “I have no further questions for you. I think it would be best if I excused you. We will adjourn for ten minutes.”
Emma hurriedly collected her papers and left the witness box, wanting to run from the court, feeling that Mr Williams’s partner and the rest of the court were staring at her and blaming her for the death.
She went into the toilet outside the courtroom and sat down crying. After a while, she took out a small clutch bag from her shoulder-bag and opened it. She removed a razor, steri-strips and a plaster. She lowered her suit trousers. She tested the sharp edge of the razor against her thumb and then made three parallel incisions at the top of her inner thigh. She drew the edges of the wounds together with the steri-strips and then applied the plaster. After making sure that there was no blood on the floor, she left the toilet, checking that no-one from the courtroom was outside.
Emma left the court building and found a café around the corner where she bought a black coffee. A short time later, Julia Simmonds came in and sat down opposite her.
“Sorry, Emma, that was really out of order.” She took her hand.
“It’s just so unfair, Julia. I called Brian to come and see him but he wouldn’t and I even went through things with his boyfriend. I mean, what more could I have done?”
“You couldn’t, Emma, you really couldn’t. Look, you’ve got nothing to worry about. If anyone’s to blame, it’s Brian, and I’m sure that’s what the coroner is going to say.”
“Thanks, Julia, but it was just so horrible being blamed.”
But whatever Julia said, and whatever the conclusion of the coroner, Emma still felt as guilty as hell and she was sure she could have done more.
February 1992
“Dr Jones,” the Chair of the Appointments Committee asked, “I wonder whether you might describe to us a couple of clinical cases that led you to changing your clinical practice.”
Emma knew that this sort of question was likely to come up at her interview for a senior registrar rotation, so she didn’t have to hesitate much before responding.
“Well, there are two cases that stick in my mind and both were on the first day of my two house jobs,” she said. “The first was an elderly man admitted for cholecystectomy who had alcohol dependence. I started him on an alcohol detox but my consultant crossed it off the day of surgery. He went into withdrawal postoperatively and stabbed a nurse and another patient. I learnt from that to stick to my guns and prescribe when appropriate. The second case was a young man with a MI admitted to CCU who went into AF. I put off starting him on amiodarone because I thought a ward round was going to happen. It didn’t and the registrar wasn’t much help, which meant that the drug was started late. Unfortunately, he died overnight following a further MI. I learnt from that to insist on a senior opinion if I’m not sure what course of action to take.”
“Thank you very much, Dr Jones; very interesting cases,” said the Chair. “I think that’s all the questions we have for you. We’ll let you know later this evening whether you’ve been successful. I believe we’ve got your home phone number.”
Emma thanked the panel members and left the room.
“Very interesting,” said the Chair, “and not a little disturbing. It does sound as if she had rather poor supervision in those jobs – just four years ago, I believe – and I would hope that supervision is much better now. She also seemed remarkably detached when talking about those cases, and I’m not sure that’s a good sign.”
“I agree, point taken,” said the Medical Director. “They were good cases and I think she demonstrates sound reflective practice and appears quite caring. I think she’d be a good pain physician. I vote that we select her for the next rotation entry point.”
“Okay, I have some concerns, but agreed,” said the Chair. “Will you ring her this evening?”
“Hello, is that Dr Emma Jones? Oh, excellent. This is Dr Michaels from the appointments committee. I’m delighted to tell you that we can offer you a place on the higher rotation in pain medicine. Well done, very well done.”
So Emma was on the next rung up the career ladder. This time, there’d been no wool pulled over anyone’s eyes; she’d been honest and direct in all the answers to their questions.
Thinking back to her childhood and adolescence, Emma found it reassuring to see the changes she’d achieved in her development, going from a spiteful child to manipulative adolescent, and then finally, to a relatively honest adult.
The rotation in pain medicine lasted three years and was divided up into a year each in palliative care, pharmacology and oncology. Aside from the clinical attachments, she also needed to plan a research project and some courses to supplement her clinical skills. She decided that cognitive behavioural therapy would be the best option to give her skills she could use in her pain management work and in her research.
Emma signed up on a one-year, part-time CBT course held in Oxford. Part of this involved seeing her own patients under supervision and so she contacted the liaison psychiatry consultant to see whether he could identify a patient for her to see. A month later, Emma had a call to say that there was a 19-year-old patient for her to see and that an appointment had been made for the first session.
August 1993
“Hello, you must be Sylvia. I’m Emma. Please come on in.”
Emma led the patient into the consulting room and completed a quick assessment whilst she was walking in with her. Sylvia was roughly the same size as her and wore a rather old-fashioned purple dress that went way below the knees with sleeves that were buttoned up at the wrist. Her shoes were flat and well-worn. The bag that she was carrying was canary yellow in colour and seemed either to have been chosen in haste or deliberately to clash with the rest of her outfit. She was looking down at the floor and avoiding eye contact.
“Okay, Sylvia, as you probably know the idea with CBT is to help you build on ways that you might already have to deal with problems that make you feel bad about yourself,” explained Emma. “And if you cope better with the problems, then you should feel better about yourself. Does that make sense?”
“I suppose so,” said Sylvia, very softly.
“Perhaps the best place for us to start is to make a list of your problems. Do you think you could do that?” asked Emma.
“How long have we got?” asked Sylvia, still speaking very quietly.
“Just 45 minutes, so it’s very important that we work together to get the most out of the session,” said Emma.
“Well, there’s this to start with,” said Sylvia, undoing her left sleeve and pulling it up to show an ugly latticework of thick scars.
“Okay, that’s certainly one problem to start with and I’d like you to write that down on this piece of paper. Where do you want to put that on the paper: top, bottom or middle?” asked Emma.
Sylvia wrote ‘CUTS’ and put it almost at the top of the paper.
“That’s good, so what problem comes next?”
Sylvi
a pointed to her head.
“Does that mean how you feel about yourself or is it about feeling sad?” Emma asked.
“Both,” said Sylvia.
“Okay, Sylvia, you write down those two problems on the piece of paper and put the words where you think they should go.”
Sylvia wrote ‘SELF’ above ‘CUTS’ and ‘SAD’ some way below ‘CUTS’.
“Is there anything else you want to write down, Sylvia?”
Sylvia pulled up some of her hair and pointed at a number of small bald patches which looked to Emma like signs of trichotillomania.
“Okay, Sylvia, you add that to the list as well.”
Sylvia added ‘HAIR’ and put it right at the top.
And so the session continued until there were seven items on the list.
“Now, Sylvia, we’ve almost come to the end of the first session and what I want you to do is to concentrate on the first problem: the hair pulling. What happens after you’ve pulled your hair?”
“I feel horrible and ugly and I cut myself.”
“Okay, and what do you think makes you pull your hair?”
“Being on my own.”
“Okay, so what about if I gave you some homework for next week so that you’re not on your own all the time? Let’s say that you go to the library for a couple of hours every day to read where you’ll be with other people but you won’t have to talk to them. Do you think you could do that?”
“I’ll try,” said Sylvia, looking up for the first time in the session.
“Good,” said Emma. “So, I’ll see you next week; same time, same place. By the way, that’s a nice bag you’ve got there; it’s an unusual colour.”
“Yes, I’ve had it for ages. It reminds me of being in a field with buttercups and feeling safe.”
Emma showed Sylvia out. She took a deep breath and decided that she was glad she wasn’t doing CBT full time; that first session really was like getting blood out of a stone. It was also just too close for comfort, although Emma’s self-harming happened very rarely these days. She thought about the lemon bag and the ‘feeling safe’ and came to the conclusion that there was still a lot more of the iceberg beneath the surface. And it was a shame you can’t do something about toxic parenting or fathers who stray from the marital bed at night.
October 1993
Sylvia seemed to be making progress despite Emma’s relative inexperience in CBT. Emma’s supervisor thought she’d hit the nail on the head with the observation about the yellow bag but agreed that diving into the depths of what that meant shouldn’t be hurried.
“Come on in, Sylvia,” said Emma.
Sylvia sat down. Unfortunately she’d reverted to wearing the same purple dress that she had on for the first session six weeks ago. And the canary yellow bag was still a constant fixture and fitting. Emma started to fantasise about what it might contain. And Sylvia seemed to have lost weight.
“Okay, Sylvia, let’s review what we did last time and the homework I set you.”
Emma heard silence. Sylvia made no eye contact and her head was hanging low. She’d taken several steps backward, by all appearances.
“How are you feeling today, Emma?”
No response.
“I see that you’ve got that nice purple dress on again; does that mean something special for you, Sylvia?”
No response.
“You know what, Sylvia, I’m just going to pop out to get both of us a glass of water and I’ll be back in a jiffy.”
Emma went out to get some water. On her way back she checked through the one-way glass in the door to see whether Sylvia had changed in her posture; she hadn’t. By this point, Emma was getting concerned that her client had become virtually catatonic, which was way outside her comfort zone as a pain physician in training.
Emma went back in and offered Sylvia the water; she reluctantly accepted the cup, and then, slowly and very bizarrely, poured the contents over her head.
Emma bent down and briefly caught a look at Sylvia’s eyes through the dripping curtain of her hair. Emma took a sudden step back and knew that the answer was in that canary yellow bag after all. Sylvia’s SOS message was flashing yellow, white, red…yellow, white, red…
“Sylvia, I think I know now that the answer is in your bag. Is it alright if I take a look?”
Sylvia let the bag slip out of her hands and Emma opened it. Inside she saw something crumpled and white. She carefully removed it and discovered a child’s white dress covered with grotesque splodges of something which she immediately recognized as old, dried blood. Emma gently put the dress and bag on the table and turned to Sylvia.
“Sylvia, I think I understand everything. Now I want you to be brave a little longer and I’m going outside to make a phone call. Do you understand?”
Sylvia looked up and slowly nodded.
Emma went outside and found a phone, keeping an eye on the room where she’d left the door ajar. Sylvia seemed to be staring at the white dress.
“Oh, hello. My name is Dr Emma Jones. I need to report a possible case of rape. Can you get some officers around immediately to the psychology outpatient clinic at the Warneford, please? Great. Thanks.”
Two female police officers arrived at the clinic within half-an-hour. The child’s dress was put into a plastic bag and taken away for forensic examination. The police officers stayed with Sylvia for some time, but she remained in a profoundly retarded state.
Reluctantly, Emma arranged for her to be admitted to an acute psychiatric ward and was relieved to hear that there was a bed on a female only ward. Over the course of a week or so, Sylvia gradually came out of her catatonic state. The story she gave was harrowing in the extreme: years and years of sexual abuse by her stepfather, and being passed around between various men for sex like a pass-the-parcel to be unwrapped and abused. Sylvia’s final tipping point had been a further rape the day before Emma saw her in the clinic.
The white dress proved to have vital forensic evidence on it and the stepfather was subsequently arrested and charged with rape and kidnap. Sylvia never did say how the dress came to be in the canary yellow bag.
September 1996
Emma had just returned from the International Pain Symposium in Oslo and she felt encouraged by the reception given to her poster presentation entitled ‘Visualisation for modification of pain perception’. Although the study was small and hardly up to the standard of a randomised-controlled trial, the results were quite impressive and the paper itself was due to be published in the journal ‘Pain’.
Emma dropped by the canteen to pick up a coffee to drink on her way to the wards. As she was leaving, she heard a voice call out “Dr Jones?” She turned to see where the voice was coming from and saw a good-looking man in his 40s with hair greying at the temples. She thought she vaguely recognised him but couldn’t put a name to the face. As she got closer, she realised that he was Michael Williams’s partner and the person who’d screamed at her in the coroner’s court. Her immediate reaction was to run for the exit but he motioned for her to sit down at the table.
“Dr Jones, I’m just so sorry that I flew at you like that. I’ve felt so bad ever since. As soon as that fucking registrar stood up, I knew it wasn’t your fault. I’m really, really sorry.”
“That’s okay, I forgive you. Grief’s a bugger really. It hits all of us,” said Emma.
Tony put his hand across the table to hold hers.
“Hello, what do we have here?” said a tall man with piercing blue eyes and short blonde hair. “Is my boyfriend going straight on me?”
“No, silly,” said Tony. “This is the doctor I was telling you about: the one I said awful things about in court and made a right fool of myself.”
“I’ve heard a lot about you, Dr Jones,” said Fred. “And whatever Tony said to you in the court, you really helped him move on after Michael’s death.”
Tony nuzzled Fred’s shoulder.
“I didn’t do anything really,” said Emma.
&
nbsp; “It was the touch and the look that did it. So, thanks, Dr Jones,” said Tony.
“Thank you, Tony. And I must say I really approve of your choice in men,” said Emma, looking at Fred. “It’s just a shame they don’t make them in a straight variety.”
Tony and Fred laughed and waved her goodbye.
What a nice couple, Emma thought, and she really did wish that a gorgeous man would enter her life soon.
Emma made her way to one of the oncology wards to see a 19-year old man with bone pain following surgery for an osteosarcoma of his leg.
“Hi, are you Julian? My name is Dr Emma Jones and I’ve been asked to help with your pain.”
Julian looked up at her with haunted eyes and she immediately saw that he was struggling to reconcile pain and an uncertain prognosis with a burning desire to get on with his life. It was that positivity which gave Emma some hope that she might make a difference.
“What I’d like to try with you is a way of getting you to take hold of the pain and reshape it using your mind. I hope that doesn’t sound too weird, but I just think it might work.”
“Okay, I guess I’m game for anything,” said Julian.
“Great,” said Emma. Now what we’ll be doing together is called ‘visualisation’. It’s a bit like hypnosis but I promise I won’t make you quack.”
Julian laughed.
“First, I need to get you sitting comfortably. That’s it, good. Now, I want you to close your eyes and start taking some breaths, listening to my voice and your breathing, but nothing else. That’s it: in, out, in, out, hearing your breath and feeling more and more relaxed with every breath. Now I’m going to take you down five steps, and with every step you’ll feel more and more relaxed: 5, 4, very relaxed, 3, listening to your breaths, 2, still so relaxed, 1. And now you’re in a place where you feel so relaxed that you can start helping your pain. So, Julian, I want you to imagine that you’ve got a thermometer in your hand that can read your pain, where red is really bad, orange less bad, yellow even less bad, then green, blue and finally white where there’s no pain at all. Now, Julian, thinking of your pain, can you tell me what the thermometer is reading?”
