Saturday (31 page)

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 a 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
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 Emily is already placing it in his hands. He finds an area of exposed but undamaged skull, and with the elevator – a kind of scraper – 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
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 passed, and Hewitt is already at the final Variation, the Quodlibet – uproarious and jokey, raunchy even, with its echoes of peasant songs of food and sex. 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
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 institutions 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 titanium plates that hold the bone secure. This part of Baxter's skull
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 crêpe 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 identity 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,
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 pass. 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 space 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
gone bright orange, face, hands, everything, and the wedding's on Saturday.'

The chatter is soothing to Henry as he quickly writes, ‘ext/subdural, sup sag sinus repair, pt prone, 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 sex, 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 passive 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 spacious, 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 Saturday. 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 glass. 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.
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 passing 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 crêpe bandage that he wound round her head yesterday afternoon, she has a dignified, sepulchral look. An African queen. She wriggles down the bed and pulls 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.