Click, Double-Click

by James Calum Campbell

  ‘You’d be surprised. All right. How about, “To cure sometimes, to alleviate often, to care always?”’

  ‘Very homespun. Alastair, I don’t think you’ve quite got the hang of what a mission statement is.’

  ‘I’m sure you’re right.’

  ‘It’s fine to be pithy, but we also need to be comprehensive. Trish?’

  Ms Campbell donned an improbable pince-nez. ‘I’ve come up with the following: We pledge to honour and respect our client on his or her journey, protecting his or her autonomy, right to health, freedom to choose, discretion to give or withhold informed consent, offering health care that is timeous, evidence-based, holistic, aligned with best practice, and focused on best quality outcomes.’

  ‘Very good. Succinct. Comprehensive. Alastair – you’re pouting again.’

  ‘It’s a camel.’

  ‘Camel?’

  ‘You know. A horse designed by a committee. And what are you going to do with it? Put it on a plaque? Perhaps we will form a ring and recite it every morning, like the Cubs and Brownies. We’ll dib dib dib.’

  MacTaggart took his glasses off and threw them down on the blotter with some impatience. ‘Why are you such a wrecker?’

  So it went on. The daily round. Who was it said we most of us live lives of quiet desperation? Up, shower, dress, apology for a breakfast, get to work, take the handover, tend the sick and needy, react to other people’s agendas, keep a record, snatch a lunch, pot a few balls, attend some ghastly and inconsequential management meeting, take calls, make calls, liaise, keep out of trouble, make an escape. It was dark when I left the flat and it was dark when I got back. I ascended four flights and there, huddled on the landing, sat my sister-in-law.

  ‘Katie.’

  ‘Ally-bally.’

  I resisted the temptation to tell her she couldn’t smoke on the landing, and I didn’t ask her what she was doing 350 odd miles north of Cheltenham. Actually, I wasn’t surprised.

  ‘Come in.’

  She cast a critical eye around the dull boxlike Victorian foyer, decorated in minimalist style and occupied by my recluse flat mate, a golden carp staring out of the tank at us and solving the mysteries of the universe.

  ‘What’s the name of the fish?’ ‘Tallulah Bankhead.’

  ‘Hi Lulah.’ She gave a girlie wave and walked through into

  my front room and across to the big bay window. She was sixteen, as tall now as Mary had been, and the sisterly similarity of the loping gait caught my breath. She stood with her back to me, staring out across Thirlestane over the roof of Warrender Baths, right elbow resting in left hand, smoking her cigarette. Jeans. Fawn kagool, auburn hair, very long. Great tresses falling to her waist. Might have been Mary. Transfixed.

  ‘Do Eric and Sally know you’re here?’

  ‘Nope.’ She carried on staring out of the window.

  ‘Mind if I call them?’

  ‘Nope.’

  I used the land line and dialled the Stow-on-the-Wold number. Caitlin didn’t move. She was listening intently to my side of the conversation.

  ‘Eric it’s Alastair … Yes she’s here … No she’s fine …’

  I drew the receiver away from my ear, pointed at it, and glanced interrogatively at Caitlin’s reflection in the bay window. She shook her head.

  ‘She’ll call you later … I’ll ask her … Yes I’ll check on that … Don’t worry she’s perfectly safe … Okay … Talk to you soon. Love to Sally. Bye.’

  She waited until I’d hung up before coming away from the window. She threw the cigarette butt into the grate under the ornate mantel without looking and without bothering to stub it out, slid the kagool off her shoulders and let it fall to the floor. She was wearing a pale lemon halter neck, not, as had been her wont recently, a turtle neck. The thick purple keloid scar which I knew crossed the length of her sternum ascended proximally to leapfrog across her neck just to access her chin, like an inverted exclamation mark. ‘Can I stay? I won’t be any trouble.’ The big brown eyes, set wide apart, gazed at me appraisingly. She was a wild Celt, as her sister had been.

  ‘What about school?’

  ‘End of term.’ She sounded a bit vague. ‘I can house-sit the gold fish. What was her name again?’

  ‘Thelonious Monk.’

  She said accusingly, ‘You said she was a girl.’

  ‘He changes her sex constantly.’ I wondered what she was running away from. It crossed my mind she was being bullied. Carrot top. Freckle face. Or maybe it was because of the scar. Yet she didn’t strike me as somebody who would be prone to bullying. All these posh friends of hers down in Cheltenham had not succeeded in modifying her beautiful soft Dublin accent. ‘Where’s your luggage?’

  ‘I don’t have any.’

  ‘Not even your oboe?’

  ‘What’s an oboe?’

  How extraordinary. She, too, had taken a vow of silence. Was music cacophony to her now, as it was to me?

  ‘You can stay as long as you like.’

  III

  After Mary went, I was ‘counselled’ about my ‘grief’. A grim, dumpy bald woman in a tweed suit told me about my ‘grief reaction’. Apparently it had four stages. Well what a lot of crap that turned out to be. I was tutored in this stuff. Stage 1 was Shock.

  I baulked at that. Shock, madam, is a catastrophic collapse of the circulation leading to irreversible multiple organ failure. Feel my resting pulse – 48 and regular. (I do triathlons.) Take my BP – 110/70. Feel my peripheries – warm, pink, and well perfused. It seems an affront, I know, but I’m not shocked.

  She listened to me with the bland complacency of somebody who knows she is right and went on to stage 2: Denial.

  Denial? What am I supposed to be denying? She is, after all, dead. She went on to stages 3 and 4 but I’d stopped listening. Besides, anybody can make this stuff up. Stage 3 would be some kind of blunting process of attenuation, an adjustment, and stage 4 would be some kind of resignation achieved on a platonic field. Closure. There’s a trendy word.

  But I can assure you there will be no closure. Angry? Moi? I’m absolutely furious. I never told that counsellor about the devastating effect Mary’s departure had on my response to music. It had always occupied such an important part in our lives and suddenly I couldn’t bear it. It had just become noise. I was reminded of that Old Testament story about the Tower of Babel, that absurd staircase to heaven, a monument to man’s pride. After it collapsed everything became unintelligible, everybody went around talking gibberish. Something like that happened to me with respect to musical language. Music as gibberish. I’m living proof that tone deafness can be an acquired condition. It wasn’t that I had lost my musical memory. I was still acquainted with the repertoire. It was just that it had lost its meaning, its emotional substance. It had become an affront.

  When does a grief reaction become pathological? I think of myself as a castle under siege. When Mary was killed my enemy pitched a bivouac in sight of my battlements and just watched me, day after day, and in a detached disinterested way, as I strutted about behind the ramparts ranting and raving and gesticulating like Hamlet. To be or not to be. The enemy waited patiently; waited for me to go mad. Then when my defences were at their weakest, they would cross the moat, broach the portcullis, and they would be in. And that would be a point of no return. My enemy would have become part of me, like a virus. I could now be destroyed from within. I would destroy myself.

  Nowadays psychiatrists tend to view depression as a matter of degree. You’re tetchy, you’re sad, you’re a miserable git, you’re a bloody miserable git … I’ve never been convinced by this depiction of wretchedness as a linear progression. Part of the misery of the condition is that you think you are light years and aeons from your destination. But you’re not. There’s a way out. And it’s right there beside you. If only you can find it. It’s like a parlour game. A sleight of hand. The trick of life. I was never any good at it.

  ‘Alastair!’

  I
t was MacTaggart, ambushing me as I escaped out the back door of the emergency department and made my way along the medical corridor. It was a chance meeting but I had the odd feeling he had been lying in wait. He smirked at the ED entrance. ‘Still down and out among the vagrants I see.’

  Ever since I had been his houseman he had been trying to recruit me. He was like a KGB agent, wheedling away. ‘Why do you persist in wasting your energy on drunks and vagabonds, stitching up heads and washing out stomachs? I’ve told you you’re better than that. It’s all very well doing pro bono work but you can’t really believe you can make a difference down here. The poor ye will always have. Think ahead. Build a career. You have the makings of a first class physician. There’s still time. I need a research fellow. Neurotransmission is an expanding field. Neural networking, neuropharmacology, computer modelling, pain modification. Come on board!’

  It was blatant piracy. Forbes would have been furious.

  I declined, politely but firmly. ‘I am a specialist emergency physician. It may be a Cinderella Specialty, but it too, has its expanding fields.’

  MacTaggart smiled thinly and gave a barely audible sniff.

  ‘Perfunctory medicine for perfunctory doctors.’

  I had the notion he would never ask me again.

  I rather like being in a Cinderella Specialty. My twin sister, MacKenzie, is the viola player in the Arnold Bax Quartet. She has been attracted by a Cinderella instrument. Like bogtrotters, Canucks, and Newfies, viola players are the butt of jokes. I think she and I must be drawn to minorities. We have been born and bred in two viola countries, Scotland and New Zealand. I may have stopped listening to music, and playing music, but I still like to think of MacKenzie as my voice, mellow like Baker, dark like Ferrier. Meanwhile I take my muted, understated viola personality and move about my viola country, my alto clef universe, sotto voce.

  Caitlin and I fell into an uneasy routine. She had the courtesy to free up the bathroom for me in the morning and let me get ready for work. She would join me for an even more derisory breakfast than I was taking, wearing a pair of my pyjamas, rubbing the sleep from her eyes, crouched sideways on the chair with both bare feet on the seat. She had intense blue-black varnish on her toenails, the colour of one’s finger nails, momentarily, as they plunge into the swimming pool, freestyle. Put your goggles on and look and see if I am not right. She would chew the edge of a bagel and absently scan The Herald, maybe précis an item that caught her eye. We would have the Today programme on Radio 4. She would raise her eyes to the ceiling as the programme’s anchors reverted to type – an intimidating man from Splott, a hectoring badgering female interrupter, a verbose Scottish windbag who posed politicians questions so lengthy you had forgotten the drift by the time he dried up. The first morning, she read me something about an ex-prime minister who, on leaving office, had kept a low profile, and was now resurfacing in Uganda to announce that the future of the continent lay with Broadband. Not with clean water, sanitation, vaccination, retrovirals, peace, harmony, and an end to exploitation. Broadband. God help us. I went to work depressed to my boots.

  When I would get back in the evening Caitlin would be cooking in the kitchen, and have the table set, and would pour me (and herself) a large glass of ice cold New Zealand Gewürztraminer. She could be chatty, but inconsequential. ‘Thelonious has changed sex again!’

  ‘What’s he called now?’

  ‘Vonda Shepard.’

  ‘A fish called Vonda? I don’t think so. We just had some guy talk on the way through. Minnesota Fats and me.’ I never talked about my patients and she never talked about her day. If I was good at confidential, she was as silent as a tomb. Sometimes I would tell her about the more outlandish shenanigans of ELSCOMF because it would make her laugh. Clotworthy and Worthington, for example, tabled this crazy idea they called ‘Opportunistic Intervention’. Down in the ED we were to ‘shoulder tap’ all males over the age of forty five and put them on statins. As if we had nothing better to do. I said, ‘Count me out! Do you want to live forever? Nobody gets out of here alive.’ A look of mock alarm came over the chairman’s face. ‘Good heavens, Alastair. For a moment I thought you were going to produce a Kalashnikov.’

  Next morning I found myself saying to Caitlin, ‘You’ll damage your thumbs. Why do you use that rubbish, outmoded, obsolete technology? Why not just make a phone call? Freeze! Look at your palmaris longus. Taut as a ship’s hawser. You’ll get RSI, or de Quervain’s.’

  ‘Whazzat?’

  ‘Texter’s thumb.’

  ‘Hmph.’ She carried on texting, nibbling her bagel.

  ‘I’m thinking of starting a society, opposed to the unfettered IT splurge bandwagon. I’m modelling it on the lobby against Muzak. That’s called “Pipe Down.” My society will be “Log Off!”’

  ‘Don’t you mean F–’

  ‘Steady. “Log Off” won’t have a web site.’

  ‘I marvel.’

  ‘It’s not a close-knit society. We’re more of a freemasonry. We all know we’re out there. We recognise one another.’

  ‘Do you have a funny handshake?’

  ‘That could be incorporated. Would you like to join?’

  ‘Wild horses, Ally, wild horses.’ She finished her bagel and lit a Stuyvesant.

  ‘I wish you wouldn’t smoke.’

  ‘You smoke.’

  ‘I’ve got it down to a pack a year.’

  ‘I’ve got it down to a pack a day.’

  ‘There. I rest my case.’

  You may have guessed that Caitlin was in the car with Mary that night. Front seat passenger, restrained. The airbag deployed to save her life but also split open a section of her integument like an orange peel. In terms of the risk-benefit analysis, it’s a small price to pay. There is no therapeutic modality in the world that is not attendant with side effects. Not one.

  Caitlin. When I started out in medicine, started pacing the wards, started speaking to patients, I only used to ask one question. What is the diagnosis? Now I ask two more. What is it you seek? And, what makes you tick? I wondered about Caitlin. What was the diagnosis? What did she seek? What made her tick? I didn’t know. I didn’t know enough. There was some vital piece of information concealed from me.

  Mr Uprichard’s attempt to seduce me was much more subtle than Prof MacTaggart’s.

  On a Wednesday night the police brought in a nineteen-year-old man they had found in a lane behind a pub on Inverleith Walk. There was a smell of blood, alcohol, vomit, excrement, and death, the latter the more so since as a matter of fact he did die, as he entered the Resus Bay.

  ‘Get him across! Protect the neck! One … two … three! Trauma arrest.’ The nurses cut through the layers of bespattered clothing to expose the torso.

  ‘Start CPR.’

  There was a single wound just below the rib cage. I had a hunch the blade of the knife had been directed, expertly, upwards.

  ‘Put the leads on.’ I glanced at the trace. It was remarkably normal.

  ‘PEA!’ My hands darted across the precordium.

  ‘Borrow your tubes.’

  I snatched the Sprague-Bowles. Quick listen. I ticked off the differential diagnosis of electrico-mechanical dissociation.

  ‘He’s got a tamponade. Pericardiocentesis needle! Stop CPR. Stop the drips.’

  No time for ultrasound guidance. Do it blind. Subxiphoid approach. Aim for the left shoulder. I got back about 15 mls of dark blood.

  Somebody with their finger on the pulse called from the head end, ‘He’s got an output.’

  Then we lost it again.

  ‘Thoracotomy set!’

  What the hell. He’s dead. Nothing to lose. Without bothering to drape up or even cleanse the skin I made a generous incision along the fifth left interspace and got out the Gigli saw, the rib retractors, Metzenbaum scissors and long DeBakey forceps. Don’t lacerate the lung! Get the rib spreaders in so you can see what you’re doing. Broach the pericardium. Don’t prang the phrenic nerve!
Too much blood. Suction, swabs. More light please. There was the dark eggplant of the myocardium, flickering in its last throes. Keep away from the coronary arteries. No sign of a wound. Ease the heart forward and have a look at the back. There it is. A hole no bigger than my pinkie nail. I stuck a gloved finger on it, like the Dutch boy at the dykes.

  ‘Foley catheter.’ I inserted it and inflated the balloon.

  ‘Open the lines. Get some O neg blood up.’

  I gave the heart a few squeezes of massage and glanced at the monitor.

  ‘He’s fibrillating. Paddles please.’

  A few joules DC countershock were enough. The heart sprang to life.

  ‘Suction.’ There was still significant seepage but with the pericardium broached at least he would not tamponade.

  ‘Swabs please. BP?’

  ‘87/52.’

  ‘Slow the drips. Keep it at that.’

  It was still pretty precarious. I was still the boy at the dykes. We needed to go to theatre.

  And thus it was that Mr Uprichard made his grand entrance, fashionably late.

  ‘Good Lord!’ He was in pastel shades, slacks and jumper, incongruously wearing his golfing shoes. Night golf? Had he been on the driving range? I fully expected a tirade of abuse but he seemed vastly amused by the whole scenario. I glanced around. The place looked, and smelled, like an abattoir.

  ‘Theatre I think.’ Uprichard gave me a look I might have interpreted. ‘You’d better come. You seem very attached to your patient.’

  What must our bloodied caravan with its retinue of attendants have looked like in the short transit across the public corridor to the theatre lifts? I skipped along in crablike fashion with my hand still inside the man’s chest. We lurched up one floor and along another tiled corridor into the theatre suite. Straight through the anaesthetic room and finally into the inner sanctum, the echoing pristine cathedral.

  After the frenetic pandemonium of the emergency department, in here it was entirely peaceful.

  ‘Could somebody relieve the doctor of plughole duty? Mr Cameron-Strange, why don’t you see this thing through to the end? Continuity of care and all that. Scrub in!’