by Jane Shemilt
‘So in any case you need to replace the tube in the brain?’
‘You’ve got it.’ His voice is deliberately cheerful; the least he can do is not share his worry. ‘It’s a straight forward procedure but there are risks, like every operation. We’ll need your consent.’
‘No problem.’ She is more relaxed now that Billy is quieter; he doesn’t tell her this kind of quietness is a bad sign.
‘We’ll need a scan before operating. Can you help me wheel him to the scan room, Judy?’
‘Jake should be here too, he’s downstairs somewhere, phoning work.’ Gita takes out her phone.
‘So he came back in the end.’
‘Not quickly enough.’ She stabs at her phone.
Judy moves the bedside table and grasps the head board, Albie pushes the other end, and together they manoeuvre the bed out of the room. The sick child moans quietly and guilt overwhelms him, a deep ache, like the descent of flu. His plan to make Jake return worked, and the wait that incurred was clinically defensible; all the same the sense of impending disaster is threaded through with dark strands of guilt. He hadn’t needed to lure Jake back. Jake didn’t find the vials, nor did Ed; they weren’t there to find. The story of the lost vials has come to an end; this is the living story, unravelling fast.
Jake meets them halfway down the corridor; his face sags when he sees his son again. ‘Jesus. He looks worse.’
‘Hello there, Jake.’ Albie continues to push the bed. ‘We are taking Billy for a scan so we can see what’s happening.’
‘You should know what’s happening.’ Jake holds his son’s hand as he walks beside the bed. ‘The shunt must be blocked with an infection; you’ve got him on the wrong bloody antibiotics.’
‘We can’t be sure of anything just yet,’ Albie replies, guiding the heavy bed around the corner.
‘You would be, if you’d been with him.’ Jake straightens and attempts to take Gita’s hand as they walk, but she wraps her arms around her body, walling herself away from him. They sit in the waiting area, while Albie continues to the scanning room with Billy.
Owen anaesthetises Billy; his normally relaxed expression is tense with concentration, his eyebrows are lowered, his mouth a tight line. Albie cleans the scalp with chlorhexidine and inserts a tiny orange needle deep into the dome to withdraw the few drops of clear fluid remaining at the base. He injects this into a pot, a nurse hurries off to take it to the microbiology lab. The little team cluster around the child as he is placed in the scanner. Albie retreats to the overlooking imaging room; he stares at the computer screen as he waits.
A sense of doom is palpable above the silent machines in the scanning room and hovers over him too. If a scan of his brain, not Billy’s, were to spring from the darkness of the screen, the limbic system might be warped beyond recognition, the amygdala diminished. He was a good doctor once, a good man, but it’s too late now for repair or repentance. He looks down at his hand as if the twisting blue veins on the back were a map that might point to where it all began. But the veins are a network that doesn’t have a beginning. They branch and circle. Where was the wrong turn? How far back should he go? He has made all the wrong choices, though perhaps they weren’t choices but consequences of how he was made and who he already was. He knits his fingers to stop the trembling.
Billy’s scan appears. The new, larger size of the ventricles is obvious. The cave-like spaces in the brain seem to fill it entirely. In addition, there are cracks of darkness within the surrounding white matter, radiating out from the lining of the ventricles – fluid under pressure being forced into the brain itself.
He brings Gita and Jake into the room; they are familiar with Billy’s scans to date. Faced with the new image, Gita gives a cry of dismay. Jake pushes forward, his face almost touching the screen.
‘The scan confirms that the cerebrospinal fluid is blocked, but from this alone, we can’t see why,’ Albie says.
‘So unblock it.’ Jake bounces on the balls of his feet. Albie can smell him, stale sweat and unwashed clothes. He is unshaven; he must have travelled non-stop, taking the ferry from Jura to Islay, then Islay to the mainland. The long drive to Glasgow then the wait for space on the next plane or the one after that. He’s done it himself, many times.
‘That’s exactly what I am about to do.’
‘Why the delay before investigation?’ Jake’s eyes are lit as if for battle. ‘He’s been getting worse all the time.’
‘His management has been systematic, Jake. I set up treatment as soon as a problem became apparent, and my team has been monitoring the situation since,’ he replies, wiping his palms against his white coat.
‘In your absence.’ Jake’s face is close to Albie’s. ‘How could anything be more urgent than a sick child?’
‘You weren’t here either, Jake.’ Gita’s voice trembles.
‘I was in Scotland, helping Ed. It was important.’
‘More important than your son?’ Gita turns away; she stares through the window to the scan room where Owen and his assistant are carefully lifting Billy from the trolley back to his bed. Jake slams one hand into another, a brutal movement. They will not survive this, whatever the outcome. Jake’s face is flushed, Gita’s tear-streaked. This is love, dying. A moment like the headache that presages cancer; destruction will follow, confusion and pain. Then, emptiness. He walks slowly from the imaging room to the corridor, trailing the anaesthetic team who are pushing the bed straight to neuro theatres. The bond between him and Beth seems broken too, as though in falling Ted pulled it down with him. He hurries to catch up with the bed. After this, when Billy is better, he’ll think about Beth then. Fractures heal, wounds aren’t always fatal. They’ll knit back together, given time. Then he empties his mind of Beth, of Gita and Jake, even of Billy. There is no sadness, no regret and no tragedy; not even a child in danger. There is simply a blocked shunt that needs removal and replacement. He will have to muster all his skill.
Fifteen minutes later he is gloved up in theatre, Billy more deeply anaesthetised, the head cleaned and positioned against a padded horseshoe rest, the right side uppermost.
The nurse tells him the results from the pathology lab show that there is no infection.
He performs a meticulous C-shaped incision in the skin of the scalp around the silicone dome and then dissects it free from the underlying burr hole in the skull. Holding the dome with a pair of toothed forceps, he very, very gently exerts the lightest pulling pressure to extract the connected tube from the ventricle. Nothing happens. He pulls again with a small increase in effort, still nothing. He tries several more times, increasing the pressure by tiny amounts. His hands begin to sweat. He remembers a French exam at school, each question more impossible than the last. At some point he’d begun to scrawl rubbish; anything to have done, desperate to get to the end no matter what. He has reached that limit now. The dead children, Ted and Bruce cluster at his elbow. Beth is hovering too. He is in too far, he has done too much. There can be no going back. He presses his lips tightly together and pulls. There is a tiny ripping sensation, and the tube comes out in his hand. He inspects the end immediately. With a sickening sense of helplessness, he sees pink-red stringy fronds, fairy seaweed, filled with blood. The choroid plexus has been torn, that delicate network of vessels that lies in the ventricles had been drawn into the holes in the tube, the diagnosis he feared the most. Now the ripped ends in the ventricles deep in the brain will be bleeding rapidly and there is no way on earth to stem the flow. He calls for another catheter, but before he can insert it down the old track to drain the blood, the brain, under overwhelming pressure, pouts up through the burr hole.
He stares at the bulge of glistening grey jelly, threaded over with red vessels. The substance of life. A child’s life, Albie.
‘Fuck,’ he mutters. ‘Fuck. Fuck.’ He senses Owen’s glance; Albie is normally quiet, not given to expletives. He should have left well alone when he sensed the tube didn’t yield; he could have inse
rted another shunt alongside, leaving the old one in place. The ghosts have disappeared, have they achieved what they wanted? He needs to be quick. There may still be a chance, another place where fluid could be drained. He pushes a new length of tubing back in along the approximate track of the one he has just removed, and positions it in the ventricles just short of where the other was. He withdraws the inner catheter: blood starts dripping fast from the end of the shunt.
His assistant wipes his face. In a calm voice he asks Owen to cross-match blood. In fifteen minutes the blood dripping from the tube slows to a standstill. He performs a burr hole on the opposite parietal bone, swiftly inserts another catheter, endeavouring to reach the ventricle that side, hoping that this will be successful, that clear fluid will begin to drip from the end to relieve the mounting pressure in Billy’s brain, but nothing. No cerebrospinal fluid, not even blood. Dismay thickens at the back of his throat, he forces himself to breathe slowly to cope with the rising panic. At his request, Billy is taken for a scan by the silent team. He can see from the images beamed to the screen in theatre that the blood has at last clotted but there is a new horror. There is now a solid cast of blood filling both ventricles, set like clay, taking up the entire volume of the ventricles both sides.
The child is returned in minutes. Albie retracts the catheter slightly in the hope that around the edges of the massive clot some of the cerebrospinal fluid will leak away. Nothing comes back. He looks down; his clogs are in a pool of Billy’s blood. The point of no return.
He gives the order for Billy to be taken to the Paediatric Intensive Care Unit. He helps Owen move the child from the operating table to the bed, and walks behind to the recovery bay. The small brain is now being forced downwards in the skull. Once the third nerve that controls pupil size is squashed, the pupils will dilate; death will follow swiftly. If he could pray, now would be the time. His thoughts jump wildly even as he walks out of theatre. Another burr hole, though how will that avail as the blood is set in a vast solid clot? Sucking out would achieve nothing. Excision of a skull flap and manual removal of the clot would mash the brain. If Billy is continuously ventilated on PICU there is an outside chance the clot might liquefy, it might be possible to drain it then. Please God …
Owen’s quiet voice cuts across his spiralling thoughts.
‘Both pupils fixed and dilated.’
The knot around the bed stands back. No one looks at him.
Owen touches Billy’s hair. ‘I’m sorry,’ he says, though it is unclear exactly who he is talking to.
30
Jura. Summer 2018
The scent of earth close up; peat and smoke. Fungus. Wood. Iron. Blood.
An ant with many legs lies on its back, becomes two, one struggling with another, pulling it over the swords of grass, dropping, picking it up, dragging it. Aggressor or helper, a fierce instinct is at play; the tangled organism carries on, staggering out of sight. There are seeds down here, brown and cream pips lying on the dark soil. Fragments of wood. The stalks of grass gone yellow at the base. Her ear is tight against the soil, listening to the sounds that seem to thrum beneath the surface – unintelligible mutterings –angry, as if the earth itself is blaming her.
A yard away is a curved back of orange hide, sides blotched with white as if touched by a finger dipped in paint. A twitching ear. The fawn has been in the grass for hours, a night and a day at least. Both have been abandoned, though she has been waiting for rescue longer than he has. Three weeks in all? Longer? She swims in time, losing track.
The little animal struggled to get up at first, and then gave up, looking at her as if she were a stone or a tree, a stain in the landscape. Pure regard, bearing witness.
The ears are long, pointed, lined with white. They flick backwards and partly rotate. She had wanted to stroke the tiny head, cup her hand at the furred angle of its jaw, but she knew not to. After a while, the neck relaxed again, extending forward, the long skull sank close to the ground. Green shines from the ring on her finger, the light could stab him in the eye like a blade. A ring should mean safety but hers feels dangerous; she doesn’t need it any more, less fettered without. Its purpose has been spent, though thinking back she can’t remember what that was. She pushes it carefully, stone side down, into the soil. The gold band follows. She lies still, like the fawn. She feels close to him now, closer as the hours tick by and the light softens. No one comes. They have been abandoned by their families, both their mothers have gone. The fawn’s mother could be eating or mating or dead. Maybe she’s watching from the shadows, waiting until Beth leaves, to fetch her fawn.
She rises to her feet at the thought, and the world becomes dark. She stays quite still until she can see again; the fawn doesn’t move. The white flap of a sail beats beyond the trees, or the tail feathers of a large bird like a sea eagle. Gone in a heartbeat. Angled sunshine on rock perhaps. Her head aches as she walks slowly to the house. The garden watches her, indifferent to her plight. Inside flies rise buzzing from the dirty wine glasses on the table and the remains of a sandwich on a plate. Last night’s supper or the night before. While chewing, a stone had rolled in her mouth; it became a tooth in her hand. It didn’t hurt, though her mouth was filled with blood.
Grass and twigs are scattered on the floor, blown in. She tries to sweep them up but her hand throbs, the mutterings swell, she drops the broom.
Someone else’s face looks back from the mirror. Wild hair, a leaf caught in the knotty black. Mud on her chin. Tears on her face. Blood on the collar of the shirt she is wearing. A man’s shirt. She stands still when the car comes down the road. It stops, footsteps come to the door. Knocking. Louder knocking. She pushes herself to the wall; the stone is cold against her flattened breasts. There is a measured thump of feet walking around the house outside. She crawls upstairs and looks down from the window, careful to stay out of sight. The man has dark wavy hair. Tweed-covered shoulders. Familiar, though she can’t place him. He walks from window to window, hooding his eyes with his hand. He doesn’t look dangerous, but that might be a disguise. She lies on the bed; after a while a car door slams, an engine starts, gets fainter.
The voices are louder, clearer, though she can’t hear the words. She understands they are blaming her for something, though she can’t think what it is. When the bright light goes from the room, and the shadows are long over the bed, she gets up, looks out of the window. White is still flickering through the trees. Sail? Bird? Sheet? Shawl? Dress? She walks downstairs, feeling sick, holding on, going slowly.
Outside, the fawn is still lying in the same place. She mustn’t touch him, though she wants to. If she touches him, he might die. A child has died; was it hers? An eye for an eye, a tooth for a tooth. She puts her hand in her mouth, her fingers come out covered in blood.
She starts to follow the white that is flickering beyond the trees, clearer now, a shawl for a baby. No, it’s a dress, a child’s dress. No, it’s a child, the little girl; she has found her way here and is dancing ahead through the gate and over the stretch of grass; she disappears down the little path. Beth follows, dizzy and sick with the heat. On the beach she sees that the child has climbed the rocks to the side under the cliffs, too high. Her heart clenches, she starts after her, but the little girl jumps, her white dress fluttering. The light from the low sun dazzles. She puts her hands over her eyes, looks closely at the glinting water. The child is up to her neck, waving.
Beth takes off the shirt, surprised at her body in the daylight. Her breasts are smaller now. Her belly and thighs have shrunk. She climbs down the shelf of rock to the lower ledge then steps off that, going more deeply than she meant to. Her bones must be nearer the surface than they used to be, they hurt in the cold. The salt finds the wound on her hand. A wave knocks her sideways and her ears fill. In a gap in the waves she glimpses the child. The white dress is floating around her; it will trap her. She needs to reach her and take it off, swim with her back to the rocks.
Silvery walls of water are
in the way. She would see better standing, but when she lowers her feet to the ground, the ground isn’t there. It occurs to her she should have told someone she was going in the sea, but there was no one left to tell. The water fills her mouth, colder than blood. The child has moved further away, out of sight.
Once someone was with her, whose face glittered in the sun. He swam through the water like a seal but he’s not here now; in this moment of fear even his name has gone. A wave hits her in the face. There isn’t a child in the water, she has made a mistake. Another wave hits and then the next one. The water is in her throat. She turns to go back but her way is barred by waves. They turn on her like animals.
The group of deer waits outside the open gate until dark. Their heads are high, they are listening, scenting the air. They approach the house gradually, feeding as they go, until a window bangs in the wind and they startle back, then they approach again, wait again. There is a noise of a dog barking for a long time, whining follows but then the noise stops. The largest female enters the garden. She walks stiffly and neatly to the tree. She bends her neck, noses the still form, licks it.
The skin twitches. The fawn lifts its head and, in a rush of unfolding legs, lurches to its feet and stands swaying. The mother turns and walks out of the garden and the small animal follows.
ACT FOUR
* * *
31
London. Autumn 2018
The post lands where it falls. Leaflets from local restaurants, political pamphlets, pictures of chained dogs and animals in cages, bills in brown envelopes, some with red type. Who cares? Albie kicks the whole lot out of the way.
Nowadays he starts early and stays late on the wards or in the laboratory. He has been promoted to consultant surgeon and official head of the lab. Both Ted’s jobs are now his. His appointment to the lab was uncontested, Ed didn’t even apply. Owen told him Ed had a place on the Nottingham rotation as a junior registrar; their paths are unlikely to cross again.