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M4, heading west, before Junction 33. Cardiff is on the left. On the right, up the hill, is a red castle. Sandstone walls and dark slate turrets jutt through the green. Even from the motorway it seems a scene from Narnia. Every year my family went camping in South Wales, and Castell Coch was the first highlight of my journey. The second was the factories of Port Talbot—flames above the factory chimneys, dense smoke and a sulphurous stench.
I didn't actually go to Castell Coch until I was eighteen, and staying with a girl nearby. Her name was Jenny. A grey Sunday morning at the end of June. Up close, the castle was disappointing. Mock this, mock that. The House Book describes it as a 'romantic folly'.1 We tried to find something interesting there for ten minutes, and then gave up. Instead we walked the path through the wood beyond, maybe two hundred yards. Looking left (down) there was twenty yards' gentle slope, then precipice. Looking right (up) was steep, but okay to clamber. She looked at me doubtfully. I think I gave her my jacket before sprinting up the scree to the top. I stood there and smiled down. From above, the gradient seemed steeper. Was I up for the view, or playing king of the castle? I remember thinking about how best to get back down. I started off facing outwards—too fast.
I slipped and the choice was to go down or try to run it out. I stayed on my feet—wrong again. The acceleration was too much. I remember the start of my plummet. Then nothing until the hospital—the corridor roof moving smoothly above me.
Jenny tells me about the in-between. I was lucky. I hit a beech tree like a jockey—rolled in a ball, my knees tucked up under my chin and my wrists crossed over the bridge of my nose. Back through time's kaleidoscope, I twist an alternative action. I climb down slowly and carefully. I slip back onto my rear and look stupid. Unfortunately, time is unidirectional. Jenny saw the irrevocable instant of impact. Broken human. She cleared tongue and blood out of my airway—mandible in pieces, jaw slackly huge and bloody—and put me in the recovery position. But I came round, and started crawling on my elbows, raising my head and dragging my lower body towards the path. I wonder if I made a noise. Jenny assures me I did, a choking, drowning, rasping rattle. She checked me again, and ran to the castle.
As she returned along the path with the castle-keeper, a jogger in a tracksuit appeared through the trees—on his Sunday morning constitutional. Without breaking his stride or looking back he casually thumbed over his shoulder, to where he had passed me, 'There he is.' He accelerated away. Our world is full of potential Samaritans. Ten years on, at an A&E course, a consultant has an aside for us initiates: '... if you're off duty and not in the hospital, and you see an accident, don't stop. Drive past. Drive on. It's not your problem.' It bothers me now that we (and I especially) kept silent.
I am lying on a woodland path with fractures of skull, nose, mandible and arm. My face is full of blood but my airway is clear. I am responding. Jenny is back. They get me to the hospital. I am moving through its labyrinth, propelled by hands unseen. A&E. Someone hurts me. I try to lash out.
Patients are anxious, confused, and suffering. They are not themselves. We forget this, especially on Fridays. We mechanically assess the 'fruits of Friday night-out'—alcohol and head-injury. For a doctor, it is hard to avoid the emotional antagonistic reaction to aggression. But aggression is a sign, and we should perceive it as such. A bang to the head—confusion, fluctuating consciousness. I remember smatterings of this altered state. Images subsist at a more fundamental level than words.2 Pictures flash through the mind, whereas words must be followed head to tail, links in a chain. And the pictures we access may be from any time, last week, last year, childhood.
Enormous scissors are cutting through my jeans, up my inside leg. Their intention is obvious. I am in Struwwelpeter3 playing the part of Conrad Suck-a-Thumb—but with each alligator lunge, the red-legged Scissorman is closer to my testicles. They want to mutilate my genitals. Again I struggle. Again I lash out. Someone understands my problem with the scissors, and starts from the top, cutting away from me. I relax. Nowadays, this is the way I cut people's clothes off too.
Where are your parents?
Where are your parents?
They have my wallet, its folded black pockets. They've rung the 'in case of accident please contact John Huntley on....' but there has been no reply. Surprisingly I can remember where they have gone and the number, but I can't talk. Jenny presses a pencil into my fist, clenching my fingers around it. My blood is all over her hand and her front. She holds the pad too. I grip the pencil and carve clumsily. Afterwards Jenny looks at what I have made, in itself unintelligible but she has read the individual intentions and has the number. We do the consent form. It is still morning. My parents are coming. The maxfax team can go to work.
They put a lot of metal—plates 'n screws—on and in my mandibular jigsaw. I have little memory of being immediately postop. I am told, however, that I disgraced myself—groaning loudly about having insurance and wishing to have a private room. I hope that this display was triggered only by my confused state and the cigarette smoke that hung in a low mist through the male orthopaedic ward. This was in the days before hospitals became smoke-free zones.
I remember a pen-torch through the night. Only my left eye opening. Neuro and airway obs. The possibility of a tracheostomy had been explained to my mother who kept vigil. My parents were there, the one staunch, the other fighting paralysis and tears. It is a depth of care that I know only now I am a father. It is said you never repay the debts you owe your parents, rather you credit your own children.
A day passed. And a second. At my request, a nurse held me a mirror. My left eye looked back. There was no white—the sclera all bright red. Out of my right forehead there sprouted the end of a thickened beef sausage. Bilateral panda eyes. There was no unblemished skin on my face. It was a monstrous scab overlying a bruised steak poultice. My right eyelid jammed shut by the periorbital swelling. My chin, big enough at the best of times, now stupidly huge and assymetric.
Jenny sat there for a while. The beauty and the beast. How can anyone look at me, eye to eye? But I was on a ward full of beasts. The man next door was one of the motorcycle victims, multiple limbs in traction or plaster and a halo for his cervical spine fracture. He was unable to move his head, but could manoeuvre a small mirror in his left hand so that he could see me, to talk. We watched a boxing match on his television.
My oldest friend visited. Realizing I would be unable to drink alcohol or chew, he brought a smoked garlic sausage and a bottle of wine. 'I thought you were going to look bad. Worse I mean.' I am grateful to him for his well-prepared lie. Another (possibly humorous) friend brought me Milan Kundera's Unbearable Lightness of Being.
More significant than pain was the discomfort of limited mobility, of stasis, and the cloying atmosphere of smoke. At least my mandible and maxilla were not wired together. My bite was wrong—it felt about half a centimetre off. They told me the muscle was damaged but would recover. I had no sensation the right side of my lower lip down to the right side of my chin. My right submental nerve then. The surgeon looked tired. It should come back he said. Should?? Should?? Yes, should. No guarantees then. What an ignorant unblemished existence I had led.
After a week I went home. I had lost a lot of weight—the catabolic component of the systemic inflammatory response. All my food was puréed. My meat-and-three-veg came via ice-cream scoop. Orange, green, white and brown. When puréed, steak tastes quite different. Texture is important.
Mainly I just had to wait for nature to do its healing thing. It was boring. The concentration lapses were frustrating—a thought wanders out there and beyond, and... and you cannot follow it head to tail. More than frustrating, frightening. The power of thought is identity, the whole damn thing. I started to read. Slower than usual. I remember Oliver Sacks' A Leg to Stand On.4 Many narratives concerning illness are about the rich potential of life in the face of progressive decline—but A Leg to Stand On is about recovery, regeneration and return. But this was no leg. This was my head. In the box is the fragile sponge that is centrality, existence, identity. Take anything else—a leg, an arm, a hand—but not my brain.
Our general practitioner visited, the one who was largely responsible for stimulating me to apply for medicine. I told him about the concentration lapses. Fractured skull, shaken brains—it'll take you about three months to recover fully, brain-wise. Two years if you were my age. And so it turned out. Three months later I was at medical school. Four months later, after ongoing pain at my right knee, he took out a piece of wood, the size of two matchsticks, under local anaesthetic, from my patellar tendon. Understandably, with all the excitement, it had been missed first time round.
My 'bite' came back fairly quickly, but the submental nerve took its time. Truth to tell, I had got used to it not being there. I had odd embarrassing moments with gravy, sauces and kissing. But you learn around these things. I used a napkin, dabbing at the right corner of my mouth during a meal, I kissed with the left side of my mouth. Six months on, in the New Year, I was up at six in the morning, splashing ice-cold water over my face, and I felt cold on my right lip and chin. Cold has never felt so beautiful. Light touch followed shortly after.
I started running at about eight months and got fit. Fifteen months after the accident, I played a low-level rugby match. Five minutes in I carved into their fly-half off the back of a line-out. It was a beautiful feeling, like cold water. Recovery, return.
Jenny did a PhD in visual recognition and a post-doc in neuropsychiatry. I guess these did not pay well. She sells drugs now (therapeutic variety). We see each other occasionally. She is a pragmatic person (a just-do-it person), and I doubt she would agree about the vast debt I owe her. She never told me about her bad dreams, the video re-runs of human impact on beech tree. Of course my debts only start with Jenny. Emotional, recuperative, supportive, directly interventional—paramedics, ambulance, A&E, surgeons, nurses, parents.
What did it leave me? A realization of the importance of living and the potential of healing. Immense personal debts (still owing). An unshakeable love of maxillofacial surgeons, all of them, worldwide, job-lot.
What I learn over and over was well put by Seneca:5
'What is man? A vessel that the slightest shaking, the slightest toss will break... a body weak and fragile, naked, in its natural state defenceless, dependent upon another's help and exposed to all the affronts of Fortune'.
The dearness yet cheapness of life may not be appreciated until we have felt it ourselves (the near-miss) or had it drip through our hands (those failures). From here it is a short step to point out the danger of a life of deferred gratification,6 especially with reference to medicine:
'Life is short, science is long; opportunity is elusive....7
Thanks to Dr J Jenkins for her critical reading and editorial corrections and suggestions.