Mark Haddon - The Pier Falls - And Other Stories

They take out their boots. “There was a beech wood just below the sawmill,” says Mikal. “It was the most astonishing place in spring. Yellow rapeseed to one side, bluebells coming up through the dead leaves.” They visually check the airtight joints at the ankles, knees and pelvis, rotating each one through 360 degrees. “I was chased by a forester once. A huge man. He had a gun. It was tremendously exciting.”

Suki appears in the doorway, noiselessly as always. There is a look on her face that Clare has never seen before. “You need to come.”

“I have pain moving from my stomach down to my right iliac fossa.” Jon is finding it hard to speak. “I have no appetite. I’ve been vomiting. I have a temperature of forty-one and I have rebound tenderness. I think it’s fairly obvious without doing a white blood cell count.”

“Antibiotics?” asks Per.

“I’m taking them.”

“When do we have to make a decision?”

“Now would be good,” says Jon.

Everyone looks at Clare. She’s never done an appendectomy.

Per turns back to Jon. “Tell her everything she needs to do. Suki, get into a blue suit, sterilise West 2, put new air filters in. Arvind, set up the equipment. Mikal, we need references, photos, notes, diagrams. Jon, morphine or ketamine?”

Everyone else leaves the room and Jon and Clare are alone. He says, “Well, this is an adventure.”

She did military medical in Florida, four years of college compacted into six months. No time for surgery. In 403 days they would be joined by Dr. Annie Chen. In the end all you could do was to rank the conceivable emergencies in order of likelihood, draw a red line where time and money and the capacity of the human brain came to an end and hope you encountered nothing on the far side.

“Sofanauts” was the word they coined, people willing to be fired into space on top of a 700-tonne firework then spend the rest of their lives playing Scrabble and cleaning toilets. You had to get pretty close to the Venn diagram to see where those two circles overlapped.

She had very little to tie her down. Her parents were dead. Three years with Peter convinced her that she did not possess a talent for intimacy. He wanted children but the rough end of her father’s anger had warned her against the dangers of that particular relationship.

She had two degrees in physics and a job as a lab technician. People told her that she should be more ambitious but it didn’t seem like something one could change. Less sympathetic people said that she was detached and uninterested. Then she found her niche. Vasco da Gama, Shackleton, Gagarin. Was it stupid to hope that your name might be remembered in four hundred years’ time?

Jon lies on his back with his right arm tucked up out of the way. He is intubated and Mikal is hand-ventilating him. She stands on his right, Suki on his left, both of them masked and blue-suited. Laid out on a second table are scalpels, six retractors, a couple of clamps, an electrocauter, suture, needles, saline and antiseptic gel. Behind the instruments are two tablets, one showing images of the skin and muscles in the abdomen, the other showing the notes she made from Jon’s instructions. Before he was anaesthetised Jon drew a 4 cm diagonal line on his own abdomen with a Sharpie to show her where to begin cutting. She washes the area and swabs it with green gel.

Suki’s and Mikal’s eyes are unreadable above their masks. Through the one porthole she can see the layered shale slopes of Mount Sharp and the featureless carbon dioxide sky. She ratchets her focus down. Be calm. Pause before every new action. Detail, detail, detail.

Mikal says, “You can do this.”

She picks up a 12-blade scalpel and cuts into the abdominal wall. The blood starts to flow. Suki hooks the tube into the lower end of the wound to pump it out. Clare can see the three layers of which the flesh is composed: the outer skin, the fatty layer of Camper’s fascia and below that the membranous Scarpa’s fascia. She cauterises the bleeding from the bigger blood vessels. It smells like bacon frying. The heart monitor chirps. 78 bpm. Mikal squeezes and releases the clear plastic ball. She makes a second incision and refers back to the diagram. She has reached the upper layer of stomach muscle. The parallel fibres run north-west to southeast. This is where the hard part begins. She makes an incision along the fibres, pushes two clamps into the slit and uses a retractor to crank it open. She is surprised by the force she has to exert and the fact that the muscle doesn’t rip. The resulting hexagonal hole is shockingly small.

Under the muscle she can see the peritoneum. She takes hold of it carefully with the Metzenbaum scissors and cuts into it making an even smaller hole. Mikal asks if she needs any help. She tells him she doesn’t. She hears the snappiness in her voice. She stops and takes three long, slow breaths. Twenty-four minutes, but doing it right is more important than doing it fast.

She checks her notes. She has to find the ascending colon and the longitudinal muscles around it. She scrolls through the pictures. Nothing seems to correlate. She is going to have to move the colon around using clamps. She is unsure of how much pressure she can apply before the glossy membrane tears. Gently pinching, she moves it to the left, shifting the clamps one over the other in turn as if she is hauling on a wet rope. Then she moves to the right in the same way. She can see them now, the taenia coli. She follows them downwards and there it is. The inflammation is all too visible.

Arvind comes in, masked and blue-suited and takes over from Mikal who leaves the room.

Clare uses the rounded metal end of a clamp to guide the appendix gently up and out through the hole. She puts a clamp on the junction between the appendix and the colon, squeezing it shut until it catches on the first notch and holds, then a second clamp beside it. There is an artery in that little isthmus of flesh around which she is going to tie the sutures. She stretches her hands and fingers to loosen them. Suki gives her the first length of suture. She threads it round the neck of flesh between the clamps and ties it tight with a reef knot. She cuts the loose ends away. She ties a second suture next to it. To make absolutely sure she ties a third. Slowly she releases the clamp on the appendix side of the suture.

She hadn’t thought to ask Jon what the appendix contained. Pus, presumably, but how liquid, and under what pressure? She asks Suki to soak several swabs in antiseptic gel and pack the opening to protect the peritoneal cavity. She uses a new scalpel to cut through the pinched flesh between the sutures and the clamp. It is tougher than she expects and when it finally gives she slips and slices through one of the swabs right into the muscle.

“Fuck.”

She waits and breathes. She examines the fresh wound. She hasn’t punctured the peritoneum. Luckier still, the swollen appendix has come away with no leakage. She drops it into a tray then cauterises the bunched flesh where it was attached.

She releases the second clamp. The sutures hold. She is going to wait for five minutes. She wants to be absolutely certain. There is no noise except the hush and crumple of the air bag. Four minutes, four minutes thirty seconds, five minutes. She rinses the wound with saline. She pulls the two sides of the cut peritoneum together and clamps them. Suki threads a curved needle and hands it to her. She stitches, moves the clamp, stitches again and moves the clamp. When she has finished she prods the peritoneum on either side of the wound. The stitches are not tidy but they hold. She washes them with saline.