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Grey Matters

Summary:

Doctor Sherlock Holmes is the hospital's new neurosurgical star. He performs miracles with his scalpel, but his bedside manner leaves a lot to be desired. The task to address the issue falls on Doctor John Watson, one of King's College Hospital's senior neuroanaesthetists.

Notes:

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[an index and guide to all my Sherlock stories]

Me, two weeks ago to a friend: "I'm never ever going to pen a hospital AU—it would be too obvious an idea."

Me, two days ago (when this idea burrowed into my brain like a maggot and wouldn't let go), in a voice not unlike Eric Cartman's: "GODDAMNIT!"

Since a lot of medical lingo will be employed, I will endeavour to explain abbreviations and other alien terms in the authors' notes. This version of King's College Hospital and its staff is entirely fictional.

This story is dedicated to all my anaesthetist colleagues (who will hopefully never find out about my strange hobbies!) and all the nice surgeons in the world. A thank-you goes to my Husband Unit, who provided some very valuable insight into cool cars. I also must thank my fic-writing co-conspirator M, who jammed this idea into my brain.

(See the end of the work for other works inspired by this one.)

Chapter 1: Hard to swallow

Notes:

(See the end of the chapter for notes.)

Chapter Text



Doctor John Watson knocks before he enters patient room number eleven in the neurosurgical ward of King's College Hospital. He walks in, then stops in front of the only bed in the room. Next to it stands a woman in her sixties, supposedly the Mrs Holborn whose chart John is holding. She seems to be frantically packing her things, assisted by a younger woman who is probably her daughter.

"Good afternoon," John says. "Am I in the right room? It seems as though you're leaving, Mrs...?"

"Holborn," The woman says, turning to face John. "Anne Holborn."

"I wasn't aware you were being discharged," John says, slightly confounded.

"I'm not being discharged, I'm leaving."

John glances at the chart, frowning. "I have you scheduled for an operation tomorrow. I was not aware it had been cancelled?" he inquires and adds, "I'm John Watson, I've been assigned as your anaesthetist for tomorrow. I'm here to discuss some related matters and to answer any questions you might have."

The woman continues to pack, looking quite upset.

Her younger companion crosses her arms and regards John with an angry look. "We're not staying here a minute more. Honestly, I wish they'd told us sooner that the surgery would be useless."

John puts the chart down on a nearby table. "Look, Mrs Holborn and---?"

"Lucy Holborn. I'm her eldest."

"Could you please sit down, Mrs Holborn? It's obvious there's something going on that I wasn't made aware of. Could you please explain why you have decided to withdraw consent?"

The older woman stops rummaging around her floral-patterned suitcase and slumps down onto the hospital bed. Her jaw is shaking as she is holding back tears. "It was that surgeon, he was just here, he told us that even with the surgery, I'm going to d---" She begins sobbing inconsolably.

The daughter leans down and puts an arm across her shoulders. "Mum, please don't. It'll be okay. We'll get a second opinion." She passes her mother a tissue from her pocket.

John grabs a chair and pulls it closer to the bed. He sits down and leans his palms on his knees.

"So, you talked to the surgeon. What did he say exactly?" John asks.

It's Lucy Holborn who answers: "He said that he is certain he can get the tumour out but, with this type and grade, it'll just grow back later and--," she glances at her mother and inhales nervously, "--be fatal."

John checks the name of the neurosurgeon on the chart. A Dr Holmes. He's not familiar with the name.

Mrs Holborn has a grade three astrocytoma. It can't really be cured, but there's always a chance of a long remission.

"If I'm going to die anyway I'm not getting the surgery. I want to go home to my family," she says slowly, sniffling.

John smiles in what he hopes is a reassuring manner. "While it's true that most patients will succumb to a grade three tumour of this type in the long run, we can usually give them many great years with surgery and other current treatments. Decades, even."

"Well he should have told us that, then!" Lucy Holborn says accusingly and leans on a wall next to the bed. Mrs Holborn has stopped sobbing but is still looking crestfallen.

"Look, sometimes surgeons are so focused on an upcoming operation that they can be a bit distracted. It's a good thing, really—it means that they're extremely focused. Unfortunately, that can sometimes make them appear a little brusque," John says in an attempt to soften the tension.

"But that doesn't explain why he'd have to be so bloody cruel about it all!" Lucy says accusingly. "He didn't seem to care about Mum at all!"

John purses his lips. "I'm so very sorry to see you this upset. Maybe I could walk you through the surgery so you could have an idea what to expect? Then you can decide together what you want to do. Does that sound okay?"

Mrs Holborn looks out of the window and then at her daughter, who shrugs. "Couldn't hurt, I guess," Lucy Holborn says.

John explains the usual course of the surgery and the post-operative care as meticulously as he can without emphasizing any potential risks in an unsettling manner.

When he has finished his explanation, he answers the many questions the two women have. Mrs Holborn decides to have the surgery after all.

 

 -o-0-o-0-o-0-o-0-o-

 

It's half-past four in the afternoon when John finally excuses himself from the company of Mrs Holborn and her daughter. The daughter had thanked John for giving them a bit of hope after "that horrible man" had tried to completely take it away from them.

Before heading home, John wanders into the OR floor break room in search of caffeine and his fellow anaesthetists. It's been a month since he's last seen his colleagues due to a long-overdue holiday. Apart from a weekend he'd spent in Kent visiting his sister, he had whittled away his free time housesitting for a mate in Birmingham.

The first person to greet him when he walks into the lounge and heads straight for the coffee machine is his ex, Doctor Natalie Temple. They'd broken up a little before John's holiday after dating for two years. Eventually, smouldering disagreements escalated into a full-on war, and they agreed that a long-term thing wasn't going to work between them. She is smart, but a little too much of a free spirit for John's tastes; at one point she'd even pushed for them to try an open relationship. Even though John did have a reputation of being quite the ladies' man, his moral compass somehow never allowed him to seek other bed companions during their relationship. Natalie, however, hadn't had such qualms. It wasn't the only reason for the downfall of their affair, but a large part of it. It seemed that their explosive break-up was the best thing that could've happened, because somehow, they'd ended up being good friends again.

Their combined salaries had been enough to get them a very nice rental in Soho. Now that John is on his own, all he can afford is an abysmal little bedsit in Shoreditch. Maybe he ought to find himself a flatmate or something to get a bit more space for his stuff and a shorter commute to the hospital.

"Johnny!" Natalie calls out from where she's stretched out on a worn couch, "How was Kent?"

"Harry's drowning herself in a bottle again; her girlfriend's moved out."

"Which one came first, the booze or the breakup?" Nat asks.

John had told her about his sister's tumultuous life when they'd still been together. "Fuck if I know," John says and sips his coffee. He sits down onto the adjoining couch. There are no noises drifting in from the corridor outside except for a cleaner's vacuum. "Everyone else still busy?"

"Nah. I let the registrars home early since I'm on call and there isn't much on. Why are you still here? I thought you only had that laminectomy today, the one that ended ages ago. Just released the patient from obs back to the ward."

"Just couldn't be arsed to shove myself into the busiest Tube carriages. So, any juicy rumours? Anything happen while I was away?" John asks, idly flipping through an old issue of the British Journal of Anesthesia.

"Not much. Oh, except they finally filled that fellowship position in neurovascular and posterior fossa surgery. Turns out there was this guy they were looking to headhunt, that's why the job has been unfilled for such a long time. He's still a reg, but apparently he's already got a research career to die for."

"Anyone we know?"

"I'd heard of him but never met him before he got hired. Dr Sherlock Holmes? He invented that new anti-siphon shunt valve a couple of years back that was all the rage in the conference circles. Did his training at The National up to now, apparently."

The National Hospital for Neurology and Neurosurgery is the country's premier unit in the field. John himself had applied for an anaesthesia registrar position there years back and got turned down even though he had quite a decent CV. Thankfully, King's College had accepted him, and a few years after reaching consultancy he'd been trained further into a neuroanaesthetist through a two-year fellowship in the subspecialty.

"Weren't they sorry to let him go if he's that good?" John asks.

Natalie leans back on the sofa, dangling her clog on her big toe. Eventually she loses control of it and it flops onto the floor, revealing a yellow sock with a smiley face on it. She mostly anaesthetizes paediatric neurosurgical patients, and has made a habit of wearing funny socks and hats she can use as a distraction while cannulating her tiny, needle-hating patients.

"That's the thing. He's supposedly really, really good with a scalpel, but I'm Facebook friends with some of the gassers at the National and they all seem to really hate his guts."

"Why's that? What's he supposed to be like, then?"

Natalie grins. "Well, as long as you don't talk to him and he doesn't talk to you, everything's just peachy."


Notes:

Welcome to the fascinating world of neurosurgery. To ensure a maximum amount of tropey AU fun, I have tweaked and twisted many facts to my liking for storytelling purposes—this is not a medical textbook. I'm using the names of existing British neurosurgical units in this story, but I know next to nothing about them. I have no idea what the quality ranking would be, or if there even is such data available. Do correct me, British colleagues, if I'm wrong in any of these explanations. Also, I am NOT a specialized neuroanaesthetist. Although I do handle neurosurgical cases (including emergencies) on occasion. I'm more of a generalist gasman. Gasperson. Gaswoman?

First, a word on preoperative visits. Practices vary between hospitals, medical specialties and countries but, as a general principle, the surgeon and the anaesthetist try to meet up with the patients and their accompanying family members prior to major surgery. They explain what's going to happen before and during the operation, and what sorts of plans have been made for the patient's care immediately after the surgery. If they haven't done so before, the surgeon will also explain potential risks and complications of the operation. The same usually applies for anaesthesia, if the surgery requires significant anaesthetic procedures such a cannulating major blood vessels. For minor routine surgery, the anaesthetist may not always meet the patient before they are brought into the OR. A lot of minor operations are done on an ambulatory/day surgery basis, which means that the patients sleep at home before the operation. In those cases it's difficult and mostly unnecessary to arrange a preop visit. Brain surgery (to which intracranial surgery is fancy synonym) is never ambulatory/day surgery.

Astrocytomas are a common type of brain tumours in adults. Grade 1 is quite benign and easiest to cure, Grade 4 is the worst and almost invariably fatal. Grades 2 can often be cured, but grade 3 may develop into 4, or simply keep growing back.

A registrar is a doctor who has graduated from medical school and who is well on his/her way in specializing in a certain field. When a registrar finishes his/her training, he/she will become a fully fledged consultant. A fellowship is a programme of extra-intensive training in a chosen subspecialty ("a specialty within a specialty"), which is usually completed towards the end of postgraduate training. King's College does really offer a fellowship in neurovascular surgery, meaning surgery involving the blood vessels inside the skull (aneurysms, arteriovenous malformations, venous sinuses…). I upped the ante by adding posterior fossa surgery, which involves structures located deep down below and behind the cerebrum, close to brain centres looking after many vital functions.

A laminectomy is a common type of back operation. As Mayo Clinic explains it: it's surgery that creates space by removing the lamina — the back part of the vertebra that covers the spinal canal. Also known as decompression surgery, laminectomy enlarges the spinal canal and thus relieve pressure on the spinal cord or nerves.

King's College is ranked among the 25 top universities in the world. The King's College Hospital's neurosurgical unit is located on the university's Denmark Hill campus in South London, sort of bordering the boroughs of Lambeth, Camberwell and Southwark. Here's a map of the hospital. I have no idea whether the neurosurgical unit has a separate OR floor or not.

Recovery/Post-anaesthesia recovery area: I'm not British nor do I work in the UK so I have no idea what doctors usually call this (patients being observed in a specialized, monitored post-anesthesia care area).

OR = Operating room. Also called an operating theatre for historical reasons. A museum in London demonstrates those reasons well.

"New antisiphon valve" = Anti-siphon-type shunt devices are used to regulate the flow of cerebrospinal fluid in patients whose own regulatory mechanism have failed.

Clogs = Many doctors wear clog-like shoes for work in the ORs. They're handy because they cover your toes and therefore prevent all sorts of biological fluids and materials seeping into your socks (which is icky, I can tell you). (Personally, I'm more of a Birkenstock girl.)

Pediatric = refers to something having to do with children

Gasser, gas man = colloquial for anaesthetist