Chapter Text
"You should have worn your new navy blue jumper," Sherlock leans closer to comment quietly from where he's standing next to John. They're watching the camera man readjust the positioning of one of the lights.
John chuckles. "I'm touched that you care what I'll look like on TV."
"Of course I care. What you look like is also a reflection of me."
"Because the anaesthetist is just the surgeon's little helper?" John quips.
Dismay takes over Sherlock's features. "No, that's not what I–– Of course not!"
"I'm just yanking your chain, love," John whispers loudly with a grin.
A glance around confirms that no one is eavesdropping on their conversation. They've just emerged from the make-up room where the staff had dusted powder on them to take the shine off a pair of faces not used to the heat of the bright studio lights. Sherlock had protested the whole thing, insisting he found just looking at the powder keg made him feel like someone was dragging nails down a blackboard in his vicinity, but John had managed to talk him out of a strop by insisting these were professionals who knew what they were doing.
Sherlock readjusts his cuffs so that they show the perfect amount of fabric beyond his jacket. He is wearing a black suit with a purple shirt, all parts of the ensemble fitting like a glove.
But… there's something missing. Something John knows his husband has purchased not two hours ago. "Well, where are they?" he asks, raises his brows.
Sherlock looks confused. "Where what are?"
"Well, your––" John mimes putting them on.
Sherlock's face falls, mouth tightening into an angry line. "Don't be daft! I'm not wearing them for this!"
"Well, I thought you'd be wearing them most of the time, now."
"I should have gone to a different optician. There's no reason why one couldn't start directly with contacts."
"You'd need a normal pair as a spare, anyway, and you did the research: they don't make photochromic contacts yet, and you'll probably prefer them to regular glasses. Plus you'd have to take the contacts off for spinal surgery, anyway, since you've got the prescription loupes now." The large surgical microscopes used for intracranial surgery can be adjusted to fit Sherlock's refraction so there's no need for any special parts for them.
Sherlock sticks his hand in his jacket pocket and shifts his fingers around as though grasping onto something. "I'll look strange with glasses."
"You'll look perfectly fine. Maybe even ador––"
The murderous glare he receives makes John quickly swallow the rest of the word.
During the first months after they had returned home from Malawi, Sherlock had begun complaining of nearly daily headaches intense enough to require popping paracetamol tablets in the evenings, squinting at the television, and resting books on his chest much closer than he ever had before. It seems that, since he hadn't done anything requiring microscopes during their sabbatical, returning to London and Sherlock's usual work, provided such a stark contrast to the way he'd been using his eyes in Africa that his slight far-sightedness began to bother him. His eyes got tired sooner than before, and his vision got blurry if he read for a long time. Using the surgical microscope lessened the symptoms since he could adjust it to perfectly compensate for the issue; it was all of the other things he did daily that strained his eyes, struggling to accommodate. But, even after it became rather obvious to John what was going on, Sherlock was — in his usual fashion — hoping for the issue to disappear on its own if he ignored it.
One evening, when he'd dragged an armchair close to the TV so that he could effortlessly read the scrolling text at the bottom of the screen as they watched the news, John could no longer delay discussing the issue. He asked Sherlock if he couldn't read the text from the sofa anymore.
"Don't be ridiculous, John. It's too small for anyone to read from that distance."
"I can read it perfectly fine from here. I've noticed you need to look at things much closer than you used. When's the last time you had your sight checked?"
"I can't recall. There's nothing wrong with it."
"No, probably nothing wrong, as in there's no illness going on, but you just might need specs, love."
Sherlock had looked like John was suggesting he needed to get his tongue pierced. John wasn't surprised — his partner is always very particular about the way he looks, and anything that alters his physical appearance could take a long adjustment period. If that something involved an item touching his face constantly, there might be a formidable struggle ahead.
"I'm not old, John," Sherlock had complained indignantly the night John had called him out.
John had snorted. "Nope, but that's got nothing to do with this. You might have been slightly far-sighted all your life, but now it's gotten ever so slightly worse in a way that you're starting to notice. Probably best fix it before your eyes start to get really tired at work."
Sherlock went quiet, blinking as he often did when he was thinking hard. "There's LASIK," he pointed out, referring to laser-assisted sight correction surgery.
"Yeah, but you'd still probably want glasses before that happened. And wasn't there that big study that showed that like thirty percent of operated-on patients still used glasses in some situations?"
Sherlock didn't seem to be listening. "I'm sure I could find someone to do LASIK next week."
"There's also contacts, though you'd have to find out if they're a good fit for your work."
"Yes, yes, of course. Clearly, they must be the superior option to visible glasses. No need to advertise one's deficiencies."
"Sherlock… It's not like that. Lots of people have glasses. Probably half our colleagues. Greg's got a pair for reading he keeps in his office."
"I've never had glasses."
It was a typical dismissal from Sherlock, who often clung to irrelevant details and illogical arguments when faced with something he didn't quite know how to deal with.
"Go see an ophthalmologist. They'll give you the lowdown on your options," John suggested.
Sherlock didn't reply and sulked for the rest of the evening as though his eyesight issue was completely John's fault.
Now, John knows that Sherlock had eventually caved in, and that he's been to an optician to pick his prescription glasses up today. He wonders what it'll take to get his partner to actually put them on. "Can I see them?"
"No," Sherlock announces coldly. He reaches up to touch the top of his curls; John knows he'd not argued with the hairstylist using a bit of hairspray even though the sensation must be strange. There's a row of products in their bathroom which Sherlock uses to keep his curls just the way he likes and John loves, and the latter hasn't really taken the time to learn the purpose of each one.
"You look lovely," John reassures him.
"I'm not aiming for 'lovely', I'm aiming for professional."
"That, too."
"Doctor Holmes? We're ready for you," The director of the documentary calls out, pointing at the chair in the middle of the set which is the target of a set of glaring lights and two cameras.
"Right, yes–– that should be Mister Holmes, actually, although using that term is an archaic practice linked to the fact that surgeons were not as revered once as other medical professionals were, so perhaps… doctor…after all?" Sherlock rattles on as he makes his way to the chair, wipes off invisible dust from it and takes a seat, his eyes unconsciously seeking John’s as though needing an anchor.
John plasters on a grin and points at it, miming that he wants Sherlock to imitate it. He'd told Sherlock to just be his charming self, to smile a little, to which his partner had replied that he doesn't want to look like a dentist in some inane toothpaste commercial.
"We can decide later on what to put in the aston — that means the superimposed text of your name and title, that is," the director explains. "The interviewer’s questions will be filmed and recorded later, so what we ask now is to get your parts in the can. Shall we start?"
"Yes," Sherlock says in a clipped tone. He frowns at an overhead microphone boom that is moved closer. “Can you keep that out of my eye-line, please? It’s distracting.”
Obediently, the sound engineer pulls it up and behind Sherlock, out of camera range.
Sherlock is first asked to introduce himself, which requires several takes: it takes a while for the director to convince him that he doesn't need to recite all the abbreviations associated with his training and academic credentials.
"Surely the viewers will require an explanation as to why I am qualified to handle such a patient case?" Sherlock points out.
"Trust me, it's enough that you're a neurosurgeon. Most people won't be familiar with the different ranks and training systems and all that," the director assures him.
"They should be," Sherlock grouses. "Only an idiot would let someone operate on their brain without researching that person's credentials."
John glances at the cameraman, hoping that the comment didn't go on tape.
"Could you explain to us what an ‘awake craniotomy’ means?" the director requests after the cameras start rolling again.
Sherlock clears his throat, squares his shoulders. He is a confident public speaker but being aware that this program might get millions of potential viewers would be enough to erode anyone's confidence. Prior episodes in the NHS documentary series have gathered huge audiences and won prizes; even healthcare professionals have lauded their knowledgeable content and respectful attitude towards the NHS and its skilled staff. As much as Sherlock has tried to project an air of his usual professional aloofness, John knows his tells: right now, Sherlock is trying hard not to fidget under the intense scrutiny.
"A craniotomy refers to surgery inside the skull; the term itself could be translated as making an opening in the cranial bones. This is done to remove tumours, to close off malformed blood vessels from cerebral circulation, to insert drains for cerebrospinal fluid, and to install nerve stimulators. Awake should be self-explanatory. The technique was first used in epilepsy surgery. Subsequently, it has been employed in tumour surgery, deep brain stimulation instalment, and for the surgical treatment of blood vessel malformations."
The questions that would be asked by the interviewer had been delivered beforehand by email. John had helped Sherlock formulate answers which should be understandable enough to the general public.
"Why would any patient agree to remain awake while they are having brain surgery?" Is the next question directed at Sherlock.
"It lowers the risk of a complication that would rob them of an ability they consider instrumental in their lives. Some brain tumours grow in areas where centres of speech, limb movement and other important functions are housed. With the patient awake, those centres can be engaged during the operation to make sure the surgeon is not causing too much harm to an ability the patient considers outstandingly important."
"Such as singing?"
"Such as singing when one is a professional tenor, yes."
"Which parts of the brain are involved in that?"
This question hadn't been included in the email and John grits his teeth; it is difficult for Sherlock to gauge the average person's knowledge level of medicine, and some of his initial suggestions of suitable answers had gone over even John's head. Sherlock has agreed to go through the operation footage with the production team afterwards to explain each phrase so that the narrator can then give concise explanations in layman terms on the proceedings. John hopes whoever is tasked with formulating that narrative doesn't end up quitting the BBC as a result of having to deal with one of Britain's finest and absolutely the moodiest neurosurgeon.
Unsurprisingly, Sherlock launches into a mouthful of jargon. "Singing is an outstandingly complex neural task that involves many cortical and subcortical centres and pathways. It also requires brain structures dealing with understanding of music, hearing it, speaking and memory. All the details of these processes in the brain are not yet fully understood, but we know that right-side fronto-temporal brain structures are deeply involved. Singers also need very precise control of the so-called phonatory muscles — those involved in moving the vocal chords and mouth structures involved in formulating different sounds — and the reticular formation of the pons and medulla seems to be instrumental in that. Of particular interest in this case is the ventral portion of the primary somatosensory cortex, which lies next to the so-called M1 phonatory area which controls––"
While he drones on, the director leans towards his assistant and John is close enough to hear his words: "We'll try to work out what the hell all of that means later. Maybe do a nice animation of it or something."
Soon, Sherlock notices that he's being ignored and snaps his mouth shut, frowning disapprovingly. "I wasn't finished."
"Could you rephrase that in a more general manner?" The director asks.
"You asked me to explain the neuroanatomy of singing. I don't know how to do that without mentioning specific functional loci in the cerebrum."
The director straightens his stack of papers. "Um––"
"You could just say that singing involves so many different brain centres that it's hard to protect them all during surgery. So, to be sure that you're not doing harm to any of them while trying to get the tumour out, you need the patient to sing during the operation?" John suggests.
Sherlock's gaze locks onto him. He doesn't look pleased with John's interference. "Shall I relinquish this seat to you, Doctor Watson?"
John slaps on a disarming smile. "Just a suggestion."
"Shall we try again?" The director asks cheerily. John has to applaud the man for being seemingly unfazed by his imposing interviewee. "Roll."
Sherlock fixes his line of sight on a wall just above the camera and lifts his chin a bit. "Singing is a neurologically complex thing to do, and in order to avoid harming any of the delicate pathways enabling Mister Waldegrave to do his job, I need him to do it while making my way through healthy brain tissue towards the tumour."
The director nods, and Sherlock receives a hastily enthusiastic thumbs-up from John as well. He's certain he catches a swiftly aborted eye roll.
"Could you explain why you need to operate on this patient?" The Director asks.
"Mister Waldegrave suffered a grand mal seizure, and what is most likely an oligodendroglioma has been discovered as the cause of that symptom."
"Is that a brain tumour? Could you explain what that is?"
"Oligodendrogliomas are the third most common type of gliomata, a common type of brain tumour in adults. The function of oligodendrocytes, which are a type of brain cells, is to produce a substance called myelin which helps signals to travel faster along nerves. Judging by the imaging results, the symptoms, the patient's age and certain other factors, this is the most likely type of Mister Waldegraves' tumour."
"Are oligodendrogliomas cancerous or benign?"
"They tend to be classified into either grade two or grade three; grade three is malignant and somewhat unlikely to be cured entirely; the average life expectancy is between three and four years after diagnosis. Grade two, which is considered a low-grade malignancy or a borderline entity carries a much more favourable prognosis; average life expectancy is twelve years after diagnosis, and many patients whose tumours can be fully removed are cured completely. In comparison with many other types of malignant or borderline malignant brain tumours in adults, patients with grade two oligodendrogliomas have a relatively high survival rate."
"What is Mister Waldegrave's prognosis?"
"Until a pathologist has graded the tumour from a sample taken during the surgery, I cannot say for certain. The tumour has distinct enough borders that I suspect it is grade two, and am willing to go in for a removal operation without doing a stereotactic biopsy first. Judging by the MRI results, if it turns out to be grade two, there is a good possibility of a complete cure. And, regardless of grade, I expect to be able to remove the entire tumour."
Expect, not hope. John grins. Sherlock's confidence is married to both skill and a bit of arrogance when it comes to surgical prowess.
"What kinds of symptoms can these tumours produce besides seizures?" The director asks next.
"Depending on the location, they may cause localised symptoms such as muscle weakness or loss of sensation in a part of the body, headaches if the tumour takes up so much space that the brain is compressed, vertigo, partial loss of sight, or hallucinations relating to smell. Mister Waldegrave's presentation of a sudden generalised seizure is quite common."
"Make a note to get the performance stage footage added here," the director tells an assistant, who grabs a pad and begins scribbling on it.
The patient — a thirty-seven-year-old star tenor called Carrington Waldegrave — had been on the covers of all the newspapers when he had suffered a seizure in the middle of "Una furtiva lagrima", an apparently legendary tenor aria in Donizetti's opera "The Elixir of Love" at the Metropolitan Opera two weeks prior. To make matters worse, the performance was live broadcast to cinemas in the UK, meaning that an even larger audience had been shocked by Waldegrave's sudden collapse.
Sherlock readjusts his suit jacket and clears his throat, after which the director returns to the matter at hand.
"Is the operation technically very difficult?" He asks.
Sherlock no longer looks slightly uncomfortable; discussing the technical aspects of neurosurgery is firmly within his social comfort zone. "No major blood vessels or brain structures involved in vital functions are close to the operative field, and the tumour has clear margins and no signs of excessive vasculature. There are always risks, but I would rate Mister Waldegrave's operation as being in a relatively low risk group in the larger context of intracranial tumour surgery."
"How does an awake approach change the experience for the surgeon?"
"It can lessen the worry of doing collateral damage to important brain structures when the functions of those structures can be constantly tested in a very authentic manner during the operation. However, if something goes wrong during an awake craniotomy, it is naturally very stressful for both the surgeon and the patient. Neurosurgeons are not as accustomed to communicating with our patients during surgery as, for instance, orthopaedists are, since a nerve block is rarely a feasible option for anaesthesia in our field."
“Is keeping a patient awake during brain surgery like this challenging for an anaesthetist?”
“This is a question that would be better answered by my colleague John Watson, but I will do my best."
John grins.
Sherlock gives him a glance, and the edge of his lip quirks up just a little bit.
"Keeping them awake is not the biggest challenge; keeping them calm and comfortable certainly is. The anaesthesia team has a great responsibility in ensuring patients don't panic or attempt to move even during awake operations where there are no particular challenges or complications. It is a challenging operating technique for the whole team but thankfully, I get to enjoy the services of some of the best-trained anaesthesia staff in the subspecialty. Questions regarding the finer details of the anaesthesia for awake craniotomies should be deferred to Doctor Watson.”
"Have the two of you worked together long?"
"Since I arrived at King's College."
"And why have you chosen to team up with Doctor Watson for this particular case? I assume you got to choose your team?"
"I––" Sherlock's eyes shift away from the camera to John; he looks as though he's pleading for help.
John gives a subtle shrug. He can't tell if this question is a veiled attempt to coax out an admission of favouritism, or just background information likely to be edited out of the final documentary. This question certainly hadn't been on the list sent to them in advance.
Sherlock takes a deep breath and squares his shoulders. John can tell the cogs are turning as determination begins rearranging his facial features.
Finally, Sherlock responds: "Due to his administrative duties, he and I do not often get to work together in the OR these days. He's one of our unit's senior consultants and for awake craniotomies in particular, I prefer to work with an anaesthetist who I know very well and with whom I have developed a good working relationship. This is not a case for a trainee. He–– Doctor Watson is an experienced neuroanaesthetist with good communication skills. Those are imperative for a good patient experience during an awake craniotomy."
Sherlock is omitting the fact that, due to the communication issues he has just mentioned, he is only supposed to do awake cases with John or if a second surgeon joins him. Sherlock had certainly made strides in improving his patient communication skills, but under duress in the OR it's best to have some cushioning forces present to reassure the patient if Sherlock gets a bit… too honest about how things are going or irritated about the patient speaking to him. The King's College Trust Picking Sherlock for a televised operation might thus seem counterintuitive, but he's undoubtedly one of the hospital's most skilled surgeons, and nearly all of his colleagues at King's College neurosurgical unit had refused to participate in the program. And, as Sherlock had put it, would the Trust really want to put Philip Anderson on BBC1?
If this case goes well, John is going to suggest to Lestrade that the conditions for Sherlock doing awake craniotomies be lifted. Sherlock will always be Sherlock but these days, he manages his patient interactions so much better than he used to.
John gives his husband a fond smile which is returned, albeit in a reserved manner.
The director consults his notes. "Thank you, Doctor Holmes. I think we got what we need for now."
Sherlock slips down from the bar stool and wastes no time in leaving the spotlight, but he does hover close by while John does his half of the interview.
"Doctor Watson; could you explain the role of the anaesthetist in awake craniotomies?" The director prompts.
"The preparations actually take less time than for a standard craniotomy since we don't use general anaesthesia. We do administer sedation to make the patient comfortable and to help them relax, but we must avoid giving so much of it that they will be too drowsy to understand what's going on and too lethargic to obey the surgeon's instructions. Sometimes we might put them under deeper sedation for the start of the surgery, but Mister Waldegrave has stated he sees no need for that. As for my and the anaesthesia nurse's role during the surgery: just as Mister Holmes explained, an awake craniotomy can be very stressful for the patient. After all, I think the thought of having one's brain operated on under any kind of anaesthesia or lack thereof would scare just about anyone. They need someone to keep them company, talk to them, reassure them and keep an eye on whatever it is that the surgeon needs them to do to monitor brain function. We also administer fluids, adjust their sedation, monitor vital functions, administer blood products if needed. The surgeon needs to be able to focus on operating; I am pretty much in charge of everything else."
"How do you control pain during the operation?"
"We give the patient intravenous doses of strong pain medications, and the surgeon injects a long-acting local anaesthetic before inserting the screws and the metal frame that keeps the patient's head in place. Most people don’t realise it, but brain tissue doesn't feel pain; the majority of the operation is painless, anyway. In some cases, the patient might be given general anaesthesia for the start and the late parts of the operation and they are only awakened for the parts where they need to co-operate; another option is to provide what we call monitored anaesthesia care, which means that they are lightly sedated for the whole operation; that means that even just talking to them will rouse them from a relaxed state. Some centres combine sedation with a so-called scalp block, which means blocking the nerves that sense pain in the scalp; it's a bit more complicated than just injecting locally but the effect lasts longer. We've been considering combining that with some newer sedatives, but since those drugs are a relatively new addition for our repertoire, we don't want to introduce two novel things at the same time."
"Does it change your anaesthesia plan if there's a complication?"
"If there is a problem with the surgery, we may have to put the patient quickly under deep general anaesthesia even just because it might be too stressful for them to listen to what's going on even if that complication doesn't affect their consciousness or require securing their airway."
John doesn't add that he may have to, for instance, intubate them in a very challenging position since their head will be attached to the metal frame called a Sugita. Such technical details probably won't interest viewers, and there is no use in making the operation sound overly scary or risky, if nothing untoward actually happens.
"How can you tell which patients are suited for awake surgery?"
"The decision is made by the surgeon and the anaesthetist together, and we can consult a psychiatrist and a neurophysiologist to help us with that decision-making. Severe difficulties in speaking, a difficult airway, brain swelling, certain psychiatric issues, and significant sleep apnoea are among potential reasons for deciding against an awake approach."
"What makes awake craniotomies special for the operating room team?" The director asks.
"We have to constantly be mindful that we have an awake patient in theatre; surgical humour can sometimes be a bit, well, brutal from a layperson's point-of-view. There are some particular rules established for these cases at King's College. We don't want extra people in the OR or any other distractions: students aren't allowed in when there's an awake case, and traffic in and out of theatre is even more tightly controlled than usual. The same team does the whole operation — no handover to the on-call staff — and the anaesthetist cannot leave the OR during the operation."
"What made you choose neuroanaesthesiology as a subspecialty, Doctor Watson?"
"They needed more people around the time when I had been a consultant for a couple of years, and I'd enjoyed what I'd seen of it. It's an area where an anaesthetist can affect the patient's prognosis, and I'm sure Mister Holmes would agree that the brain just might be the most fascinating organ."
"We will be filming the procedure tomorrow; will that add additional challenges for the surgical team? Do you think the patient is going to be more worried?"
"Having spoken to Mister Waldegrave at length about this, I can say that he appears confident to proceed this way. As he put it, the very moment when he became a brain tumour patient happened on stage with the worried eyes of the world on him. He says he wants people to see him being cured, too, and that's why he's letting the cameras into the OR."
"Thank you, Doctor Watson."
"See you in the OR tomorrow, then," John tells the director as he drops down from the chair.
Sherlock is waiting for him at the door, tying on his scarf. "Ready for lunch, Doctor Watson?"