The Starvation Response By Patrick Christie

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My father always took a nap after lunch. He claimed it wasn’t a matter of choice. He simply couldn’t keep his eyes open. I’m convinced that the main reason he set up his own company was to indulge this habit. It was a small publishing house that printed etiquette guides. Miscellanea protocol of a world long since disappeared, if it ever existed. Each weekday he went to the same restaurant on Piccadilly and had a three-course lunch with wine. After coffee and a cigar he would retire to his wood-panelled office and have his nap. The business never turned a profit.

The cleaner found him at the end of her working day paralysed in a pool of his own urine. An embolus from the wall of one of his arteries had broken off and caused a massive intracerebral haemorrhage. He fell into a coma and died three days later. The Times posted his obituary and all manner of minor aristocrats attended his funeral. It was as if straight from the pages of one of his own books. He was a man completely in thrall to self-gratification, whose life’s accomplishment was squandering an ample inheritance. I miss him everyday.

I operated on this woman not long ago. She’d had a rupture in her bowel, a gastrointestinal perforation, and was in need of emergency surgery. If it had been an elective procedure I couldn’t have gone through with it. I would have taken the fleshy slab that constituted her hand and explained that the risks of complication were too great at her size. Now that her death was imminent the complications didn’t seem so complicated.

What my father never learnt was that freedom lies in ignoring your desires. I never eat before surgery. Digestion consumes huge amounts of energy; sends your insulin levels skyrocketing. Fasting does the opposite. It keens the mind. By not inundating my body with calories I’m clear-eyed and alert in theatre. I don’t rely on coffee to stay awake. No surgeon should drink coffee before a procedure because it makes your hands jitter. If I tried to make an incision while my hands were shaking I could nick an artery and cause my patient to bleed out. My anaesthetist lives off coffee. It runs through his veins instead of blood. He stands there, checking the levels rocking back and forth on his heels while I wait for him to make a mistake and kill another patient.

We opened the woman up and two theatre nurses held up her fat flaps for me. It was near impossible to see what I was doing – fat surrounded everything, choking the organs. Fat is bright yellow. It looks similar to loft insulation, though it feels more like gelatine if you touch it, and the smell is sweet, like candied almonds. The odours of surgery are not pleasant ones. For invasive surgery such as this I use an electric cautery – a scalpel that becomes hot enough to cauterise small blood vessels while you cut. This fills the operating theatre with the scent of barbecue. Added to this, the perforation had caused faecal matter to spill into her abdominal cavity and the smell of excreta was thick in the air. We doused it in warm saline and hoovered up the woman’s insides. The hole was too large to stitch closed so I resectioned her bowel. If it weren’t unethical, I would have fitted a colostomy bag instead. Forcing people to carry around a bag of their own faeces seems the most effective way of encouraging them to think about what they eat.

The anaesthetist has a very beautiful wife. Once, when he was very drunk, he showed me a naked picture of her on his phone and now I often imagined her when I had sex with other women. He is regularly drunk, which is why he consumes so much coffee.

A large gap after meals is a boon to your health. It allows the body to enter its post-absorptive state where your insulin levels drop low enough to enable the burning of fat cells. Your growth hormone production increases and your cells begin to repair themselves. Most people eat so often they never enter this state. If your body never stops digesting, it neglects other functions, leaving toxins to build up in the liver and kidneys. During the first two days of fasting, the body uses up the glycogen stored in the liver. Once that’s burnt, it turns to any sick or old cells, converting them into ketone. Then, on around the fourth day, the hunger stops because you start eating again. Eating yourself, your fat cells, the body’s larder. The starvation response begins once every last morsel of fat has been burnt and your body turns to less efficient sources of energy, such as muscle.

Surgeons don’t lead regular lives. On a daily basis, we see things that would traumatise normal people. Bodies lie there, split open, their exposed organs pulsating, glistening with blood. If a patient dies, in effect, you are left with a mutilated corpse. The reality is far more horrifying than any film. Such sights bring on PTSD in soldiers. Yet for the surgeon, this is routine. I do not emerge sickened or horrified. That affords us special treatment and privileges. I can always get a table in any restaurant in town. I recently took this psychiatrist I used to date out to eat. Once you stop eating you realise how food-centric society is. A restaurant is the last place I’d wish to find myself. But people expect to be taken out to dinner. I had been in surgery all day – an appendectomy followed by a kidney transplant. I hadn’t eaten for four days and I found even the idea of doing so was exhausting, the thought of it nauseating – teeth grinding against each other, stomach churning, spasming intestines. It felt akin to self-harm. So I ate as little as possible, cutting up what was left, rearranging it on my plate and focused the conversation on her. Most people don’t pay close attention to anything other than themselves anyway.

Seducing women is easy when you’re a surgeon, which is fortunate for me, as I can’t enjoy pornography. I feel as though I’m watching an anatomy lesson. I find myself dissecting the actors, watching their pupils dilate, the blood flowing to their genitals, their muscles stretching and tautening under that thin layer of skin. The psychiatrist had a number of predilections when we used to date and it became apparent later that evening she had not shed them. We put Brahms’ Symphony No.2 on the stereo. She lay down on the bed, naked except for a silk scarf covering her face, and I traced spirals into her skin with a blunt carving knife. Afterwards, when it was my turn and my face was covered, I thought of the anaesthetist’s wife.

For those few hours in the operating theatre, all surgeons feel like God. It’s natural. Life and death are in your hands. Sometimes you even feel superior to God because you’re fixing his mistakes – congenital defects and the symptoms of hereditary diseases. The death of a patient is a reminder that you’re just a man. I don’t keep count. No one does and even if they try, they lose track eventually. What is the benefit of carrying so many ghosts around with you? The only time you do count is when you’re on a streak – losing one patient after another. I had recently reached my fourth. A long streak for me. The common denominator in all of these surgeries was the anaesthetist. I suspected he might have started drinking in the morning. He is supposed to monitor everything during surgery – the patient’s blood pressure and temperature, their pulse – right down to the amount of carbon dioxide in every breath. How would he do that if he couldn’t even see straight? I found his lack of self-control contemptible. Many days I found myself hating him. He’s my dearest friend.

I’d been waking up in the night, in the throes of violent convulsions. To get back to sleep I’d slip into a warm bath to stop my muscles from spasming further. An hour later I would wake up again, in a tub of freezing cold water. I had lost my usual clarity. Instead of being unflappable in the theatre, I was prone to bouts of indecision. After my fifth patient flatlined, I asked myself why I should break my fast when I knew I could keep going? Why not wait until the starvation response kicked in? People fail to understand that it’s easier to not eat than to eat. Eating is one of the most strenuous things we do. Made worse by the fact that so much of what we eat is poison. People’s blood becomes so salty from the processed food they eat that it tricks their brain into thinking it’s thirsty. Then they drink so much water to dilute their blood that their blood pressure increases.

I don’t often connect with others. This shouldn’t come as a surprise. It’s hard to think of anything that sets you apart more than cutting people open. Apart from surgeons, the only other individuals that do it are psychopaths. In the theatre you don’t think of the person you are operating on as a person. You can’t think that way. You see moving parts, pieces of a complex machine needing repair. I diagnose everywhere I go. I can’t help myself. I see an old man with shaking hands in the supermarket queue and wonder if anyone has prescribed him L-DOPA. A woman at the bus stop with obvious chronic sleep deprivation sits next to a child who can’t stop scratching himself – probably suffering from Impetigo. There is a homeless man I often see near the hospital. I’m convinced he has Huntington’s Chorea. This compulsion is a problem the psychiatrist shares with me. It’s one of the reasons the psychiatrist and I dated for so long. I explained that I thought she had Fibromyalgia, given her penchant for popping pain pills. She, in turn, diagnosed me (wrongly) with a mild case of Narcissistic Personality Disorder. Psychiatrists will deduce psychological symptoms where doctors will find physiological ones. Together we were able to provide complete diagnoses. Gray’s Anatomy sat alongside DSM-5 on our coffee table. Back then, apart from being respected in her field, the psychiatrist was also very attractive. She could turn a roomful of heads. Despite this, she had few meaningful relationships – unable to stop herself getting inside her partners’ heads and exposing their inner fears and perversions. This was not something that ever bothered me.

When I picture her back then, the thing which draws my mind most is how thin she was. The anaesthetist’s wife too is very slim. In all other aspects of life more is more – consumption is in excess. People are the exception. We idolise the thin and demonise the fat. I wonder what the cause for this paradox is. If eating more made people thinner the situation would not reverse. Celebrities would brag about how many cheeseburgers they’d eaten in a single sitting. When I was a boy we had red meat once a week, my grandparents ate it a few times a year. Now some people eat it every single day. They treat their bodies like waste disposals. They put no thought into the amount of work the body has to put in to dissolve and absorb that flesh and sinew.

My fast was approaching the longest I’d ever attempted. I felt calmer and more perceptive than I ever had. There was no swell inside me, only the stillness of a void. Without digestion fettering my body I felt as though time had slowed down. I could see a thousand possibilities in every situation. I wasn’t having trouble sleeping anymore because I wasn’t sleeping at all. I didn’t need to. I had boundless depths of energy. The only thing that made me tired was seeing other people eat. Shovelling alien matter into their orifices, packing it down, filling themselves up with dead plants and animals.

People think fasting is difficult but it’s not. The difficulty is psychological. The compulsion they feel to always be doing something, to have the television on in the background while they browse the internet, to listen to music while they walk, to gorge on popcorn when they are at the cinema. People can’t enjoy each other’s company unless they are consuming – drinking, eating, shopping. They can’t meet somewhere that doesn’t serve anything and just talk to each other. It would make them feel tense, unsure of what to do with their hands while all the time the receptors in their brain would be screaming for their fix of sugar, salt and fat.

Despite my new sense of wellbeing, the streak continued. I had lost ten patients in a row. There was no doubt in my mind that the cause was my best friend the anaesthetist. He was a walking smear, slurring his words. I had grave concerns about him. Imagine my surprise then, when the Surgical Division Director called me in to discuss my recent performance. I had little respect for him. He had given up being a second-rate surgeon to become a third-rate bureaucrat. He told me that if the mortality rate of the Trust grew any higher or if it saw another major malpractice lawsuit then it would be put on special measures. Although I failed to see what this had to do with me, I was put on a medical leave of absence. I assume an even worse fate befell the anaesthetist. I didn’t brood. It’s not in my nature. Instead, I resolved to make good use of my leave – an opportunity to focus on fasting for its own end, not to serve another purpose. I wanted to overcome hunger once and for all.

I found the adjustment difficult at first. My days were empty but my mind was keen and I tried to commit it entirely to fasting. By expending minimal energy through movement my body could dedicate itself to the process it was going through. I read a little, I didn’t sleep, I hardly moved. I stared at the walls and focused.

I turned up at the physiatrist’s house unannounced; though from her body language and the way she was dressed I knew that somehow she had been expecting me. I have a great deal of respect for the psychiatrist’s field but no envy. I find it a very frustrating specialism. Our understanding of the mind is infantile. We prescribe SSRIs and hope for the best. Surgery is simple by comparison. Either an operation is a success or it is not. There are few such clear successes in mental health. The absence of closure would drive me insane.

Everything in the psychiatrist’s home was white, from the walls, to the carpet, the sofas and the stout Persian cat staring at me with suspicion from the doorway. I followed her through to the kitchen and we sat at the table. There was still a piece missing from my self-actualisation and I couldn’t express it, despite of my best efforts. I had been vacant for too long – had returned to find squatters on my tongue, fat and corpulent. I could see in her eyes she didn’t understand what I was trying to explain, the urgency of it. I was too far in front of her. It must have been like trying to watch a video on fast forward. As my voice gave way in desperation, a force struck me square in my chest. Pain radiated from my core. As I fell to the floor I saw the psychiatrist running into the other room. The kitchen swum out of focus and I wished I could slow down to diagnose what was wrong with me. I wondered why she had chosen to dim the lights of all things, why her voice sounded as if it were underwater. As I turned my head I saw my father lying next to me, paralysed, in a pool of his own urine. The scent of ammonia seared my nostrils.

I refuse to accept bad things can happen to surgeons. I don’t believe in damnation. If such a place exists it must be replete without surgeons. Saving so many lives counts for something. When the lights were switched back on I could see I was being wheeled into the operating theatre. I perceived my friend the anaesthetist leaning over me, telling me it was all going to be OK and I thought to myself: Shit. I’m doomed.


Patrick Christie

Patrick holds a degree in Politics and works in higher education. He lives in London with his partner and cat.

This is his first publication.


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