the battle of don’s deep

Donald sits low in the armchair, his left leg bouncing up and down like a jackhammer, his left arm in a sling, his right hand restlessly picking at the chair fabric. However neutrally or sympathetically I try to phrase my questions to gauge what he needs since his discharge home, it’s impossible to get a straight or reasonable answer. I’m not making  progress.

I have to say I’ve never met anyone quite so burned-up with fury – or anyone whose eyebrows angled up in the middle so perfectly. It’s like his nose is the prow of a bony ship, and the eyebrows are the arms of a cantilever bridge raising to let it through. His eyes are in sync, too; closing as the eyebrows go up, as if he’s reading his diatribes back of the eyelids, like an autocue.

At least Don’s environment is fine. Potted plants. Laminate flooring. An enormous flat screen TV. Donald muted it when we came in, but the show he was watching continues to play. I think it’s one of those how things are made programmes, this episode all about buttons. Pastel buttons, tartan buttons, spotty buttons, two-holes, four-holes…. The manufacturing process is complex and fascinating. About a million buttons pouring into some kind of steaming bath, then rolling out on a conveyor belt. What for? Do we need this many buttons in the world…?

‘…all you bureaucrats, trying to reduce everything to a simple yes or no, clicking your little keys, ticking your little boxes. Life doesn’t work like that. Pain certainly doesn’t. Pain doesn’t conform to your pissy rules. If I say yes I can do that, you’ll put down yes, and you’ll say he can totally do that – he’s fine, we can leave him alone. But the fact is sometimes I can and sometimes I can’t. It costs me enormous levels of pain and suffering just to get out of the chair. You don’t know what it’s like. I used to be a bodybuilder. I used to be fifteen stone, built like a brick shithouse. I’ve got a toleration for pain your brain could never conceive of, never conceive. I’ve got an IQ that’s in the top one percent. I know what you’re talking about, so don’t try to fool me. I know what’s behind your words. I can’t be bought off like the rest of them. And just because I refuse to be bullied into accepting things that aren’t right, I get stigmatised and put down as difficult…’

I’m so glad I’m doing this assessment with Agnes. She’s so experienced and battle-hardened, I couldn’t feel better about it if I was an elf on the ramparts of Helm’s Deep watching the orcs approach with ladders, and Gandalf was holding my hand.

‘I’m sorry to have to ask you these things,’ I say to Don. ‘I know it’s a bit one size fits all. But we need to get a rough idea what we can do to help. Like physiotherapy, for example. Do you think you might benefit from some?’
The eyebrows flick up; the eyes close.
‘Oh? Yeah? Physiotherapy? You try living with the pain I’ve got. You try doing their little exercises. Me just scratching my head is like you running a marathon. Physiotherapy! And what will they do? They’ll come and they’ll sit where you are and they’ll say Oh, Donald, if you don’t do anything you’ll get this and that. You’ll get muscle wastage, deconditioning, ligament contracture…. Bullshit! They don’t know what it’s like to suffer like this. They wouldn’t last five seconds.’
‘And where was your fracture again? It’s on the system somewhere, but if you could just tell me…’
Eyebrows up.
‘What’s the point? You wouldn’t understand. I’ve got a better understanding of anatomy and physiology than the surgeons. That’s why they didn’t like me. They couldn’t get rid of me quick enough. I knew their language. I knew what they were up to.’
‘Try me. Just – you know – the basics.’
He sighs, then winces, fiercely and dramatically, as if that simple exhalation of breath was the most exquisite form of torture. And then when he’s recovered from that, and re-found the energy and the deep spiritual reserves required to continue talking, the eyebrows go up again, and the eyelids come down.
‘I have a type two coracoid process fracture distal to the coracoclavicular ligament. Yeah? Know what that is? Thought not. Just put busted shoulder. What’s the point of talking about physiotherapy if you don’t even know what it is I’ve got?’
‘The thing is, Don – I know this is difficult for you…’
‘Oh! You know, do you? How do you know? Been through it yourself, have you?’
‘What I mean is – I can see how distressed you are and from that I can guess how difficult you’re finding it…’
‘This is the problem,’ he says, eyebrows up, lids down. ‘This is the problem, right there. Everyone thinks they know but everyone in fact doesn’t know. Everyone knows precisely jack shit….’

I’m struggling to make any headway at all with this assessment. And because Don’s speech is so overwhelming and so full of invective, and because his eyes are closed and I can get away with it, I can’t help glancing at the screen again. Another batch of buttons are going through some kind of electroplating bath, in plain, out golden. They look great. A bit showy, maybe. Still. Nice to have gold buttons….

Agnes takes over. The fact that she’s Scottish seems to help. There’s a broad warmth to her voice that deflects Don’s sniping more successfully, for a while at least. But after ten minutes or so of her best attempts, even she begins to waver. In fact, I’d go as far as to say she starts to sound a little snappy – but then her phone rings.
‘Sorry!’ she says. ‘Do you mind if I take this…?’
And she ups and leaves the room.
I couldn’t feel more abandoned than if Gandalf suddenly waved a bony finger in the air, produced a phone from his cloak, and stepped back from the ramparts just as the orcs came over the top.

I turn to face Don again.

His eyebrows go up.

the community witch

To begin with, I’d had an unsettling dream. Lola, our lurcher, was stuck in mud down in a ditch, and I’d struggled with a short hose to wash her out of there. She’d accepted my help with a boneless kind of resignation, lapping at the water more to please me than anything else. I’d woken up exhausted. Found myself downstairs having coffee and toast, driving into work, parking, tapping out the code for the security door, swiping my card and passing through into the frenetic office – the whole thing so toneless and heavy-eyed I wouldn’t have been surprised to find I was still in my pyjamas.

I sat down and started to plan the day, struggling against the feeling that I was out of place, faking it. To be fair, it was a feeling I’d had before, that I was an imposter, acting out a role, and it was surely only a matter of time before I was found out. I could see it all, the sudden fall of silence, the turning of faces in my direction, the manager standing over me with her arms folded, tough detectives just visible in her office, smiling, shaking their heads, cracking their knuckles.

A disconnected, dizzying kind of feeling. I forced myself out of it by focusing on the task at hand, probably in the same way you might dampen down vertigo on a cliff face by describing in detail the tiny wildflower growing close to your face.

All this is to say I had a muzzy headache when I sorted out my list of patients for the day and went outside.

It was the perfect day for a headache. Even the pigeons were off, either comatose on the ledges or pitching forwards, gliding a little, slamming into the ground. The sky was a hard, preternatural blue, with that artificial depth you only get in cheap, 3D pictures.

My first visit didn’t go well. I’d already established – or thought I had – that I’d be visiting early today to take blood before Mr Williams had taken his digoxin. When I rang to give him the heads up I was on my way, there was no reply. I tried the mobile. Same thing. I texted the mobile to say I was coming, and headed over. They had a keysafe, so access wasn’t an issue. At least, it shouldn’t have been. Outside the block there were only two keysafes. One was so crapped up it looked like it had been salvaged from the Titanic and stuck on the wall as a talking point. The other was obviously the one I needed – pristine, the label still bright. Which was fine, except the number didn’t work. I went round the back of the block, to the courtyard parking area. The early sun was angling in, falling on a pot of large, white lilies, which seemed like a sign, although of what, I couldn’t say. There was no access, so I returned to the front and used the tradesmen button, which seemed appropriate, anyway. It worked. Two floors up, I knocked on Mr Williams’ door. I knew he couldn’t get up to answer it, but he lived with his son Nathan, so that was okay. After a while I knocked again. I heard some shouting, and I guessed Mr Williams hadn’t told his son about the visit. Still – it was nine o’clock by now, so I didn’t feel too bad. I left it a good while before I knocked again, just in case Nathan was in the shower and needed time to dry off. All in all it was probably twenty minutes. At last, the sound of movement in the hallway, latches thrown, and the door was suddenly wrenched open.
‘What?’ said Nathan, round eyed, furious, peering round the edge of the door with one hand either side of his face like a malevolent Kilroy.
‘I’ve come to take some blood,’ I said. ‘I rang and sent a text.’
He stared at me for a long second, like he was running through the consequences of tearing me to pieces – (on the run; helicopters, hounds, handcuffs; the cells; the dock; the nick; stepping out into the broad bright world with a brown paper parcel under his arm twenty-five years later with a long beard and a crooked back…).
‘On you go, mate,’ he snarled, and released the door.

I was thinking about all this when I was sitting in a slow line of traffic on my way to the next patient. It added to the fugged stew of the day. What was I doing with my life? Was it a struggle simply because I was forcing myself to do something that wasn’t a good fit? What was a good fit? How was it possible that I had got to this age, having done so much, still struggling to orientate myself in the world?

The traffic loosened a little and we all nudged forwards. I sighed, pulled on the handbrake again, glanced in the rearview mirror at the car behind me. It was a battered old Micra, the red pinking out, a line of plastic animals along the dash. The driver was a middle-aged woman, her hair in a Little My bun so high on the top of her head it flattened against the roof. She was wearing white plastic sunglasses which made her look like an owl on acid. As soon as she noticed me she spread the fingers of either hand widely with the thumbs still hooked in the wheel, like she was flaring her wings. I smiled awkwardly and looked forward again – only to find the traffic had moved on. I fumbled the gears, stalled, started again, caught up.

But then – a strange thing. I thought: what if she wasn’t annoyed with me? What if she was actually a witch, dedicated to casual acts of magic wherever she went. What if the Micra was her familiar? That flare of her fingers – maybe that was the spell being released, sparkling through the air from her to me like that beam of sunlight on the pot of lilies?

I decided that’s what it was. And strangely enough, as soon as I did, the day got better. The next patient and his family were as warm and welcoming to me as if I were the son they never had. I sat between them, sunk deep on the ludicrously comfortable sofa, taking notes, making them laugh. And the patient after that, who I’d found hanging half-in and half-out of his bed, who I’d treated as best I could till the ambulance came – well, I could see he appreciated it, too. And when the ambulance did turn up I knew them, and it was like a reunion. And it was all warm and easy and right. And I finished late but I didn’t care.

And it was all down to that witch.

sig

character lines

Ellie is a clinician with years of experience in hospitals, hospices and the community. Everything she does comes from a simple love of humanity, in all its mess and interest. And like all people skilled in their art, she practises it with a glorious kind of flow, intuitively adapting her stance to events, almost like a dance, making it look effortless and free. I’ve never seen her lose her temper. I’ve never seen her fail.

Which is why I’m glad we’re visiting Mr Coulsdon together.

There are so many exclamations, warning triangles and block caps on Mr Coulsdon’s record, it would be tidier if they simply replaced them all with a picture of a snarling beast and the words Here be dragons. Mr Coulsdon is notoriously, emphatically, tirelessly bad-tempered – a situation exacerbated by ill health, both mental and physical, of course, and his social situation. But it has to be said the starting point was maybe never that propitious.

Mr Coulsdon’s lounge window is just to the right of the entrance to the block. He has a tatty sheet permanently taped across it, bowed down in the middle. The TV is on full volume – Formula One, by the sound of it. We ring the bell a couple of times, but nothing happens.

‘He’s definitely at risk, so we’d better go in and see he’s okay,’ says Ellie. ‘A quick in and out. I’ll do the obs, you do the typing. How’s that?’
‘Fine by me.’
We let ourselves in using the ‘tradesmen’ button. His flat door is always open – taped up, dented, the scars of many forced entries in the past.

‘Hellooo? Mr Coulsdon? It’s Ellie and Jim – from the hospital. Come to see how you are…’

Other than a plain leather sofa in the far corner, the room is surprisingly, resonantly bare. No carpet, shelves or decorations, no pictures or home comforts. Mr Coulsdon is sitting in the middle of the room in an office chair, his bandaged, ulcerated right leg up on a stool. Just beyond it is the TV, cars screaming round a track. His foot is right in the middle of the screen, and you’d think Mr Coulsdon would angle things – the telly or the foot – so he could get a better view. But it’s hard to shake the idea that like a dodgy off-peak boiler, Mr Coulsdon will find a way of keeping the needle in the red.

‘Mind that!’ he snaps. I’m not sure what he means, because there’s really nothing to mind. ‘These people!’ he says, and links his fingers across his belly.

‘We won’t keep you long’ says Ellie, standing where he can see her, tilting her head on one side as if he’s the most fascinating thing she’s seen so far this morning. ‘How’re you feeling?’
‘How d’ya think I’m feeling?’ he says. Then he flicks me a sly glance and waggles his fingers in the air. ‘With my hands!’
‘Oh – that old chestnut’ says Ellie, putting her bag down. ‘Now then Mr Coulsdon. First things first. Can we turn the TV down a touch, please? Only I can’t hear myself think’
‘Who’s taken the bloody remote?’ he says, scratching his enormous beard as if he thinks it might feasibly be in there. He catches me watching him.
‘What’ve you done with it?’ he snaps.
‘Found it!’ says Ellie, picking it off the floor beside him and flourishing it in the air. The furious yowling of the racing cars eases up.
‘There! That’s better!’
‘For you!’ says Mr Coulsdon. ‘How long’s this nonsense going to take?’
‘Oh not long. Of course – you don’t have to have it at all if you don’t want.’
‘Well I don’t want it! All these people coming round here, messing me about. And nothing ever gets done!’
‘About what?’
‘This!’
‘What – the foot or your flat?’
‘The flat! The flat!’
‘What’s the matter with the flat?’
‘It’s a dump. A trash heap. I wouldn’t keep a dog here.’
‘It looks pretty tidy to me. Do you have people come round to help?’
‘If you can call them people.’
‘Well – look. That’s another matter. I can have a word with one of our social workers about it if you’d like?’
‘Social workers? Scum of the earth.’
‘I’m sorry you feel like that. I think they do a great job under difficult circumstances, Mr Coulsdon.’
‘Do you?’
‘Yes. Absolutely. But look – I’m not here for that. I’m here to do your obs and make sure your leg is okay. That’s it. I won’t if you don’t want me to, but I have to know you understand the consequences of saying no before we leave. Do you follow me?’
‘Jesus Christ! Just get on with it, will you? I haven’t got all day.’
‘All right, then. Thank you. Jim’s here to write the facts and figures down.’
‘Hi’ I say, perching on the edge of the sofa and opening the laptop.
‘I did wonder,’ he sniffs, his chair creaking dangerously as he shifts position. ‘I can see it wasn’t for his looks.’
‘No – you see? That’s what they call character lines,’ I tell him.
‘Oh is that right?’ says Mr Coulsdon. ‘I thought it just meant you were old.’

bonnets vs aliens

Like a country that declares war on its neighbours over a mountain ridge, Mrs Alderman has gone to war over her back.

It’s been the cause of a great many problems and pain for her over the years, and lots of clinicians of one sort or another have been involved. But there are some degenerative diseases that can’t be cured with medication or fixed with surgery, and the best you can do is try to ease the symptoms and find a way of organising your life in a more accommodating way. Unfortunately, Mrs Alderman’s response has been to declare war on everyone who has tried to help. Top of her list are the orthopods, who – according to Mrs Alderman – are a bunch of clowns with chainsaws. The orthopods are followed by everyone else who works in the hospital, Consultant to Cleaner, then the ambulance service, Community health teams, doctors, their reception staff, and really anyone who happens to be driving past, and then her neighbours, of course, and most of all, her family.

Her grandson Joey has been staying with her a few days since this latest discharge from hospital. His main contribution has been to restock the fridge freezer with ready meals. Much further than that he’s unwilling to go, and it’s hard to blame him, really. The flat is an absolute mess, and even if you brought in a team to straighten the place out, Mrs Alderman would have it back in its current state before they’d posed for photos and shut the door behind them.

This sprawling sense of chaos and complaint seems to attach itself to any contact with Mrs Alderman. I’d been sent in to conduct the initial assessment, which is essentially a fact-finding mission, to see how she is and what she needs from us. We’d had a frank conversation about emergency care support, what she could and couldn’t do for herself. She’d agreed that one care call in the morning might be helpful to get her washed and dressed; everything else – taking her medication, putting a ready meal in the microwave – she could do for herself. She could get out the chair by herself and take her four-wheeled walker out of the flat, down the corridor and back, so she was by no means immobile. And it was important to take regular exercise, however limited.

What happens next is that Mrs Alderman is on the phone that evening complaining that the carers hadn’t shown up, that the morning carer had done nothing but stand in front of a photograph of a dog she used to own called Rusty saying how nice ginger dogs were, for fack’s sake, and then pulled off her support stockings and took them down to the laundry room.

‘They’re in the dryer,’ she says.
‘Who put them in the dryer for you?’
‘How the fack would I know?’
‘Can’t Joey fetch them up?’
‘Why should he? He’s seventeen! And anyway, even if he did he can’t put them on for me, can he? And I can’t. Not with my back. I thought you were supposed to be facking helping…’

The carer isn’t around to ask about any of this. My suspicion is that Mrs Alderman removed her own stockings and took them to the laundry room herself, but the Coordinator is worried.

‘It might be easiest if you just go there tonight and sort her out,’ she says. ‘And try to clarify the situation whilst you’re there.’

* * *

There’s just one person in the laundry room, an ancient woman bent over a broken plastic trug, busy shovelling the contents into a machine. She looks up when I come in, supporting herself on one arm so precariously she looks in imminent danger of pitching head-first into the washing machine.
‘Hello,’ I say. ‘I’m Jim, from the community health team at the hospital. I’ve just come to pick up Mrs Alderman’s washing and take it up to her. I think she left it in the dryer.’
The woman straightens.
‘Oh! She’s got you running around now, has she?’
I smile and shrug.
‘That’s her lot, there,’ she says, nodding at another plastic trug, piled up with dressing gowns and throws and things and two blue support stockings artfully draped on top.
‘She puts too much in’ says the woman, tightening the scarf round her head, then leaning back in to her load.

* * *

When I knock and struggle through into Mrs Alderman’s flat, the TV is on full volume. She’s watching a film – marines fighting alien invaders or something. A helicopter gets blown to bits and there’s a close up of Aaron Eckhart looking worried.
‘Put it down there,’ shouts Mrs Alderman to me, as if we were under fire, too, pointing the remote at an undifferentiated heap of crap in the middle of the room.
‘Fack me, I don’t know,’ she says, muting the TV. ‘One minute it’s Sense and Sensibility, the next it’s facking aliens.’

full volume

Rita is sitting in a high-backed chair watching a veterinary programme on television. A cow is so bloated the vet is driving a cannula big as a marlinspike into its abdomen; the farmer and his wife put their hands over their noses. ‘She’ll be a lot more comfortable now,’ the vet says. They nod, keeping their hands in place.

The television is on so loud Rita hasn’t heard us come in, so as gently as I can I say Good Morning and move into her line of sight.

She screams.

I’ve met Rita before, and I’d told Andreas what to expect. It’s a particularly terrifying scream, though, and he visibly reddens.
‘It’s okay! It’s okay!’ he says. ‘We’re from the hospital. We’ve just come to see how you are and what you might need.’

She screams again – exactly the kind of sound effect you’d want in a horror film if an elderly person was being murdered. Such an open-throated and desperate noise, made worse by the slack cavity of her mouth and the two, blockish teeth, offset top and bottom.

The odd thing is, she’s not screaming because we’ve scared her coming into the flat. She’s screaming because she wants us to do something. And sure enough, when I ask what it is, she points to the kitchen trolley.

‘The remote? You want me to pass you the remote?’
She screams again.
‘There you are, Rita! And please try very hard not to scream like that if you can, because it makes it difficult to understand what you’re after.’
‘Thank you,’ she says, in a normal voice, and stuffs the remote into the cushion beside her on the chair.

My colleague Andreas looks shaken, but I think he’s reassured I’m not freaking out. He adopts a similarly calm, super-moderate tone.
‘Now then, Rita,’ he says, squatting down and resting a hand on hers. ‘I’m the physiotherapist, and you’ve met Jim before, the nursing assistant. Is it okay if we ask you a few questions to find out how we can help you after your stay in hospital? Would that be alright?’
She fishes out the remote control with her free hand again and raps him on the knuckles with it – I guess because he’s in the way of her vet programme.
‘Oh! Sorry!’ he says, rubbing his hand and standing up again. ‘But Rita – would you mind if we turned the television down a little bit? So we wouldn’t have to shout?’
She screams again, and he almost falls over.
‘Now, now!’ I say. ‘Come on, Rita! Remember what we said about the screaming? Try to tell us as calmly as you can what it is you want.’
‘Soup!’ she says. ‘I want soup!’
‘Okay. That’s okay. I’ll make you some soup’ says Andreas, ‘but first let’s get the assessment out of the way, shall we?’
She turns off the TV and grumpily stuffs the remote into the chair cushion again.
Andreas has just turned his back to open his folders when she screams again, so loudly he almost dumps the lot on the floor.
‘What is it now?’ he says.
‘Clean these!’ she shouts, handing him two filthy magnifying lenses. ‘Clean them!’
‘Okay. I’ll rinse them under the tap for you, but then I really must get on with my paperwork. Okay?’
He takes the glasses, shakes his head at me, then goes into the kitchen.
‘Whilst Andreas is doing that, d’you mind if I take your blood pressure and so on?’
She grunts, staring at the television.
A rabbit is being sedated prior to an operation. The vet says he’ll take this opportunity to clip its nails, too.
I approach with my kit, gently wrapping a blood pressure cuff round her arm, and then putting the steth in my ear. Just behind her I notice a yellowing, photocopied picture taped to the wall – a Welsh terrier, sitting with its paws on a table. The dog is wearing pince-nez specs, a red spotted neckerchief and a knitted waistcoat. ‘He’s lovely’ I say, nodding at the picture. What’s his name?’
Rita screams.
It’s completely heart-stopping, like I’ve put the stethoscope into the mouth of a roaring lion. I snatch it clear and take a step back.
‘What?’ I say, shakily.
‘A girl!’ she says, in her normal voice. ‘She was a girl’.
Then she picks up the remote control, points it at the TV, and turns it up, full volume.

head to head

‘Shall I take my shoes off?’
‘No! Why? Why would you take your shoes off?’
‘I don’t know. It’s what I’d do at home…’
‘Are you at home?’
‘No.’
‘Is it raining outside?’
‘No.’
‘Then leave your shoes on and stop making such a fuss.’
‘Okay.’
Masha turns round in the narrow hallway and shuffles ahead of me down the hallway. I feel uneasy, like I’m being led into a cave by a ferocious old bear I’ve accidentally woken from hibernation.
‘Where shall I sit?’ I ask her, stepping into a bright and clinically tidy room.
‘Not in my chair!’ she says. ‘The sofa – perhaps.’
I put my bags down, take my jacket off.
‘There!’ I say. ‘That’s better!’
Masha sits on the edge of her armchair. She’d be an extraordinary figure in any circumstance – her hair dyed a rich, autumnal red and swept back off her head into something like a horn; her face slack and mournful – but illuminated as she is by the sunlight sparkling in through the window behind her, she seems hardly real at all, more like a brilliant, cartoon illustration from an article about a lonely clown. She reaches for a box of tissues, takes one out and starts folding it on her lap, over and over and over, into a tight little pad. I half expect her to reach for a pair of scissors, make a few adept snips, and unfold it to reveal a chain-word. грустный, perhaps. несчастье
‘How are you today?’ I say, throwing my hands wide, smiling as warmly as I can.
‘How do you think I am?’ she says. ‘Terrible. I am terrible.’
‘Oh! I’m very sorry to hear that.’
‘You’re sorry. Everyone is sorry. But no-one does a thing to help. So I am left here on my own, with nowhere to go, and nothing to do.’
And now I learn what the pad is for. She starts to cry – not an open sobbing so much as a discreet overflow of tears, oozing out through the myriad folds of her face, like her sadness was a water table of misfortune, high after a particularly long and inclement season.

Masha has a chronic condition that surgery hasn’t helped. She’s been in and out of hospital over the past few years, enduring several interventions that haven’t worked. This would be hard enough in itself, but the way Masha describes her experiences, it’s difficult to resist the feeling that her rather blunt way of talking has only made things worse.

‘…. an Asian consultant, he appeared at the bottom of the bed with a nurse, and he talked and talked without looking at me once, and at the end of all this nonsense he said Does that answer your question? So I said no it does not answer my question. I did not understand a single word you said. And I looked at the nurse, and she just clamped her mouth shut, like this… and shook her head from side to side, like this… and then they both went away. Later on I could hear them all talking about me in the office, because my bed was at the end of the ward. When the nurse passed my bed again I called her over. I told her I heard everything she said, and how she was a disgrace to her profession, and if I was in charge she could be sure I would throw her out, and good riddance. And she cried then, and everyone made a big fuss about it, but I’m not afraid of saying when something is wrong. Like yesterday, when I telephoned the hospital to find out why I had been forgotten, and the woman who answered the phone, she asked me what my problem was, and I told her I would not talk to her about it because what was she? A doctor? No – she was a silly little taker of messages who had no business asking intimate questions about someone’s health. And please would she fetch a manager, because I would not be spoken to in such a manner….’

And all the while Masha talks, she punctuates her sentences with a little dab of the tissue to the end of her nose.

She talks at great length. Her tone is curiously unsettling – self-assertive to the point of hostile, but with the occasional upward inflection that’s pitiful, almost childlike. She lists all the dreadful things that have happened to her, from rude reception staff and patronising community nurses to incompetent paramedics.

‘My sister said to me before I came to this country, she said Masha? You will find yourself in trouble over there. But I have never been afraid to speak the truth. I will not dress a thing up just so that people can feel okay.’

Masha pulls a fresh tissue from the box, and I take advantage of the pause to ask if she has any family nearby. She nods to a framed photo on the sideboard. It’s a photo of a young woman, forehead to forehead with a horse. On the left of the picture is the enormous eye of the horse; on the right, the young woman, her eyes closed, her left hand pressed affectionately to the angle of the horse’s jaw.

‘My niece, perhaps,’ says Masha, smoothing out the tissue on her lap and starting to fold it as meticulously as the first. ‘But she is busy.’