Dirty Work

by Gabriel Weston

  ‘Suddenly, the department was full of shouting and blood. The boys the crew dragged in were injured, but they were still at each other. Blood was literally flying around. Their faces were gashed and there were bloody T-shirts and then this young lad was carried past me. He wasn’t fighting because he was in a bad way. He was on a gurney, being taken into resus and there was a bobby walking next to the paramedic, carrying a machete. And I tell you, for a moment, I thought it was the most ghastly thing I’d ever seen until I looked down on the stretcher and saw that the man lying on it had only one of his arms. The other one wasn’t attached to him any more. It was kind of laid alongside him, but not connected to him, if you know what I mean. And that was the last thing I knew, before I hit the deck. I don’t know how long I lay there for. I guess everyone was too busy to pick me up. But eventually I came to. I was all covered in blood from the floor. And I almost wished I didn’t have to get up because of the shame. Everything around me was business-as-usual. I went and got changed. I carried on for the rest of the shift and, you know, no one said a thing. But there was no coming back from that. So I’ve always wondered. What did I lack? What makes you lot, who are okay with all that blood, different to me? Did you have a moment, an equal and opposite moment from the one I had, when you saw claret for the first time, maybe, and you thought, wow, look at all this blood and guts. I can really do this?’

  Red autumn. Second year as a doctor. Outside my home there is leaf-smell, and the air sparkles clearer than water. I am at my desk. My window is open and I have been sitting there for hours reading an endocrinology book, because a woman has been admitted to my ward with a rare hormone disease called acromegaly, and I want to learn all about it before I meet her. But I am about to completely stop thinking about medicine. The phone rings. It is Julia, and she speaks directly to my heart. Tom, is what she says. This is all I hear. Tom. He’s back. My sister talks slowly to me and then she stays quietly on the end of the phone. She knows full well that no one has dethroned him. I listen to her breathing. When I’m ready, she hangs up. I look back at the colourful text in front of me, but its pages hold no drama now. I close the book and stand up. I lean right out of the window and, stretching my face up to the sky, I breathe. The air is rich with leaves, and the leaves by my window are herald-colours. The pavements are laden with brightness and I gaze all the way along these avenues of red and orange and yellow.

  I look hard at the glass of water Dr Gilchrist has brought me, focus on the distinctness of the vessel, the purity of its contents. I try to keep its outline very clear. I pick it up just to feel it in my hand, the verifiable truth of it. I take a sip. What good are all these thoughts if they stay in my head? I know I need to speak. No one else is going to defend me. It’s up to me to represent myself, to describe myself as I wish to be understood. When my voice does come, I am reassured by how I sound. ‘She was my first surgical patient and her name was Violet.’ The words select themselves. And with this one sentence, the story I am happy to tell asserts itself over the one I cannot.

  ‘I was a house officer when I met Violet. I was working for a team of endocrinologists at the time, and I just loved the job. There’s that perfect logic about the pathophysiology of hormone diseases and, when I wasn’t on the ward, I was in the library. All my bosses were so brainy.’

  My knee almost touches Dr Gilchrist’s. We are much closer together than we were, and both leaning forward on our seats. It feels nice to have his full attention, to know where I am heading, to be putting one foot steadily in front of the other.

  ‘She came into hospital on a Friday. One of the registrars gave me the tip-off. He knew it would only be a matter of time before every medical student and junior doctor in the establishment would be hanging around her, wanting to check her out. He advised me to get in there before the weekend. But I didn’t go and see her that day. I didn’t want to treat her like some kind of freak show. I wanted to learn about her disease before I approached her. So I took a book out of the library. It was a beautiful autumn and I remember poring over that book at home, at a table by the window, for hours that weekend. The following week, though, I pretty much took up residence by her bedside.’

  ‘She was that interesting?’

  ‘She was. And she was a welcome focus.’

  ‘Because?’

  ‘She just was. Look, I don’t want to get off track. What was I saying? I went in on the Monday, keen as mustard, really impatient to meet her. I’d made myself wait. I’d studied pretty much everything there was to know about her illness. And I wondered if I’d recognise her, from all that I’d learned. Would I know her across a room? Would my instincts lead me to her?

  ‘I walked on to the ward – and it was just as I’d hoped it would be. I knew exactly who she was as soon as I clapped eyes on her. She was in the middle bay, in the bed nearest the walkway. Unlike everyone else on the ward, however, folded into blankets, twisted this way and that or hidden behind curtains, she was sitting in her chair, knitting.

  ‘She had the characteristic mighty big skull and big bony ridges over her eyes because of the tumour in her brain producing too much growth hormone, but her hair was soft and silvery and feminine as anything. Her nose was huge and so were her ears and lips, but the dressing gown she wore looked like it might be a Liberty print. Her forearms were graceful and she wore a gold lady’s watch but this only emphasised her hands. They were like butcher’s hands, massive, with thick meaty fingers. She was like a bizarre mixture of total femininity and monstrousness. I remember thinking, here is a woman who has literally outgrown herself, who doesn’t fit her own skin any more.’

  ‘Then what?’

  ‘She beckoned me over. She must have noticed me standing there, textbook in hand, staring. It might have offended someone else, but not Violet. She welcomed me from the outset. When I went over to her she took my hand and introduced herself to me. It was the opposite of the usual order of things. I sat down on her bed and that was the beginning of what I really would like to call a friendship. But I know that doesn’t sound right, so how’s this? That was the beginning of me and Violet. The start of how important she became to me. I mattered to her, too. Even now, I still believe that.’

  I have another drink. It gives me an opportunity to look again at Dr Gilchrist. It’s good to see the expression on his face, to mark the effect that my words can have.

  ‘I was busy, of course. Every day was hectic. In the mornings I’d rush about on the ward round, getting whatever my seniors needed, making long lists of tasks. Afterwards, it could take me hours to get all these jobs done. But when I completed my work each day, I went to Violet. She was like a reward, a comfort or something. We liked to sit together with her notes and have a look at any new results, track the ebb and flow of her electrolytes. She was particularly interested in the circular photos taken by the colonoscope, which showed the folds of her bowel. I remember Violet saying she thought they looked like petals, all heaped up on some curious plant.

  ‘But it wasn’t always clinical conversations we had. She told me plenty of other stuff about herself as well. I heard about her antiques business, about her husband who’d died a few years before. Even about a girl called Kitty, who she remembered from her childhood. And there were other things too, you know, funny things. She had a basket she’d hung from her kitchen ceiling, which she kicked every morning, to reassure herself she was still fit. She even kept a shotgun under her bed.

  ‘Anyway, one afternoon, maybe a couple of weeks after we met, I was sitting in my usual spot with Violet. For once we weren’t talking. Violet was knitting and I was just sitting beside her. A doctor I’d never seen before turned up. He wasn’t part of my team. I thought he must have got the wrong bed at first, but it was Violet he was after, all right. He was Mr O’Keefe, he said, and he was a surgeon. He’d come to discuss the operation he would be performing to remove Violet’s pituitary tumour. Just like that. I don’t think anyone had mentioned the possibility of surgery to her b
efore. And he just blundered in and said he’d be cutting her open later that week.

  ‘She was really shocked, I could tell. There had been some discussion about the different treatments that were available, but surgery had never seemed to be top of the list. We’d certainly not discussed it, she and I. And suddenly, here was this guy, who might as well have had a knife in his hand right there and then. I could see he had no idea – no conception at all of how she was feeling. Of what it might mean to a person to have to consider being put under anaesthetic, to think about completely losing control like that, to have something done to her that would change her for ever. An operation she would never be able to undo—’

  ‘But, Nancy, she was ill. She had a tumour. Wasn’t he just trying to help her, this surgeon?’

  ‘Yes. Yes, of course he was. But he really did not consider her feelings at all.’

  ‘Okay. So, then what?’

  ‘I didn’t know what she was going to do. I reckon I was more upset than she was, hearing the details of how he was going to remove her tumour. But then she surprised both of us. She gave a little speech which, truly, I’ll never forget. First, she introduced me to the consultant. You should have seen his face! She said how much I’d comforted her during her stay in hospital. She referred to me as her lucky charm. And the long and short of it was she agreed to go ahead with the op but only on condition that I was there, next to her, through all of it. I don’t know who must have looked more horrified. Me, because I’d never been at all keen on going to theatre, or him for having this hopeless junior foisted on him by one of his patients. But one thing was clear: neither of us had much of a choice in the matter.’

  ‘So, what happened then? What was it like in theatre?’

  Dr Gilchrist sounds so keen, so boyish almost, that for a second I think he must be mocking me. Yet it’s clear he’s completely genuine. He’s beaming. It’s the first time I’ve seen him smile.

  ‘I wanted to see Violet before she was put under anaesthetic, so I got up especially early on the day of her operation. I felt queasy, but I made myself eat a banana.’

  ‘You’d heard enough about what happened to rookies who couldn’t deal with the sight of blood to know you should take precautions.’

  ‘I was still feeling a bit sick on the bus—’

  ‘Nerves?’

  ‘— so I revised the whole course of my relationship with Violet in my head, played it over, from the time we’d met. I thought about how stoical she’d been, and started to feel bad about how little I’d considered this before, how awful it must have been for her, while I was just enjoying her company. I suppose I felt a bit ashamed of how selfish I’d been because I started thinking, for the first time, that the surgery was in fact a really good thing after all, even though I didn’t like the guy who was going to do it, because it would make Violet better and she’d be able to get home at last.’

  ‘And you were trying to settle your nerves too, am I right?’

  ‘Maybe I was. Quite possibly. Although it was really Violet who ended up doing that for me as well. So, I got to the hospital, went to the ward, determined to cheer Violet up. She was all ready. Even the way she was lying on her bed, stiff as a board, was like she was showing her readiness to be operated on. And, of course, she wasn’t a bit scared, didn’t need any reassurance from me. There I was, ready to cajole her, and there was no need. I was—’

  ‘– all revved up with no place to go.’

  ‘Worse than that. I realised how well she’d got to know me because, despite my cheery-cheery look, she could tell I was feeling rotten and—’

  ‘– she comforted you?’

  ‘Yes. But in a strict kind of way. “Stop hiding yourself under a stone, Nancy”. That was exactly what she said. She wanted me to push myself forward more, I think. She even told me to enjoy myself. In theatre, I mean.’

  ‘And did you?’

  ‘To begin with, when I left her and went to put scrubs on, I think I was putting a brave face on for Violet’s sake. Because she had been so brave, and I knew she wanted me to be more positive.’

  ‘And, when you got into theatre?’

  ‘Things changed. You know it, don’t you? You can tell from my—’

  ‘– from what I remember myself. So, what—’

  ‘I walked over the threshold. And I felt it instantly, the excitement. I was amazed by it. But only for a second before Violet was wheeled in, under anaesthetic, and I reminded myself it was her I was there for. Two guys moved her to the centre of the room and lifted her on to the operating table. I saw a single strand of Violet’s hair billowing as they lifted her across. In no time, her entire body was covered in drapes, sheets of green paper. You could see where the folds had been, and the paper was tented over prominences, over her knees and stomach and her face. One minute, she was there in front of me and then she wasn’t. It was like a shroud.’

  ‘And how did you feel, seeing her like that? Did you feel bad?’

  ‘No. It just reminded me of my childhood. My sister and I built a miniature landscape once with forests and a lake made from foil, and a quarry made with gravel from the street. I stared at Violet’s sheathed body without focusing, imagining its contours to be those others. Then suddenly Mr O’Keefe was standing there and I remember the weird tilting, having to readjust my perspective.’

  ‘Did he acknowledge you?’

  ‘More. He said, “Are you going to scrub, or what?”’

  ‘Wow.’

  ‘I know. I was so grateful to Violet, for the conversation that morning, for the way she’d encouraged me. Now my nerves were long gone. My pulse was through the ceiling but it wasn’t fear any more, it was excitement, and I was glad I didn’t have to feel bad about that, or guilty. I was the first assistant, you know – there was no one else. I was essential to the surgery Violet needed. If the anaesthetist had held her stethoscope to my chest she would have heard it going like the clappers.

  ‘A nurse helped me to scrub. It took me a while to get the hang of it. And when I went back into theatre what I beheld was a wonderland. With a space in it for me. I went over the to the table, my gloved hands over my chest like the nurse had shown me. The room scintillated around us, the grand consultant, Violet in her landscape of green, and me. The floor was buffed and gleaming. Three or four theatre staff, looking just like surgeons apart from the different colour of their caps, busied themselves quietly around the room. The anaesthetist sat enthroned in her machines.

  ‘And – maybe I can only say this to another doctor – but it was a perfect universe, all action, no need for talking. A place with no rough or imperfect surfaces. No windows to remind you of the real world outside. The only view was into the operating theatre next to ours, through a small window. In there, I could see another surgical team bending over their work.

  ‘When Mr O’Keefe took the scope from the nurse, my heart was beating like a hammer. My fingers prickled. “Frears,” he said and I was thrilled by his code. I loved the fact that a syllable foreign to me could refer to the instrument she passed him. It was like a slim metal handle slightly flattened and curved at one end.

  ‘When the scope went into Violet’s nostril, the black screen flared into a perfect red circle showing the inside of her nose. Then Mr O’Keefe handed the scope to the nurse for a moment and took my hands in his own. He placed them on the sterile drapes in front of me so that I wouldn’t make the mistake of dropping them to my sides and needing to rescrub. I felt his hands on mine, their great weightiness and then the lightness when they were gone. He started operating and he explained everything that he was doing, softly, because he was concentrating.

  ‘And I knew Violet wouldn’t mind what I was thinking – which was that it was much better than being on the wards. It felt incredible to be a part of this procedure, to be actually assisting in it. On the screen, I saw Mr O’Keefe pressing a pink structure inside the nose over to one side, where it seemed to stick, before he went further. Then he went thro
ugh the choana, at the end of the nostril, and found the sphenoid ostium. He pushed into it, then pressed forwards. He called it tiger country. He had to go through the back of the sinus, right next to the optic nerves, the cavernous sinuses. It was astonishing. He was so calm. Next thing I knew, he’d made this hole – I could see it on the screen – and he was cutting through the dura, and he found what he wanted: the tumour. There it was, for the taking. On the screen it looked huge. And nothing could stop him now, this man, he was hooking the tumour out through Violet’s nostril. When he put the scope back in, all that appeared on the screen was blood and I was afraid. But then he inserted an instrument into her and everything was brought under his control. Lakes of red disappeared into the metal rod and against the lateral wall of the nose I could see quite clearly where the blood was coming from. Mr O’Keefe directed his sucker there, so that the red went straight into the grey with none escaping, and then there was a single prolonged beep as he controlled the diathermy on the instrument and cauterised the bleeding vessel. As smoke curled out of Violet’s nose I realised that this was what I was seeing on the screen, only magnified, so that it appeared like a sandstorm, like a cloud of sparkling confetti.’

  My story is suddenly over. I have reached the conclusion of the series of events I embarked on telling. But I don’t feel finished. It’s as if I’ve just warmed up, should still be in the middle of things. I watch Dr Gilchrist scribble away on his pad. I wonder if he senses that I haven’t finished, if he will help me find a way to start again. He stops writing. His smile is not an opening but a gesture of punctuation. He puts his pen down, turns to look out of the window where we both see clearly that the sky has darkened. He looks at his watch. I do not like these signs.

  ‘We’re very nearly done, Nancy. I just have a few quick questions for you before I let you go. Starting with this. In the weeks leading up to your crisis in theatre, did you have any avoidant or intrusive symptoms? I’m sorry, it’s awkward talking to colleagues, isn’t it? Did you feel, for example, less sociable than usual? Did you want to hide yourself away during this time?’