Dirty Work

by Gabriel Weston

  But, in another sense, it all seems pretty academic. Because I know one thing for sure. If I ever had been asked, if some kind of open forum had existed at which registrars had been invited to take a line on the subject, I could only ever have gone one way. Not only because, like every other civilised person I knew, I agreed with abortion on principle. But because, once upon a time, I had needed one myself.

  I knew what colour the paint was inside the Marie Stopes clinic near Victoria station. I knew what it was like to walk in there and be stared at by everyone in the reception room. I knew how it was to feel like a fool and a fraud for not having better reasons for making my solemn request. It was in that place, not my own hospital department, that I had seen my first HSA1, the single-sided blue form on which each woman’s reasons for wanting to terminate her pregnancy are inscribed. There that I had given my blood and lain down for a scan. There that I had bartered for the abortion of my own foetus, not hesitating for a heartbeat to agree, when asked, that I believed my mental health would deteriorate significantly if I continued with my pregnancy. And, you know, a person can’t have a thing like that in their life, and just edit it out.

  For the first few months, I only did the occasional abortion, just as they happened to crop up on Mr Kapoor’s general list, among all the other gynaecological procedures I was becoming a dab hand at. But the day came when my boss asked me if I’d be interested in doing more. Maybe he told me that the department was snowed under with work. Or perhaps it was that an opportunity had arisen for a keen young registrar wanting to make their mark. I don’t remember the introduction. But I do remember the deal. For one day per fortnight I would get my own termination clinic in the morning, followed by an operating list in the afternoon. Real independence with the safety net of a consultant working nearby at all times. All I needed to do to sign up was go and see Frederick.

  And that was how I found myself in his office for the first time. High up on the fourth floor one sunny afternoon, with the windows open and the sun shining in and the radio on. Being served tea by the most unlikely consultant I had ever met, a man with a ponytail and multicoloured trousers. Sitting on his sofa beneath a wall full of baby pictures and thank-you cards from all the couples he had seen in the Assisted Conception Unit and hearing some of their stories. Eating biscuits and watching Frederick pace about his office, oblivious to the papers fluttering across his desk by the wide-open window as he expounded on his equal commitment to providing abortion and fertility services. Two sides of the same coin, was how he saw it.

  I still like the way Frederick didn’t separate abortion out from everything else. Because, in some ways, it is no different to any other kind of surgery. Not easier or harder, not more gory or more disgusting. Every surgeon picks the organ they will spend the whole of their career protecting. The neurosurgeon gets the brain, the coloproctologist the bowel. And we gynaecologists have the womb to look after. A piece of tissue as small as a fist but with the capacity to expand and fill the whole abdomen. An organ with great tensile strength but delicate as paper and as easy to perforate. And whichever specialty we choose, each of us has to do something ruthless to keep our patients safe. We have to forget about the human significance of the organ we are operating on. So this is what I do. Before each abortion, I tell myself that the precise contents of my patient’s womb cannot be my concern. The foetus is merely the potentially treacherous surgical field in which I am working, while my patient, the person whom I have made myself absolute protector of, sleeps her sleep.

  And there’s something else I want my judges to know. I have derived great satisfaction from becoming expert in this procedure. From knowing exactly which dilator to choose for which cervix. From the sixth sense I have developed about the angle of each uterus. From my growing confidence in knowing how far to go to empty the womb safely but without damaging it, so that it might serve its owner well in other, happier circumstances. I am proud of the work I have done.

  But the story doesn’t stick. All night long, the wind bellows down the empty communal corridors of my home and, in the morning, I wake from a dream in which I am sitting in theatre, face blank as a canvas, blood dripping from my hands. Except it isn’t a dream. It’s the real, final act in my short adventure as a doctor. And, as such, any version of events I concoct has to lead directly up to it. I stare out of the window, down to the courtyard which is strewn with branches and green leaves, and I wonder suddenly whether it was all bound to happen. Wasn’t I always a passive little wretch? Even as a child, I never could say no. Maybe that bloody surgical scene was the last of a long string of mistakes. Perhaps each moment of disastrous inaction could have been detected in the one before it. Silence giving birth to silence, one missed opportunity to save myself after another.

  It’s not as if that last day came out of the blue. I went to see Frederick weeks before the end. I didn’t mull over exactly what I’d say when I got there, I just woke up after yet another of those dream-filled nights and knew I couldn’t go on as I was. I remember how out of breath I was as I climbed the stairs to his office. Tired. Nervous about how I would articulate what I hardly understood myself. None of the other registrars talk to me any more. I believe but I don’t believe. I want to carry on, because this is the most important thing I’ve ever done in my life – but I think I’ll have to quit because it’s making me ill.

  When I reached Frederick’s office, I found the door open but no one there. I stood on the threshold. Papers fluttered across the desk, spilling on to the floor as the wind blew through the open window. Two teacups sat on the table by the sofa, small brown puddles in their bases. A hundred pairs of babies’ eyes stared at me from the photo display on the wall. I crossed the room and lowered the sash. I stood for a moment or two, not knowing what to do next and looked out at the Day Surgery Unit, three storeys below.

  A few minutes later, I was standing beneath its great porch. I passed through the waiting room and up the stairs to change into scrubs. I headed for theatre. I didn’t go through the normal door, though, the one that would bring me right to him. I entered through the anaesthetic room, so that I would come in near the patient’s head. I wanted to look at her face. I hoped it would give me courage.

  What a cool blue room. What a background for such redness. The radio blared unhelpful songs. ‘When I kissed the teacher’. ‘Rude Boy’. The anaesthetic assistant stood in his usual position to one side, ultrasound probe resting on the patient’s distended belly. Beyond her outstretched legs, I saw Frederick, hair pulled back under his surgical cap, neck and arm sinews stretched with effort beyond the green drape. The bowl not visible, the ultrasound not visible, the work not visible.

  It wouldn’t have taken much. It would have been enough to have said just a few words. Hello, colleague. What a fine day it is outside. But not in here. I simply cannot bear to stand alongside you and watch what you are doing. Perhaps he saw it in my face. I didn’t need to speak: Frederick filled the silence instead. If only our doubters would bother to find out about these women’s stories, Nancy. I think we’d change their minds, don’t you? Take this lady. Twenty-two weeks’ gestation. Recent diagnosis of breast cancer, aggressive type. If she keeps the baby, she dies. And, even after this, she’ll need the whole deal. Surgery, radio, chemo.

  I inched closer to him. He talked me into his orbit. But it isn’t just the women with cancer, is it, Nancy? Not just those whose babies are growing without kidneys or brains. It isn’t just the rape victims or the abused ones. They’re not the only cases with merit. They’re just the ones whose sad stories are the easiest to fathom.

  By now, I was standing next to him, at the heart of his justification. This is what our arms worked so strenuously for. To help others whom no one else would give relief. For the good. And soon, I found it wasn’t too awful after all to stand next to my boss. To look into the bowl in front of me and confront the sight of absolute brokenness there.

  I’ve asked myself the question a hundred times. Why did
n’t I speak up that day? Why didn’t I try harder to make myself understood? I could have saved a woman’s life if I had stepped out of the ring in time. I could have saved myself. But I think I understand now what I felt that afternoon. The bald fact of it. Which is that some acts can never be undone. It’s not possible to un-become a killer. Once you have ended a life, you cannot walk back over that line, however blindly you may have crossed it.

  There was nothing unusual about the way that first day began. Nothing odd in the weather, nothing strange or silent when I stepped out of my flat that morning to go and do my operating list with Mr Kapoor. No single magpies, or broken mirrors or swirls of smoke. The bus came on time and I don’t remember a single soul on it. I didn’t commit to memory the faces of the people who saw me just before I made the biggest moral leap of my life.

  I don’t remember anything particular about my passage through the hospital either, though I must have taken those last innocent steps past the cashpoint machine, up to the first floor and towards the theatre suite. There would have been a receptionist sitting there, even at such an early hour, and perhaps she wished me a cheerful good morning, the last warm, pure, unsuspicious greeting I would ever have from someone sitting at that desk.

  In my mind’s eye, my footsteps etch a red track. I see myself walking towards my fate. I stop at the scrubs shelves and select my surgical attire. I take top and bottoms into the women’s changing room and, a few minutes later, I am out again. Transformed for my work. Keen and ready to go although there is nothing indecent about this hunger. It is just another day at the hospital.

  I meet my boss at the noticeboard. Good morning, Mr Kapoor. It must still be the first few weeks of my apprenticeship for me to address him this formally. We look together at what the day has in store. The operating list does not say Hazard. It does not say Go Home Young Surgeon, or Beware. There is just a list of short cases. ERPC, D & C, ToP, EUA, insertion of IUD. Mr Kapoor decodes them for me. He tells me there will be plenty for me to do. He extends his hand out to the side, a chivalrous gesture, and points me in the right direction. Look at me now, the jejune trainee, all puffed up with pride, leading the way. A pool of blood already collecting around my feet, if only I could see it.

  In theatre, I wait on a stool. Mr Kapoor opens his briefcase on his lap and attends to some papers. I hear the anaesthetist, in the room next door, greeting our first patient. I take out my surgical logbook and open it. Its leaves are blank and white. A tabula rasa. I look at the page in front of me. Core Module 15: Sexual and Reproductive Health. There is a list of procedures beneath the heading, skills I need to master. And there is something else: a footnote in tiny font which says ‘Please mark conscientious objection (CO) alongside skills not acquired. What can this mean? I scan the list again to see what act a person might possibly want to abstain from. I see Termination of Pregnancy.

  This is the warning. This is the signal. Here is the moment of great commotion. There is blood pouring down the walls. The room is a river of blood. The walls shake and trumpets blast and drums roll. I must be deaf and blind to hear and see nothing of this. I ignore the sign, although it is so very clear.

  I look back at the footnote and at the serious words there. Conscientious objection. It seems a fat phrase. I sit there quietly on my stool and I think of the pacifist, arguing against his own conscription. The very thought feels anachronistic. A question forms in my mind: is there a difference between conscientiously objecting to doing something and conscientiously objecting to something being done? But I don’t get the chance to think about it.

  Suddenly, the room is all action. The double doors bang open. The patient is wheeled into the centre of the room. People cluster round to move her on to the table. One, two, three, over. This is what a person becomes a doctor for. Nurses unfurl drapes. The bottom section of the bed is cracked loose from its hinges. The monitor blinks and the patient’s legs are up in stirrups. A pack of instruments clatters on to a trolley. I approach the bed in my gown and mask and all the loud and moving things become still around me. My boss watches as I lower my weight on to the stool the nurse pushes foward. I am pinpoint-focused.

  ERPC. Evacuation of the retained products of conception. I clean my patient’s pudendum. Miscarrige at thirteen weeks. Some retained products on ultrasound. My hand hovers over the instruments. I select a cannula to suit the size of my patient’s cervix. The nurse turns on the suction and I introduce my instrument, using it to gently sweep the uterus, to empty it of its contents and stop it bleeding. Good job, says Mr Kapoor when I am finished. Do the next one too.

  D & C. Dilatation and curettage. Exactly the same as before, just differently named because of its different indication. Last time, a miscarriage. This time, heavy periods. I finish the second case. Well done, but make sure you’re thorough, says my boss. He nods for me to scrub again as he talks. What you see on the ultrasound screen is no substitute for what you have to learn to sense with your hands. A scratchy feeling against the curette tip that tells you if the uterus is empty. Here, show me. He nods to the operating table, where our third patient is already waiting.

  ToP. Termination of pregnancy. I know which patient this is. I know what she is having done. I look at Mr Kapoor, to gauge the loaded expectation in his face but find his expression blank. Everything else is just the same as before. The anaesthetist reads his paper. The scrub nurse stands by the trolley. The radio plays quiet classics. I breathe in and I breathe out. Just for a second, I pause. Something in me stretches and arcs. And then, the moment is gone. My assistant squirts jelly on the woman’s abdomen and applies the probe there. I soak a swab-on-a-stick with chlorhexidine. All the moments run together quite smoothly again. I have placed the Sims speculum in the introitus and opened the vagina. I am visualising the cervix. I attach Vulsellum forceps to the cervical lip and select a Hegar dilator. I am putting in the suction curette.

  There is nothing in the mechanics of what I do to distinguish this procedure from the two I have done before it. Not the size of the cannula. Nor the time it takes to complete the job. Not the small amount of blood which empties discreetly along the tubing into a closed drain by my feet. Not the sanitary towel I press against my patient when I am finished. Not the sparse conversation I have with my boss. Nothing whatsoever that might indicate to a young woman that she has just made the biggest mistake of her life.

  I am walking out of my flat to get the bus, when I suddenly change my mind. I go back indoors and struggle out of my suit. Leaving it lying on the floor, I quickly re-dress in trousers and a jumper. I take the lift to the basement and, after rummaging around for ten minutes, haul out the bicycle I inherited from my mum. Mint green, straight handles, light frame. Is superstition all I have left? Some flimsy notion that, by sitting in my mother’s saddle, I’ll intuit what she might have advised me. How to approach my last panel, in what manner to put things to my judges, which of the many explanations I have come up with is the most authentic.

  The sky is fresh and blue up above my block of flats, but the street is still cast in shadow, a deep cold grey. I pull the collar of my jumper up around my neck, and the sleeves down over my hands. I push off the kerb and change into third gear straight away, eager to feel my body do something that feels like work.

  Soon, I am speeding along the Embankment, looking for clues. I turn alternative stories over in my mind, trying each one against the world around me. Beech trees line the pavement in front of the smartest of houses. It is hard not to believe that everything will be all right, looking at all this bright stucco, the window boxes full of blinding red and blue. A whole row of houseboats passes me on my right. For a second, a man is spraying his deck with a hose, then my face is full of lime-bright leaves and I am cycling through the embrace of trees.

  I reach the bridge. Up its slope I pedal, to its gentle summit, and look down on to the muddy, dimpled banks of the Thames, chocolate-brown in the glare. I see a couple beneath me in waders, mudlarks, foraging in the grime. I
freewheel down the bridge into the sun’s full rays, which pick out the dirt in the air and cracked paint on buildings, and the fumes from cars and the glint of litter. I alternate tales again to see which one fits best here, and it is not the same as before.

  Finally, I arrive at the hospital. The huge building rears up, centre stage. For the monumental task ahead I must pull myself back into the concrete world from the blankness of pedalling and the empty wind of my journey. From the details all around me, which might so easily sabotage reason. The low hum of the automatic door opening and shutting to let people in and out. A mother shouting in the car park to her child. A family gathered tightly round a man in a wheelchair telling jokes. The alarm on a supplies lorry – out of the way, blind people! – reversing into its allocated slot.

  I find a place to lock my bike. I fix the front wheel to a black cycle-stand, and when I stand up, someone is right next to me. David.

  ‘I wanted to wish you luck.’ He wears a new white coat over his clothes. I can see the creases in it from when it was square in its plastic pack. ‘Actually that’s not quite true.’ He pushes his hands deep into his pockets. ‘What I really wanted was to ask you out for a drink.’

  I look down. After a while I say, ‘Your boots. They drop mud.’

  A couple walk past me. First floor, the man explains to his companion. Turn right, second on the right. I envisage the orthopaedic ward. When I look up at David, he seems amused. ‘Why do Santa’s little helpers wear seatbelts?’ he says. And then, apologetically, ‘Elfin safety.’

  I smile, and this is all he needs. He throws his head back and laughs, so loudly that all the people outside the hospital turn and look at him. He is still laughing as I turn away and walk towards the tall doors of the hospital’s main entrance, and on to where my judges await me.

  Everything is going smoothly.

  ‘One day you were operating safely,’ says Miss Mansfield. ‘Then you weren’t. What happened that day? Can we satisfy ourselves it was an aberration? Or is the problem more serious? Can we fix it and, if so, how? This is what we have to cover in the next hour.’