Dirty Work

by Gabriel Weston

  For a moment, I thought I might cry. I squeezed May’s arm and said I’d see her in theatre, before grabbing a handful of yellow forms and all the slim sets of patient notes and heading off towards the series of shut curtains behind which I knew my patients were waiting.

  I consented the six of them fast. Their ages ranged from fourteen to forty. In affect, they occupied the usual ground between nervous and surly. Three had undergone terminations of pregnancy in the past, and didn’t need anything explained. Another had given birth to one child by Caesarean section. The remaining ones were straightforward. I was satisfied with my interaction with each of them, although I cannot believe now that it felt adequate to me.

  Upstairs in the locker room, I changed quickly. There was no one about and again I felt scared, at the silence of being alone, at my own reflection in the mirror. When I went to close my locker, I found that it stuck. A rusty old thing with a bent distressed door, at first I just thought it needed a kick, but after trying this a couple of times I looked more closely. Something was peeping out of the bottom of my locker, holding it open, poking out from just under a spare set of scrubs folded there. It was small and tubular, grey in colour. I crouched down and pulled the snag from the door. In my palm lay a tiny, disconnected baby doll’s hand. It wasn’t the first time I’d been left such tokens. But this was stranger than usual because little lengths of Elastoplast had been wrapped painstakingly around all of the doll’s fingers. I felt spooked. I put the hand in my pocket, resolving to show it to someone, maybe one of the theatre managers. I’d been quiet about things like this for too long.

  Afterwards it was hard to keep my focus. I was worried about going to theatre and I kept looking behind me. My mind wandered. A memory came to me from when I had spent a summer as a teenager with my family in apartheid South Africa. At the theatre one evening, we had seen a famous actor called Pieter-Dirk Uys who was satirising a far-right racist faction called the Witwolwe, the White Wolves, and his act was a short mime. He came on to the bare stage wearing a wolf’s mask and in his arms he carried a black baby doll. Silently, he crept to the middle of the stage and stopped there. And then he lifted up the snout of his mask and clicked open a little hook at the back of the doll’s head, so that the top of the plastic skull fell open on its hinge like when you open an egg to eat it with soldiers. Then he scooped stuff from the doll’s head into his mouth and ravenously ate it. By turns looking up to meet the audience’s eyes, making us complicit in this obscene feast, and down again to the doll’s open cranium, he gobbled.

  Still alone in the locker room, I went over to the basins. I looked myself in the eye, and said aloud, ‘Pull yourself together, Nancy.’ I was grateful to see myself in surgical scrubs and reminded myself that I had a job to do. I had plenty of practice girding myself in this setting, quarantining apprehension, and the rough words I spoke did me good. A short time later I left the locker room, partly becalmed, ready to start my list.

  In theatre, everything was orderly. May had already anaesthetised our first patient. Her legs were up in stirrups, a drape over her crotch to protect her modesty until I arrived. The ultrasound scanner was next to her, its screen giving out a grainy image of nothing yet. Joe, the anaesthetic assistant, was in the corner finding a station on the radio, and Felisa was at the computer, embarking on the necessary admin. I rested my hand on May’s shoulder as I bent over the anaesthetic station to check the notes. The seventeen-year-old. Eight weeks pregnant. One previous termination. Rhesus positive. No medical history. I checked the name band around the girl’s wrist to make sure we had the right patient.

  I worked through my first case without event. The second operation should have been the same. This woman was also surgically uncomplicated, with healthy anatomy and a pregnancy of only a few weeks’ gestation. But, although I performed all the same steps I had during the first operation, in more or less the same time, inside I was beginning to feel different, as I had done in several of my recent lists. Detached, not completely rooted.

  I stared at my hands. The left one had the job of holding the Vulsellum, of bringing the cervix forward, the more easily to access it. This hand looked familiar, like a part of my body belonging to me absolutely. But when I glanced over to my right hand in the size 7 glove which was just the tiniest fraction too big, I felt differently towards it. There was some slack in the web spaces and at the fingertips, and droplets of moisture were collecting on the other side of the yellow latex. All these features were normal. But the way that this hand was moving, the way it held the plastic cannula, guiding the tubing which travelled down to floor level and emptied into the measuring jar, the way the wrist rotated at the same time as the hand moved in and out, forwards and back, seemed ghastly to me. It was as if this active extremity had nothing to do with the rest of my body, with any aspect of my thinking or sentient self. It was as if it moved despite me.

  I had experienced this unnerving feeling of dissociation for the first time at the very end of a list a few weeks previously. Initially, I had thought I was having some kind of neurological event, the onset of a migraine or something worse, a transient ischaemic attack, even a stroke. I had managed to keep calm until the end of the case before going to the toilets and giving myself a mini neurological examination to make sure my sensory and motor function was still intact.

  And the same thing had happened quite a few times since, particularly when I had a lot of cases to get through and didn’t have the leisure to think about each of the patients separately. As I completed the second case of that day I resolved that, for my own frail sake, I would have to work harder for the rest of the morning, for the four operations that remained, to find stories for the women I was operating on whose real histories were unknown to me.

  I have no memory of the next two patients. They have become insignificant to me now, by comparison with the fifth case of the morning, the catastrophe. Perhaps I had done so well in returning myself to a normal functioning state that I was lazy for that last woman.

  But here’s what I am sure of. This was the point at which I should have stopped operating. I was feeling unwell. I had encountered a sentinel moment of crisis, heralding what was to come. As a responsible health professional I should have recognised my inability to continue, sought out my immediate line manager, outlined the risks I posed to patient safety, and cancelled the last case. I might even have been applauded for my probity, my adherence to the all-important tenets of patient safety and clinical governance.

  As it was I don’t think the idea crossed my mind. Doctors rarely consider their own feelings, never mind complaining about them. And the fact was that I wasn’t going to let something like this make me stop operating, any more than I would have allowed a head cold to prevent me driving my car. So I decided to press on through the next case. I’d be finished soon enough.

  So, I embark on my next operation with my eye on the horizon, as it were. I begin the procedure estimating that it will be over in ten minutes, that I can find a place afterwards to breathe in some air, or a remote hospital toilet to cry in. Only after doing my duty and sorting out my patient will I attend to myself.

  I work. Minutes pass. Before long, I think I’ve reached the end of the operation. I see May tailing off her anaesthetic gases. I’m leaning over to the trolley to pick up the Flagyl suppository and maxi pad. I pause because May is asking me a question.

  ‘Can I get some advice from you about my sister-in-law? So, she’s thirty-two weeks pregnant and she’s had some bleeding.’

  The antibiotic bullet is in my right hand. I hold it in a pincer grip between my thumb and forefinger. I don’t want to look at this hand, would rather not discover if it is still mutinous. I prefer to control it by feeling what it needs to do, by stereognosis alone. The sanitary pad is in my left, reliable hand. The hand that belongs to me. The hand I can depend on. I am lifting the pad through the air from the trolley to where I will tuck it snugly just under my patient’s buttocks, while listening to May. I
t looks fat and clean. I am pleased by its whiteness against the faraway gloom of the operating theatre behind it.

  My retina is soaked in this whiteness. It is not ready for all the blood that awaits its next glance. My eyes cannot take in the redness to start with. It is as if what I am looking at is the character of red, not the colour. Like looking at the sun, or staring into a fire. Automatically, I get some forceps and a four-by-four swab to blot the blood away, but as soon as I do this, more comes, like a stream now. I reach for more swabs, folding each one tightly in turn, and I grasp them in my forceps and push them further in, one after another, rotating my arm and wrist briskly as I do so, hoping for a bit of vasospasm, praying for contraction. But this has the opposite effect, as if my attempt to stem the blood has disturbed whatever small amount of clot formation was taking place.

  ‘She’s bleeding,’ I announce. I expect my voice to be loud, but it comes out as no more than a whisper.

  I know I am in trouble. I must do something. I need to find a way to pull myself together. My mind races in pursuit of a trick, an exercise, a measure of any kind that might call me back to myself. I remember a neurosurgeon telling me to trust in a patient’s inner physiological strength. And this is what I do now.

  I think of how together my patient and I are strong enough to stop this blood loss. I think of her insides. When a person is bleeding profusely, certain organs get first dibs on the remaining circulation. The kidneys are high up in this pecking order and grab blood from less important places. I can’t see my patient’s kidneys, but they’re not far below the surface, just under where your hands would be if you were a dancer or an ice-skater about to raise your partner to the sky in a beautiful lift. They are made of a smooth outer cortex, and an inner medulla, which is the complicated-looking textured part. Their main function is to regulate the body’s fluid balance and to remove waste products from the blood for excretion in the urine.

  For all this to work, over a litre of blood needs to be delivered to these organs every single minute. If someone’s bleeding, and there’s only so much to go round, the kidneys make sure they get their quota by dilating the vessels that supply them. It’s as if they’re a sponge sucking more fluid in.

  This is all very well, but once my patient’s mean arterial pressure drops too low, the clever autoregulation of the kidneys will break down. Then all those stress hormones circulating around the body will have the opposite effect, causing the previously dilated vessels in the kidneys to constrict, reducing even further the amount of blood that can reach them. If this was an operation that anyone had anticipated would go so badly, my patient would have had a urinary catheter in place, and the anaesthetist would be noticing it run dry.

  In front of me, blood is no longer just between the woman’s legs, but snaking everywhere else now, completely ungoverned. It has made a river which runs across the drape until it meets the edge. Then it is on the floor and a new pool is forming there, and getting bigger too.

  May is doing her arcane, professional dance, administering a milky-white substance into the woman’s arm which I know is Propofol, to prevent her from waking up to this. She has turned up the oxygen so that I can hear its loud, mechanical sigh. And now I see her collecting a tiny bit of the precious blood that remains in my patient, to send to the lab to be cross-matched for a transfusion. Joe stands by with a bag of fluid, though whether it is crystalloid or colloid it is not my place to know.

  It’s not my job to understand these things. All that is expected of me is to perform one simple task: to stop my patient from bleeding. Chapter one in my surgical textbook: ‘Exsanguinating patients need immediate definitive treatment by surgery.’ The duty of my anaesthetic colleague is to buy me some time, to keep my patient alive while I do this cardinal thing.

  The other really greedy organ is the heart. Normally, blood entering the right side of the heart gets laced with oxygen from the lungs before being pumped from the left side back round the body.

  But my patient’s bleeding so much there’s not much left in her. The only way the body can compensate for this is to make the heart beat faster. That’s why, if you feel the pulse of someone who’s exsanguinating, it becomes fast or tachycardic. The heart is working extra-vigorously to try and make up for the fact it has less in it to deliver around all those thirsty tissues. Eventually though the heart rate will drop very low and become bradycardic. It will give up its fight. This usually happens just before a patient dies.

  I haven’t moved much while thinking these thoughts. And there’s no point in thinking of my patient’s innards any more to try and galvanise myself because the biggest organ of all, her skin, is right in front of me telling its own tale. This vast epidermis is redelivering its share of the body’s blood to the parts deep inside which need it most. The tiny capillaries, which are usually plumped to prettiness, are squeezing tight, so that the complexion is losing its blush. Her legs are ashen, cerulean, and the pale skin under her toenails is turning blue.

  I would like to help her, but there is no possibility of action in me. The connections between my motor cortex and spinal cord and limbs seems bust. My arms hang pointlessly from my shoulders. And there are my hands, dead at the ends of those arms. They look ruddy next to the mottling skin of my patient’s thighs. Under my skin, I imagine the complicated layering and overlapping of my extensor muscles. If I stretch my fingers out just a little, there are the tendons too. And by turning my hands over, I can see the thenar and hypothenar eminences, the delicate curves of the intrinsic muscles of the hand, the bulges of the flexors, the pulps of each surgical finger, the adductors in each thumb.

  I can even see beneath them to the bones of the hand – and I know the mnemonic. Scared New Lovers Try Positions That They Can’t Handle. Scaphoid, navicular, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate. The bones seem so bright to me in that moment that once I settle on them, I can no longer see the muscles and skin. I can only frame the bones, the scaffolding of these hands, the essential units, the part of my extremities that will remain after I am dead. It doesn’t hurt me to focus on these bones now, dwelling on the acceptability of their deadness. Hands already inert, whose functional covering is not worth recognising or even looking at in its failure to act.

  The only movement in the room now is not of my making. May is at my shoulder now and is commanding me, ‘Nancy, for God’s sake! Don’t just sit there. I’m right up to the line here!’ And Joe, a man known for bulk and slow feet, a guy who does nothing in a hurry, is not dawdling any more but moving mightily and is hooking up more fluid; his body-built arms are in an arc waiting for the next instruction, the next thing he can do which will feel like help. Felisa is fleet in moving from where she was standing sentry to inert instruments: she is at the phone in the corner of the theatre, making a call, telling one of my gynaecology colleagues who she knows is operating next door to drop what he is doing. ‘Come now! Come now!’ she says. And the rest of the room’s motion is just the spreading of blood. While I sit absolutely still, quite frozen, watching my patient bleeding almost certainly to death in front of my very eyes.

  When I recollect this scene I see it as if from the outside. And even though my memory gives the truth to me so that in one sense it has no mystery, it also looks absurd. The people in the room who have been trained to be still and calm are moving around frantically and showing their fear. They scan the room for a solution. Felisa, who has not managed to get my gynaecology colleague to leave what he is doing to come and help, now calls the hospital switchboard and puts out an urgent pager call for Frederick, who she hopes is somewhere nearby and not on the other side of the hospital. And while they all bustle, the patient and I remain stock-still. She looks as if she ought to be dead by now, but the blood is still coming out of her briskly enough to suggest some cardiac output. And I, the one person in the room who has the capacity to save this situation from disaster, continue to do nothing. My shoulders are slumped and I am looking down at the
useless hands in my lap.

  How long this carries on I do not know. Many minutes. Perhaps half an hour. As long as it takes a person to die? This is what I am thinking at the moment when I feel the very walls shake. I wonder whether there is an earthquake, whether the building is falling down, whether what is happening in my operating theatre is, in fact, part of a wider, larger natural disaster, some outside catastrophe. Both doors fly open, and Frederick crosses the room in two strides. With hands under my arms, he lifts me off the operating stool and passes me over, like the pointless cargo I am, to Joe. He sits down and holds out his wonderful large, veined hands for gloves, raising them up, palms open, fingers bent, as if in supplication. And once sheathed, these hands of his stay still for just a second or two, poised in the air before he picks up suction in one hand, forceps in the other. Before they descend into the pool of blood all around him, into the bleeding insides of my woman patient, just long enough to ask May one question.

  ‘Is she still alive?’

  I nearly miss my train stop. I get up from where I have been sitting intently for over an hour, knocking an empty paper cup off the table. Stooping to pick it up, I see my jacket underneath the seat, almost forgotten. I only just manage to get off the train before it pulls away. See the shambolic woman, I think, standing on the platform, whom the other passengers would look at with new eyes if they knew she was a doctor. Ha! See the harried abortionist under cover. See the visitor to the coast, off on a simple jaunt to hear her sister sing in a choir concert. I do not catch my usual ten-minute bus to the beach. I walk the pavements to the concert hall. Mark is looking after the kids so that I can hear Julia sing. I’ve never gone to one of my sister’s concerts before. I’m due to stay with her afterwards, but just for one night this time, then back to London and head-first into the week when I will find out what is to become of me.