Dirty Work

I have never seen so much blood.

My eyes can’t take in the redness to start with. It’s as if what I am looking at is the character of red, not the color, like looking at the sun, or staring into a fire. I try to blot the blood away, but as soon as I do this more comes, like a stream now. I reach for swabs, folding each one tightly in turn. Grasping them in my forceps I push them in, one after another, rotating my arm and wrist briskly as I do so. But my action only seems to make things worse.

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 if there is an earthquake, whether the building is falling down, whether what is happening in my operating theater 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. 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 the anesthesiologist one question.

“Is she still alive?”

A good doctor needs to know how to spin a yarn. That’s what they teach you at medical school, though no one ever says it in so many words. They prefer to give it a safe sort of name, the powers that be. They call it history-taking, this supposedly neutral process in which a patient and doctor collaborate to weave a shape out of what’s gone wrong. They make it sound straightforward. And to the patient it probably feels that way. In reality, though, the competent clinical inquisitor is all the while asserting their own semantic frame, encouraging the patient to dwell on key symptoms, ignoring the white noise of emotion, veering away from anything that has no pathological meaning, doing what is necessary to help a diagnosis emerge. The doctor is rewriting the patient’s story while seeming only to bear witness to it.

The second part of the doctor’s quest, the clinical examination, is even more undemocratic. Here, all pretense of equality is done away with and the medic’s interpretation takes over completely. Unless the voice or psyche is being examined, the patient must remain silent now, allowing the doctor to feel and listen to their body, to what it can tell them to counter or concur with the verbal details they have heard. The patient may not know it, but the body is in the dock, testifying for or against the character it houses.

I’ve tried to fly in the face of all this, to protect the sanctity of the patient’s version of events, to eschew the medical convention which demands that a history should have a clear structure, a smooth finish and no loose ends. And look where it’s got me. To this grim waiting room. To this leather chair where I sit, great with information, waiting to be ushered through that unopened door. To absolutely the wrong side of the investigative line, where it is now I who must submit to questions and a thorough grilling. And it turns out that all the hundreds of histories I have taken over the years have not prepared me one iota for the dreadful prospect of having my own reality doctored. I think this is the reason why we surgeons and physicians make the worst patients. It’s not that we’re more afraid of illness than the rest of you. It’s because we’re all hermeneutic tyrants, jealous guards of our own truths. Especially those we have kept quiet about.

My aunt owned a hotel when I was growing up, and we often visited my cousins there. When we did, as long as we didn’t bother her with our prattle, we were free to roam over the whole establishment as if it were our home. My sister was still a baby, but my cousins and I loved to rampage around the place. We played noisy hide-and-seek under beds with fringed coverlets, and shouted in the dark-brown dining room when it was empty. We rushed to the clanking kitchen for snacks, and even went to the bar, as long as no guests were there.

It was underneath that bar that my boisterous play came to an end, though, and I learned real silence. I have no mental picture of the barman’s face but I do remember the height of the barstools, and the way my cousins and I climbed up onto them, to the footrest first, and then the seat. This was always a bit precarious. Each stool was heavy as a cliff, and listed into the deep foresty pile of the carpet. You had to knee your way up and sit down really fast or it might tumble towards you, keel you over, push you to the ground.

I don’t remember the barman’s hands. But I do recall what these hands passed to me and my cousins as we sat on our stools, what lucky children we were as we sat there all three in a row, or sometimes two or even just one of us. The other two might be running down corridors connected by weighty doors with crisscross glass in their huge panes; or they might be outside in the bleached-grass garden in summertime, among the glare of flowers. It might just be one of us who chose to stay inside that cool, dark bar on an empty day with no one about.

I don’t remember the smell of the corridors or of the garden, but I can recollect the whiff of the sweet cherries the barman put in my drinks, which he passed me with slow ceremony across the bar. They were in proper pretty cocktail glasses, and he filled them soundlessly with sticky juice. Each drink was given his very special attention and had a sharp stick in it, piercing a luminous maraschino cherry. The cherry against the juice was so bright it caused the body a tiny shock.

I find that my mind can’t take me to the cellar without first going to the cherries. The cherries and the smell of them are the gateway through which my thoughts must pass before the next image comes, and I know I have reached this second scene when the olfactory memory of cherries changes sharply to one of urine.

I don’t remember the barman’s face. Instead, I think of dark words and see the dank floor. In my right hand, I am holding a bouncy rubber ball. It is marbled, a mixture of dark red and dark blue, and it fills my hand because my hand is small. I have been given this ball by the barman and I am bouncing it carefully on the concrete floor. It is that clever, hard kind of rubber that makes no noise. I am mindful to keep my eyes on the ground to make sure that the piece of concrete I drop it on is smooth enough to send the ball back into my palm, for it not to bounce off elsewhere, crazy-style, away from all the corners of this space. Or maybe this is not the reason I am looking at the floor.

Here I see myself from the outside as if I don’t belong to myself anymore. The small and cobwebby window gives just enough light to show the barman and a young child standing among the brutish silhouettes of beer kegs. And what I see, as if from above, is a harsh fountain of very yellow pee arcing from its source to the concrete floor and splashing there, the little drops spraying up and wetting the girl’s socks which are those white crochet ones, in blue Clarks sandals.

The last image I have is of the girl, one of her hands holding a rubber ball and the other one holding the liverish penis of the barman. That is, insofar as her hand can reach around it. They are both standing in the puddle of urine, now at rest on the concrete floor. And all the things that were moving in this scene, the ball, the pee, the man, the child, are now so quiet and still.

The door opens on a young woman in brown. I am on my feet. I feel the heat of adrenaline in my limbs. But I have to sit down again. She tells me the panel of judges will only keep me waiting five more minutes then, without pausing for a response, she goes back into the meeting room.

Surely, you might ask, medical evidence comes to the rescue? Doesn’t it tell the objective truth? However warped a patient’s story may be by the way a doctor reconstructs it, there can’t possibly be room for error in this empirical zone? But still I say that there is bias. Take biopsies, for example. Any pathologist, looking at a piece of tissue under a microscope, will tell you that their ability to reach an accurate diagnosis depends on the quality of the sample they are sent by their surgical colleagues.

An unhelpful sample may be too small, or messily excised. It might be taken from the wrong part of the lesion, or from the right place but confusingly orientated for the histologist’s microscope. Sometimes, it has simply been badly preserved or labeled. Even in an expert’s hands, such a biopsy is only capable of rendering a partial truth.

A good biopsy, on the other hand, is cut from a representative area of presumed disease. It is removed with sharp and generous margins. It is preserved and presented clearly in a way that elucidates how the excised area fits into the rest, so that this pathology may then be analyzed within the context of the body overall. There are more bad biopsies taken than good.

What, then, should I hand over for the pathologist’s scrutiny? How will I select the right fragment to give to my judges?

When I went to tell my parents what had happened that day, words failed me. In fact, until we moved abroad a few years afterwards, it seemed as if I had lost my voice, somewhere in that dark cellar. For ages my mother allowed me to hide in the shadow of her, or among her skirts. If someone asked my name, she spoke for me. She let me hide myself away in the soft places of the house, nearest to wherever she might be: under the beds, in the airing cupboard, behind the sofas. I read in these safe corners and, at night, I was read to by my father, hearing his stories from a position of exquisite bedtime snugness, thrilled by the sense of security a duvet and my dad’s proximity could give. But there was also the unforgiving empty shade of school, the place where, for all my attempts to remain inconspicuous, I was expected to shape up, to become a person for the world.

Even from the outside, my primary school looked gloomy, a Victorian building set in the middle of black asphalt. The playground roared with boys, and they invaded everywhere, including the outside loos, which I tried to hide in during break-time. These loos stank and had see-through crackly paper into which the pee didn’t blot but ran off along its sharp creases into your hands.

The school was dark inside too, and huge, and full of an indistinct din. The classrooms had high ceilings, and old-fashioned desks with the chairs attached, and inkwells, and scored wooden lids that could snap down on your fingers at any time. The names of the teachers are a blank to me now, though I can call to mind the fat blond face of one of them who grabbed me by the nylon V-neck jumper one afternoon and said something mean to me because I had been asking her for a new reading book.

The door opens a second time. I think I might be sick. The woman in brown asks me in. Is my patient dead? Have I killed her? What about all the people I have tried to help? Do they no longer count? I follow the young woman through the doorway. I watch her suit. Will I ever wear my white coat again?

I enter my judgment chamber. My limbs, at least, still function as they should. I approach and sit in the chair meant for me. It is in the center of the room and faces a long conference table at which my opponents will sit. In some respects, it is like any of the other hospital seminar rooms in which I have listened to lectures or participated in tutorials over the years. But there are small differences. My judges’ table is covered with a heavy green cloth. In the middle of the table there is an object. It has the shiny, heavy look of a trophy. I see the initials GMC emblazoned on its gleaming surface. There are other things on the table too, forms and pads of paper, a tray with a jug of water and a stack of Duralex glasses. It’s the nearest I’ve ever got to stepping into a court of law. I wonder if I’ll be asked to swear on the Bible before I speak.

I notice that the young woman with the brown skirt is at one end of the table, consulting papers. The room flutters with them, the light changes with her riffling. It is these details I must endeavor to pull myself away from. I feel my physical mass on the chair and the presence too of the other person in the room, just a little older than me, his blond hair as soft as a baby’s, plaid sleeves rolled up over smooth forearms. He tries a smile but doesn’t wait to see if he’ll get one back. Perhaps he doesn’t want me to witness the look on his face as he joins me up with my crime: not just this misdemeanor, but all the others he probably connects with it. He is a mouse of a man.

The room is perfectly square and family-planning-clinic beige. The carpet is thick. I hear the puff of the door opening and then “Good morning” behind me, in a woman’s voice which would usually ring out, a voice used to making a brisk impact, although the acoustics of this room put a dampener on it. As she comes past my right side I see tiny holes in the pile where her suede aubergine heels wound the carpet. She carries a leather binder under one arm, bearing the same insignia as the metal statue on the table. A column of sun comes through the single window behind my judges’ table and the room makes merry with her lipstick; all its corners receive her scent. She passes me in her pale suit and tips her femininity across the table as she shakes her colleagues’ hands. Her fatness does not matter one bit. On the ward, we would call it centripetal obesity or lemon-on-a-stick. When she goes around the bank of chairs to take up the middle one, there mixes up in me, with her pearls, a prayer for my patient. Please live. Surely, my judges wouldn’t look this equable if she were dead? All the room settles for a moment around my fear, and my fear changes too. Oh, please don’t let me be undoctored. Do not strike me off, erase me, make me nothing.

I was good at all those exams. I kept boxes of index cards, packed full of medical facts, all color-coded. And now I will prepare the ghosts of index cards in my mind. A pink for my patient. A blue for me. I will record only crucial facts since I know I cannot expect to catch every detail. With this wandering, this unraveling, there is only so much I can achieve.

The middle-aged woman, who reminds me of Boadicea, is a surgeon called Dr. Mansfield. She is to chair the four sessions which will define at least the next month, if not the rest, of my life. The guy is a GP, Dr. Garber. The lady in brown is Vivien from Occupational Health. She is like the court stenographer. With effort, I assimilate these words:

“…a complaint lodged last week with the General Medical Council by Joseph Jones, one of the anesthetic staff…” Joe? Who would have thought it? I assumed it was Frederick. I listen again. Her voice is clean as a wire. “…GMC contacted the Chief Executive of this hospital trust having accorded this complaint Stream 2 status.”

I dip and I surface, down into myself and back into the room. I grasp what I can of what is being said.

“…been asked to assess this case locally. We, the panel, have been assembled by the Chief Executive for this purpose. We have all received training from the GMC. There is an additional member of the panel, not here today. This time next week, you will meet Dr. Gilchrist from our neighboring psychiatric unit. He will report back to us on his findings after that meeting. During the third session, we will concentrate on your recent performance as a doctor. In a fourth session, we will give our verdict. We have the facility to refer the case back to the GMC for reclassification as Stream 1 if things become too complicated or difficult for us to manage here. Or we may arrive at a decision ourselves about your professional future.”

There is talk of bureaucratic bodies. The brown woman has to write fast to get down the National Clinical Assessment Service as well as the National Patient Safety Authority. They are the ones that have recommended my suspension from work until a conclusion is reached. I am afraid of these institutions, previously unheard of, now pitted against me. But I know that it is the people in front of me, these appointed colleagues from my own hospital, who hold the real power when it comes to deciding my fate.

Dr. Garber’s voice comes low and I think of Julia and wonder how she might represent these two voices, the woman’s and the man’s, on a musical stave. But then I am all focus again because the soft GP is mentioning my girl, my woman, my patient, talking about her in the present tense, and the flood of relief to hear her spoken of in this way means I miss the first bit of what he is reading from the sheet in front of him. But, when I do listen, the medical language is like a balm. It is made of words I still trust:

“…was admitted to the ICU of this hospital straight from theater suffering the acute effects of major hemorrhage. E.S. required a transfusion of twelve units of blood in the first twenty-four hours. After two days of ventilation on the unit, a tracheostomy was performed and is still patent. The patient’s main problems currently are disseminated intravascular coagulation and respiratory distress syndrome.”

Alive, alive, thank God. Still alive, although of course she is far from safe. I watch the GP’s face. He looks up at me and smiles.

“The good news is that her hemoglobin is…well, it’s actually seven-point-nine,” he says.

He places his hands in front of him on the desk and I hear a quiet tap as his wedding ring makes contact with its surface. His features are cast in shadow by the light from behind, but I know his face is a gentle one. And my patient is still alive.

“It’s not such a bad result now, is it?” he says.

I was nine years old when my dad came home one day and announced that we would be moving to America for a few years. He was leaving the following month to get things ready, and my mum and sister and I would follow him a few weeks after that. With this one statement, he changed the course of my life.

The transformation in me began even before we left England. As soon as my dad arrived in our new home he began sending us parcels, each one contributing to the imagined scenery of the new life that awaited us. There were photographs of a cherry-red car, of sunshine on a pretty house and garden, of my dad smiling and wearing his first ever pair of blue jeans. And scratch-and-sniff stickers, each paper circle smelling of a foreign and wonderful junk treat—pizza, popcorn, bubble gum, Coke. Best of all was the package in which he sent my sister and me each a kazoo, a bizarre little plastic toy which, applied to the mouth, turned one’s voice into a wonderful sonorous buzz. My mum was amazed to see me making so much noise on mine as I tootled away, all around the house.

When my dad met us off the plane, I saw the bright truth of the story his missives had told us. In the airport car park, the vehicle he led us to was enormous, and scarlet with bright yellow seats. The front part, where the adults sat, was a whole bench stretching across from steering wheel to passenger side, not like the frigid arrangement back at home. And there were two whole rows behind this for children, one facing forward and one backward so that you could choose whether to gaze into the future or look back into the past. My dad showed us all how the windows went up and down at the push of a button, and he blasted us with air conditioning and turned up the radio loud.

Our new house was on a main road, opposite one of the city’s biggest hospitals. But it was set back behind a tall hedge so that once the car was in the driveway you could forget that you were really in the hub of a metropolis. Viewed from just inside this hedge, the house looked to me like something from a storybook. It was made of red brick, and it had a shiny tiled roof with a perfect little chimney, and a path covered in white gravel leading up to the door, which was glossy green with a brass knocker. Only the house number, on a matching brass plaque, reminded one by its four digits what an endless urban road we were on, for the character of the place was all intimacy. Flowers banked the gravel path and these same blooms filled bright window boxes outside each of the gabled windows.

My dad had arranged for my sister and me to sleep on the landing where he and my mother were, one of us on each side of them. I felt great pleasure at the glamorous prospect of having a whole room to myself. Dad had brought some familiar things over with him from England. I noticed straightaway the blue Picasso poster, which looked so pretty here on my new yellow walls, and one of my mother’s colorful handmade quilts. My father had cozied my bed up in a corner of the room so that its head end was right next to a window through whose fly-netting I could look down on the cupcake-pink petals of a magnolia tree and, beyond it, the green slope of our new neighbor’s miniature golfing range.

At the foot of the bed was an orange corduroy beanbag for sitting on. Against the facing wall, whose window looked out on the hedge and the main road beyond, I found a perfect bureau-style desk. The fact that it was made from real wood gave it a certain grown-up cachet, but it was child-sized. It had a curved rolltop and a small swivel stool, and two deep square drawers next to the space in which my legs would be tucked. Against the only remaining free wall my dad had put all my toys, the box of Lego, the red cot with the white rubber rim and my teddies.