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Book review
Direct red: a surgeon’s story
  1. N Craft

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    By Gabriel Weston. Published by Jonathan Cape 2009 9780224084390.

    Written by a bona fide surgeon with a background in English literature, Direct red is, on the face of it, simply a collection of anecdotes about the author’s experiences during her training. Each chapter illustrates a theme—such as “Death”, “Sex”, “Ambition” and “Children”, and encapsulates a selection of vignettes. For anyone who has gone through medical training there is nothing surprising about these stories: the “my first night in casualty” genre of anecdotes will be familiar to all doctors and anyone who’s sat next to one at a dinner party. Some of them are gruesome, and very often they are painfully sad. While the subject matter may be familiar, it is rare to find fictionalised accounts of these events that have been written so well, and treated so sensitively and with respect.

    Weston has a definite voice. In the chapter on “Beauty”, she describes “the way the anaesthetic doors would open to deliver a bedded, tubed patient at the same time as the scrub nurse appeared with her trolley, like a hostess bringing out a science-fiction tea”. The familiar stories slip out effortlessly, so that each chapter reads like a well-rounded short story. At times the writing is so skilful that some passages could easily be cut and pasted into a novel waiting in the wings to be written. It’s only because I’ve been there, done that, that I know this isn’t fiction.

    The stories are intertwined with reflection and insight into what medicine does well and where it is miserably lacking. There’s a poignancy in her analysis and interpretation that is unusual in medicine, in my experience. After a failed attempt to save a man from a ruptured aortic aneurysm, she reflects that “in the process of acting in a patient’s best surgical interests, we may sometimes make the final moments of their life more terrible than they would ever have been had we left them alone to say their farewells uninterfered with, more wholly, and with more grace”.

    In the emergency room, Weston feels at her most powerless, observing that “I came to see A&E as a sort of departure lounge in which every patient had come to say goodbye to someone or something, often with no warning, usually with no time or peace or preparation”. The experience has the effect of making her begin to notice the detail of relationships between people and the desire to create community within the individual cases as a coping strategy for being in this harsh and dramatic environment.

    There were countless moments when I identified with what I was reading. I could picture the scene in the dissection room with Bernard the technician drinking John Smith’s bitter and smoking a cigarette while he expertly prepared dissections to illustrate anatomical structures to the students. I cringed as she described her first attempt to insert a catheter only to find it “kept popping out of the baggy eye of the man’s penis, flicking jelly around with every jaunty boing”. I felt for her on her first night as a junior surgical trainee, or “clinical virgin” in her words, when she is called to see a woman who has been shot, not knowing whether she will know what to do, only to be surprised to find that something in her training has been absorbed and she turns out to be a highly competent professional.

    This same patient also illustrates the frustration of the hierarchy in medicine, and the arrogance of some senior surgeons. Believing the woman needs emergency surgery, she calls her consultant, only to be reprimanded for jumping to conclusions without proper and careful assessment. After her “foolish” boss takes half an hour to turn up, ridicules her for being too hasty, orders an unnecessary scan and picks up an instant coffee, he finally operates. After an hour of trying to stem the heavy bleeding, he frantically calls for another surgeon who eventually repairs the damage. The patient survives this experience, but the prolonged blood loss leads to multi-organ failure and she dies the next day. As Weston removes her surgical scrubs in the “empty gloaming” of the women’s changing room to find the patients’ blood has soaked through to her underwear, she reflects on the surgeon’s incompetence dressed in “a mannered slowness of action”. Junior team members are frequently undervalued and unsupported. The story elegantly illustrates the ethical pitfalls for these inexperienced doctors—and the skill of knowing when and how to speak out, despite feeling trapped by their level in the hierarchy.

    Weston remains embedded and committed to the medical training traditions, acknowledging the value of experience and team structure, so that although junior doctors do most of the preparation, complex decisions are delegated to older and wiser team members of the team. With each promotion there is a big jump in responsibility, the decisions get harder, and the subject gets more complex.

    Sometimes the stories seem cathartic, and these are the ones that stayed with me after the book was finished. In the chapter on children, there is a child who dies from an undiagnosed rare brain tumour, possibly because he didn’t make a fuss. Not being confident of her ability to talk to children, Weston spent as little time as possible with him and when he dies realises no amount of training could make up for her lack of compassion at that moment in the child’s short life.

    It was these stories that lingered that made me wonder if Weston is really a frustrated novelist, and this is the equivalent of her thinly veiled autobiographical first novel. What we need now is a second book which captures her literary skill but isn’t so much of a confessional.

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    • Provenance and peer review Commissioned; not externally peer reviewed.

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