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Views & Reviews Review of the Week

Cutting it

BMJ 2009; 338 doi: (Published 14 May 2009) Cite this as: BMJ 2009;338:b1933
  1. Luisa Dillner, head of new product development, BMJ Group
  1. ldillner{at}

    A surgeon’s slim collection of vignettes from the frontline of a British hospital are arresting and stark, finds Luisa Dillner

    There are some things only doctors know. What it’s like to be a doctor is one of them. Most doctors have stories squirreled away of events that were defining, whether for being shocking, sad, frightening, or hilarious. Suspecting and glimpsing the complex and emotional fabric of doctoring, the public has an endless fascination for what doctors, do, think, and feel that has spawned a plethora of books and television series.

    In her slim volume Direct Red (the name of a histology stain) Gabriel Weston provides poetic but precise medical vignettes, partly from her career as an ear, nose, and throat surgeon, although her author’s note says, “This book is not literally true.” She provides no traditional chronological narrative, instead using chapter headings such as “Speed,” “Sex,” “Death,” “Beauty,” and “Emergencies.” Weston graduated in English before studying medicine, and her writing reflects this, with an accuracy and lyrical beauty that are all the more startling when they describe, for example, the bowel being heaved out of the abdominal cavity in a laparotomy:

    This forced me, and the guy I was next to, to huddle together, to form a barricade with our two adjacent bodies, to stop the snaking mass of large and small bowel from slipping between us, or around either us onto the floor. Arms outspread, we held its writhing bulk and I will never forget the eerie movements it made, vermiculating in our joint embrace.

    What is striking about Weston’s stories is that all doctors will have their own variation of each. There’s the charming elderly man whose renal colic is actually a leaking aortic aneurysm (he dies in a frantic, brutal operation) and the beautiful young man who harbours terminal bowel cancer but presents with inconsequential symptoms, the alarm bell being that he isn’t the sort to frequent accident and emergency departments.

    Having spent five years in surgical training, I found some relief in Weston’s account of the conflict between the desire to please a boss and acting in the best interests of the patients. In trying to prove herself a speedy operator in front of a surgeon nicknamed “the Lion,” she nicks a patient’s facial artery in excising a submandibular gland. To avoid an admission she reduces a woman’s prolapsed piles with inadequate analgesia in the accident and emergency department. And she is, I believe, misguidedly forgiving of a consultant whose response to her request for help in a tricky tonsillectomy is to send a message back saying “Just fucking do it.”

    My favourite description is that of her first weekend on call as the ear, nose, and throat registrar. Something about Mr Charles, admitted with a sore throat the previous night, feels wrong, and Weston does a flexible nasendoscopy on the ward. “Like a pot-holer, I advanced past the nasopharynx, a shady chamber flanked by the wonderfully named Caves of Rosenmuller.” It looks like his airway is obstructed, and Weston decides to call the registrar on call before remembering that it’s her. To get him into theatre she must leapfrog a kidney transplantation and call in her boss, the anaesthetic registrar, and the consultant. It’s a big call. “As the anaesthetic registrar flicked open his laryngoscope with its curved metal tongue, and bent forwards over our supine charge, my only prayer was that Mr Charles should be in real trouble, about to die even.” She has made the right call and reflects that “good surgeons are decisive.”

    Other vignettes are less convincing. The story in which she is attracted to a hunky bricklayer and nearly gets into his bed feels contrived. And her account of Ben, a stoic 10 year old whose mother is at home looking after his siblings while doctors try to find out why he has headaches, feels like a literary construction but is still powerful. Weston is called to see Ben in the middle of the night, prescribes analgesia, but doesn’t bother to comfort him. When she hears he has died from a pineoblastoma a few days later she feels ashamed. Why couldn’t she have been more kind to him (my words, not hers)? She is not, she says, good with children. She wanted her bed, and in a phrase noted by other reviewers she says, “I may have argued to myself that ten years was plenty old enough to be spending the night alone since at this same age I was spending all of my nights unparented.” This is perhaps an intentional clue as to why her own emotions and insights do not bleed onto these pages to blot her prose. The book gives only superficial nods to self analysis. Her disenchantment with a full time career in surgery is dealt with swiftly. She has had a child, on whom she doesn’t dwell, but treating a 10 day old baby pushes her into resigning from her training post to choose a life with “more home in it.”

    Weston’s book has attracted critical acclaim, and rightly so. There have been many books about being a doctor, from the anarchic House of God (BMJ 2007;334:99, doi:10.1136/bmj.39084.673889.59) to the mature and insightful Complications (BMJ 2002;325:663). But Direct Red is primarily a literary take on being a surgeon, with a richness of language and imagery that make it an arresting and memorable read.


    Cite this as: BMJ 2009;338:b1933


    • Direct Red: A Surgeon’s Story

    • Gabriel Weston

    • Jonathan Cape, £16.99, pp 192

    • ISBN 978-0224084390

    • Rating: ***

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