23 December 2004
I’ve never seen a patient who looks so scared.
‘This is Zoë, aged twenty-five. She arrived in A & E shortly after midnight last night, with abdominal pain, query premature labour. No antenatal care recorded but obviously they sent her up to us. How are you feeling now, Zoë?’
The consultant directs his full-beam benevolent smile at the woman, who stares back, pupils dilated, afraid. Zoë’s body is so slim she could be a child herself, except for the taut, distended belly that fixates us all. Her cheeks appear flushed but when I look more closely, I realize they are lesions, livid and sore against her otherwise pale face.
‘I’m not in so much pain now, thank you.’ Her voice is a surprise: calm and unaccented. Her hands – one cannulated – lie on her lap.
‘Let’s keep it that way. We believe that Zoë is in her thirty-sixth week of pregnancy, although her . . . lifestyle means we can’t completely rely on the size of the neonate to estimate gestation. Any thoughts on the treatment plan?’
Lifestyle? I am trying to interpret this when Laura raises her hand. The consultant nods at her, and she answers, ‘Corticosteroid injections. Attempt tocolysis to see if we can avoid premature delivery, but ensure medication isn’t contra-indicated in the case of a substance-abusing patient?’
The young woman looks at the floor. Substance-abusing. It’s so obvious. The wasted appearance, the lesions, the lack of antenatal care.
The consultant nods. ‘So far the tocolysis appears to be working and we have a second corticosteroid due at around two p.m. Foetal heartbeat is normal but being monitored. We will review again tomorrow morning. You try your best to stay nice and relaxed there, Zoë, OK? With luck, we can keep your baby safe and sound well into 2005.’
We move out of the bay and out of earshot. The consultant stops and says, ‘Social services are aware. If her contractions start again, we’ll probably allow labour to proceed: apart from anything else, there’s space on the NICU at the moment, so that could work well as he – it’s a boy, but she doesn’t know – will almost certainly need treatment for Neonatal Abstinence Syndrome. Either of you know the likely symptoms in the infant?’
Laura is on it again. ‘Tremors, uncontrollable crying and irritability. Sweating. Similar to the symptoms of adult withdrawal.’
‘But much more distressing to see, and hear, and it can last for several months.’ The consultant shakes his head. ‘Silly girl. If she’d sought help, we’d have popped her on buprenorphine to reduce the duration of the NAS.’
I wonder if he’d feel as judgmental about my old habits, and any of his colleagues who might use drugs themselves to get through the day. But no, we’re different: our self-medication is necessary, our stresses so extraordinary we can justify most things. It is amazing, the way doctors can place themselves above the rest of the human race when it suits them.
‘Will she be allowed to keep the child?’ I ask.
‘They’ll try with her and if she works hard then perhaps. But would you leave an infant in the care of someone so patently unable to look after herself?’ The consultant shakes his head. ‘I think it’d be a brave social worker who’d make that call.’
I’d been dreading Ob/Gyn, but to my astonishment, I like obstetrics, because there’s hope here, and moments of real joy. Babies don’t judge. If you can work out their needs and meet them, they respond with incredible speed. And labouring women are refreshingly direct.
Woolworth’s helps. I’ve developed my own fail-safe method of overcoming my introversion when I start a new placement: I buy whichever chocolates are on special offer – one box of dark and one of milk – and take them straight to the nurses’ station on day one. I also make it a priority to memorize the tea/coffee preferences of everyone I work with.
When the ward round is done, Laura follows me into the kitchen. ‘I can’t believe that patient didn’t try to detox once she realized she was pregnant,’ she says, as I line up seven mugs and add the requisite teabags or spoonfuls of instant coffee granules. Laura had better not be angling to try to take the credit for them.
‘How do you know she didn’t?’
‘You’d try properly, wouldn’t you, if you were having a baby.’
Laura has hardened up since we started medical school. Everyone has, except me. I’ve gone the other way. Things that wouldn’t have affected me at all, that I’d barely have noticed before, now lodge themselves inside my head. When I’m trying to remember symptoms or conditions, the words elude me. Instead, I see the faces of patients in pain, patients who died.
One of the midwives pops her head around the door. ‘Which one of you two requires a complex needs for your project portfolio?’
Laura shrugs. ‘I’ve already got two written up.’
‘You then, Timmy? The girl in bay three is threatening to leave. Sit with her and make sure she doesn’t.’
I look at the row of teas. ‘Is she nil by mouth?’
‘No, a tea might shut her up for a bit.’ I grab two mugs and follow her out.
Zoë’s voice echoes down the corridor. ‘Has anyone seen my shoes? Has some bastard nicked them?’ She sounds a lot less well-spoken than she did talking to the consultant.
I nudge my elbow through the gap in the privacy curtains, holding a mug in each hand. ‘I’ll go and look for your shoes in a minute, Zoë. But would you like a drink first? Coffee or tea, I’ve got one of each?’
She looks suspicious. ‘Who are you?’
‘I’m Tim. I’m a medical student.’
‘No way are you watching me push this baby out.’
I shrug. ‘That’s fair. The offer of a drink still stands, though.’
‘Tea. Then I’m off. Out of here.’
I gesture at the chair next to her bed. ‘Can I hide with you in here for a bit? Otherwise the midwives will put me on bedpan duty.’
‘They look like total bitches.’
‘Actually, they’re really nice to patients. But med students are the lowest in the pecking order in the whole hospital.’
‘Lower than junkie scum?’
I don’t know how to reply: it’s something they don’t train you for. I sip my coffee and wonder how I’ll write up this encounter. We’re meant to keep a record of challenging cases and reflect on what we’ve learned.
Mostly, I learn that I can’t do small talk. I look around the curtained space for inspiration. Usually, there’s something on the bedside table: ‘get well’ or ‘congratulations’ cards from family, a puzzle book to dip into.
Zoë has no belongings here. Her body offers the only obvious topics for conversation: how long ago did you start using heroin? Have you self-harmed lately? What the hell were you thinking, getting pregnant?
Even I know none of that counts as appropriate small talk.
‘So, what’s the goriest thing you’ve seen since you started your doctor training?’
I smile: why do people always ask me this? ‘You really want to know?’
‘I’ve got a strong stomach.’
‘I went to India last year, observed a few clinics. There was a man with gangrene in his leg. When the nurse moved the dressing aside, there were more maggots than flesh.’
She looks unimpressed. ‘That all? I’ve seen that on the streets, it’s no big deal. I was hoping for a crossbow through someone’s chest. Or someone with a firework up their arse.’
‘Does a bicycle pump count?’
She laughs. ‘Did you try blowing it up?’
‘It was tempting. Might have stopped him doing it again.’
Zoë’s face changes. ‘Have you delivered a baby, then?’
‘Not on my own, but I’ve seen three births since I’ve been here.’
Her hands are gripping the mug so hard her fingers have gone white. ‘And those births didn’t count as the goriest thing?’ Her eyes dart up to meet mine, then she looks away.
She’s scared. Of course she is.
‘It can be messy but . . .’ I try to think of a way to reassure her, without lying about what lies ahead. ‘It’s a productive mess. Most things I’ve seen in hospital are where something’s gone wrong. Birth is different. Human bodies – women’s bodies – are designed for this.’
Though it was having me that kicked off my mother’s lupus: more than once, she’s called me a parasite. Technically, she’s right, though it’s an odd way to think of your child.
‘Hurts, though, right?’
‘They won’t let the pain get out of control.’
She bites her lip. ‘Mate of mine said they don’t give you anything if you’re a user, because the baby’s hooked enough as it is.’
‘Honestly? I don’t know quite how it works. But they’ll do what’s best for you and for the baby.’
‘Don’t know much, do you? When do you become a proper doctor?’
‘I’ll have my final exams in April, and if I pass those, they let me loose on the wards in August.’
‘That’s fucking soon, considering you know nothing.’
I laugh. ‘You took the words out of my mouth. What work do you do, Zoë?’
‘Casual pub shifts. Not round here. I’ve been in the West Country for a bit. But when I got too big to stand up for hours, I came back to Brighton.’
‘Are you still with the baby’s dad?’
She gawps at me and I hope she’s not going to make a complaint about me asking inappropriate questions. ‘Yeah. He’s popped out for champers and the biggest bunch of red roses you’ve ever seen,’ she says, putting on an accent like the Queen’s.
Her voice is transformed and I smile. ‘Amazing. You sound like a member of the royal family.’
‘Yeah, I wanted to be an actress. I can do all different voices. I could play Scottish junkies, or Welsh junkies from the vaaalleys, American cheerleader junkies—’ She stops abruptly and looks down at her body.
‘Come on, Zoë. This could be a new beginning for you. I’m sure the hospital could help put you into a rehab programme . . .’
‘I don’t want this. Any of it. I don’t want to be having a baby!’
Instantly, she’s on the edge of tears. I think back to my obstetrics lectures: she’s on a hormonal rollercoaster. Perhaps she needs me to hold her hand while she rides it. ‘Did you not mean to get pregnant then?’
She scowls: that’s better than crying. ‘I didn’t think it’d be like this.’
Something about the way she says it makes me think that she did want this baby, once. ‘Tell me what happened, Zoë. If you want to, I mean.’
To my surprise, she does. There was this guy she liked, a bit younger than her. Kinder and less messed up than most of the addicts she hung out with, or so she thought. So yes, maybe she wasn’t too upset about getting pregnant at first. Maybe she even wanted it to happen.
‘I was gobsmacked, after all the shit I’ve done to my body. I’d already stopped using when I fell pregnant and it gave me the best reason to stay clean. But then . . .’
I wait, not knowing whether she’s stopped because of physical pain, or sadness. ‘What changed, Zoë?’
She sighs. ‘When I told the dad, he was so angry. He told me . . . well, stuff that made me realize the whole thing was fucking doomed. He even paid for an abortion, but I did a runner at the last minute. I was back on my own, thought I could manage, but I was too weak. Started using again. Smoking. Thought it might do less harm to the baby, no dirty needles, right?’ She looks at the cannula in her hand. ‘I wanna get out of here . . .’ Her face crumples.
She needs someone who loves her, not a tongue-tied student like me. But I’m all she’s got right now. ‘Even if you don’t want your baby now, you do want to do the best for him, don’t you?’ I remember that she doesn’t know it’s a boy. ‘For him or her?’
‘I’ve already screwed it up. Poor little sod is going to come out disabled and addicted, all because of me.’
‘Disabled?’
She’s becoming agitated again and the midwives will not be impressed if she rips out her cannula and does a runner while I’m meant to be calming her down.
‘Look, I’m not a doctor yet. But you can tell me or ask me anything. I promise I’ll be completely honest with you in return.’
Her face is wary. ‘What if there was something wrong with the baby’s father?’
‘He was on drugs too?’
Zoë shakes her head. ‘No. He got clean. Cleaner than me, anyhow. I mean something in his blood. His genes?’
‘Oh.’ I was revising genetic conditions last week. ‘Well, we can inherit illnesses or traits from either parent. But even the more serious conditions can be managed if we know early on, ideally from birth.’
She says nothing.
‘Is this what you’re worried about? Talk to me, Zoë.’
But I’ve lost her to her memories or her fears. She starts to claw at the bedding and when she lifts the sheet, her bed is saturated. Zoë looks at the clear liquid and begins to sob.
Looks like labour is on, despite our attempts to stop it. ‘It’s all right, Zoë. It’s only your waters breaking. I think things might be moving now. I’ll just go and get the midwife.’
She grabs my hand and holds on. ‘Don’t leave me on my own!’
The midwife will be cross if I don’t fetch her straight away. But for once, I don’t want to do the correct thing. I sit back down, gripping Zoë’s hand back and I push the call button. ‘I promise you, I’m not going anywhere.’
There are times over the next nineteen hours when I regret making that promise to Zoë, but mostly I am focused on her and her pain.
She needs somebody. It could be anybody. But today it happens to be me.
I get sworn at, and her fingers leave bruises on my arm. I reassure her she can do it, even when I have my doubts. I ask her every few hours whether she’s certain there’s no one I can call – a friend, a family member, her baby’s father.
She swears some more.
Sometimes, when the door to the labour suite opens, we hear carols and Christmas songs coming from patients’ TVs. The contrast between the sentimentality of ‘When a Child is Born’ and the messy reality of Zoë’s labour makes me feel uncharacteristically feminist. Women are much stronger than men.
In the downtimes between contractions, we walk up and down outside the delivery suite, and I honour my other promise – to answer every question honestly. She uses it against me for her own amusement, as though we’re playing a one-sided spin the bottle.
‘How many people have you had sex with?’
‘Two.’
‘Wow. How many times a week do you do it with your girlfriend now?’
‘Once.’ This is not strictly true, not since Kerry found out about my exam screw-up, but I justify it by telling myself I am averaging it out over our three-and-a-bit years together.
‘Is she the love of your life?’
‘Yes.’
‘Are you the love of hers?’
I hesitate. ‘You’d have to ask her that question.’
Zoë nods. ‘Is she a doctor too?’
‘No. Well, not yet. She works for the ambulance service but—’
‘Arrrgh! Fucking hell. It’s back again.’
The midwife examines Zoë but when she asks me if I’d like a look, it feels odd, as though I’ve crossed an invisible barrier from student observer to birth partner.
‘Go on,’ Zoë says. ‘You might as well get something out of the beating you’re taking from me.’
‘I’m no expert but I think you’re not far off,’ I say, looking to the midwife for confirmation.
She nods in agreement. ‘Yup. Now, Zoë, because Baby is coming a bit early, it might get quite crowded in here. Would you rather not have a student in the room?’
‘Tim’s not going anywhere. But now I need him up at my end.’
The room does start to fill up, till I’m the only one still focused on Zoë’s face. It’s almost more frightening because I can’t see how the delivery is advancing.
‘We’re very close to Baby arriving, Zoë. Hold on to all your energy so you can give a great big push when I say so, all right?’
I hold Zoë’s hand and I smile at her, not letting her look away, as she puts everything she has into pushing.
‘You’re amazing, Zoë,’ I whisper, and I mean it.
She screams, once, and the midwife says, ‘I can see Baby’s head, so wait . . . One last push, now, my love, come on . . . that’s it . . . and Baby is here! . . . It’s a boy, Zoë, your little baby boy is here and he’s a beauty!’
We wait for the moment that means it’s all OK: the moment when the baby takes in air and lets out his first howl. I don’t break eye contact even now, though it’s taking so very long . . .
‘We’ve just cut the umbilical cord now, Zoë, and the team are checking on your baby. You’ve done so well!’
I hear the urgency in their voices and catch the odd word that I hope Zoë doesn’t understand.
‘Why isn’t he crying?’ Zoë’s eyes are wide from the pain and the shock and the fear and it takes everything I have not to let on that I am afraid for her baby too. ‘He should be crying.’
The midwife says: ‘Zoë, your baby needs help with his breathing so they’re using a machine to help, which means he can’t cry yet. But we’ll let you see him as soon as we can.’
Zoë begins to sob, but I’m the only one comforting her. Everyone else is focused on the new life.
‘I’ve killed him,’ she whispers to me, ‘haven’t I? I’ve killed my baby before he was even born.’
What do I say? Because she almost certainly has affected this baby’s chance of survival by using drugs. ‘Zoë. The doctors are doing everything they can—’
A cry comes, not the angry protest of a healthy baby but a keening sound. Still, after that terrible silence, it is the most hopeful sound I’ve ever heard.
‘He’s alive,’ I say.
The NICU team are placing him on a heated bed, but before they wheel him out they pause next to Zoë so she can see him. He has an astonishing crop of dark hair, and his body, though small and skinny, is complete. The swollen eyes are shut tight.
‘He’s mine?’ she asks numbly.
‘You’ll be able to see him properly later,’ the midwife says. ‘Right now, they’re going to look after him and we’re going to look after you.’
I stay until she’s delivered the placenta and has returned to the ward.
‘You’ll come back and see me?’ Zoë asks.
‘I’ll try,’ I say, though I’m meant to have Christmas off. My spirit soars a little bit in anticipation of the surprises I’ve planned for Kerry, between her shifts. By the time I’m back at the hospital, Zoë will probably have been booted out, though her baby will be kept here for weeks. And even when he is ready to leave, I don’t think he’ll be going to his mother.
I walk all the way back to the bungalow, my breath condensing in the sub-zero air. A taxi slows down next to me, and I am so tempted to get in, but we’re in full-on money saving mode, putting everything away for September when Kerry won’t be earning and we’re all trying to exist on my FY1 salary.
As I walk along the sparkling pavements, the thought of climbing into the warm bed beside Kerry is all that gives me the energy to keep me putting one foot in front of the other. But when I let myself into the dark bungalow, she’s not there.
I must have got her shifts wrong.
The shock of the icy sheets is like a slap, and now my mind starts racing, with thoughts of what will happen to Zoë, what will happen to her baby.
I understand why she couldn’t cope without something to take away the pain life has inflicted on her. I’ve had so many more advantages than her: a stable home, a loving fiancée, a supportive mother, the prospect of a rewarding career. Yet still I needed the uppers, the downers, the sleeping pills, the odd line.
Life is better now I’m clean. Even lying alone in this cold bed, there’s a purity about my doubts and fears. Perhaps now, with the right help, Zoë will realize it too: that however tough things get, drugs just postpone the moment of reckoning, when you have to face your responsibilities.
Kerry helped me realize that love is stronger than addiction. Maybe Zoë’s baby will help her feel the same way.