Do No Harm: Stories of Life, Death and Brain Surgery (11 page)

‘No! No!’ he said, laughing ‘You decide.’

‘Well, left side it is then,’ I said.

I left the anaesthetic room. The nurse would now tell the anaesthetist that she was allowed to start the operation. I went back to the red leather sofa.

Forty minutes later the nurse returned to say that the next patient was now anaesthetized and I sent my junior off to start the case. The junior doctors work such short hours that they are desperate for even the most basic surgical experience and I feel obliged to leave all of the opening and closing to them as this is a simple and relatively safe part of brain surgery, even though I would much prefer to do it myself. The intense anxiety I experience when supervising my juniors, however, so much greater than when I operate myself, means that I find it quite impossible to leave the theatres when they are operating on anything but the simplest cases, and there is far too much paperwork to bring up from my office, so I feel compelled instead to stay in the room with the red leather sofa.

I will wander in and out of the theatre and watch, a little jealously, what they are doing and only scrub up when the patient’s brain is reached and the operation becomes more intricate and dangerous. The point at which I take over will depend on the experience of the trainee and the difficulty of the case.

‘How’s it going?’ I will ask, as I walk into the theatre, putting on my reading glasses and a face mask, to peer into the wound.

‘Fine, Mr Marsh,’ my trainee will reply, wanting me to go away, and well aware of the fact that I would love to elbow him or her aside and take over the operation.

‘You’re sure you don’t need me?’ I will ask hopefully and will usually be assured that everything is under control. If this indeed appears to be the case I will turn away from the operating table with a sigh and walk the few yards back to the sitting room.

I stretched out on the sofa and carried on reading my book.

As a practical brain surgeon I have always found the philosophy of the so-called ‘Mind-Brain Problem’ confusing and ultimately a waste of time. It has never seemed a problem to me, only a source of awe, amazement and profound surprise that my consciousness, my very sense of self, the self which feels as free as air, which was trying to read the book but instead was watching the clouds through the high windows, the self which is now writing these words, is in fact the electrochemical chatter of one hundred billion nerve cells. The author of the book appeared equally amazed by the ‘Mind-Brain Problem’, but as I started to read his list of theories – functionalism, epiphenomenalism, emergent materialism, dualistic interactionism or was it interactionistic dualism? – I quickly drifted off to sleep, waiting for the nurse to come and wake me, telling me it was time to return to the theatre and start operating on the old man’s brain.

10

TRAUMA

n.
any physical wound or injury.

psychol.
an emotionally painful and harmful event.

I was early and had to wait for the junior doctors to arrive. The days of white coats are long gone and instead the juniors turn up in Lycra bicycling gear or, if they have been on duty overnight, in the surgical scrubs made popular by
TV
medical dramas.

‘There was only one admission last night,’ the on-call registrar said, sitting at the front of the room beside the computer keyboard. She was quite unlike the other trainees, who are usually full of youthful enthusiasm. She talked in an irritated and disapproving tone of voice. This invariably had a dampening effect on the meetings when it was her turn to present the cases. I had never understood why she wanted to train as a neurosurgeon.

‘He’s a forty-year-old man,’ she said. ‘Seems he came off his bike last night. He was found by the police.’

‘Push-bike?’ I asked.

‘Yes. And like you he wasn’t wearing a crash helmet,’ she said, with a look of disapproval. As she talked she typed on the keyboard and the slices of a huge black-and-white brain scan started to appear, like a death sentence, out of the dark onto the white wall in front of us.

‘You won’t believe this,’ one of the other registrars broke in. ‘I was on yesterday evening and took the call. They sent the scan on a
CD
but because of that crap from the government about confidentiality they sent two taxis. Two taxis! One for the fucking
CD
and one for the little piece of paper with the fucking encryption password! For an emergency! How stupid can you get?’

We all laughed, apart from the registrar presenting the case who waited for us to calm down.

‘The police said he was talking when they found him,’ she went on, ‘but when he was admitted to the local hospital he started fitting so he was tubed and ventilated and then scanned.’

‘He’s stuffed,’ somebody called out from the back of the room as we looked at the scan.

‘I hope he doesn’t survive,’ the on-call registrar suddenly said. I was very surprised since I knew from past experience that she believed in treating patients even with a hopeless prognosis.

I looked at the junior doctors in the front row.

‘Well,’ I said to one of them, a dark-haired girl who had only just started in the department, and who would only be with us for two months. ‘There are many abnormalities on the scan. See how many you can identify.’

‘There’s a frontal skull fracture, and it’s depressed – the bone’s been pushed into the brain.’

‘What’s happened to the brain?’

‘There is blood in it – contusions.’

‘Yes. The contusions on the left are so big that it’s called a burst frontal lobe. All that area of brain has been destroyed. And what about the other side?’

‘There are contusions there as well, but not as big.’

‘I know he was talking at first and in theory might make a good recovery but sometimes you get delayed intraparenchymal bleeding like this and the scan now shows catastrophic brain damage.’

‘What’s his prognosis?’ I asked the registrar.

‘Not good,’ she said.

‘But how much not good?’ I asked. ‘Fifty per cent? Ninety per cent?’

‘He might recover.’

‘Oh come off it! With both his frontal lobes smashed up like that? He hasn’t got a hope in hell. If we operate to deal with the bleeding he might just survive but he’ll be left hopelessly disabled, without language and probably with horrible personality change as well. If we don’t operate he’ll die quickly and peacefully.’

‘Well, the family will want something done. It’s their choice,’ she replied.

I told her that what the family wanted would be entirely determined by what she said to them. If she said ‘we can operate and remove the damaged brain and he may just survive’ they were bound to say that we should operate. If, instead, she said ‘If we operate there is no realistic chance of his getting back to an independent life. He will be left profoundly disabled. Would
he
want to survive like that?’ the family would probably give an entirely different answer. What she was really asking them with the first question was ‘Do you love him enough to look after him when he is disabled?’ and by saying this she was not giving them any choice. In cases like this we often end up operating because it’s easier than being honest and it means that we can avoid a painful conversation. You might think the operation has been a success because the patient leaves the hospital alive but if you saw them years later – as I often do – you would realize that the result of the operation was a human disaster.

The room was silent for a while.

‘The decision has been made to operate,’ the registrar said stiffly. Apparently the patient was under the care of one of my colleagues and one of the unwritten rules of English medicine is that one never openly criticizes or overrules a colleague of equal seniority, so I remained silent. Most neurosurgeons become increasingly conservative as they get older – meaning that they advise surgery in fewer patients than when they were younger. I certainly have – but not just because I am more experienced than in the past and more realistic about the limitations of surgery. It is also because I have become more willing to accept that it can be better to let somebody die rather than to operate when there is only a very small chance of the person returning to an independent life. I have not become better at predicting the future but I have become less anxious about how I might be judged by others. The problem, of course, is that so often I do not know just how small the chance of a good recovery might be because the future is always uncertain. It is much easier just to operate on every case and turn one’s face away from the fact that such unquestioning treatment will result in many people surviving with terrible brain damage.

We all filed out of the room and scattered over the hospital for the day’s work – to the theatres, to the wards, to the outpatient clinic, to the offices. I walked down the X-ray corridor with my neuroradiological colleague. Neuroradiologists spend their day analysing brain and spinal scans but do not usually deal directly with patients. I think he had started his career in neurosurgery but was too gentle a soul to be a neurosurgeon and so had become a neuroradiologist.

‘My wife’s a psychiatrist, you know,’ he said. ‘When she was training she worked in a brain damage unit for a while. I’m with you on this one – so many of the head injuries have terrible lives. If neurosurgeons followed up the severe head injuries they treated I’m sure they’d be more discriminating in whom they operated upon.’

I went down to my office where I found my secretary Gail cursing her computer again while she tried to get onto one of the hospital databases.

I noticed a sheet of paper beside her keyboard printed in crude colours with flowery capitals.

‘This certificate is presented . . .’ it began. It went on to state that Gail had attended something called a
MAST
Catchup Seminar.

‘What this?’ I asked pointing to the piece of paper.

‘Mandatory and Statutory Training.’ she said. ‘It was a complete and utter waste of time. It was only bearable because some of your colleagues were there and spent the whole time taking the piss out of the lecturer who was completely useless. I was told afterwards his background was in catering – he didn’t know anything he was talking about. He’d just been trained to say it. You’re going today, have you forgotten?’ she added in a mockingly disapproving voice. ‘It’s mandatory for all members of staff and that includes consultant surgeons.’

‘Oh really?’ I replied, but it was true that I had received a letter from the chief executive a few weeks earlier. The letter stated that it had been brought to his attention that I had not attended Mandatory and Statutory Training and that it was indeed mandatory and statutory that I attend. The fact that he had found the time to write to me showed that the
MAST
course was clearly of vital importance.

So I walked out of the hospital into the late August sunshine and made my way across one of the hospital’s many car parks, narrowly missed being run over by a long line of wheelie bins being tugged round the perimeter road by a bored-looking man on a small tractor, and presented myself to the Training and Development Centre, a large and flimsy mobile home, the floor of which shook as I strode angrily down the corridor to the room where the
MAST
seminar was to be held. I was late and there were already about forty people sitting glumly at desks – a mixed group of nurses, cleaners, clerks and doctors and doubtless other members of the huge bureaucracy that forms an
NHS
Trust. I took a chair and sat in the far corner at the back. The lecturer – a young man with a trimmed ginger beard and shaven head – came and presented me with a folder entitled ‘
MAST
Workbook’. I felt as though I was back in school and I refused to take it from him – so, with a sigh, he patiently left it on the floor beside me and returned to the front of the room and turned to face his audience.

The seminar was scheduled to last three hours and I settled down to get some sleep. The long hours I worked as a junior doctor in the distant past have taught me the art of getting to sleep virtually anywhere on any surface.

Halfway through there was a coffee break before we were to learn about Fire Drill and the Principles of Customer Care. As we walked out of the room I picked up a message on my mobile phone, which I had dutifully turned off. One of my patients on the women’s ward was dying and the ward sister had rung to say that the family wanted to talk to me. So I returned to the hospital and went up to the ward.

The patient in question was a woman in her forties with breast cancer who had developed a secondary tumour in her brain. This had been operated on and removed by one of the senior trainees a week earlier but two days after the operation – which had gone uneventfully – she had suffered a major stroke. She was now dying. I had realized earlier in the week, with something of a shock, that nobody had spoken to the family about this. The surgeon who had done the operation was away on leave, as was my own registrar. I had been busy operating and none of the small army of shift-working junior doctors had felt sufficiently involved with the patient – whom they did not know – to talk to the family. I had therefore arranged to meet them at nine in the morning, forgetting that I was supposed to be attending the
MAST
seminar.

I found the patient’s husband and elderly mother sitting sadly beside the woman’s bed, squeezed into the narrow space between her bed and the next patient’s in a six-bed bay. She was unconscious, and breathing heavily and irregularly. There were five other patients in the room, with only two feet or so between their beds, who could watch her slowly dying.

I hate breaking bad news to patients and their families in rooms like this, overheard by others, hidden by a flimsy curtain. I also hate talking to patients and their families – ‘customers’ as the Trust would have it – while standing, but there were no empty chairs in the bay so I stood unhappily above the dying woman and her family as I spoke to them. It seemed inappropriate to sit on the bed, besides I believe it is now banned by Infection Control.

‘I’m very sorry I didn’t talk to you earlier,’ I began. ‘I’m afraid she suffered a stroke after the operation. The tumour was stuck to one of the major arteries for her brain and when this happens, even though we are able to remove the tumour, sometimes a stroke occurs in the artery a few days later.’

The husband and mother looked at me silently.

‘What will happen?’ her elderly mother asked.

‘Well,’ I said hesitating, ‘I think she will probably . . .’ I hesitated again, and dropped my voice, acutely aware of the other patients listening and wondering whether to use one of the many euphemisms for death. ‘I think she will probably die, but I just don’t know if it will be within the next few days or take longer.’

Her mother started crying.

‘It’s every parent’s worst nightmare to outlive their children,’ I said.

‘She was my only child,’ her mother replied through her tears. I reached out to put my hand on her shoulder.

‘I’m so sorry,’ I said.

‘It’s not your fault,’ she replied. There was nothing else to be said so after a while I went to find the ward sister.

‘I think Mrs T is dying,’ I said. ‘Can’t we put her in a side room?’

‘I know,’ the sister said, ‘We’re working on it but we’re desperate for beds at the moment and we’ll have to shift an awful lot of patients around.’

‘I’m at the
MAST
meeting all about Customer Care this morning,’ I said.

The ward sister snorted. ‘We just give such crap care now,’ she said with feeling. ‘It used to be so much better.’

‘But the patients are always telling me how good it is here,’ I said, ‘compared to the local hospitals.’ She said nothing and hurried away, forever busy.

I returned to the Training and Development Centre. The second session had already started. The PowerPoint presentation now showed a slide with a long list of the Principles of Customer Service and Care.

‘Communicate effectively,’ I read. ‘Pay attention to detail. Act promptly.’ We were also advised to develop Empathy.

‘You must stay composed and calm,’ Chris the lecturer told us. ‘Think clearly and stay focused. Your emotions can affect your behaviour.’

How strange it is, I thought as I listened to him talking, that after thirty years of struggling with death, disaster and countless crises and catastrophes, having watched patients bleed to death in my hands, having had furious arguments with colleagues, terrible meetings with relatives, moments of utter despair and of profound exhilaration – in short, a typical neurosurgical career – how strange it is that I should now be listening to a young man with a background in catering telling me that I should develop empathy, keep focused and stay calm. As soon as the signing-out register had been passed around, and I had signed it, thus confirming that the Trust could now state that I had been trained in Empathy and Self-control, and the classification of Abuse and of Fire Extinguishers, in addition to many other things I had already forgotten, I charged out of the room despite Chris’ protests that he had not yet finished.