Do No Harm: Stories of Life, Death and Brain Surgery (20 page)

‘I’m very sorry to disturb you,’ he said, going through the usual polite litany my juniors always recite whenever they call me, ‘but could I discuss a case with you please?’

‘Yes, yes, of course,’ I said, hurrying off to find shelter in a warehouse full of terracotta pots.

‘This is a thirty-four-year-old man who fell from a bridge . . .’

‘A jumper?’

‘Yes. Apparently he’d been depressed for some time.’

I asked if he had landed on his head or on his feet. If they hit the ground feet first they fracture their feet and spines and end up paralysed and if they hit their head first they usually die.

‘He landed on his feet but he hit his head as well,’ came the reply. ‘He’s a polytrauma case – he’s got a fractured pelvis, bilateral tib and fibs and a severe head injury.’

‘What does the scan show?’

‘A large haemorrhagic contusion in the left temporal lobe and the basal cisterns are gone. He’s had a big, fixed pupil on the left for five hours now.’

‘And his motor response?’

‘None, according to the ambulance men.’

‘Well, what do you want to do?’

Rob hesitated, reluctant to commit himself.

‘Well, I suppose we could pressure monitor him.’

‘What do you think is his prognosis?’

‘Not very good.’

I told Rob that it would be better to let him die. He would probably die whatever we did, and even if he did survive he’d be left terribly disabled. I asked him if he had seen the family.

‘No, but they’re coming in,’ he replied.

‘Well, spell it out to them,’ I said.

While we were speaking, the rain had stopped and the sun had come out from behind the broken clouds. The plants around me glittered with reflected light. The shoppers emerged from the shelter of the shop and the pastoral scene of the garden centre resumed – happy gardeners walked between the rows of plants and trees, stopping to examine them, and wondering which to buy. I bought myself a
Viburnum paniculata
with little starbursts of white flowers and drove home with it perched in a friendly sort of way on the passenger seat beside me.

I could have operated on this poor suicidal man and possibly saved his life, but at what cost? Or so I told myself as I started to dig a hole in the back garden for the
viburnum
. Eventually I felt forced to go in to the hospital to look at the scan myself and to see the patient – despite my best efforts I found it difficult to deliver a death sentence, even on a jumper, on the basis of hearsay evidence alone.

My shoes had become soaking wet in the downpour and I changed them for a new pair, recently re-soled, before driving in to the hospital.

I met Rob in the dark X-ray viewing room. He summoned up a brain scan on the computer screens.

‘Well,’ I said as I looked at the
CT
scans, ‘he’s wrecked.’ It was a relief that the scan looked even worse than Rob’s description of it over the phone. The left side of the man’s brain was smashed beyond repair, his brain darkened on the scan by oedema and flecked with white, the colour of blood on
CT
brain scans. His brain was so swollen that there was no hope of survival, even in a disabled state, even if we operated.

‘There are two great benefits to medicine as a career,’ I said to Rob. ‘One is that one acquires an endless fund of anecdotes, some funny, many terrible.’

I told him about a jumper I had treated years ago, a pretty young woman in her twenties who jumped under a tube train. ‘She had to have a hindquarter amputation of one leg – the leg removed completely at the level of the pelvis – I suppose the train had run lengthwise over her hip and leg. She’d also suffered a compound depressed skull fracture which was why she was sent over to us after the local hospital had done the amputation. We sorted her head out and she slowly woke up over the next few days. I remember telling her she’d lost her leg and she said “Oh dear. It doesn’t sound very nice, does it?” But she was quite happy at first, obviously couldn’t remember all the unhappiness that had made her throw herself under the train. But as she recovered from her head injury, as she got better, so to speak, she got worse since her memory started to return and every day you could see her become more and more depressed and desperate. When her parents eventually turned up you could see why she had tried to kill herself. It was very sad to watch.’

‘What happened to her?’ Rob asked.

‘I haven’t a clue. We sent her back to the local hospital and I heard no more.’

‘What is the second benefit of a career in medicine?’ Rob asked politely.

‘Oh, just that if one falls ill oneself one knows how to get the best care.’ I waved at the brain scan on the monitor in front of us. ‘I’ll go and talk to his parents.’

I left the X-ray viewing area and walked along the dull and overlit hospital corridor to the
ITU
. The hospital was still very new. It felt like a high-security prison – doors could only be opened with a swipe card and if the doors were left open for more than a minute an ear-splitting alarm would sound. Fortunately since then most of the alarms have broken or been sabotaged, but our first few months in the new building were spent with the almost constant sound of alarms going off – an odd phenomenon for a hospital full of sick people, one might think. I walked into the
ITU
. Lined around its walls were the forms of the unconscious patients on ventilators surrounded by machinery, with a nurse at each bed.

The nurses at the central desk pointed to one of the beds when I asked about the new admission and I walked over to it. I was taken aback by the fact that the poor jumper was immensely fat. For some reason I didn’t expect a suicide to be fat, so fat that from the end of the bed I could not see his head at all – only the great pale mound of his naked belly, partly covered by a clean sheet, and beyond it the monitors and machinery and syringe drivers at the head of the bed, with their flashing red
LEDs
and digital read-outs. An elderly man was sitting on a chair at the bedside and got up when he saw me. I introduced myself and we shook hands.

‘Are you his father?’ I asked.

‘Yes,’ he said quietly.

‘I’m very sorry,’ I said, ‘but there’s nothing we can do to help.’ I explained that his son would die within the next twenty-four hours. The old man said nothing other than to nod his head. There was little expression on his face – whether he was too stunned, or too estranged, I do not know. I never got to see his son’s face, and I do not know what human tragedy lay behind the pathetic, dying bulk that lay on the hospital bed beside us.

I went home and climbed up the stairs to the attic room I had built the previous year to where Kate was lying on a sofa, recovering from a particularly bad relapse of her Crohn’s disease. I had made the staircase of oak myself and had sanded and polished the steps to a high finish. We discussed the need for an extra handrail on the stairs since she Kate slipped on the stairs and bruised herself quite badly two nights earlier. We have both always been a little dismissive of the Health and Safety culture that increasingly dominates our risk-averse society but decided that a handrail was probably a good idea. I set off downstairs, down the handmade oak stairs, each tread and riser carefully made by myself, to finish planting the
viburnum
in the back garden. My newly soled shoes slipped on the over-polished oak, I lost my balance, heard the horrible, explosive crack of my leg breaking and my foot dislocating and fell down the stairs.

Although breaking one’s leg is indeed very painful it is surprisingly easy to tolerate – it is well known, after all, that soldiers in battle rarely feel great pain if they are seriously wounded – the pain comes later. You’re too busy working out how to save yourself to think much about the pain.

‘Bloody hell! I’ve broken my leg,’ I shouted. Kate at first thought I was joking until she found me at the bottom of the stairs, with my left foot twisted round at an improbable angle. I tried to pull my foot out straight with my hands but started to pass out with the pain so Kate called our neighbours who put me on the back seat of their car and took me to A&E at my own hospital. A wheelchair was found and soon I was in a short queue at the reception desk, manned by two fierce-looking women behind what looked like bullet-proof glass. I sat there patiently, gritting my teeth, my broken leg sticking out in front of me. After a short delay I was facing one of the receptionists.

‘Name?’ she asked.

‘Henry Marsh’.

‘Date of birth?’

‘Five three fifty. Actually I’m the senior consultant neurosurgeon at this hospital.’

‘Religion?’ she asked in reply, without batting an eyelid.

‘None,’ I replied, crestfallen but thinking that at least my hospital was truly egalitarian.

The interrogation went on for a short time and I was then rescued by one of the Casualty sisters who promptly established that my foot was dislocated and that it needed reducing. I was very gratified at how quickly this was done, and painlessly at that, thanks to IV morphine and midazolam and Entonox. My last memory, before the drugs rendered me unaware of everything around me is of my trying to persuade the enthusiastic sister not to take an enormous pair of scissors to my brand new, green corduroy trousers.

When I started to come round in a happy haze from the drugs, and reflected on what it would have been like to have had a fracture like mine reduced in the past, without any anaesthetic at all, I found my orthopaedic colleague standing at the end my trolley. I had called him on my mobile from the backseat of my neighbours’ car on the way to A&E.

‘It’s a fracture dislocation,’ he said ‘They’ve reduced it nicely but it will need an operation – internal fixation. I could do that tomorrow at the private hospital.’

‘I’ve got insurance,’ I said. ‘Yes, let’s do that.’

‘We’ll have to get a private ambulance,’ said the sister.

‘Don’t worry,’ said my colleague, ‘I can take him myself.’

So I was wheeled out of A&E, my left leg in a long plaster back-slab and helped into my colleague’s red Mercedes sports car. Thus I was taken in some style to the private hospital three miles away, where the fracture was duly fixed the next day. My colleague insisted on keeping me in hospital for five days on the grounds that I was a doctor and would not listen to his medical advice that I should rest my leg for the first few days after surgery. So I spent much of the following week in bed, with my leg propped up in the air, looking at a rather fine oak tree outside the window of my room, reading P.G. Wodehouse and reflecting on the way in which many of the government’s so-called ‘market-driven reforms’ of the
NHS
seemed to be driving the
NHS
even further away from what went on in the real market of the private sector, in which I was once again a patient. I could occasionally hear my colleagues going to visit their patients in the rooms next to mine, their voices full of charm and polite encouragement.

On the morning of my discharge I went down to the outpatient area to wait to have the plaster changed. I watched the many outpatients coming and going.

My colleagues, in smart dark suits, would emerge from time to time from their consulting rooms to bring in the next patient waiting to see them. Some of them knew me and looked somewhat startled to see me disguised as a patient in a dressing gown with a leg in plaster. Most of them stopped and commiserated and laughed with me at my bad luck. One of them, a particularly pompous physician, stopped for a moment and looked surprised.

‘Fracture dislocation of the left ankle,’ I said.

‘Oh dear,’ he said in a very prim voice, as though he disapproved of the vulgar way in which, by allowing my leg to be broken, I had become a mere patient, and he quickly returned to his room. I was summoned to the plaster room where my orthopaedic colleague removed the old dressing and carefully studied the two incisions, one on either side of my ankle. He declared himself happy and then, taking my leg in his hands, re-dressed the wounds and placed a new plaster back-slab against my foot and leg, holding it in place with a crepe bandage. I thought rather wistfully of the huge gulf that separates this sort of medicine from what I practice as a neurosurgeon.

‘I rarely touch my patients, you know,’ I said to him. ‘Other than when operating on them, of course. It’s all just the history and the brain scan and long, depressing conversations. Not at all like this. This is rather nice.’

‘Yes, neurosurgery is all doom and gloom.’

‘But our occasional triumphs are all the greater as a result . . .’ I started to say before he interrupted my philosophizing.

‘You have got to keep that foot up for the next few weeks ninety five per cent of the time because it’s going to become very swollen.’

I bade him goodbye and, picking up my crutches, hopped out of the room.

A few weeks later I suffered a vitreous haemorrhage and retinal tear in my other eye but it was easier to fix than the left eye had been. I was back at work within a matter of days. I had been lucky compared to my patients, and I was full of the profound and slightly irrational gratitude for my colleagues that all patients have for their doctors when things go well.

22

ASTROCYTOMA

n.
a brain tumour derived from non-nervous cells. All grades of malignancy occur.

After the success of the trigeminal neuralgia operation Igor was keen that when I next went out to Ukraine I should operate on a number of patients with especially challenging brain tumours, which he assured me could not be treated safely in Ukraine by his senior colleagues. I did not share his enthusiasm and told him so, but when I arrived on my next visit there was a long queue of patients with quite dreadful brain tumours waiting to see me in the dingy corridor outside his office.

The outpatient clinics I have conducted over the years in Igor’s office have always been bizarre events, and quite unlike anything else I have ever done. As Igor’s fame grew, patients would come from all over Ukraine to consult him. There was no appointment system – patients would turn up at any time, and seemed to accept that this might involve waiting all day to be seen. On the occasion of my visits the queue of patients would stretch all the way down the long hospital corridor outside his office and disappear from view around a distant corner.

We would start at eight in the morning and continue until late in the evening without a break. There would often be several patients and their families in the small office all at once, some of them dressed, some of them undressed. There might also be journalists and
TV
crews conducting interviews, especially when Igor’s political situation was proving problematical. There were three telephones in the room and most of them were in constant use. There were rarely fewer than seven or eight people in the room at the same time. I found all this chaos exhausting and irritating and at first I blamed Igor for it, telling him that he should institute an appointments system, but he said that in Ukraine nobody would adhere to it and that it was best to let people turn up whenever they wished.

Igor’s manner with patients was somewhat brusque, although at times he seemed capable of sympathy. Since I do not speak Russian or Ukrainian I could only guess at what was being said, before it was translated by Igor, and I discovered that often I was entirely wrong. The patients brought their own brain scans, arranged previously, and without further ado I would be asked whether surgery was possible or not. In English medicine it is drilled into one at a very early stage that one should base one’s decisions on taking a history and examining the patient and that only at the end should one look at the ‘special investigations’ such as X-rays and brain scans. Here the whole process was reversed and compressed into a few minutes or even seconds. I felt like the emperor Nero at the Roman games. It was made all the more difficult by the fact that the brain scans were usually of poor quality. It was difficult to see clearly what was going on and this made me even more uneasy about having to make so many rapid life-or-death decisions.

On this particular visit, in the summer of 1998, it became clear that Igor’s many enemies in the medical establishment had brought pressure to bear on the hospital director who had welcomed the British ambassador the previous year. On the morning of the first outpatient clinic I learnt that I had been ‘banned’ from the operating theatres by the director, and also that he would not meet me. I was, in fact, quite relieved – the cases I had seen were daunting and I was frightened by the thought of operating on them in the primitive operating theatres.

The fact that I had been banned from the operating theatres was headline news and the outpatient clinic next day had more than its usual share of journalists and
TV
crews in attendance. Halfway through the morning, as I was being interviewed by a Ukrainian
TV
journalist, while simultaneously trying to decide whether somebody’s brain tumour was operable or not, the head of the hospital’s surgical department arrived and ordered the journalists and film crews out of the hospital. He wore a particularly tall chef’s hat, and an outsize pair of spectacles to go with it, and looked reassuringly absurd. It was difficult to take him seriously. We left the hospital and continued the interview outside, with the hospital in the background.

One of the patients I had just seen, and agreed – with considerable misgivings – to operate on, was also interviewed and asked what she felt about the fact that I was not going to be allowed to treat her. Ludmilla had come up from the south of the country to see a famous professor of neurosurgery in Kiev. She had become increasingly unsteady on her feet in recent months and a brain scan had shown a large and very difficult tumour at the base of her brain – an ependymoma of the fourth ventricle, a benign but often fatal growth. There was no question of her undergoing surgery in her home town. She arrived on time for her appointment but the professor was late. His junior doctors looked at her brain scan.

‘If you want to live, leave before the professor returns,’ one of them had said. ‘Go and see Kurilets. He has contacts with the West and may be able to help. If you let the professor operate, you will die.’ She quickly left and a few days later I saw her in Igor’s office.

We both appeared on the national nine o’clock television news that evening.

‘What do you want?’ the journalist was seen to ask Ludmilla.

‘I want to live,’ she replied quietly.

The urge to help, the planning of difficult and dangerous operations, of taking carefully calculated risks, of saving lives, is irresistible and even more so if you are doing it in the face of opposition from a self-important professor. When I met Ludmilla the next day I felt that I had no choice other than to tell her that, if she wished, I would arrange for her to come to London and I would operate on her there. Not surprisingly, she agreed.

It was the next day that I first saw Tanya. Igor wanted us to leave for the hospital by 6.30 in the morning but I overslept and once we had set off I quickly realized why Igor had been keen to leave early – the morning Kiev rush hour meant that a journey of thirty minutes took, instead, one and a half hours. We joined an endless queue of grubby cars and trucks, dull grey shapes in the fog, with red tail-lights turning their exhaust into small pink clouds, inching along the enormous wide roads towards the centre of Kiev. The roads are lined by huge advertisements for cigarettes and mobile phones, scarcely visible in the fog. Many cars queue-jump by mounting the pavements and weaving between the lamp posts. Heavy 4x4s leave the road altogether and career across the muddy patches of grass beside the road if it will get them ahead.

Tanya was near the end of the queue of patients with inoperable brain tumours. She was eleven years old at the time. She walked into Igor’s office, unsteadily, supported by her mother, with a scratched piece of X-ray film that showed an enormous tumour at the base of her brain that must have been growing for years. It was the largest tumour of its kind that I had ever seen. Her mother, Katya, had brought her all the way from Horodok, a remote town near the border with Romania. She was a sweet child, with the awkward long-legged grace of a foal, a page-boy haircut and a shy, lopsided smile – lopsided because of the partial paralysis of her face caused by the tumour. The tumour had been effectively deemed inoperable both in Moscow and Kiev and it was obvious that it was going to kill her sooner or later.

Just as it is irresistible to save a life, it is also very difficult to tell somebody that I cannot save them, especially if the patient is a sick child with desperate parents. The problem is made all the greater if I am not entirely certain. Few people outside medicine realize that what tortures doctors most is uncertainty, rather than the fact they often deal with people who are suffering or who are about to die. It is easy enough to let somebody die if one knows beyond doubt that they cannot be saved – if one is a decent doctor one will be sympathetic, but the situation is clear. This is life, and we all have to die sooner or later. It is when I do not know for certain whether I can help or not, or should help or not, that things become so difficult. Tanya’s tumour was indeed the largest I had ever seen. It was almost certainly benign and, at least in theory, could be removed, but I had not tried to operate on such a large tumour in a child her age before, nor did I know anybody else who had tried. Doctors often console each other, when things have gone badly, that it is easy to be wise in retrospect. I should have left Tanya in Ukraine. I should have told her mother to take her back to Horodok, but instead I brought her to London.

Later that year I arranged for Tanya and Ludmilla to come to London and I had organized a mini-van to meet them at Heathrow and deliver them with their accompanying relatives at the entrance to my hospital. How proud and important I felt when I met them there! I carried out both the operations with Richard Hatfield, a colleague and close friend and who had often come out to Ukraine with me.

The operation on Ludmilla took eight hours and was a great success. The first operation on Tanya took ten hours, and then there was a second operation that took twelve hours. Both operations were complicated by terrible blood loss. With the first operation she lost four times her entire circulating blood volume but she emerged unscathed, although with half of the tumour still in place. The second operation – to remove the rest of the tumour – was not a success. She suffered a severe stroke. She had to stay in the hospital for six months before she was, more or less, well enough to return home to Ukraine. I drove her and her mother to Gatwick, with the help of Gail and her husband. We stood by the Departures gateway. Tanya’s mother, Katya, and I kept on looking each other in the eyes – she with desperation, I with sadness. We embraced, both of us crying. As she started to wheel Tanya in her wheelchair through the gate she ran back to me and hugged me again. And so they left – Katya pushing her mute and disfigured daughter in her wheelchair, and the Ukrainian doctor Dmitri beside them. Katya probably understood better than I did what the future would bring.

Tanya died eighteen months after her return home. She would have been just twelve years old. Instead of a single, brilliant operation she ended up having to undergo many operations and there were serious complications – ‘complications’ being the all-encompassing medical euphemism for things going wrong. Instead of a few weeks she had ended up spending six months in my hospital, six horrible months. Although she did eventually get home she returned more disabled than when she had left it. I don’t know exactly when she died and I only got to hear of it by chance from Igor. I had telephoned him from London to discuss another brain tumour case. I had asked in passing, a little anxiously, after Tanya.

‘Oh. She died,’ he said. He didn’t sound very interested. I thought of all that Tanya and Katya had been through, of what we had
all
been through in our disastrous efforts to save Tanya’s life. I was upset, but his spoken English is limited and broken and perhaps something was being lost in translation.

I had last seen her shortly before her death, after her return from England, on one of my regular trips to Kiev. Katya, her mother, had brought her to see me all the way from her home in Horodok. She could just walk if somebody held her, and her faint, lopsided smile had returned. For the first few months after the operations her face had been completely paralysed. This had left her at first not just unable to talk but also with a face like a mask, so that it seemed she had no feelings at all – even the most intense emotions were hidden, unless sometimes a tear rolled down her expressionless cheek. It is sad how easy it is to dismiss people with damaged or disfigured faces, to forget that the feelings behind their mask-like faces are no less intense than our own. Even then, a year after surgery, she was still unable to talk or to swallow although she could now breathe without a tracheostomy tube in her throat. Katya had been with her in London throughout those endless six months, and when I had seen them off at Gatwick Airport, Katya had sworn to give me a present whenever we next met. She now came not just with Tanya but with a large suitcase. This contained the family pig, which had been slaughtered in my honour and turned into dozens of long sausages.

A few months later Tanya was dead. She probably had died from a blocked shunt. After the catastrophic second operation on her brain tumour I had had to insert an artificial drainage tube into her brain and this might well have blocked, causing a fatal increase in the pressure inside her head. Living, as she did, far away from modern medical facilities, it would have been impossible to deal with this. I will never know for certain what actually happened. Nor will I ever know whether I had been right to uproot her from her home in impoverished, rural Ukraine for so many months, and to operate on her in the way that I had done. For the first few years after Tanya’s death Katya would send me a Christmas card – coming all the way from Horodok it did not usually reach me until the end of January. I would put it up on my desk in my windowless office in the huge, factory-like hospital where I work. I would leave it there for a few weeks as a sad reminder of Tanya, of surgical ambition and of my failure.

Several years after Tanya’s death a documentary film about my work in Ukraine was being made and I suggested that it should include a visit to see Katya. The film crew and I were driven in a minibus the four hundred kilometres from Kiev to Horodok. It was in late winter and much of the filming had gone on in deep snow and in temperatures of minus 17 degrees centigrade but as we drove west the snow faded away and, although all the rivers and lakes we passed were frozen solid, often with men fishing through holes sawn in the ice, there was a distinct feeling of spring in the air. I wanted very much to see Katya again – during the six months she and Tanya had been in London I had come to feel very close to them, even though we had no language in common. I also felt very anxious as I could not help but blame myself for Tanya’s death.

Horodok, as with so much of rural western Ukraine, was impoverished and depopulated. Since the fall of the Soviet Union the economy had collapsed and most of the young people had left. There were the rust-coloured, derelict factories that are to be found all over Ukraine and rubbish and broken machinery were scattered everywhere. Katya lived in a small brick-built house beside a muddy yard – when we arrived she seemed as nervous as I was, although she was clearly very happy to see me. We waded across the mud and puddles to reach the little house where there was an enormous meal laid out for us. We sat down with her family round the table as the film crew filmed us. I was so intensely moved to see Katya again that I could scarcely talk, and was quite unable to eat, much to Katya’s distress. I managed to stumble through giving a toast as we followed the Ukrainian tradition of proposing toasts with vodka, accompanied by short speeches.