Do No Harm: Stories of Life, Death and Brain Surgery (4 page)

‘Well. It’s just asking to be clipped, isn’t it?’ I say to Jeff, suddenly happy and relaxed. The greatest risk is now past. With this kind of surgery, if the aneurysm ruptures before you reach it, it can be very difficult to control the bleeding. The brain suddenly swells and arterial blood shoots upwards, turning the operative site into a rapidly rising whirlpool of angry, swirling red blood, through which you struggle desperately to get down to the aneurysm. Seeing this hugely magnified down the microscope you feel as though you are drowning in blood. One quarter of the blood from the heart goes to the brain – a patient will lose several litres of blood within a matter of minutes if you cannot control the bleeding quickly. Few patients survive the disaster of premature rupture.

‘Let’s have a look at the clips,’ I say.

Irwin hands me the metal tray containing the gleaming titanium aneurysm clips. They come in all shapes and sizes, corresponding to the many shapes and sizes of aneurysms. I look at the aneurysm down the microscope and at the clips and then back at the aneurysm.

‘Six millimetre, short right-angled’ I tell him.

He picks out the clip and loads it onto the applicator. The applicator consists of a simple instrument with a handle formed by two curved leaf springs, joined at either end. Once the clip is loaded at the instrument’s tip, all you have to do is press the springs of the handle together to open the blades of the clip, position the opened blades carefully across the neck of the aneurysm and then allow the springs to separate gently apart within your hand so that the clip blades close across the aneurysm, sealing it off from the artery from which it has grown, so that blood can no longer get into it. By finally letting the springs of the handle separate even more fully the clip is released from the applicator which you can then withdraw, leaving the clip clamped across the aneurysm for the rest of the patient’s life.

That, at least, is what is supposed to happen and had always happened with the hundreds of similar operations I had carried out in the past.

Since this looks a straightforward aneurysm to clip I let Jeff take over, and I clamber out of the operating chair so that he can replace me. My assistants are all as susceptible to the siren call of aneurysms as I am. They long to operate on them, but the fact that most aneurysms are now coiled rather than clipped means that it is no longer possible to train them properly and I can only give them the simplest and easiest parts of the occasional operation to do, under very close supervision.

Once Jeff is settled in, the nurse hands him the loaded clip applicator, and he cautiously moves it towards the aneurysm. Nothing much seems to happen, and down the assistant’s arm of the microscope I nervously watch the clip wobble uncertainly around the aneurysm. It is a hundred times more difficult and nerve-wracking to train a junior surgeon than it is to operate oneself.

After a while – probably only a few seconds though it feels much longer – I can stand it no longer.

‘You’re fumbling. I’m sorry but I’ll have to take over.’

Jeff says nothing and climbs out of the chair – it would be a rash surgical trainee who ever complained to his boss, especially at a moment like this – and we change places again.

I take the applicator and place it against the aneurysm, pressing the springs of the handle together. Nothing happens.

‘Bloody hell, the clip won’t open!’

‘That was the problem I was having,’ Jeff says, sounding a little aggrieved.

‘Bloody hell! Well, give me another applicator.’

This time I easily open the clip and slip the blades over the aneurysm. I open my hand and the blades close, neatly clipping the aneurysm. The aneurysm, defeated, shrivels since it is now no longer filling with high pressure arterial blood. I sigh deeply – I always do when the aneurysm is finally dealt with. But to my horror I find that this second applicator has an even more deadly fault than the first: having closed the clip over the aneurysm the applicator refuses to release the clip. I cannot move my hand for fear of tearing the minute, fragile aneurysm off the middle cerebral artery and causing a catastrophic haemorrhage. I sit there motionless, with my hand frozen in space. If an aneurysm is torn off its parent artery you can usually only stop the bleeding by sacrificing the artery, which will result in a major stroke.

I swear violently while trying to keep my hand steady.

‘What the fuck do I do now?’ I shout to no one in particular. After a few seconds – it feels like minutes – I realize that I have no choice other than to remove the clip, despite the risk that this might cause the aneurysm to burst. I re-close the applicator handle and to my relief the blades of the clip open easily. The aneurysm suddenly swells and springs back into life, filling instantly with arterial blood. I feel it is laughing at me and about to burst but it doesn’t. I throw myself back in my chair, cursing even more violently, and then hurl the offending instrument across the room.

‘That’s never happened before!’ I shout but then, quickly calming down, laugh to Irwin, ‘And that’s only the third time in my career I’ve thrown an instrument onto the floor.’

I have to wait a few minutes while yet another applicator was found. The faulty ones, for some strange reason, turned out to have stiff hinges. Only later did I remember that the surgeon I had watched thirty years ago, and whose trainee I became, had told me that he had once encountered the same problem, although his patient had been less fortunate than mine. He was the only surgeon I knew who always checked the applicator before using it.

Doctors like to talk of the ‘art and science’ of medicine. I have always found this rather pretentious, and prefer to see what I do as a practical craft. Clipping aneurysms is a skill, and one that takes years to learn. Even when the aneurysm is exposed and ready to take a clip, after the thrill of the chase, there is still the critical question of how I place the clip across the aneurysm, and the all-important question of whether I have clipped the aneurysm’s neck completely without damaging the vital artery from which the aneurysm has grown.

This aneurysm looks relatively easy but my nerves are too frayed to let my assistant take over again and so, with yet another applicator, I clip the aneurysm. The shape of this aneurysm, however, is such that the clip does not pass completely over the neck – I can just see a little part of the aneurysm neck sticking out beyond the tips of the clip.

‘Not quite across,’ Jeff says helpfully.

‘I know!’ I snap.

This is a difficult part of the operation. I can partly open the clip and re-position it to get a more perfect position but I might tear the aneurysm in the process and be left looking at a fountain of arterial blood rushing up the microscope towards me. On the other hand if the aneurysm neck is not completely occluded there is some danger – though it is difficult to say how great – that the patient will eventually suffer a further haemorrhage in the future.

A famous English surgeon once remarked that a surgeon has to have nerves of steel, the heart of a lion and the hands of a woman. I have none of these and instead, at this point of an aneurysm operation, I have to struggle against an overwhelming wish to get the operation over and done with, and to leave the clip in place, even if it is not quite perfectly placed.

‘The best is the enemy of the good,’ I will growl at my assistants, for whom the operation is a wonderful spectator sport. They take a certain pleasure in pointing out that I have not clipped the aneurysm as well as I might have done, since they will not have to cope with the consequences of the aneurysm tearing. And if that happens, it is always exciting to watch their boss struggling with torrential haemorrhage – I certainly enjoyed it when I was a trainee. Besides they will not have to experience the hell of seeing the wrecked patient afterwards on the ward round and feel responsible for the catastrophe.

‘Oh, very well,’ I will say, shamed by my assistant, but also thinking of the hundreds of aneurysms I have clipped in the past and how, like most surgeons, I have become bolder with experience. Inexperienced surgeons are too cautious – only with endless practice do you learn that you can often get away with things that at first seemed far too frightening and difficult.

I cautiously open the clip a little and gently push it further along the aneurysm.

‘There’s still a little bit out,’ says Jeff.

Sometimes at these moments my past disasters with aneurysm surgery parade before me like ghosts. Faces, names, wretched relatives I forgot years ago suddenly reappear. As I struggle against my urge to finish the operation and escape the fear of causing a catastrophic haemorrhage, I decide at some unconscious place within myself, where all the ghosts have assembled to watch me, whether to re-position the clip yet again or not. Compassion and horror are balanced against cold, technical precision.

I re-position the clip a third time. It finally looks well placed.

‘That will do,’ I say.

‘Awesome!’ says Jeff happily, but sad not have put the clip on himself.

I left Jeff to close, retired to the surgical sitting room next to the theatre and lay down on the large red leather sofa which I had bought for the room some years ago and thought, once again, of how so much of what happens to us in life is determined by random chance. After brain surgery all patients are woken up quickly by the anaesthetist so that we can see if they have suffered any harm or not. With difficult operations all neurosurgeons will wait anxiously for the anaesthetic to be reversed, even if – as with this operation – one is fairly certain that no harm has been done. She awoke perfectly, and once I had seen her I left the hospital to go home.

As I cycled away from the hospital under dull, grey clouds, perhaps I felt only a little of the joy that I used to feel in the past after successful aneurysm operations. At the end of a successful day’s operating, when I was younger, I felt an intense exhilaration. As I walked round the wards after an operating list with my assistants beside me and received my patients’ heart-felt gratitude and that of their families, I felt like a conquering general after a great battle. There have been too many disasters and unexpected tragedies over the years, and I have made too many mistakes for me to experience such feelings now, but I still felt pleased with the way the operation had gone. I had avoided disaster and the patient was well. It was a deep and profound feeling which I suspect few people other than surgeons ever get to experience. Psychological research has shown that the most reliable route to personal happiness is to make others happy. I have made many patients very happy with successful operations but there have been many terrible failures and most neurosurgeons’ lives are punctuated by periods of deep despair.

I went back into the hospital that evening to see the woman. She was sitting up in bed, with the large black eye and swollen forehead that many patients have for a few days after an operation like hers. She told me that she felt sick and had a headache. Her husband was sitting beside her and looked angrily at me as I quickly dismissed her bruises and post-operative pain. Perhaps I should have expressed more sympathy but after the near disaster of the operation I found it difficult to take her minor post-operative problems seriously. I told her that the operation had been a complete success and that she would soon feel better. I had not had the opportunity to talk to her husband before the operation – something I usually take great care to do with relatives – and he had probably appreciated the risks of the operation even less than his wife had done.

We have achieved most as surgeons when our patients recover completely and forget us completely. All patients are immensely grateful at first after a successful operation but if the gratitude persists it usually means that they have not been cured of the underlying problem and that they fear that they may need us in the future. They feel that they must placate us, as though we were angry gods or at least the agents of an unpredictable fate. They bring presents and send us cards. They call us heroes, and sometimes gods. We have been most successful, however, when our patients return to their homes and get on with their lives and never need to see us again. They are grateful, no doubt, but happy to put us and the horror of their illness behind them. Perhaps they never quite realized just how dangerous the operation had been and how lucky they were to have recovered so well. Whereas the surgeon, for a while, has known heaven, having come very close to hell.

3

HAEMANGIOBLASTOMA

n. a tumour of the brain or spinal cord arising from the blood vessels.

I arrived at work feeling cheerful. There was a solid cerebellar haemangioblastoma on the list. These are rare tumours which are formed of a mass of blood vessels. They are benign – meaning that they can be cured by surgery – but they will prove fatal if untreated. There is a small risk of disaster with surgery, since the mass of blood vessels can cause catastrophic haemorrhage if you do not handle the tumour correctly, but there is a much greater chance of success. This is the kind of operation that neurosurgeons love – a technical challenge with a profoundly grateful patient at the end of it if all goes well.

I had seen the patient in my outpatient clinic a few days earlier. He had been suffering from severe headaches for the last few months. He was a forty-year-old accountant, with a head of curly brown hair and a slightly red face that made him look continually embarrassed. As we spoke, I felt embarrassed in return and became self-conscious and awkward as I tried to explain the gravity of his illness to him. Only later did I realize that he had a red face because he was polycythaemic – he had more red blood cells in his blood than normal, since his particular tumour can stimulate the bone marrow to over-produce red blood cells.

‘Do you want to see your brain scan?’ I asked him, as I ask all my patients.

‘Yes . . .’ he replied, a little uncertainly. The scan made the tumour look as though it was full of black snakes – ‘flow voids’ – produced by the blood rushing through the potentially disastrous blood vessels. I viewed these on the scan with enthusiasm, as they meant that a challenging operation was in prospect. My patient looked cautiously at the computer screen in front of us as I explained the scan to him and we discussed his symptoms.

‘I’ve never been seriously ill before,’ he said unhappily. ‘And now this.’

‘I’m almost certain it’s benign,’ I told him. Many brain tumours are malignant and incurable and I often have to overcome my instinct, when talking to patients with brain tumours, to try to comfort and reassure them – I have sometimes failed to do this and have bitterly regretted being too optimistic before an operation. I told him that if I thought it was benign it almost certainly was. I then delivered my standard speech about the risks of the operation and how they had to be justified by the risks of doing nothing. I said that he would die within a matter of months if he did not have the tumour removed.

‘Informed consent’ sounds so easy in principle – the surgeon explains the balance of risks and benefits, and the calm and rational patient decides what he or she wants – just like going to the supermarket and choosing from the vast array of toothbrushes on offer. The reality is very different. Patients are both terrified and ignorant. How are they to know whether the surgeon is competent or not? They will try to overcome their fear by investing the surgeon with superhuman abilities.

I told him that there was a one or two per cent risk of his dying or having a stroke if the operation went badly. In truth, I did not know the exact figure as I have only operated on a few tumours like his – ones as large as his are very rare – but I dislike terrorizing patients when I know that they have to have an operation. What was certain was that the risk of the operation was many times smaller than the risk of not operating. All that really matters is that I am as sure as I can be that the decision to operate is correct and that no other surgeon can do the operation any better than I can. This is not as much of a problem for me now that I have been operating on brain tumours for many years, but it can be a moral dilemma for a younger surgeon. If they do not take on difficult cases, how will they ever get any better? But what if they have a colleague who is more experienced?

If patients were thinking rationally they would ask their surgeon how many operations he or she has performed of the sort for which their consent is being sought, but in my experience this scarcely ever happens. It is frightening to think that your surgeon might not be up to scratch and it is much easier just to trust him. As patients we are deeply reluctant to offend a surgeon who is about to operate on us. When I underwent surgery myself, I found that I was in awe of the colleagues who had to treat me though I knew that they, in turn, were frightened of me as all the usual defences of professional detachment collapse when treating a colleague. It is not surprising that all surgeons hate operating on surgeons.

My patient listened in silence as I told him that if I operated upon one hundred people like him, one or two of them would die or be left hopelessly disabled.

He nodded and said what almost everybody says to me in reply to this: ‘Well, all operations have risks.’

Would he have chosen not to have the operation if I had said that the risk was five per cent, or fifteen per cent, or fifty per cent? Would he have chosen to find another surgeon who quoted lower risks? Would he have chosen differently if I had not made any jokes, or had not smiled?

I asked him if he had any questions but he shook his head. Taking the pen I offered him he signed the long and complicated form, printed on yellow paper and several pages in length, with a special section on the legal disposal of body parts. He did not read it – I have yet to find anybody who does. I told him that he would be admitted for surgery the following Monday.

‘Sent for the patient?’ I asked as I entered the operating theatre on Monday morning.

‘No,’ said U-Nok the
ODA
(the member of the theatre team who assists the anaesthetist). ‘No blood.’

‘But the patient has been in the building for two days already,’ I said.

U-Nok, a delightful Korean woman, smiled apologetically but said nothing in reply.

‘The bloods had to be sent off again at six this morning,’ said the anaesthetist as she entered the room. ‘They had to be done again because yesterday’s bloods were on the old
EPR
system which has stopped working for some reason because of the new hospital computer system which went live today. The patient now has a different number apparently and we can’t find the results from all the blood tests sent yesterday.’

‘When can I start?’ I asked, unhappy at being kept waiting when I had a dangerous and difficult case to do. Starting on time, with everything just right, and the surgical drapes placed in exactly the right way, the instruments tidily laid out, is an important way of calming surgical stage fright.

‘A couple of hours at least.’

I said that there was a poster downstairs saying that i
CLIP
, the new computer system should only keep patients waiting a few extra minutes.

The anaesthetist laughed in reply. I left the room. Years ago, I would have stormed off in a rage, demanding that something be done, but my anger has come to be replaced by fatalistic despair as I have been forced to recognize my complete impotence as just another doctor faced by yet another new computer program in a huge, modern hospital.

I found the junior doctors in the theatre corridor standing around the reception desk, where a young man was sitting in front of the receptionists’ computer with an embarrassed smile. He wore a white
PVC
tabard on which was stamped in friendly blue letters, on both back and front, ‘i
CLIP
Floorwalker’.

I looked questioningly at Fiona, my senior registrar.

‘We’ve asked him to find the blood results for the brain tumour case but he’s not succeeding,’ she said.

‘I suppose I should go and apologize to the poor patient,’ I said with a sigh. I dislike talking to patients on the morning of their operation. I prefer not to be reminded of their humanity and their fear, and I do not want them to suspect that I, too, am anxious.

‘I’ve already told him,’ Fiona replied to my relief.

I left the junior doctors and returned to my office, where my secretary Gail had now been joined by Julia the bed manager, one of our senior nurses, who is responsible for the thankless task of trying to find beds for our patients. There are never enough beds, and she spends her working day on the telephone, frantically trying to cajole other bed managers elsewhere to swap one patient for another or to take patients back from the neurosurgical wards so that we can admit a new one.

‘Look!’ said Gail. She pointed to the welcome screen for i
CLIP
that she had opened. I saw bizarre names such as Mortuary Discharge, Reverse Decease or Birth Amendments – each with its own colourful little icon – flash past as she scrolled through the long list.

‘I have got to select from this insane list every time I do anything at all!’ said Gail.

I left her to her struggle with the strange icons and sat in my office doing paperwork until I was telephoned to be told that the patient had finally arrived in the anaesthetic room.

I went upstairs, changed, and joined Fiona in the operating theatre. The patient, now anaesthetized and unconscious, was wheeled into theatre with a little entourage of two anaesthetists, two porters and U-Nok the
ODA
, pulling drip stands and monitoring equipment along with a tangle of tubes and cables trailing behind the trolley. His face was now hidden by broad swathes of sticking plaster, protecting his eyes and keeping the anaesthetic gas tubing and facial muscle monitoring wires in position. This metamorphosis from person to object is matched by a similar change in my state of mind. The dread has gone, and has been replaced by fierce and happy concentration.

As the tumour was at the base of the man’s brain, and as there was the risk of heavy blood loss, I had decided to carry out the operation in what is called, simply enough, the sitting position. The unconscious patient’s head is attached to the pin headrest which in turn is connected to a shiny metal scaffold, attached to the operating table. The table is then split and the top half hinged upwards, so that the patient is sitting bolt upright. This helps reduce blood loss during surgery and also improves access to the tumour, but involves a small risk of anaesthetic disaster as the venous blood pressure in the patient’s head in the sitting position is below atmospheric room pressure. If the surgeon tears a major vein air can be sucked into the heart, with potentially terrible consequences. As with all operating, it is a question of balancing risks, sophisticated technology, experience and skill, and of luck. With the anaesthetists, the theatre porters and U-Nok, Fiona and I positioned the patient. It took half an hour to make sure his unconscious form was upright with his head bent forward, that there were no ‘pressure points’ on his arms or legs where pressure sores might develop, and that all the cables and wires and tubes connected to his body were free and not under tension.

‘Well, let’s get on with it,’ I said.

The operation went perfectly with scarcely any blood loss at all. This type of tumour is the only time in brain tumour surgery that you have to remove the tumour ‘en bloc’ – in a single piece – since if you enter the tumour you will be instantly faced by torrential bleeding. With all other tumours in brain surgery you gradually ‘debulk’ it, sucking or cutting out the inside of it, collapsing it in on itself, away from the brain, and thus minimizing damage to the brain. With solid haemangioblastomas, however, you ‘develop the plane’ between the tumour and the brain, creating a narrow crevice a few millimetres wide by gently holding the brain away from the surface of the tumour. You coagulate and divide the many blood vessels that cross from the brain to the tumour’s surface, trying not to damage the brain in the process. All this is done with a microscope under relatively high magnification – although the blood vessels are tiny, they can bleed prodigiously. One quarter of the blood pumped every minute by the heart, after all, goes to the brain. Thought is an energy-intensive process.

If all goes well the tumour is eventually freed from the brain and the surgeon will lift the tumour out of the patient’s head.

‘All out!’ I shout triumphantly to the anaesthetist at the other end of the table, and wave the scruffy and bloody little tumour, no bigger than the end of my thumb, in the air at the end of a pair of dissecting forceps. It hardly looked worth all the effort and anxiety.

With the day’s operating finished I went to see the patient on the Recovery Ward. He looked remarkably well and wide awake. His wife was beside him and they expressed their heartfelt gratitude.

‘Well, we were lucky,’ I said to them, though they probably thought this was false modesty on my part, which I suppose to an extent it was.

As I left, dutifully splashing alcoholic hand gel on my hands on my way out, James the registrar on-call for emergencies came looking for me.

‘I think you’re the consultant on call today,’ he said.

‘Am I? Well, what have you got?’

‘Forty-six-year-old man with a right temporal clot with intraventricular extension in one of the local hospitals – looks like an underlying
AVM. GCS
five. He was talking when he was admitted.’

An
AVM
is an arterio-venous malformation, a congenital abnormality which consists of a mass of blood vessels that can, and often do, cause catastrophic haemorrhages. The
GCS
is the Glasgow Coma Scale and a way of assessing a patient’s conscious level. A score of five meant that the man was in coma, and close to death.

I asked him if he had seen the scan and if the patient was already on a ventilator.

‘Yes,’ James replied, so I asked him what he wanted to do. He was one of the more senior trainees and I knew that he could deal with this case himself.

‘Get him up here quickly,’ he said. ‘There’s a bit of hydrocephalus so I’d stick a wide bore drain in and then take out the clot, leaving the
AVM
alone. It’s deep.’

‘Carry on,’ I said. ‘He’s potentially salvageable so make sure they send him up the motorway pronto. You might point out to the local doctors that there’s no point sending him if they don’t do it quickly. Apparently they need to use the magic phrase “Time Critical Transfer” with the ambulance service and then they won’t mess about.’