Do No Harm: Stories of Life, Death and Brain Surgery (10 page)

‘But why wasn’t she changed already?’

‘We’re not allowed to.’

‘What do you mean?’ I asked in exasperation. ‘Who doesn’t allow it?’

‘It’s the government,’ the nurse replied.

‘The government?’

‘Well the government says we can’t have patients of different sexes sitting in the same room in theatre gowns.’

‘Why not put them in dressing gowns?’

‘We suggested that ages ago. The management said the government wouldn’t allow it.’

‘So what should I do? Complain to the prime minister?’ The nurse smiled.

‘Here she is,’ she said, as Mrs Seagrave appeared, being pushed along the corridor in a wheelchair by her daughter. She was dressed in one of those undignified hospital gowns that scarcely cover one’s buttocks, so perhaps the government was right after all.

‘She had to change in the toilet,’ said her daughter, rolling her eyes.

‘I know. There are no separate facilities for the patients who come in on the morning of the operation,’ I said. ‘Anyway, we’re running out of time. I’ll take her to theatre myself.’ So I took hold of the wheelchair and rolled her rapidly down the corridor.

The ward nurse came running down the corridor after me clutching Mrs Seagrave’s notes.

By now it was three o’clock and the anaesthetist was looking distinctly unhappy.

‘I’ll do it all myself,’ I hurriedly assured her. ‘Skin to skin.’ Mike was disappointed that I would be elbowing him aside – earlier in the day I had told him that I would assist him doing it. Now he would have to assist me.

‘It looks very straightforward. It’s going to be easy,’ I added. This was a lie and I did not expect Rachel to believe it. Few anaesthetists believe what surgeons tell them.

And so, at half past three, we started.

Mike bolted the patient’s head to the operating table and shaved the left side of her head.

‘These are operations where one really doesn’t know what’s going to happen,’ I muttered to Mike, not wanting Rachel to hear. ‘She might bleed like a stuck pig. The tumour might be horribly stuck to the brain so it will take hours and at the end we’re left with the brain looking a horrible mess and she’s crippled, or the tumour might just jump out and scamper round the theatre.’

With scalpels, drills and clips, together we worked our way steadily through the scalp and skull of the late eminent gynaecologist’s widow. After forty minutes or so we were opening the meninges with a small pair of scissors to expose her brain and the meningeal tumour pressing into it.

‘Looks pretty promising,’ said Mike, bravely hiding his disappointment at not doing the operation himself.

‘Yes,’ I agreed. ‘Not bleeding much and looks as though it will suck nicely.’ I picked up my metal sucker and stuck it into the tumour. It made an unattractive sucking sound as the tumour started to disappear, peeling gently off the brain as it shrank.

‘Awesome!’ said Mike. After a few minutes I shouted out happily to Rachel: ‘Forty minutes to open her head. Ten minutes to remove the tumour! And it’s all out and the brain looks perfect!’

‘Wonderful,’ she said, though I doubted if I was forgiven.

I left Mike to close up the old lady’s head and sat down in a corner of the theatre to write an operating note. It took another forty minutes to finish the operation and the patient was being wheeled off to the Intensive Care Unit by 5 p.m.

Mike and I left the theatres and walked round the wards to see our inpatients. Apart from the two surgical cases we had just done there were only a few patients, recovering uneventfully from relatively minor spinal operations done two days earlier so the ward round took only a few minutes and we ended up on the
ITU
. Examining patients at the end of the operating list, making sure that they are, as the jargon has it, ‘awake and fully orientated with a
GCS
of 15’, is an important part of the neurosurgeon’s day.

Mrs Seagrave was sitting half-upright in her bed, with drip-stands and syringe pumps and monitors with flashing displays beside her. With so much technology it is hard to believe that anything can go wrong but what really matters is that a nurse wakes the patient up every fifteen minutes to make sure they are alert and not slipping into a coma caused by post-operative bleeding. A nurse was cleaning blood and bone dust from her hair. I had finished the operation in a hurry and had forgotten to wash and blow-dry her hair, something I usually do with female patients.

‘It all went perfectly,’ I said, leaning slightly over her from the side of the bed. Mrs Seagrave reached out for my hand and held it tightly.

‘Thank you,’ she said, in a voice a little hoarse from the anaesthetic tube.

‘All out, and definitely benign,’ I said. I turned away and went to see the man with the trigeminal neuralgia who was in the bed next to hers. He was asleep and I shook him gently. He opened his eyes and looked a little groggily at me.

‘How’s your face feel?’ I asked.

He cautiously touched his cheek. Before the operation doing this would have caused him the most terrible agony.

He looked surprised and prodded his cheek a little more forcefully.

‘It’s gone,’ he said, in an awe-struck voice and smiled happily. ‘That’s wonderful.’

‘The op went fine,’ I said. ‘Definite artery on the nerve. Consider yourself cured.’ I saw no need to mention the awful bleeding.

I went down the stairs to my office to see if there was any more paperwork to be done but just for once Gail had left my office empty. It had been a good day. I had not lost my temper. I had finished the list. The patients were well. The pathology had been benign. I had been able to cancel the two spines at the beginning of the list rather than at the end. There were no major problems with the patients on the wards. What more could a surgeon want?

On my way out I passed Anthony, who was coming in for the evening shift. I asked about the old lady with a chronic subdural who wanted to die.

‘I think they operated,’ he said. He headed off to the wards and I walked out into the night. Mrs Seagrave’s daughter was standing outside the hospital entrance, beside the railings where I padlock my bicycle, smoking a cigarette.

‘How did it go?’ she asked when she saw me.

‘It went perfectly,’ I replied. ‘She might be a bit confused for a few days but I think she’ll make a very good recovery.’

‘Well done!’ she said.

I told her that it was largely a matter of luck but she probably didn’t believe me – they never do when an operation has gone well.

‘I’m sorry I lost my temper with your registrar yesterday. . .’ she began.

‘Don’t think about it,’ I replied cheerfully. ‘I was an angry relative myself once.’

8

CHOROID PLEXUS PAPILLOMA

n.
a benign tumour of the choroid plexus, a structure made from tufts of villi within the ventricular system that produces cerebrospinal fluid.

Thirty years ago British hospitals always had a junior doctor’s bar where you could go for a drink at the end of a long day, or where – if you had any free time – you could spend the evening smoking and drinking when on call, or playing on the Space Invaders or Pacman machines in a corner of the room.

I was working as a gynaecological houseman, and had only been qualified as a doctor for four months. It was to be eighteen months before I saw the operation that convinced me to become a neurosurgeon. I was standing at the bar one evening, drinking beer and gossiping with colleagues, probably discussing patients and their illnesses in that slightly swaggering way that young doctors have when talking to each other. I was probably also feeling a little guilty about not returning home more promptly to see my wife Hilary and our three-month-old son William when my bleep announced an outside call. I found the nearest phone to be told by Hilary, who sounded desperate, that our son had been admitted to the local hospital, seriously ill, with some kind of problem in his brain.

I remember very clearly how I ran from the hospital to the underground station, and once off the train, sick with anxiety, sprinted through the dark and deserted back streets of Balham – it was winter and it was already late in the evening – to the local hospital. There I found a distraught Hilary in a quiet side-room, our baby son sleeping restlessly in her arms, and a consultant paediatrician who had waited for my arrival. He told me that William had acute hydrocephalus and would be transferred to the children’s hospital at Great Ormond Street the next day for a brain scan.

My wife and I spent the next few weeks in that strange world one enters when you fear for your child’s life – the outside world, the real world, becomes a ghost world, and the people in it remote and indistinct. The only reality is intense fear, a fear driven by helpless, overwhelming love.

He was transferred on a Friday afternoon – never a good time to fall seriously ill – and a brain scan was organized. Because I was a doctor myself, and the junior doctor looking after William turned out, by an odd coincidence, to be an old school-friend of Hilary’s, I was allowed to stand in the control room for the scanner. It was strange to hear the two radiographers happily chatting about a party they had been to, detached and uninterested in the little baby wrapped in a blanket who could be seen through the control room window lying in the big mechanical doughnut of the machine with his mother, looking drawn and desperate, sitting beside him. I watched the images appearing on the computer screen as the scanner slowly worked its way up through William’s head. They showed acute hydrocephalus and a tumour immediately in the centre of his brain.

He was taken back to the ward from the scanner. I was told the consultant surgeon would be coming to see him later. William was now obviously – or at least it looked obvious to me – unconscious and very ill but I was assured by the surgical registrar that he was just sleeping off the sedation he had been given for the scan. The afternoon passed and it became dark outside. We were then told that possibly the consultant surgeon would not be coming until the following Monday. In a kind of fugue state, I wandered around the hospital’s long corridors, now largely empty, helplessly trying to find the consultant – a man who seemed to have become as mythical as the neurosurgeons in my own hospital – and eventually, despairing, unable to stand it any longer, I abandoned my wife and child and went home, where I smashed a kitchen chair in front of my alarmed parents and swore to sue the hospital if William came to any harm.

While I was failing so dismally to cope with the situation the surgeon had, I later learned, appeared, taken one look at William and ushered Hilary out of the room. He inserted emergency drains into William’s brain through the fontanelle to relieve the build-up of pressure – at least in retrospect I could claim to have been right to have been so frightened. We were told that an operation to remove the tumour would take place five days later. The five days were torture.

When I drove home the night before the operation, a black cat had suddenly run out in front of my car, a few hundred yards away from our home. The wheels of my car ran straight over it. I had never killed any animal in this way before and have yet to do so since. I got out of the car and went to look at the poor creature. It lay in the gutter, obviously dead, its mouth and eyes open, bared at the moon above in the clear winter sky. I remembered how the name tag around William’s little wrist had a cat’s face on it, since he was in a children’s hospital, and they like to do things that way. I am not a superstitious man but I found this very frightening.

William underwent surgery on a Wednesday morning. Hilary and I spent many hours pacing around central London while the operation went on. It was a useful lesson for me, when I became a fully trained surgeon myself, to know how much my patients’ families suffer when I am operating.

The operation was a success and William survived, since the tumour proved to be a benign choroid plexus papilloma even though the pathology report had reported it to be malignant. I came to realize later that few brain tumours at that age are benign, and that even with the benign tumours the risks of surgery in such young children are immense. Years afterwards, when training as a paediatric brain surgeon myself, I watched a child bleed to death in the very same operating theatre where my son had been treated, as my boss – the very surgeon who had saved my son’s life – now failed with a similar tumour.

Anxious and angry relatives are a burden all doctors must bear, but having been one myself was an important part of my medical education. Doctors, I tell my trainees with a laugh, can’t suffer enough.

9

LEUCOTOMY

n.
the surgical cutting of tracts of white nerve fibres in the brain; orig. spec., prefrontal lobotomy; an instance of this.

My department is unusually fortunate in having a sitting room for the surgeons beside the operating theatres. The room is furnished with the two large red leather sofas that I bought shortly after we moved from the old hospital. When our department was moved from the old hospital to a newly built block at the main hospital some miles away, the entire second floor of the new building was dedicated to neurosurgery. As time passed, however, the management started to reduce our facilities and one of the neurosurgical theatres became a theatre for bariatric surgery – surgery for morbidly obese people. The corridors and rooms were starting to fill with unfamiliar faces and patients the size of small whales being wheeled past on trolleys. The department no longer felt like our home and I feared that I was starting to develop the slightly alienated, institutionalized outlook that afflicts so many of the staff working in huge, modern hospitals.

I was sitting in the red leather sofa room one day reading a book while my registrar started a case. We had taken to keeping the door of the room locked, as there were so many strangers now present in the theatre department. As I sat on my sofa somebody started knocking and shaking the door. I felt increasingly foolish sitting there refusing to open the door. Eventually, to my dismay, the door was forced open and four doctors – none of whom I recognized – burst into the room with sandwiches in their hands. Embarrassed, I stood up.

‘This is the neurosurgical office!’ I said, feeling like a pompous fool. ‘You’re not welcome here!’

They looked at me in surprise.

‘The management said all the facilities would be shared,’ one of them said, looking at me in disgust.

‘Well the management never discussed it with us,’ I replied. ‘If you had your own office, wouldn’t you resent it if other people barged in without asking?’

‘We’re surgeons,’ one of them said, shrugging, but they left the room, and I also left, too upset to remain, yet determined to maintain what little remained of our neurosurgical territory.

I joined my registrar in the operating theatre, where I took over the operation. It was an unusually difficult case and I damaged the nerve for the left side of the patient’s face as I removed the tumour. Perhaps this was going to happen anyway – it is called a ‘recognized complication’ of that particular operation – but I know that I was not in the right state of mind to carry out such dangerous and delicate surgery, and when I saw the patient on the ward round in the days afterwards, and saw his paralysed face, paralysed and disfigured, I felt a deep sense of shame. It is little consolation that my colleagues and I have been left undisturbed in the red leather sofa room, our little oasis, ever since, although I believe I have become an object of deep dislike among many of the other surgeons in the hospital.

For reasons that have never been determined, all the windows in the offices for the operating theatre block, including the room with the red leather sofas, are five feet off the floor. All you can see through them, once you sit down, is the sky, with an occasional plane on its way to Heathrow or more often a pigeon, or sometimes a sea gull and very occasionally a kestrel. I have spent many hours lying on the longer of the two sofas, reading medical journals, struggling to keep awake, waiting for the next case to begin, watching the dull clouds through the high windows. In recent years the delays between finishing one operation and starting the next have become longer and longer. The trouble is that we cannot start the operation until we know that there is going to be a bed into which to put the patient after the operation, and this is often not the case. The stream of initiatives and plans and admonitions from the government and management that we must work ever more efficiently feels like a game of musical chairs – the music is constantly being changed, indeed with the latest round of reforms the government has even changed the orchestra – but there are always more patients than beds and so I spend many hours lying on a sofa, staring gloomily at the clouds, watching the pigeons hurrying by.

I was lying on the sofa waiting for the next case to start and dozing over a book. My colleague who operates on the same days as I do was sitting in a chair, waiting like myself for his next case to be anaesthetized.

‘I see that we have been told that the whole culture of the
NHS
must change – after all those patients died in Stafford. What a whitewash. It’s all about who’s in charge,’ he said.

I remembered when, still a student, I had spent several months working as a nursing assistant on the long-term psycho-geriatric ward of one of the huge long-term psychiatric hospitals that used to surround London. Most of the patients were profoundly demented. Some had come from the outside world with degenerative brain diseases, some were schizophrenics who had already spent most of their lives in the hospital and were now sinking to the end of their lives. To go to work at seven in the morning to be faced by a room of twenty-six doubly incontinent old men in beds is an education of sorts, as it was to wash them and shave them and feed them, and pot them, and strap them into geriatric chairs. I met some nurses who were utterly unsuited to the work and others who were quite remarkably patient and kind, in particular a wonderful West Indian man called Vince Hurley, who was the charge nurse for the ward. It was miserable work, with little reward, and I learned much about the limitations of human kindness, and in particular my own.

I was told that in the nineteenth century when the severe and prison-like hospital had been built that there had been a hospital farm on the extensive grounds and that the patients had worked on the farm, but when I was there the grounds were just a series of wide, empty fields. Rather than carry out farm work outside, some of the patients now received something called Occupational Therapy. This involved three occupational therapists – stout middle-aged ladies in maroon-coloured housecoats – leading out a straggling line of demented old men onto the fields around the hospital twice a week. It was 1976, the year of the great drought, and the hospital grounds had been burnt brown and yellow, and the patients’ faces had been burnt red since most of them were on the anti-psychotic drug Largactil which is a photo-sensitizer. The patients were given a football and left to their own devices – most of them sat down and stared into space. The three therapists also sat down. One particularly catatonic patient – he had been lobectomized many years ago – could sit immobile for hours on end and served as a backrest for one of the therapists, as she sat on the burnt grass, her back resting comfortably against his as she did her knitting. He was called Sydney, and he was famous for having enormous genitals. I had been summoned by the other nurses, at washing time, on my very first day at work, to admire Sydney’s equipment, as he lay catatonically in the bath.

It was while working here that I first came across the name of the famous neurosurgical hospital where I was to train and eventually become the senior consultant neurosurgeon myself. In the 1950s many of the patients I was now looking after – like the catatonic Sydney – had been sent to that hospital and subjected to the psychosurgical procedure known as a frontal lobectomy or leucotomy. It was a fashionable treatment at the time for schizophrenia and was supposed to turn agitated, hallucinating schizophrenics into calmer, happier people. The operation involved severing the frontal lobes from the rest of the brain with a specially shaped knife and was completely irreversible. Fortunately it was rendered obsolete by the development of phenothiazine drugs such as Largactil.

The lobectomized men were, it seemed to me, some of the worst affected of the patients – dull and apathetic and zombie-like. I was shocked to find, when surreptitiously looking at their notes, that there was no evidence of any kind of follow-up or post-operative assessment. In all the patients who had been lobectomized there would be a brief note stating ‘Suitable for lobectomy. For transfer to
AMH
’. The next entry would read ‘Returned from
AMH
. For removal of black silk sutures in nine days’, and that was it. There might be the occasional entry years later stating, for instance ‘Called to see. Fight with other patient. Scalp laceration sutured’, but other than the notes made at the time of the patient’s first admission to the hospital, usually with an episode of acute psychosis, the medical notes were empty even though the patients had been in the hospital for many decades.

Two years earlier a Royal Commission on Psychiatric Care had been established in response to an outcry in the press over accusations of brutality made by a student who, rather like myself, had worked as a nursing assistant in a long-term psychiatric hospital. It was why I was viewed with considerable suspicion by the other hospital staff when I arrived and it took me some time to persuade them that I was not spying on them. I suspect that some things were kept hidden from me, but I saw little, if any, actual cruelty when I was there.

I was surprised one morning, when spooning gruel into an old man’s edentulous mouth, to see the nursing officer come into the dining room. He told me that I had the afternoon off, though gave me no reason. He had brought with him a large laundry bag full of worn but clean old suits, some of them pinstriped, and much underwear. The patients were all doubly incontinent so we kept them all in pyjamas as it was easier to change them and keep them clean, but my fellow nurses and I were told that all the patients were now to be dressed in suits and underwear. So our poor, demented patients were all dressed up in sagging, second-hand suits, and put back in their geriatric chairs and I went home. When I clocked in for the late shift next day I found the patients all back in pyjamas and the ward back to normal.

‘The Royal Commission came yesterday,’ Vince said to me with a grin ‘They were very impressed by the suits. The nursing officer didn’t want you around in case you said the wrong thing.’

Vince was one of the most impressive people I have met in my long medical career. To work on that ward, with those hopeless cases, to treat them with such kindness and tact, was remarkable. Sometimes he would stand behind one of the babbling, demented incontinent old men, and lean his hands, sleeves of his white coat rolled up, on the high back of the patient’s chair.

‘What’s it all about?’ he would say with a sigh. ‘That’s what I want to know. What it’s it all about?’ and we would laugh, and get on with the day’s work – feeding the patients, washing the patients, lifting them on and off the toilet, and eventually putting them to bed for the night.

Thirty-five years later the hospital is still there but the grounds have been sold and have become a smart golf course. The patients I looked after must all have died a long time ago.

‘What are you reading?’ my colleague asked, seeing that there was a book on my lap.

‘Something incomprehensible about the brain,’ I said, ‘written by an American psychologist who specializes in treating obsessional compulsive disorder with group therapy based on combining Buddhist meditation with quantum mechanics.’

He snorted. ‘How fucking ridiculous! Didn’t you once do psychosurgery for
OCD
?’

It was true. I had inherited the operation from my predecessor but had been happy to abandon it. It involved making lesions in the caudate nucleus and cingulate gyrus of the frontal lobes – a sort of micro-lobectomy without its awful effects. The psychiatrists told me that the operation really did work. It had all seemed rather like guesswork to me but recent high-tech functional scanning in
OCD
shows that these are indeed the areas involved. Psychosurgery was banned by law in California so a few desperate Californians who had become quite suicidal because they couldn’t stop washing their hands – fear of dirt being one of the commonest problems with
OCD
– used to come to this country for treatment. I remembered how one of them had to put on three pairs of gloves before he could touch the pen I handed him for signing the consent form that allowed me to burn a few holes in his brain. As I told my colleague about my experience of psychosurgery a nurse came into the room.

‘Mr Marsh,’ she said, looking disapprovingly at me as I lay sprawled on the sofa in my theatre pyjamas, ‘the next patient says his tumour is on right side but the consent form says for surgery on left.’

‘Oh for God’s sake,’ I said. ‘He’s got a left parietal tumour and has got left-right confusion as a result. You might like to know it’s called Gerstmann’s syndrome. He’s the last person to ask where to operate! He’s been thoroughly consented. I spoke to him myself last night. And the family as well. Just get on with it.’

‘Some people don’t think Gerstmann’s syndrome really exists,’ my colleague – who is very knowledgeable about such things – said from across the room.

‘You must go talk to him,’ the nurse said.

‘This is ridiculous,’ I grumbled as I rolled off the sofa. I walked the short distance to the anaesthetic room, through the theatre where Kobe the theatre porter was cleaning up after the first operation, mopping up blood, smeared in ragged lines on the floor. There was the usual pile of rubbish – several thousand pounds worth of single-use equipment scattered around the operating table, waiting to be bagged up and sent off for disposal. I pushed through the swing doors to the anaesthetic room where the old man was lying on a trolley.

‘Mr Smith. Good morning!’ I said. ‘I gather you want me to operate on the right side of your head.’

‘Oh Mr Marsh! Thank you for coming! Well I thought it was on the right,’ he replied, his voice trailing off in uncertainty.

‘Your weakness is on the right,’ I said. ‘But that means the tumour is on the left of your brain. Everything is crossed over, you know.’

‘Oh,’ he replied.

‘Well, I’ll operate on the right side if you want but would you perhaps prefer me to decide on the side?’