Do No Harm: Stories of Life, Death and Brain Surgery (16 page)

My colleague looked surprised. Litigation is not something we are supposed to encourage.

‘But my duty is to him, not to the Trust – isn’t that what the
GMC
piously tells us doctors?’ I said. ‘If he’s been left crippled and somebody’s made a mistake – he ought to get some financial compensation, shouldn’t he? The irony is that if we hadn’t had to have that meeting with that fatuous manager I’d have been in theatre sooner and this disaster probably wouldn’t have happened. I wish I could blame the manager,’ I added. ‘But I can’t.’

I went off to write an operating note. It’s quite easy to lie if things go wrong with an operation. It would be impossible for anybody to know after the operation in what way it had gone wrong. You can invent plausible excuses – besides, patients are always warned that nerve damage can happen with this operation, even though I have scarcely ever seen it happen. I know of at least one very famous neurosurgeon, now retired, who covered up an even more major mistake on a very eminent patient with a dishonest operating note. I wrote down, however, an exact and honest account of what had happened.

I left the theatre and thirty minutes later saw Judith leaving the recovery ward.

‘Awake?’ I asked.

‘Yes. He’s moving his legs . . .’ she said a little hopefully.

‘It’s the ankle that matters,’ I replied gloomily, ‘not the legs.’

I went round to see the patient. He was only just awake, and was not going to remember anything I said so soon after the operation, so I said little to him and just sadly confirmed my worst fears: he had complete paralysis of lifting the left foot upwards – a foot drop as it is called in the trade – and, as I had told my junior, it is a very disabling condition.

I went to see him two hours later after he had returned to the ward and was fully awake. His wife was sitting anxiously beside him.

‘The operation was not straightforward after all,’ I said. ‘One of the nerves for your left ankle was damaged and that’s why you can’t bend the foot up at the moment. It might get better – I really don’t know. But if it does I’m afraid it will be a slow process that takes months.’

‘But it should get better?’ he asked anxiously.

I told him that I didn’t know and could only promise to always tell him the truth. I felt quite sick.

He nodded in numb agreement, too shocked and confused to say anything. The anger and tears, I thought as I walked away, and dutifully squirted alcohol gel on my hands from a nearby bottle on the wall, will come later.

I went downstairs to my office and dealt with mountains of unimportant paperwork. There was a huge box of chocolates on my desk from a patient’s wife. I took them through to Gail’s office in the next room as she likes chocolates more than I do. Her office, unlike mine, has a window, and I noticed that it was pouring with rain in the hospital car park outside. The pleasant smell of rain on dry earth was filling her office.

‘Have some chocolates,’ I said.

I cycled home in a furious temper.

Why don’t I just stop training juniors? I said to myself as I angrily turned the pedals. Why don’t I just do all the operating myself? Why should I have to carry the burden of deciding whether they can operate or not when the fucking management and politicians dictate their training? I’ve got to see the patients every day on the ward anyway as the juniors are so inexperienced now – on the few occasions when they’re actually in the hospital, that is. Yes, I shall no longer train anybody, I thought with a sudden sense of relief. It’s not safe. There are so many consultants now that having to come in occasionally at night wouldn’t be a great hardship . . . The country’s massively in debt financially, why not have a massive debt of medical experience as well? Let’s have a whole new generation of ignorant doctors in the future. Fuck the future, let it look after itself, it’s not my responsibility. Fuck the management, and fuck the government and fuck the pathetic politicians and their fiddled expenses and fuck the fucking civil servants in the fucking Department of Health. Fuck everybody.

15

MEDULLOBLASTOMA

n.
a malignant brain tumour that occurs during childhood.

There was a child – Darren – who I had operated on many years ago for a malignant tumour called a medulloblastoma when he was twelve years old. The tumour had caused hydrocephalus and although I had removed the tumour completely the condition continued to be a problem and a few weeks after the operation I had carried out a ‘shunt’ operation, implanting a permanent drainage tube into his brain. My son William had undergone the same operation after his tumour had been removed for the same reason. William has been fine ever since but Darren’s shunt had blocked on several occasions – a frequent problem with shunts – and he had required several further operations to revise the shunt. He was treated with radiotherapy and chemotherapy and as the years passed it appeared that he had been cured. Despite the problems with the shunt Darren had otherwise done very well and he went on to study accountancy at university.

He had been at university, away from home, when he started to develop severe headaches. He was brought to my hospital while I was on sick leave with a retinal detachment. A brain scan showed that the tumour had recurred. Although tumours such as Darren’s can and do recur it is usually within the first few years after treatment. For the tumour to come back after eight years – as with Darren – is very unusual and nobody had expected it. Recurrence is inevitably fatal although further treatment can postpone death by a year or two with luck. The plan was that one of my colleagues would operate again in my absence but the evening before the operation Darren suffered a catastrophic haemorrhage into the tumour – an entirely unpredictable event that happens occasionally with malignant tumours. Even if he had been operated upon successfully before the haemorrhage it is unlikely that he would have had long to live. His mother had been with him when he had suffered the haemorrhage. He had been placed on a ventilator on the
ITU
but he was already brain dead and the ventilator was switched off a few days later.

I had got to know Darren and his mother well over the years and I had been very upset to hear of his death when I got back to work, though it was not the first time a patient of mine had died like this. As far as I could make out his treatment once he arrived in my department had been entirely appropriate but his mother was convinced he had died because of my colleague’s delay in operating upon him. I received a letter from his mother requesting an appointment with me. I arranged to see her in my office rather than in one of the impersonal consulting rooms of the outpatient clinic. I brought her into the room and sat her down opposite me. She burst into tears and started to tell me the story of her son’s death.

‘He suddenly sat up in bed and clutched his head. My son cried out “Help me, help me, Mummy!”’ she said, in torment as she told me. I remembered how once a patient of mine, dying from a tumour, had cried out for help to me and how awful and helpless I had felt. How much worse, I thought, how utterly unbearable it must be if it were one’s own child crying for help, and if one could not help them.

‘I
knew
that they should have operated but they just wouldn’t listen to me,’ she said.

She went over the sequence of events over and over again. After forty-five minutes I threw my hands up in the air and shouted in some desperation.

‘But what do you want me to do? I wasn’t there.’

‘I know it wasn’t your fault but I was hoping for some answers,’ she replied.

I told her that as far as I could tell the haemorrhage could not have been predicted and it had been perfectly reasonable to plan on operating the next day. I said that the doctors and nurses who had been looking after Darren were terribly upset about what had happened.

‘That’s what they said on the
ITU
when they wanted to turn the ventilator off,’ his mother said, her voice choking with anger. ‘That keeping him on the ventilator was upsetting for the staff. But these people are paid,
they are paid
, to do their job!’ She became so angry that she rushed out of the room.

I followed her out of the hospital into the afternoon sunlight to find her standing in the car park opposite the main entrance

‘I’m sorry that I shouted,’ I said. ‘I find this all very difficult.’

‘I thought you would be furious when you heard about his death,’ she said to me in a disappointed voice. ‘I know that it’s difficult for you . . .’ – she waved her arm at the building behind us – ‘You have a duty to the hospital.’

‘I’m not trying to cover up for anybody,’ I replied. ‘I don’t like this place and have no loyalty to it whatsoever.’ As we talked we had started to walk back to the steel and glass front entrance to the hospital. The constant passage of people coming and going through the automatic doors made it feel like a railway station.

I took her back to my office, past the threatening notice at the entrance to the outpatient clinic over which I had once got into trouble for denouncing on the radio. ‘This Trust’ – states the notice – ‘operates a policy of withholding treatment from violent and abusive patients . . .’ It was ironic, I thought, how the notice expressed the hospital management’s distrust of patients, and it was a corresponding lack of trust in the hospital which was now tormenting Darren’s mother. She collected her bag from my office and left without saying anything more.

I went back up to the wards. I met one of my registrars on the staircase.

‘I’ve just seen Darren’s mother,’ I said to him. ‘It was pretty grim.’

‘There had been a lot of problems when the boy was dying on the
ITU
,’ he replied. ‘She wouldn’t let us turn the ventilator off, even though he was brain dead. I had no problem with that, but some of the anaesthetic staff got pretty difficult over the weekend and some of the nurses were refusing to look after him since he was brain dead . . .’

‘Oh dear,’ I said.

I remembered how angry I had been myself many years ago, at how my own son had almost died due to what I felt had been the carelessness of one of the doctors looking after him when he had been admitted to hospital with his brain tumour. I also remembered how, after I had become a neurosurgeon myself, I had operated on a young girl with a large brain tumour. The tumour was a mass of blood vessels, in the way that some brain tumours can be, and I had struggled desperately to stop the bleeding. The operation became a grim race between the blood pouring out of the child’s head and my poor anaesthetist Judith pouring blood back in through the intravenous lines as I tried, and failed, to stop the bleeding.

The child, a very beautiful girl with long red hair, bled to death. She ‘died on the table’ – an exceptionally rare event in modern surgery. As I completed the procedure, stitching together the scalp of the now dead patient, there was utter silence in the operating theatre. The normal sounds of the place – the chatter of the staff, the hissing of the ventilator, the bleeping of the anaesthetic monitors – had suddenly stopped. All of us in the theatre avoided each other’s eyes in the presence of death and in the face of such utter failure. And as I closed the dead child’s head I had to think about what to tell the waiting family.

I had dragged myself up to the children’s ward, where the mother was waiting to see me. She would not have been expecting to hear this catastrophic news. I had found it very difficult to talk, but managed to convey what had happened. I had no idea how she might react, but she reached out to me and held me in her arms and consoled me for my failure, even though it was she who had lost her daughter.

Doctors need to be held accountable, since power corrupts. There must be complaints procedures and litigation, commissions of enquiry, punishment and compensation. At the same time if you do not hide or deny any mistakes when things go wrong, and if your patients and their families know that you are distressed by whatever happened, you might, if you are lucky, receive the precious gift of forgiveness. As far as I know Darren’s mother did not pursue her complaint but I fear that if she cannot find it in her heart to forgive the doctors who looked after her son in his final illness she will be haunted forever by his dying cry.

16

PITUITARY ADENOMA

n.
a benign tumour of the pituitary gland.

By the time that I became a consultant in 1987 I was already an experienced surgeon. I was appointed to replace the senior surgeon at the hospital where I had been training and as the senior surgeon wound down his career he had delegated most of his operating to me. Once you become a consultant you are suddenly responsible for your patients in a way that you never were as a junior and trainee. You come to look back on your years of training as an almost carefree time. As a trainee the ultimate responsibility for any mistakes that you might make are ultimately borne by your consultant and not by yourself. As I get older I find the self-assurance of many of my trainees, for whose mistakes I am responsible, a little irritating but I was no different myself once. This all changes when you become a consultant.

My first few months in the role passed without incident. I was then referred a man with acromegaly. The disease is caused by a small tumour in the pituitary gland producing excess growth hormone. The person’s face slowly changes – it becomes heavy and block-like, not unlike the cartoon figure Desperate Dan in the
Dandy
magazine, with a massive jaw and forehead. The feet enlarge and the hands become large and spade-like. The changes in this patient’s case were not especially severe, and often the changes are so gradual over so many years that most patients and their families do not notice them. If one knew he had the condition one might notice that his jaw was a little heavy. The high levels of growth hormone ultimately damage the heart and it is for that reason, not the cosmetic changes, that we operate. The operation is done through the nostril, since the pituitary gland lies beneath the brain at the top of the nasal cavities, and is usually simple and straightforward. There are, however, two major arteries next to the pituitary gland that can, if the surgeon is exceptionally unlucky, be damaged during the operation.

His wife and three daughters had all come with him to my office when I first saw him. They were Italian and had become extremely emotional when I said that surgery would be required. They were obviously a close and loving family. Despite their anxieties about the operation, they expressed great confidence in me. He was a particularly nice person – I had been in to see him on the Sunday evening before the operation and we talked happily together for a while. It is a pleasant feeling when your patient obviously trusts you so completely. I operated the next day and the operation went well. He awoke perfectly. I went round to see him late that evening, and his wife and daughters were full of praise and thanks, which I happily acknowledged. The next day some of the symptoms of acromegaly – the feeling that his fingers were swollen – were already a little better and on Thursday morning I went to see him before he went home.

When I went to his bed and spoke to him he looked blankly back at me and said nothing. I then noticed that his right arm was lying useless beside him. One of the nurses hurried up to the bedside.

‘We were trying to find you,’ she said. ‘We think he must have had a stroke just a few minutes ago.’ My patient and I looked uncomprehendingly at each other. I could scarcely believe, and he could not understand, what was happening. I felt a bitter wave of dread and disappointment break over me. Struggling against this I did my best to reassure him (though he would not have understood the words) that all would be well. But a brain scan later that morning confirmed a major stroke in his left cerebral hemisphere. This must have been caused in some unknowable way by the operation. He was by now aphasic – utterly without language. He did not seem too distressed by this, so presumably had little awareness of the problem and was living in some strange language-less world like a speechless animal.

Forgotten memories of other patients I had reduced to this grotesque state in the past suddenly came back to me. A man with an aneurysm in his brain, one of the first such operations I had carried out on my own as a senior registrar; another was an operation I had done on a man with a blood-vessel malformation in his brain. Unlike with this man, where the stroke occurred three days after the operation, with both these patients the operations had gone badly and they had suffered major strokes during the procedures. They had both looked at me afterwards with the same terrible dumb anger and fear, a look of utter horror – unable to talk, unable to understand speech – the look of the damned in some medieval depiction of hell. With the second patient, I remember the intense relief when I came to work next morning to find that he had suffered a cardiac arrest – as though the sheer trauma of what had happened to him had proved too much for his heart. The resuscitation team were working away at him – they were clearly not achieving anything, so I told them to stop and leave him in peace. I do not know what happened to the other man other than that he survived.

At least the Italian man seemed merely puzzled, and looked at me with a vague and empty expression. I had many long and emotional conversations with the family later that day. This involved floods of tears and much embracing. It is difficult to explain, let alone to understand, what it must be like to have no language – to be unable either to understand what is said to one, or put one’s thoughts into words. After major strokes people can die from brain swelling, but this patient remained unchanged for forty-eight hours, and the next evening I assured the family that he would not die, although I did not know if he would regain his speech, and rather doubted it. Nevertheless, two days later, at one o’clock in the morning he deteriorated.

My young and inexperienced registrar rang me.

‘He’s gone off and blown both his pupils!’ he excitedly told me.

‘Well, if both pupils have blown that means he’s coned. He’s going to die. There’s nothing to be done,’ I told him. Coning refers to the way in which the brain is squeezed like toothpaste out of the hole in the base of the skull when the pressure in the skull becomes very high. The extruded part of the brain is cone-shaped. It is a fatal process.

I went to bed, having growled to my registrar that I was not going to come in. But I couldn’t get to sleep and instead drove in to the hospital, the streets deserted apart from a single fox confidently trotting across the road in front of the hospital, summer rain falling. The empty hospital corridors were ringing with the family’s cries, including the three-year-old grand-daughter’s. So I gathered them all together and sat in a chair facing them and explained things and told them how sorry I was. The patient’s wife was on her knees in front of me, clasping her hands, begging me to save her husband. This went on for half an hour or so – it felt longer. They came to accept the inevitability of his death, and perhaps even that it was better for him than to live without language.

I remember another time I had had a patient die from a stroke after an operation. The family had sat staring at me, glaring at me and saying nothing as I tried to explain and to apologize. It was quite clear they hated me and felt that I had killed their father.

But this family was extraordinarily kind and considerate. His daughters said that they did not blame me, and that their father had had great confidence in me. Eventually we parted – one of the daughters brought the three-year-old grand-daughter to me, who had now stopped crying. She looked up at me with two large and dark eyes above her tear-stained cheeks.

‘Kiss the doctor good night, Maria, and say thank you.’

Maria laughed happily as we rubbed each other’s cheeks.

‘Goodnight, sweet dreams, Maria,’ I dutifully said.

My registrar had been watching all this. He thanked me for sparing him the painful task of talking to the family.

‘Terrible job, neurosurgery. Don’t do it,’ I said as I went past him on my way to the door.

I passed the patient’s wife, standing beside the public phone in the corridor, as I walked to the front door.

‘Remember my husband, please think of him sometimes,’ she said, reaching a despairing hand out to me. ‘Remember him in your prayers.’

‘I remember all my patients who die after operations,’ I said, adding to myself as I left, ‘I wish I didn’t.’

I was relieved that he had died – if he had survived he would have been left terribly disabled. He had died because of the operation but not as a result of any obvious mistake on my part. I do not know why the stroke had happened or what I could have done to avoid it. So, just for once, I felt, at least in theory, innocent. But when I arrived home I sat in my car outside my house, the rain falling in the dark, for a long time, before I could drag myself off to bed.