Do No Harm: Stories of Life, Death and Brain Surgery (17 page)

17

EMPYEMA

n.
a condition characterized by an accumulation of pus in a body cavity.

It was a simple list: a craniotomy for a tumour, with a couple of routine spinal operations to follow. The first patient was a young man with a glioma on the right side of his brain that could not be removed completely. I had operated for the first time five years ago. He had remained perfectly well but his follow-up brain scans showed that the tumour was starting to grow back again and further surgery was now required, which would hopefully keep him alive for a few more years. He was unmarried and running his own business in IT. We got on well together whenever we met in the outpatient clinic and he had taken the news that he now needed further surgery with remarkable composure.

‘We can hope that another op will buy you some extra years,’ I told him. ‘But I can’t promise it . . . It might be much less. And the operation is not without some risks.’

‘Of course you can’t promise, Mr Marsh,’ he replied.

I carried out his operation under local anaesthetic, so that I could check directly – simply by asking him – that I was not producing any paralysis down the left side of his body. When I tell a patient that I think I should do their operation under local anaesthetic they usually look a little shocked. In fact the brain cannot itself feel pain since pain is a phenomenon produced within the brain. If my patients’ brains could feel me touching them they would need a second brain somewhere to register the sensation. Since the only parts of the head that feel pain are the skin and muscles and tissues outside the brain it is possible carry out brain surgery under local anaesthetic with the patient wide awake. Besides, the brain does not come with dotted lines saying ‘Cut here’ or ‘Don’t cut there’ and tumours of the brain usually look, more or less, like the brain itself, so it is easy to cause damage. If – as was the case here – the tumour was growing near the movement area in the right side of his brain that controlled the left side of his body, the only certain way I had of knowing if I was doing any damage while I operated was by having him awake. It is much easier to carry out brain surgery under local anaesthetic than you might think, provided that the patient knows what to expect, and trusts the surgical team – especially the anaesthetist who will look after the patient while the operation proceeds.

This man coped especially well and while I worked away he talked happily with my anaesthetist Judith – they remembered each other from the first operation and it was like listening to two old friends as they talked about holidays and families and recipes (he was a keen cook), while every few minutes Judith would ask him to move his left arm and leg and make sure that he could still move them as I worked on his brain with my sucker and diathermy.

So it was indeed a straightforward operation and after supervising my registrar with the two spinal cases I walked round to the
ITU
to see that he was fine, chatting to the nurse looking after him. I left the hospital to travel in to central London where I had a conference to attend.

I took my folding bicycle on the train to Waterloo. It was a singularly cold day with freezing rain and the city looked bleak and grey. I cycled to the legal chambers off Fleet Street where the conference was to be held. The case was over an operation I had carried out three years earlier. The patient had developed a catastrophic streptococcal infection afterwards, called a subdural empyema, which I had initially missed. I had never encountered a post-operative infection like this before and did not know any other neurosurgeons who had either. The operation had gone so well that I had found it impossible to believe it might all go wrong and I dismissed the early signs of the infection, signs which in retrospect were so painfully obvious. The patient had survived but because of my delay in diagnosing the infection she had been left almost completely paralysed and will remain so for the rest of her life. The thought of the conference had been preying on my mind for many weeks.

I presented myself to the receptionist in the grand and imposing marble lobby and was ushered into a waiting room. I was soon joined by a fellow neurosurgeon I know well who was advising my Defence Union over the case.

I told him about how I had come to make such a disastrous mistake.

Her husband had rung me up on my mobile phone on a Sunday morning when I was in the hospital dealing with an emergency. I didn’t really take in what he said and misdiagnosed the infection as harmless inflammation. I should never have diagnosed that on the basis of a phone call but I was busy and distracted and I’d never had a serious complication with that particular operation before in twenty years.

‘There but for the grace of God it could have been me,’ my colleague said, trying to cheer me up. We were then joined by two solicitors from the Defence Union. They were very polite but quite without smiles. I thought that they looked tense and drawn but perhaps this was simply my imagination, produced by my awful feeling of guilt. I felt as though I was attending my own funeral.

We were taken downstairs to a basement room where a courteous
QC
– many years younger than me – was waiting for us. A large wall display extolled the virtues of his chambers in fine Roman capital lettering. I cannot remember what was claimed – I was too miserable to take much in.

Coffee was served and one of the solicitors unpacked box after box of documents onto the table.

‘It’s terrible how much trouble one phone call can cause,’ I said sadly as I watched her, and she now smiled briefly at me.

‘I need to start’, the
QC
said very gently, ‘to explain where we are coming from. I think this will be difficult to defend . . .’

‘I entirely agree,’ I interrupted.

The meeting only lasted a couple of hours. It was painfully clear – as I had always known – that the case could not be defended.

At the end of the meeting the barrister asked my colleague to leave.

‘Mr Marsh, perhaps you could stay behind,’ he said.

I remembered once having to wait outside the office of my school headmaster fifty years ago, sick with anxiety, to be punished by the kind old man for some misdemeanour. I knew that the barrister was going to be professional and matter-of-fact but I nevertheless felt overcome with dread and shame.

After my colleague had left he turned to me. ‘I’m afraid I don’t really think we have a case here,’ he said with an apologetic smile.

‘I know,’ I said. ‘I’ve felt it was an indefensible mistake all along.’

‘I’m afraid this might all drag on for a while,’ one of the solicitors added, sounding as I suspect I must sound when I break bad news to my patients.

‘Oh that’s all right,’ I said, trying to sound brave and philosophical. ‘I’m reconciled to this. It’s neurosurgery. I’m just sorry to have wrecked the poor woman and to have cost you millions of pounds.’

‘That’s what we’re here for,’ she said. The three of them looked at me with kind, slightly questioning expressions. Perhaps they expected me to burst into tears. It felt strange to be an object of pity myself.

‘Well, I’ll leave you to discuss the awful financial consequences.’ I said and picked up my satchel and folding bike.

‘I’ll see you to the door,’ said the barrister and insisted on showing me the professional courtesy of accompanying me to the lift in the corridor outside. I did not feel that I deserved it.

We shook hands and he returned to discuss quantum, as lawyers call it – the cost of the settlement – with the two solicitors.

I found my colleague waiting for me in the lobby.

‘It’s the professional shame that hurts the most,’ I said to him. I wheeled my bike as we walked along Fleet Street. ‘Vanity really. As a neurosurgeon you have to come to terms with ruining people’s lives and with making mistakes. But one still feels terrible about it and how much it will cost.’

The weather forecast had promised a dry morning and neither of us were dressed appropriately. Our professionals’ pinstripe suits were getting soaked as we crossed Waterloo Bridge. As the rain streamed off my face my cheeks turned to ice.

‘I know one has to accept these things,’ I went on lamely, ‘But nobody, nobody other than a neurosurgeon understands what it is like to have to drag yourself up to the ward and see, every day – sometimes for months on end – somebody one has destroyed and face the anxious and angry family at the bedside who have lost all confidence in you.’

‘Some surgeons can’t even face going on those ward rounds.’

‘I told them to sue me. I told them that I had made a terrible mistake. Not exactly the done thing, is it? So I remained – crazily enough – quite good friends with them. At least I think so but I can’t expect them to have a very high opinion of me, can I?’

‘You can’t stay pleased with yourself for long in neurosurgery,’ my colleague said. ‘There’s always another disaster waiting round the corner.’

We walked into Waterloo Station, where the crowds were gathering to head south for the weekend, and shook hands and went our respective ways.

I had not dared to ask for how many millions of pounds the case would probably be settled. The final bill, I learned two years later, was for six million.

Back at the hospital that evening I went up to the
ITU
to see the young man with a recurrent tumour whom I had operated upon in the morning – it already felt like a lifetime ago. The operation had gone well enough but we both knew that I had not cured him and that the tumour would grow back again, sooner or later. He was sitting up in his bed, with a lopsided bandage around his head.

‘He’s fine,’ said the nurse looking after him as she looked up from the lectern at the end of his bed where she was writing down the observations.

‘Once again, Mr Marsh,’ my patient said, looking at me intensely, ‘My life in your hands. Really I can’t thank you enough.’ He wanted to say more but I put my finger to my lips.

‘Ssshh,’ I said, as I turned away to leave the
ITU
. ‘I’ll see you tomorrow.’

18

CARCINOMA

n.
a cancer, esp. one arising in epithelial tissue.

I went to see my mother in hospital on Saturday. The cancer ward to which she had been admitted was on the tenth floor and her bed was beside a huge panoramic window. The view was of the Houses of Parliament and Westminster Bridge across the river, seen from above yet very close. The spring weather was exceptionally clear. The River Thames below us reflected the sunlight like polished steel and hurt my eyes. The city beyond was almost oppressive in its clarity – an unrelenting view of buildings, inhuman in scale and size – an inappropriate view, I thought, for somebody who was dying.

My mother said that the staff were very friendly but hopelessly overworked and disorganized compared to when she had been a patient in the same hospital many years earlier, gesturing to her bed which had been left unmade for two days as she said this. She hated complaining but admitted she had been kept starved for two consecutive days while waiting for an ultrasound scan – a scan which I knew was entirely unnecessary since she was already becoming jaundiced and obviously had metastases in her liver from the carcinoma of the breast for which she had been treated twenty years earlier. There was some light relief, she said, in using a commode while looking down on the nation’s rulers across the river. She had grown up in Nazi Germany (from which she had escaped in 1939) and although a perfectly law-abiding citizen she was always sceptical of authority.

She was wasting away, as she herself commented. The bones of her face were becoming increasingly prominent and as she was stripped down to her underlying skeleton, I could recognize myself in her all the more clearly – people have always said that of her four children I am the closest to her in appearance. I could only hope that she might have a few good months left. We had an inconclusive discussion as to what she should do with what time she still had. My mother was one of the bravest and most philosophical people I know but neither of us could bring ourselves to refer to death by name.

I was on call for the weekend and was telephoned endlessly by a new and inexperienced registrar about many difficult problems. These were not clinically difficult problems but problems caused by the chronic lack of beds.

On the following Monday there were various complaints from patients about my trying to discharge them from hospital too quickly. One of the complaining patients was a garrulous old man who was reluctant to go home with an in-dwelling urinary catheter after a simple spinal operation. I’d told him that he would be doing another patient a favour if he went home that day since we had no beds available for the patients who were due to be admitted for surgery next day. He was still on the ward three days later and the ward sister criticized me for having spoken to him in the way that I had (although I thought that I had been scrupulously polite). I had had to cancel an operation on a woman with severe trigeminal neuralgia because he wouldn’t leave. The ward sister, nevertheless, told me that I had to apologize to him for having tried to get him to leave the hospital before he wished. So I went to say sorry to him (through silently gritted teeth). He accepted this happily.

‘Yes, I understand, doctor,’ he said. ‘I used to work in the kitchen-fitting trade and sometimes couldn’t complete a job on time. I also disliked disappointing people.’

I muttered something about brain surgery and building kitchen cupboards not being entirely equivalent and left his room – a balcony room, overlooking the hospital gardens and trees, with a distant view towards Epsom on the horizon. I was still working in the old hospital at the time – it was to be closed three years later. Perhaps if he had been in a more typical
NHS
bay, and not in a room on his own with a view of the hospital gardens and the many daffodils I had planted years before, he might have wanted to leave earlier.

I was away in Glasgow at a medical meeting two days later when the diagnosis of untreatable cancer was finally made and my mother was sent home to die. There was no question of chemotherapy in somebody her age with such advanced disease and she didn’t want it either, which my father found hard to accept. I returned from Glasgow and went to my parents’ house to find them sitting in the kitchen. My mother had become more jaundiced from liver failure since I had last seen her and looked worn and frail though fully herself.

‘I don’t want to leave you all,’ she said sadly. ‘But I don’t think death is the end, you know.’ My eighty-six-year-old father – already starting to suffer from the dementia from which he died eight years later – looked on, with a vague, lost expression as though he couldn’t really take in what was happening: that his fifty-year-old son was crying over his wife of over sixty years, and that she was shortly to die.

Her condition deteriorated very quickly over the next few days, and she was dead within a fortnight; a short illness as the obituaries call it, though it felt quite long while it lasted. Until the very end she remained entirely lucid and completely herself, with her slightly ironical, modest sense of humour preserved until the last.

Each day she weakened, and soon she was established in a bed during the day in the music room downstairs. I would carry her up the staircase of my parents’ house in my arms at the end of the day – by now she weighed next to nothing. But even this was quickly too much for her, and so after discussion with myself and one of my sisters, who is a nurse, my mother remained in the bedroom she had shared with our father for the last forty years. This, she decided, would be where she would die. It was a beautiful room – a perfectly proportioned Georgian room with wood-panelling, painted a quiet, faded green, and an open fireplace and mantelpiece decorated with her collection of little pottery birds and eggs. The tall windows, with their rectangular panes of glass, looked out over the trees of Clapham Common, especially beautiful at that time of year. To the left one could see the church on the Common which she attended every Sunday and where her funeral service would be held.

Every morning and evening my sister and I would come in to care for her. At first I would help her to the bathroom where my sister would wash her but soon she was unable to walk even this short distance and instead I would lift her onto the commode we had borrowed from the local hospice. My sister was wonderful to watch, kindly and gently discussing and explaining everything as she carried out the simple, necessary nursing. We have both seen many people die, after all, and I had worked as a geriatric nurse many years ago too. It felt quite easy and natural for us both, I think, despite our intense emotions. It’s not that we felt anxious – the three of us knew she was dying – I suppose what we felt was simply intense love, a love quite without ulterior motive, quite without the vanity and self-interest of which love is so often the expression.

‘It’s a quite extraordinary feeling to be surrounded by so much love,’ she said two days before she died. ‘I count my blessings.’

She was right to do this, of course. I doubt if any of us will enjoy – if that’s the word to use – such a perfect death when our own time comes. To die in her own home, after a long life, quite quickly, looked after by her own children, surrounded by her family, entirely free of pain. A few days before she died, almost by chance, the family – children, grandchildren and even great-grandchildren, and two of her oldest friends – found themselves all gathered in the family home. We staged what amounted to an impromptu wake, before her death, much to my mother’s delight. While she lay dying upstairs we sat down round the dining room table and remembered her life, and drank to her memory even though she was not yet dead, and ate supper cooked by my wife-to-be Kate. I had only met Kate – to my mother’s joy, after the trauma of the end of my first marriage – a few months earlier. Kate had been slightly surprised to find herself cooking supper for seventeen people when earlier in the day I had hesitantly asked her if she might cook supper for five.

Each day I thought might be the last but each morning when I returned she would say to me, ‘I’m still here.’

Once when I told her, as I kissed her goodnight, that I would see her in the morning, she replied with a smile,

‘Dead or alive.’

My family were playing out an age-old scene that I suppose is rarely seen now in the modern world, where we die in impersonal hospitals or hospices, cared for by caring professionals, whose caring expressions (just like mine at work) will disappear off their faces as soon as they turn away, like the smiles of hotel receptionists.

Dying is rarely easy, whatever we might wish to think. Our bodies will not let us off the hook of life without a struggle. You don’t just speak a few meaningful last words to your tearful family and then breathe your last. If you don’t die violently, choking or coughing, or in a coma, you must gradually be worn away, the flesh shrivelling off your bones, your skin and eyes turning deep yellow if your liver is failing, your voice weakening, until, near the end, you haven’t even the strength to open your eyes, and you lie motionless on your death bed, the only movement your gasping breath. Gradually you become unrecognizable – at least you lose all the details that made your face characteristically your own, and the contours of your face are worn away down to the anonymous outlines of your underlying skull. You now look like the many old people, with drawn and dehydrated faces, identical in their hospital gowns, to whose bedside I would be summoned in the early hours when I worked as a junior doctor, down the long and empty hospital corridors, to certify death. Your face becomes that of Everyman, close to death, a face we all know, if only from the funeral art of Christian churches.

By the time she died my mother was no longer recognizable. I last saw her on the morning of the day she died before I set off to work. I had spent the night in my parents’ house, sleeping on the floor of my father’s study, near my parents’ bedroom. I could hear her rasping breath through the open doors between the study where I was lying and her bedroom. When I went to see her at four in the morning she shook her head when I asked her if she wanted some water and morphine, even though one would have thought from her appearance that she was already dead, had it not been for her laboured, occasional breathing. Before I finally left I said to her, to her death mask, as I held her hand, ‘You’re still here.’ Almost imperceptibly she slowly nodded her head. I cannot remember my last sight of her when I went to work in the morning – it no long mattered. I had said goodbye to her many times already.

My sister rang me shortly after midday, as I sat at some dull medical meeting, to say she had died a few minutes earlier. Her breathing, she told me, had become shallower and shallower until eventually my family, who were gathered round her bed realized, with slight surprise, that she had died.

I felt no need to pay her body my final respects – as far as I was concerned her body had become a meaningless shell. I say ‘body’ – I could just as well talk of her brain. As I had sat by her bedside I had often thought of that – of how the millions upon millions of nerve cells, and their near-infinite connections that formed her brain, her very self, were struggling and fading. I remember her on that last morning, just before I went to work – her face sunken and wasted, unable to move, unable to talk, unable to open her eyes – yet when I asked her if she wanted any water to drink she shook her head. Within this dying, ruined body, invaded by cancer cells, ‘she’ was still there, even though she was now refusing even water, and clearly anxious not to prolong her dying any longer. And now all those brain cells are dead – and my mother – who in a sense was the complex electrochemical interaction of all these millions of neurons – is no more. In neuroscience it is called ‘the binding problem’ – the extraordinary fact, which nobody can even begin to explain, that mere brute matter can give rise to consciousness and sensation. I had such a strong sensation, as she lay dying, that some deeper, ‘real’ person was still there behind the death mask.

What makes for a good death? Absence of pain, of course, but there are many aspects to dying and pain is only one part of it. Like most doctors I suppose I have seen death in all its many forms and my mother was indeed lucky to die in the way that she did. If I ever think about my own death – which, like most people, I try to avoid – I hope for a quick end, with a heart attack or stroke, preferably while asleep. But I realize that I may not be so fortunate. I may very well have to go through a time when I am still alive but have no future to hope for and only a past to look back on. My mother was lucky to believe in some kind of life beyond death but I do not have this faith. The only consolation I will have, if I do not achieve instant extinction, will be my own last judgement on my life as I look back on it. I must hope that I live my life now in such a way that, like my mother, I will be able to die without regret. As my mother lay on her death-bed, drifting in and out of consciousness, sometimes lapsing into her German mother-tongue she said:

‘It’s been a wonderful life. We have said everything there is to say.’