Do No Harm: Stories of Life, Death and Brain Surgery (6 page)

I went off to get a cup of coffee and get some paperwork done in my office. Patrik stayed behind to watch the Caesarean section.

He rang me an hour later. I was sitting at my desk dictating letters.

‘It all went fine. She’s on the ITU and the baby’s next to her.’

‘Can she see?’ I asked.

‘Too early to say,’ Patrik said. ‘Her pupils are a bit slow . . .’

I felt a familiar drag of fear in my stomach. The fact that the pupils of her eyes were not reacting properly to light might just be a temporary anaesthetic effect but it could also mean that the nerves were irreparably damaged and that she was completely blind, even though the operation had seemed to go so well.

‘We’ll have to wait and see,’ I replied.

‘The next patient’s on the table,’ Patrik said. ‘Shall we start?’

I left my office to go and join him.

The second patient on the list was a woman in her fifties with a malignant left temporal glioma, a cancerous tumour of the brain itself. I had seen her a week earlier in my outpatient clinic. She had come with her husband, and they held each other’s hands as they told me how she had become confused and forgetful over the preceding weeks. I explained to them that her brain scan showed what was undoubtedly a malignant tumour.

‘My father died from a malignant brain tumour,’ she told me. ‘It was terrible to watch him deteriorate and die and I thought that if that happened to me I would not want to be treated.’

‘The trouble is,’ I said reluctantly, ‘it will happen to you anyway. If I treat you, with a bit of luck, you might have some years of reasonable life but if we do nothing you have only a few months left to live.’

In reality this was probably optimistic. The scan showed a foul malignant tumour in her dominant temporal lobe – dominant meaning the half of the brain responsible for speech and language – that was already growing deep into her brain. It was unlikely that she had more than a few months left to live whatever I did, but there is always hope, and there are always a few patients – sadly only a small minority – who are statistical outliers and defy the averages to live for several years.

We had agreed that we should operate. Patrik did most of it, and I assisted him. The operation went well enough though as soon as Patrik drilled open her head and cut through the meninges, we could see that the tumour was already spreading widely, more widely than in the brain scan done only two weeks earlier. We removed as much of the tumour as we safely could, tangled as it was with the distal branches of the left middle cerebral artery. I did not think we had done her any serious harm though nor had we done her much good.

‘What’s her prognosis, boss?’ Patrik asked me as he stitched the dura and I cut his stitches with a pair of scissors.

‘A few months, probably,’ I replied. I told him about her father and what she had said to me.

‘It’s difficult to do nothing,’ I said. ‘But death is not always a bad outcome, you know, and a quick death can be better than a slow one.’

Patrik said nothing as he continued to close the woman’s meninges with his sutures. Sometimes I discuss with my neurosurgical colleagues what we would do if we – as neurosurgeons and without any illusions about how little treatment achieves – were diagnosed with a malignant brain tumour. I usually say that I hope that I would commit suicide but you never know for certain what you will decide until it happens.

As we stitched her head up I did not expect any problems. Judith took her round on her trolley, pushed by one of the
ODAs
and nurses, to the
ITU
while I sat down and wrote an operating note. A few minutes later Judith put her head round the theatre door.

‘Henry, she’s not waking up and her left pupil is bigger than her right. What do you want to do?’

I swore quietly and quickly walked the short distance to the Intensive Care Unit. In the corner of the room I could see Melanie, and a baby’s cot beside her bed, but I hurried past to look at the second patient. With one hand I gently opened her eyelids. The left pupil was large and black, as large as a saucer.

‘We’d better scan her,’ I said to Patrik who had come hurrying up when he had heard the news. Judith was already re-anaesthetizing the woman and putting a tube down into her lungs so as to put her back on a ventilator. I told Patrik to tell the staff in the scanner that we would be bringing her for a scan immediately and never mind what else they were doing. I wasn’t going to wait for a porter. Patrik went to the nurses’ desk and picked up the phone while Judith and the nurses disconnected the woman from all the monitoring equipment behind her and with my help wheeled her quickly out of the
ITU
to take her to the
CT
scanner. Together with the radiographer we quickly slid her into the machine. I walked back to the control room with its leaded, X-ray- proof window looking out into the room where the patient lay with her head in the scanner.

Impatient and anxious I watched the transverse slices of the scan appear on the computer monitor, gradually working their way up towards where I had been operating. The scan showed a huge haemorrhage deep in her brain, on the side of the operation although slightly separate from it. It was clearly both inoperable and fatal – a post-operative intracerebral haemorrhage, a ‘rare but recognized’ complication of such surgery. I picked up the phone in the control room and rang her husband.

‘I’m afraid I have rather bad news for you . . .’ I said.

I went round to the surgical sitting room and I lay on the sofa, staring at the sky through the high windows, waiting for her husband and daughter to arrive.

I spoke to them an hour later in the little interview room on the
ITU
. They collapsed into each other’s arms in tears. Dressed in my theatre pyjama suit, I looked on miserably.

As she was going to die the nurses had moved her into a side room where she lay on her own. I took her husband and daughter to see her. They sat down beside her. She was unconscious and mute, her eyes closed, with a lop-sided bandage around her head beneath which her bloodied hair hung down. The ventilator which was keeping her alive gently sighed beside her.

‘Are you really sure she cannot hear anything we say to her?’ her daughter asked me.

I told her that she was in a deep coma but that even if she could hear she would not understand what she heard since the haemorrhage was directly in the speech area of her brain.

‘And will she have to stay in hospital? Can’t she come home?’

I said that I was certain that she would die within the next twenty-four hours. She would become brain dead and then the ventilator would be switched off.

‘She’s been taken from us. So suddenly. We were going to do so many things together in the time we had left, weren’t we?’ her husband said, turning to his daughter as he spoke. ‘We weren’t ready for this . . .’ He held his daughter’s hand as he talked.

‘I trusted you,’ he said to me, ‘and I still do. Are you certain that she might not wake up? What if she wakes up and finds that we aren’t here? It would be so frightening for her although I know she kept on telling us last week that she did not want to be a burden to us.’

‘But love is unconditional,’ I said and he burst into tears again.

We spoke for a while longer. Eventually I turned to the door saying that I had to leave or I would start crying myself. The husband and daughter laughed at this through their tears. As I left I thought of how I had granted her wish, albeit inadvertently, that she should not die miserably as her father had done.

Back in the operating theatre Patrik was having difficulties stopping the bleeding after removing the disc prolapse in the third and last case on the list. I cursed and abused him half-jokingly and scrubbed up and quickly brought the bleeding under control. We closed up the man’s incision together and afterwards I returned to the
ITU
to see Melanie. She was peacefully asleep and her baby son was asleep in the cot beside her. Her observation chart showed that her pupils were now reacting to light and the nurse looking after her said that all was well. There was a small group of laughing and smiling nurses beside the cot looking at the baby.

Her husband rushed up to me, almost delirious with joy.

‘She can see again! You’re a miracle worker Mr Marsh! She woke up from the op and she could see the baby! She said her eyesight’s almost back to normal! And our son is fine! How can we ever thank you enough?’

What a day, I thought as I went home, what a day. When I recounted this story – which I had quite forgotten until then – to the
Holby City
writers gathered round the hotel table, they broke out in little cries of delight and amazement, though whether they used the story about Melanie or not, I do not know.

5

TIC DOULOUREUX

pl.n.
brief paroxysms of searing pain felt in the distribution of one or more branches of the trigeminal nerve in the face.

Once I had sawn open the woman’s skull and opened the meninges I found to my horror that her brain was obscured by a film of dark, red blood that shouldn’t have been there. It probably meant that something had already gone wrong with the operation. The light from the battered old operating lamp above me was so dim that I could scarcely see what I was doing. The possible repercussions for my colleague and me did not bear thinking about. I had to fight to control my mounting panic.

I was operating on a woman with an agonizing facial pain called trigeminal neuralgia (which is also known as
tic douloureux
) – a condition that was considered by her doctors to be inoperable. A television crew was filming the operation for the national news. There were many doctors and nurses, looking down on me like gods through the glass panes of a large dome built into the ceiling above the operating table. Many of the panes in the glass dome were cracked and broken and the view outside through the large windows of the operating theatre was of snow falling onto a grey wasteland of broken machinery and derelict buildings. I often have an audience when operating and I dislike it when things are going badly – but this was many times worse. I had to radiate a calm, surgical self-confidence, which was not what I felt.

This was Ukraine, in 1995. I was 2,000 miles from home, operating without any official permission – probably illegally – doing a dangerous operation on a woman’s brain never done in the country before, using second-hand equipment that I had driven out myself from London a few days earlier. My colleague was an obscure junior doctor who had been declared in an interview on the
BBC
World Service, by the senior professor of neurosurgery in the hospital where I was operating, to be suffering from schizophrenia. Nor was I being paid to do this – indeed, it was costing me a lot of my own money.

I muttered unhappily to myself as I tried to stop my hands shaking: ‘Why on earth am I doing this? Is it really necessary?’

I had first gone to Kiev three years earlier in the winter of 1992, almost by accident. I had been a consultant for five years by then and already had a large and busy practice. It was a few months after the collapse of the Soviet Union. An English businessman, hoping to sell medical equipment in Ukraine, rang my hospital to find out if any neurosurgeons were interested in joining him on a trip to Kiev. There was a famous neurosurgical hospital in Kiev and he wanted to take some British neurosurgeons with him to deliver lectures about modern brain surgery and the equipment needed for it. The switchboard operator was rather puzzled by the enquiry and so put the call through to Gail, my secretary, who has the well-earned reputation of being able to solve most problems. I was in my office and she put her head round the door.

‘Do you want to go to Ukraine next Thursday?’

‘Certainly not. I’m far too busy and I’ve got a clinic then.’

‘Oh go on. You’re always saying how interested you are in Russia and you’ve never been there yet.’

Gail is usually the first person to complain if I cancel an outpatient clinic as she will then have to field all the phone calls from the disappointed and sometimes angry patients and rearrange the appointments, so I had to take her advice seriously.

And so, with two colleagues, I travelled to the newly independent Ukraine. There had never really been a separate Ukrainian state before the Soviet Union fell apart, and it was not at all clear what independence would mean. What was clear was that the country was in utter chaos, with the economy close to collapse. The factories were all closed and everybody seemed to be out of work. The conditions in the hospitals I visited were out of a nightmare.

We had arrived in Kiev early in the morning on the overnight train from Moscow. The line crosses one of the long bridges over the great river Dnieper which flows through Kiev, and as we approached the steep western riverbank we could see the golden domes of the Lavra monastery above us catching the light of the rising sun – a dramatic contrast to the dark railway stations we had passed through during the night and the grim apartment blocks on the outskirts of the city. I had lain in my bunk, under a thin blanket, drifting in and out of sleep, listening to the old-fashioned, rhythmic sound of a train running over bolted rails, travelling southwards across Russia, stopping at dimly-lit stations where I could hear incomprehensible announcements echoing over the empty, snow-covered platforms.

It all felt wonderfully strange and yet also strangely familiar – I suppose from the Russian literature in which I had steeped myself in the past. We had only been in Moscow for a few hours. Long enough to stand in Red Square in the dark, in the falling snow, where despite the fall of communism, a huge red flag was still flying, a little listlessly, from the Spassky Tower of the Kremlin. Long enough to have a splendid meal in a hotel that one had to enter through three lines of armed security guards, to find long, shabby corridors with worn, thin carpets and a bewildering number of disconcertingly beautiful girls looking for business. Long enough to understand that with the collapse of the rouble the few hundred dollars we carried in our pockets made us virtual millionaires compared to the impoverished Russians we met.

Once in Kiev we were taken to the Neurosurgical Research Institute, a huge and ugly building with the endless corridors that are the curse of all large hospitals. The corridors were dark and poorly lit. On the walls one could see serious displays of the triumphs of Soviet neurosurgery, with grainy black and white photographs of heroic men in the tall white chef’s hats that Soviet surgeons used to wear, interspersed with hammers and sickles, red stars, inspirational slogans and photographs of scenes from the Great Patriotic War, as the Russians call the Second World War. But everything, from the building itself to the pictures on the walls, and the stale air which smelt of cheap tobacco and some odd, sickly-smelling disinfectant, felt tired and faded. We were ushered into the office of Academician Romadanov, an old, imposing and very eminent man and the director of the Institute. He was tall, with a large head and a mane of white hair, and he wore a high-collared white coat, buttoned round his throat. He looked, however, as tired and faded as the corridors, and was in fact to die a few months later. After the usual introductions – all conducted through an interpreter – we sat down round the long table in his office.

‘Why have you come here?’ he asked angrily. ‘As tourists? To amuse yourselves by seeing all our problems? This is a very difficult time for us.’

We tried to answer diplomatically and talked of friendship and professional collaboration and international cooperation. He looked unconvinced and he was, of course, entirely right.

We were then shown round the famous institute by one of his assistants.

‘This is the largest neurosurgical hospital in the world,’ we were told.

‘There are eight departments and five floors and four hundred beds.’

I was amazed – my own hospital, one of the largest neurosurgical units in Britain, had only fifty beds. We traipsed up and down the stairs and along corridors and visited each identical department in turn.

We started on the ground floor.

‘This is the Department of Posterior Fossa Tumours,’ we were told.

As we came through the doors the staff came out to meet us, to shake hands and to be photographed with us. I was told all about the wide range of operations that went on in the department, although any detailed questions on my part were usually met with rather vague answers. We went through exactly the same ritual in the seven other departments. When I asked if we could see the operating theatres I was told that they were being redecorated and were closed. We saw scarcely a single patient.

We delivered our lectures. The few questions afterwards showed a complete and utter lack of understanding of what we had been trying to explain. We returned to our hotel. As with the hotel in Moscow, there were beautiful young women to be seen everywhere. I was told that they were not professional prostitutes but respectable women desperately trying to make some money. One session with a western businessman was, at that time, worth more than a whole month’s income. Embarrassed and fascinated, we made our way shyly past them and retreated to one of our rooms to drink duty-free whisky, confused and shocked by the surreal discrepancy between what we had seen and what we had been told as we toured the hospital.

The next day I was taken to the Emergency Hospital on the eastern side of the city. I had asked to see how trauma was managed and my guides – a little reluctantly – had agreed to take me. We arrived in the late afternoon. The light was starting to fade. The hospital was ten storeys high, apparently with eight hundred beds. It was only ten years old but already looked derelict. We approached it through a wasteland of broken buildings and those gigantic, incomprehensible pipes that always seem to surround Soviet buildings, on which pure white snow was starting to fall from a leaden sky. At one side there was a large and ramshackle open-air market, with battered zinc-covered huts displaying rather sad little collections of cheap cosmetics and vodka. Decrepit Lada and Moskvitch and Volga cars were parked in utter disorder. Everything was grey, colourless and drab in the way that only Soviet cities could be. Collecting the illegal rent paid by the market traders was, I subsequently heard, an important part of the hospital director’s job and a useful source of income for the officials of the city’s health administration.

The electricity supply had failed and much of the hospital was in pitch darkness. The whole place stank of ammonia – the hospital had run out of disinfectants and only ammonia was available for cleaning. The building seemed almost uninhabited. I was taken to one of the dark operating theatres – a huge cavernous place with a large window looking out onto what appeared to be a bombsite. Flurries of snow could be seen there, caught in the dim light from the window of the theatre. An operation was going on. A surgeon was ‘operating’ on a paralysed man, paralysed from the neck down in an accident some years previously, I was told. There was a small tray of battered instruments beside him that looked as though they came from a scrapyard. The patient was lying on his side and was partially covered with old curtains with a faded floral pattern. The surgeon had inserted several large needles into his spine and was injecting cold saline through them into the spinal canal. This was, apparently, supposed to stimulate the spinal cord to recover. The reflex movements in the paralysed man’s legs that the injections produced were greeted with cries of excitement and seen as evidence that the treatment was working.

While I was walking along one particularly dark and dismal corridor, a young man came hurrying up to me like an enthusiastic spaniel. It was the surgeon I had seen ‘operating’ on the paralysed man.

‘This is neurosurgical department,’ he announced in broken English. ‘There are three departments of emergency neurosurgery. I am Igor Kurilets, director of spinal emergency department.’ I expected the long and tedious description to continue. I was quickly becoming familiar with the litany of departments and beds and achievements with which one was greeted when one visited a Ukrainian hospital and expected to be reassured that Ukrainian emergency spinal neurosurgery was the equal of the world, if not better.

‘Everything terrible here!’ he said.

I liked Igor immediately. Apart from Academician Romadanov, he was the only doctor I met on my first visit who seemed able to admit openly that the medical situation in Ukraine – at least in neurosurgery – was dire. The Soviet Union had excelled at producing guns and rockets but failed miserably at producing decent health care. Although there were impressive-sounding research institutes and thousands of professors, the reality was of poorly trained doctors and poorly equipped hospitals that were often little better than what one might find in the Third World. The Soviet Union, it used to be said, ‘is Upper Volta with rockets’ – Upper Volta, as it was then called, being the poorest country in Africa. Most of the doctors I met, driven by a mixture of shame, patriotism, envy and embarrassment, felt compelled to deny this, and did not welcome people like Igor who dared to point out the emperor’s lack of clothes. Soviet culture had never encouraged criticism and had gone to great lengths to isolate its citizens from the rest of the world. Despite the fall of the Soviet Union, newly independent Ukraine still had the same leaders as in the past, but the country and its people were suddenly exposed to the outside world and the huge gulf that had developed between western and Eastern European medicine.

Before I left Kiev after this first visit I attended a meeting at the Ministry of Health. An expressionless, florid-faced bureaucrat, the umpteenth secretary of some umpteenth department of this or that, walked round the long table handing out his business card, where his umpteen titles were all duly listed. The more important bureaucrats, I had noticed, would have so many titles and appointments that more than one card was needed to list them all. This man was only a one-card bureaucrat so clearly not too important.

I soon lost interest in what was being said. Besides, it all had to be slowly translated, which made it doubly tedious. The room, panelled in cheap plywood like most Soviet government offices, had tall windows that looked out onto an attractive park. Snow was starting to fall again. A police van was disgorging heavily armed riot police in grey uniforms with German shepherd dogs. Both dogs and men seemed to be jumping out of the back of the vehicle with great enthusiasm. We had seen a demonstration by the Ukrainian Nationalist Party going on outside the nearby Parliament building on our way to the Health Ministry so perhaps the policemen and their dogs were looking forward to a good fight. The English businessman who had brought me to Ukraine was sitting next to me and leant over to whisper that the riot police were the pimps for the girls we had seen in the hotel.