Do No Harm: Stories of Life, Death and Brain Surgery (5 page)

‘It’s already done,’ James replied happily.

‘Splendid!’ I said. ‘Just get on with it.’ And I headed off downstairs to my office.

I cycled home, stopping off at the supermarket to get some shopping. Katharine, the younger of my two daughters, was staying with me for a few days and was to cook supper. I had agreed to do the shopping. I joined a long queue of people at the check-out.

‘And what did
you
do today?’ I felt like asking them, annoyed that an important neurosurgeon like myself should be kept waiting after such a triumphant day’s work. But I then thought of how the value of my work as a doctor is measured solely in the value of other people’s lives, and that included the people in front of me in the check-out queue. So I told myself off and resigned myself to waiting. Besides, I had to admit to myself that soon I will be old and retired and then I will no longer count for much in the world. I might as well start getting used to it.

While I was standing in the queue my mobile phone went off. I experienced an immediate flash of alarm, instantly frightened that this would be my registrar calling to say that there was a problem with the brain tumour case but instead I heard an unfamiliar voice as I scattered my shopping over the counter while struggling to answer the phone.

‘Are you the consultant neurosurgeon on call?’

Emergency calls are usually all sent to the on-call registrar so I answered warily.

‘Yes?’ I said.

‘I am one of the
A&E SHO
s,’ said the voice self-importantly. ‘My consultant has told me to ring you about a patient here. Your on-call registrar is not answering his bleep.’

I was immediately annoyed. If the case was so urgent why didn’t the
A&E
consultant ring me himself? There used to be a certain etiquette about ringing a colleague.

‘I find that hard to believe,’ I said, as I tried to gather up the hot cross buns and clementines I had dropped.
A&E
were probably just trying to shift patients quickly to meet their target for waiting times. ‘I was just speaking to him ten minutes ago . . .’

The
A&E SHO
didn’t seem to be listening.

‘It’s a sixty-seven-year-old man with an acute on chronic subdural . . .’ he began.

I interrupted him and told him to ring Fiona, who was not on call but I knew was still in the building and then switched the phone off, giving an apologetic smile to the puzzled check-out girl.

I left the supermarket feeling anxious. Perhaps the patient was desperately ill, perhaps James
had
failed to answer his bleep so I rang Fiona on her mobile. I explained the problem and said that I was worried that maybe just for once it really was an urgent referral and not just an attempt to get a patient out of
A&E
.

I went home. She rang me half an hour later.

‘You wait until you hear this one,’ she said, laughing. ‘James had answered the call and was already on his way to
A&E
. The patient was perfectly well, he was eighty-one not sixty-seven and they’d completely misinterpreted the brain scan, which was normal.’

‘Bloody targets.’

By the time that I had got home it had started to rain. I changed into my running clothes and reluctantly headed for the small suburban park behind my home. Exercise is supposed to postpone Alzheimer’s. After a few laps round the park my mobile phone went off.

‘Bloody hell!’ I said, dropping the wet and slippery phone as I tried to pull it out of my tracksuit and answer the call.

‘James here. I can’t stop the oozing,’ a voice said from the muddy ground.

‘What’s the problem?’ I asked, once I had managed to pick the phone up.

‘I’ve taken the clot out and put a drain in but the cavity is oozing a lot.’

‘Not to worry. Line it with Surgicel, pack it and take a break. Go and have a cup of tea. Tea is the best haemostatic agent! I’ll look by in thirty minutes or so.’

So I finished my run, had a shower, and made the short journey back to the hospital, but in my car, because of the rain. It was dark by now, with a strong wind, and there had been heavy snowfalls in the north, even though it was already April. I parked my car in the scruffy delivery bay by the hospital basement. Although I am not supposed to park there, it does not seem to matter at night and it means that I can get up to the theatres more quickly than from one of the official car parks which are further away.

I put my head past the doors of the theatre. James was standing at the end of the operating table, holding the patient’s head in his hands as he wound a bandage around it. The front of his gown was smeared with blood and there was a large pool of dark red blood at his feet. The operation was clearly finished.

‘All well?’ I asked.

‘Yes. It’s fine,’ he replied. ‘But it took quite a while.’

‘Did you go and have a cup of tea to help stop the bleeding?’

‘Well, no, not tea,’ he said, pointing to a plastic bottle of Coca-Cola on one of the worktops behind him.

‘Well, no wonder the haemostasis took so long!’ I said with mock disapproval and all the team laughed, happy that the case was over and that they could now go home. I went briefly to check on the tumour patient who was now on the
ITU
for the night as a matter of routine.

The
ITU
had had a busy week and there were ten patients in the large and brightly-lit warehouse of a room, all but one of them unconscious, lying on their backs and attached to a forest of machinery with flashing lights and digital read-outs the colour of rubies and emeralds. Each patient has their own nurse, and in the middle of the room there is a large desk with computer monitors and many members of staff talking on the phone or working on the computers or snatching a plastic cup of tea in between carrying out the constant tasks that are needed in intensive care.

The one patient who was not unconscious was my brain tumour case, who was sitting upright in bed, still looking red-faced, but wide awake.

‘How are you feeling?’ I asked.

‘Fine,’ he replied with a tired smile.

‘Well done!’ I replied, as I think patients need to be congratulated for their surviving just as much as the surgeons should be congratulated for doing their job well.

‘It’s a bit of a war zone here, I’m afraid,’ I said to him, gesticulating to the depersonalized forms of the other patients and all the technology and busy staff around us. Few – if any – of these patients would survive or emerge unscathed from whatever it was that had damaged their brains.

‘I’m afraid you won’t get much sleep tonight.’

He nodded in reply, and I went downstairs to the basement in a contented frame of mind.

I found my car with a large notice stuck to the windscreen.

‘You have been clamped,’ the notice said, and there was a long list beneath this accusing me of negligence and disrespect and so on and so forth, and telling me to report to the Security Office to pay a large fine.

‘I really can’t take this anymore!’ I burst out in rage and despair, shouting at the concrete pillars around me but when I furiously marched round my car, to my surprise I found that none of the wheels had been clamped and then, when I came round to the notice again, I noticed that added in ballpoint to the notice were the words ‘Next time’ with two large exclamation marks.

I drove home torn between impotent rage and gratitude.

4

MELODRAMA

n
. a sensational, dramatic piece with crude appeals to the emotions and usu. a happy ending.

I was recently asked to talk to the script-writing team for the
TV
medical drama
Holby City
. I took the train from Wimbledon to Boreham Wood at the opposite end of London and went to the well-appointed country house hotel where they were meeting. There were at least twenty people sitting round a long table. They were thinking of adding a neurosurgical ward, they told me, to the fictional Holby City General Hospital, and wanted me to talk to them about neurosurgery. I talked for almost an hour without stopping, something I don’t find very difficult to do, but I probably concentrated too much on the grim and tragic aspects of my work.

‘Surely you have some more positive stories to tell, which our viewers would like?’ somebody asked and then I suddenly remembered Melanie.

‘Well’ I said,’ Many years ago I did once operate on a young mother who was just about to have a baby and was going blind . . .’

There were three patients for surgery on that Wednesday – two women with brain tumours and a young man with a disc prolapse in his lumbar spine. The first patient was Melanie – a twenty-eight-year-old woman in the thirty-seventh week of pregnancy who had started to go blind over the preceding three weeks. She had been referred as an emergency to my neurosurgical department from the ante-natal clinic of her local hospital on Tuesday afternoon. A brain scan had shown a tumour. I was on call for emergencies that day so she was admitted under my care. Her husband had driven her to my hospital from the ante-natal clinic; when I first saw them on the Tuesday afternoon he was guiding Melanie down the hospital corridor towards the ward with one hand on her shoulder and the other hand holding a suitcase. She had her right arm stretched out in front of her for fear of bumping into things and her left hand was pressed onto the unborn child inside her as though she was frightened she might lose it just as she was losing her eyesight. I showed them the way to the ward entrance and said that I would come back later to discuss what should be done.

The brain scan had shown a meningioma – a ‘suprasellar’ meningioma growing from the meninges, the membrane that encases the brain and spinal cord – at the base of her brain. It was pressing upwards onto the optic nerves where they run back from the eyes to enter the brain. These particular tumours are always benign and usually grow quite slowly, but some of them have oestrogen receptors and, very occasionally, the tumours can expand rapidly during pregnancy when oestrogen levels rise. This was clearly what was happening in Melanie’s case. The tumour did not pose a risk to the unborn child, but if it was not removed quickly Melanie would go completely blind. It could happen within a matter of days. An operation to remove a tumour like hers is relatively straightforward but if the visual loss before surgery is severe it is by no means certain it will restore vision and there is some risk it will make it worse. I have once left one person completely blind with a similar operation. Admittedly he was already almost blind before the operation – but then so was Melanie.

When I went to the ward an hour or so later I found Melanie sitting up in her bed, with a nurse beside her completing the admission paperwork. Her husband, looking desperate, was on a chair next to the bed. I sat down on the end of the bed and introduced myself. I asked her how it had all started.

‘Three weeks ago. I scraped the side of the car on the garage gates when I was coming home from my ante-natal class,’ she said. ‘I couldn’t understand how I had managed to do it but a few days later I realized that I couldn’t see properly out of my left eye.’ As she spoke her eyes moved restlessly with the slightly unfocused look that people have when they are going blind. ‘It’s been getting worse and worse since then,’ she added.

‘I need to examine your vision a bit,’ I said. I asked her if she could see my face.

‘Yes,’ she replied. ‘But it’s all blurry.’

I held up my hand in front of her face with the fingers outstretched. I asked her how many fingers she could see.

‘I don’t really know,’ Melanie said with a note of desperation ‘I can’t see . . .’

I had brought an ophthalmoscope, the special torch used for looking into eyes, from my office. I fiddled with the dial on the ophthalmoscope, put my face close up to hers, and focused on the retina of her left eye.

‘Look straight ahead,’ I said. ‘Don’t look into the light since it makes your pupil smaller.’

The eyes are said by poets to be the windows to the soul but they are also windows to the brain: examining the retina gives a good idea of the state of the brain as it is directly connected to it. The miniature blood vessels in the eye will be in a very similar condition to the blood vessels in the brain. To my relief I could see that the end of the optic nerve in her eye still looked relatively healthy and not severely damaged, as did the retinal blood vessels. There was some chance surgery would get her better rather than just stop her going completely blind.

‘Doesn’t look too bad,’ I said, after looking into her right eye.

‘My baby! What will happen to my baby?’ Melanie asked me, clearly more troubled about her child than her eyesight.

I reached out and held her hand and I told her that her baby would be fine. I had already arranged with the obstetricians that they would come and perform a Caesarean section and deliver the baby once I, so to speak, had delivered the tumour. It could all be done under the same anaesthetic, I said. I hoped that surgery would improve her eyesight as well, but had to warn her and her husband that I could not guarantee this. There was also some risk, I told them, that the operation might leave her blind. It was all a question of whether the tumour was badly stuck to the optic nerves or not, which I would not know until I had operated. All that was certain, I said, was that she would go completely blind without surgery. I added that I had seen many patients in poor countries like Ukraine and Sudan who had indeed gone completely blind with tumours such as hers because of delays in treatment. I asked her to sign the consent form. Her husband leant forward and guided her hand with the pen. She scribbled something illegible.

I carried out the operation first thing the next morning with Patrik, the senior registrar who was working with me at the time. The operation had inevitably caused great excitement and there was a small army of obstetricians, paediatricians and nurses with paediatric resuscitation kit in the corridor outside the operating theatre. Doctors and nurses enjoy dramatic cases like this and there was a carnival-like atmosphere to the morning. Besides, the idea of a baby being born in our usually rather grim neurosurgical operating theatres was delightful and the theatre staff were all looking forward to the event as well. The only worry – which was largely mine and Melanie’s and her family’s – was whether I could save her eyesight or whether I might even leave her completely blind.

She was brought to the theatre from the women’s ward on a trolley with her husband walking beside her, her pregnant belly rising up like a small mountain under a hospital sheet. Her husband, fighting back his tears, kissed her goodbye outside the doors to the anesthetic room and was then escorted out of the theatre by one of the nurses. Once Judith had anaesthetized her, Melanie was rolled onto her side and Judith carried out a lumbar puncture, using a large needle up which she then threaded a fine white catheter which we would use to drain all the cerebrospinal fluid out of Melanie’s head. This would create more space inside her head – a matter of a few millimetres – in which I could operate.

After a minimal headshave Patrik and I made a long curving incision a centimetre or so behind her hairline following it all the way across her forehead. Pressing firmly with the tips of our fingers on either side of the incision to stop the scalp bleeding we placed plastic clips over the skin edges to close off the skin’s blood vessels. We then pulled her scalp off her forehead and folded it down over her face, already covered in the adhesive tape that secured Judith’s anaesthetic tube in place. I talked Patrik through the opening stages of the procedure.

‘She’s young, she’s good-looking,’ I said. ‘We want a good cosmetic result.’ I showed him how to make a single burr hole in the skull just out of sight behind the orbit and then use a wire saw called a Gigli saw after its inventor – a sort of glorified cheese wire which makes a much finer cut through bone than the power tools we usually use – to make a very small opening in the skull just above Melanie’s right eye. Using the Gigli looks brutal since, as you use your hands to pull the saw backwards and forwards, a fine spray of blood and bone flies upwards and the saw makes an unpleasant grating sound. But, as I said to Patrik, it makes a fine and perfect cut.

Once Patrik had removed the small bone flap – measuring only three centimetres or so – I took over for a while, and used an air-powered drill to smooth off the inside of Melanie’s skull. There are a series of ridges, like a microscopic mountain range, two to three millimetres in height, that run across the floor of the skull. By drilling them flat I create a little more space beneath the brain so that I can use less retraction when climbing down under the brain to get at the tumour. I told Patrik to open the meninges with a pair of scissors. The lumbar drain had done its work and the blue-grey dura, the outer layer of the meninges, was shrunken and wrinkled as the brain had collapsed downwards away from the skull as the cerebrospinal fluid had been removed. Patrik tented up the dura with a fine pair of toothed forceps and started to cut an opening in it with a pair of scissors. Patrik was a short, determined and outspoken Armenian-American.

‘They’re blunt. They don’t cut, they chew,’ he said as the scissors jammed on the leathery meninges. ‘Give me another pair.’ Maria the scrub-up nurse turned back to her trolley and returned with a different pair with which Patrik now exposed the tip of the right frontal lobe of Melanie’s brain by cutting through the dura and folding it forwards.

The right frontal lobe of the human brain does not have any specific role in human life that is clearly understood. Indeed, people can suffer a degree of damage to it without seeming to be any the worse for it, but extensive damage will result in a whole range of behavioural problems that are grouped under the phrase ‘personality change’. There was little risk of this happening to Melanie but if we damaged the surface of her brain as we lifted the right frontal lobe up by a few millimetres to reach the tumour it was quite likely that we would leave her with life-long epilepsy. It was good to see that Melanie’s brain, as a result of the lumbar drain and my drilling of her skull, looked ‘slack’ as neurosurgeons say – there was plenty of room for me and Patrik to get underneath it.

‘Conditions look lovely,’ I shouted to Judith at the other end of the table where she sat in front of a battery of monitors and machines and a cat’s cradle of tubes and wires connected to the unconscious Melanie – all the anesthetists can see of the patients are the soles of their feet. Judith, however, had to worry here not just about Melanie’s life but about the unborn baby’s as well who was being subjected to the same general anaesthetic as his mother.

‘Good,’ she said.

‘Bring the ’scope in and give Patrik a retractor,’ I said and, once the heavy microscope had been pushed into position and Patrik was settled in the operating chair, Maria held out a handful of retractors, fanned out like a small pack of cards, from which he took one. I stood at one side, a little nervously looking down the assistant’s arm of the microscope.

I told Patrik to place the retractor gently under Melanie’s frontal lobe while sucking away the cerebrospinal fluid with a sucker in his other hand. He slowly pulled her brain upwards by a few millimetres.

Look for the lateral third of the sphenoid wing, I told him, and then follow it medially to the anterior clinoid process – these being the important bony landmarks that guide us as we navigate beneath the brain. Patrik cautiously pulled Melanie’s brain upwards.

‘Is that the right nerve?’ asked Patrik.

It most certainly was, I told him, and it looked horribly stretched. We could now see the granular red mass of the tumour over which the right optic nerve – a pale white band a few millimetres in width – was tightly splayed.

‘I think I’d better take over now,’ I said. ‘I’m sorry, but what with the baby and her eyesight being so bad it’s not really a training case.’

‘Of course,’ said Patrik, and he climbed out of the operating chair and I took his place.

I quickly cut into the tumour to the left of the optic nerve and to my relief the tumour was soft and sucked easily – admittedly, most suprasellar tumours do. It did not take long to debulk the tumour with the sucker in my right hand and the diathermy forceps in my left. I gradually eased the hollowed out tumour away from the optic nerves. The tumour was not stuck to the optic nerves and after an hour or so we had a spectacular view of both right and left optic nerves and their junction, known as the chiasm. They look like a pair of miniature white trousers although thin and stretched because of the tumour which I had now removed. On either side were the great carotid arteries that supply most of the blood to the brain and further back the pituitary stalk, the fragile structure that connects the all-important pea-sized pituitary gland to the brain, which co-ordinates all the body’s hormonal systems. It sits in a little cavity, known as the sella, just beneath the optic nerves, which is why Melanie’s tumour is called a ‘supra-sellar’ meningioma.

‘All out! Let’s close up quick and the obstetricians can do the C section,’ I announced to the assembled audience. I muttered in an aside to Patrik that I hoped to God that her eyesight would recover.

So Patrik and I closed up Melanie’s head and left our colleagues to get on with delivering the baby. As we walked out of the theatre the paediatricians passed us wheeling a paediatric ventilator and resuscitation equipment into the room.