EVERYTHING
THAT
MAKES US
HUMAN
For my family
First published in Great Britain in 2020 by
Michael O’Mara Books Limited
9 Lion Yard
Tremadoc Road
London SW4 7NQ
Copyright © Jayaratnam Jayamohan 2020
Text written by Jeff Hudson 2020
Text copyright © Michael O’Mara Books Ltd 2020
All rights reserved. You may not copy, store, distribute, transmit, reproduce or otherwise make available this publication (or any part of it) in any form, or by any means (electronic, digital, optical, mechanical, photocopying, recording or otherwise), without the prior written permission of the publisher. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages.
A CIP catalogue record for this book is available from the British Library.
Some names and identifying details have been changed to protect the privacy of individuals.
ISBN: 978-1-78929-140-7 in hardback print format
ISBN: 978-1-78929-154-4 in ebook format
www.mombooks.com
CONTENTS
PROLOGUE | Do No Harm
ONE | Holy Moly
TWO | Call Me ‘Mister’
THREE | See One, Do One, Teach One
FOUR | Just Another Saturday Night
FIVE | Batman and Robin
SIX | That’s Not Fat
SEVEN | Everything That Makes Us Human
EIGHT | Wiggle Your Big Toe
NINE | The Tesco Test
TEN | She’s Coning
ELEVEN | CSI Oxford
TWELVE | Suck it and See
THIRTEEN | My Last Patient Did Really Terribly
FOURTEEN | Smash a Hole in the Window
FIFTEEN | What Would You Do?
SIXTEEN | You’re One of Those
SEVENTEEN | You’re Trying to Murder Our Baby!
EIGHTEEN | It’s Your Decision
NINETEEN | It’s Not You, it’s Me
TWENTY | The Customer is Always Right
TWENTY-ONE | You Said That Last Time
ACKNOWLEDGEMENTS
PROLOGUE
DO NO HARM
Uh. Uh-uh-uh. Uh-uh-uh. Uh. Uh. Uh. Uh.
The opening chords of AC/DC’s ‘Back in Black’ ring out. The image of Angus Young – the band’s guitarist in trademark schoolboy uniform – flick fleetingly across my mind. Very fleetingly.
The large screens behind me are in focus, ready to go. I look at the anaesthetist. She gives me the nod. I check with the scrub nurse. She’s primed, prepped. Ready.
Finally, I look down at the tiny bundle of humanity on the table beneath me. I pick up my knife and I say, ‘Let’s begin.’
Ever since I was little, music has meant a lot. When I was nine, my uncle gave me a cheap Pye tape recorder. I used it to do what I imagine everybody my age did back then, which was to tape the Top 40 singles chart. I realized that when I was listening to that, the rest of the world faded away and I was able to concentrate. Everything just stuck when the volume was up. I could do my homework and read books so much more easily. Through O levels, A levels and medical school, if I didn’t have my headphones on then nothing was sinking in. There was too much extraneous noise. I was too easily distracted.
And in an operating theatre with an eighteen-month-old baby in front of you, distracted is the last thing you can afford to be. For their sake and yours, you want and need to be at the top of your game. It’s the only way to stack the odds against whatever is attacking them. Tumour, spina bifida, massive head trauma. I – we – can try to fight them all. But only when I’m concentrating.
I don’t always win. I can’t always win. But I try. I do everything possible to abide by the number-one rule in the doctors’ handbook, and the title of a book written by one of my old teachers and inspirations, Henry Marsh: do no harm. And then some. And that’s what I tell the patients and their parents when they come to the question they always eventually ask: ‘Doctor Jay, tell us. What are the odds?’
They can’t help it. They want to know, in terms they can understand, just how likely it is that their child will survive. How certain that the operation their loved one is about to undergo will be successful. They want a percentage, a number out of 100. Something they can translate. Something they can process.
I’m no mathematician, but I do my best. I’m always honest. I always reply. Sometimes the win/lose ratio is 50:50. Sometimes it’s 90:10. Sometimes it’s the opposite way round.
It doesn’t really matter. I always follow up with the same words: ‘I can tell you the odds, but whether there’s a five per cent or a ninety-five per cent chance of success, it doesn’t matter. We’re going to go for it. We’re going to do our best.’
The ‘we’ means all of us – doctors, nurses, scrub staff and, of course, parents and patients. Because the alternative doesn’t bear thinking about.
I became a doctor to save lives. I became a neurosurgeon because I believed it to be the highest achievement in medicine. I became a paediatric neurosurgeon to give a voice to those patients so long overlooked because of their age. To give them a life. To give them a chance. To give them respect.
In the background my young registrar flicks the volume dial on the speaker.
UH. UH-UH-UH. UH-UH-UH. UH. UH. UH. UH.
‘Let’s do this.’
CHAPTER ONE
HOLY MOLY
It’s 7.45 a.m. Surgery day. Time to meet the contestants.
The pre-operative ward is – I like to think in my egotistical way – a bit like the airlock chamber in a spacecraft. It prepares you for what’s to come. I’m there with a junior trainee neurosurgeon plus a couple of young doctors, the core of the team soon to go to work. To be honest, it’s more of a courtesy call than anything, as the patient and her family have seen us all before. We’ve already gone through the procedure at length during clinic and then again over the last few days. In the week before an operation, I like patients to come in beforehand to be assessed by the whole team of specialists. Nobody stays over unless they’re too ill to move. They get checked and double-checked by everyone who I think can offer some insight. I prefer to keep surprises during the operating process down to a minimum.
These eleventh-hour visits are mainly to check that the little one hasn’t developed a chest infection or anything overnight and to make sure there are no last-minute questions from anyone. It’s also the last chance that parents and patient get to meet the team before we dive behind our face masks. It’s important to me that they know exactly who is looking after their pride and joy.
Finally, we get a few confirmation signatures – ‘You accept the risks, any more questions?’ – and we’re ready. All the big conversations have been had on previous days. I ensure that they hear the standard Jayamohan promise: I will treat their child as I would want my own kids treated if they were sick. No bigger promise exists, in my opinion.
If we have our timing right we should run into the rest of the team for ward rounds at exactly 8 o’clock. We have four neurosurgeons, two or three plastic surgery consultants who work alongside us, a smattering of juniors – a couple of registrars and ward doctors – a nurse or two, plus the odd medical student. It can turn into a large crowd.
I’m sure it can be quite intimidating to have a John Radcliffe XI surround your bed, especially if you’re barely old enough to fill a third of it, but I hope it conveys the right message: we’re here to help. All of us.
Babies tend to treat it as they do everything else, with sleepy indifference. They’re like cats
but less fickle. Parents, on the other hand, don’t know where to look, let alone stand.
No patient is more important than another – except on surgery days. At 8.30 a.m. I break off from the general meet ’n’ greets and make my way to theatre.
You see sportsmen and women often get into a huddle before a big match. For them it’s a sign of public solidarity. The Team vs The World. When we do it, it’s more about making sure that we don’t chop out the wrong bit of the brain.
Before every operation these days we tick off the ‘WHO’ – the surgery checklist introduced by the World Health Organization to eradicate errors. It’s so simple, yet so effective.
Patients are already booked in on our electronic system, to let the scrub nurses know what we’ll be doing and which kit needs to be prepared. Everyone about to be involved in the forthcoming operation introduces themselves to the others. Nine times out of ten we know each other anyway, but new trainees or nurses do appear every so often. Research shows that even knowing everyone’s name and role can reduce errors.
Next, we’ll talk about the patients. Whoever the ‘lead’ is will give a quick, short version of the history and map out what we’re planning to do. If I’m there it usually means I’m the lead. On cases that are predominantly cranial or facial reconstruction, then a colleague from plastic surgery will step forward. We talk about what equipment we need. We check with the nurses that they have all the tools that we have requested previously. We go around the room and just get that verbal guarantee that there are no issues or concerns.
If I have any pointers, I’ll call them out. For example, ‘the main issue today is going to be blood loss’ or ‘the key concern for this case will be post-operative infection, so let’s make sure the doors are shut, there are no students in the room and no one walks in and out’. It’s all common sense, but it bears repeating.
One of the premises of WHO is to make everyone feel equal so that the most junior member of staff is able to question what the most senior person is doing. From my point of view, being the most senior surgeon in most operating rooms, that could get quite annoying quite quickly, but the logic is sound. If we’ve said we’re going to do an operation on the left side of the head and if a student watches us about to start an operation on the right, then they need to feel comfortable enough to say, ‘Excuse me, Doctor Jay, but I’m pretty sure you said the left side of the head.’
Trust me, it’s happened elsewhere – otherwise they wouldn’t introduce a rule about it.
If everyone is satisfied about what’s to follow, we break off. While most of us go back to finish off our ward rounds, the anaesthetist then calls for the patient. What happens next depends on how long it takes for the patient to be prepared for the anaesthetic and then be put ‘under’. The longer the anaesthetist takes to prep, the happier I am. In forty minutes I can squeeze in about ten patient visits. It’s all about spinning as many plates as possible at once.
If I’m the guy leading the operation – and today I am – I’ll peel away from the ward before the others finish. If it’s one of my neuro patients, I like to get ready and be in the room before they’re completely under.
Each set of operating theatres has its own changing area. I strip down to my underwear and pull on my blues and surgical shoes. For reasons of hygiene, the blues get boil-washed by the hospital, so they smell like everything else in the building. They are available in four different sizes, which in theory is enough to fit every shape. In practice, however, ‘no size fits anyone’ would be more accurate.
The shoes look like uglier versions of Crocs, but if you get the right pair they’re super comfortable. I tend to squirrel away my ones in my locker. If I left them out, someone would pinch them – probably a student. When you’re on your feet for seven or eight hours it’s important not to be hopping from foot to foot. We used to have a dishwasher that was bastardized into a shoe washer, but we don’t anymore. You have to clean your own shoes now.
Medicine isn’t the ideal game for anyone with sensitive skin. By 9.30 a.m., I’ve probably washed my hands fifteen to twenty times. Every time you touch a patient, you wash; before you touch a patient, you wash; in between, you wash out of habit. You’re just constantly scrubbing or disinfecting.
It’s nearly show time. The quickest way into the operating theatre is via the anaesthetist’s room. Generally, out of respect for his or her workspace, we’ll use the doors at the back. The patient will be wheeled through from next door when the time is right.
The theatre is probably about 5 metres by 5 metres or thereabouts. It’s all designed around the space for the table in the middle. You could plonk me in any hospital and I probably couldn’t tell them apart. They’re all lined with the same boring melamine-type walls that can easily be sterilized and washed down. They have a set of lights in the roof and the various pipes and cables that send around oxygen and other gases, and suck away all the unwanted leftovers of an operation – blood, mucus, saliva, and other slip hazards. Most of the equipment is portable. It gets wheeled in and out as and when required.
Today, we have the anaesthetic machine at the foot of the bed – obviously, since I’m working on the other end. Then we’ve got a few bits of kit, like suction and electrocautery (a means of using electricity to literally cut tissue – the closest to a real-life light sabre that exists, I think), sitting on a large trolley at the end of the table as well. Four computers are scattered around for maximum access. We’ll put the scans up on the large screens, conduct electronic monitoring of the patient and provide notes for the anaesthetist. That is if all the machines are working …
You only have to have one failure at a crucial time for you never to trust any piece of technology again. And it’s just as well we checked.
‘Jay, I can only see one of these screens working,’ says my assistant. I’m no Bill Gates, but I take a look anyway. ‘Do you think it’s the machine or the screen?’
‘Not a clue.’
‘Do me a favour – go and swap it with Theatre Twelve.’
‘Oh, come on. I did it last time.’
‘You bloody didn’t – I was the one nearly caught, not you.’
Oh, the joys of the NHS … I’m not sure why our machine doesn’t work. I suspect that one of the other theatres switched their duff one with ours, so it’s only fair if we steal a working one back. I do usually try to send one of the juniors, but I’m not above a little light-fingered jiggery-pokery myself.
With all the machines that go ‘ping’ in place, we load up the scans and once again I’ll talk the team through our aims and hopes. Depending on when you meet them, registrars can be box fresh or have up to eight years’ surgical experience, so it’s good to know who’s who. Of course, I know the more senior ones, but usually you can work it out. The novices ask dozens of questions and the older ones just want to grab your tools and do everything themselves. It’s not unknown for them to try to steal patients from me. As a speciality there’s probably more work performed by consultants in paediatric neurosurgery than in other disciplines, for the simple reason that things can go pear-shaped so much more quickly. But I do try to encourage and involve where I can. As soon as the scans are loaded, I ask the registrar’s opinion of what we’re about to embark upon.
The final check is with the nurses, or ‘scrubs’ as surgical specialists are called. You’ll have seen the big tray of shiny silver implements on TV. Based on what they know of my plans, everything on the tray should be ready and waiting.
‘Does this look okay, Jay?’ the lead scrub asks. It would be unprofessional of me not to check, but I know everything I could possibly need will be there. I look down at the 250 or so instruments. It’s quite the expensive toolbox. We have different-sized clips, different-sized scalpel holders, different-sized ‘rakes’ and retractors – tools used to pull tissue out of the way with; some sharp, some blunt. We have bone nibblers – instruments like pliers that will bite off or ‘nibble’ bone; brain retractors – lollipop s
ticks that range in size from ginormous to tiny, which you can use to move the brain out of the way; spatulas; suckers; scissors, from the very big for cutting heavy tissue or stitches, through to micro-scissors, which are tiny. We have tools for probing, for pushing, for pulling, for poking, for cutting, for grabbing. It’s pretty impressive.
Once all the checks are done, we’re ready to go. All we need now is our star attraction. If it’s a quick anaesthetic on a small case that doesn’t need lots of drips, catheters and other pipes inserted, it may be fifteen or twenty minutes before the patient is signed off as ready. If it’s a bigger sort of operation, like a tumour removal, or if the patient has an abnormal anatomy, it could take as long as ninety minutes to get prepped. The anaesthetist isn’t just responsible for pain and consciousness management; he or she will have blood ready in case of significant loss. Their job is essentially to keep the patient alive while I work at the other end.
Eventually, the doors swing open and the patient arrives. I have a quick chat with the anaesthetist again to make sure everything is still okay. Then we scoop the patient from the anaesthetic trolley onto the operating table itself, and spend serious time getting them positioned properly. Operations can take seven or eight hours. Patients need to be able to lie still for that long without long-lasting effects. If they’re lying on a wire or a hard catheter, after eight hours that can actually kill the skin. We pack their body with lots of swabs and gauzes, and nowadays we also use a special memory foam which cuddles the patient and gives them a really nice, soft, yielding surface to lie on.
We also need to ensure that we have easy access. We know exactly where we want to operate, but we have to be able to get into that area safely and easily, and think about whether we want to stand or sit during the operation. All of these permutations go through my head prior to commencing the surgery.
The one thing I don’t have to worry about is the team around me. There’s an element of ‘emergency’ about neurosurgery; plenty of what we do happens in response to a 999 call. When it does, it’s all hands on deck. At least it should be. I’ve worked with anaesthetists and trainees who, to be frank, loved the job and were very good at it between the hours of nine to five. But I’ve had to steel myself plenty of times to phone certain people in the middle of the night, knowing they’ll not be that interested. When it’s 3 o’clock in the morning and you’re dead on your feet, what really doesn’t help is if somebody’s got a face like a wet weekend. It’s not a great vibe for life-or-death work. I’d rather have the guys who bite my head off and get it out of their system, then crack on as normal. Or, ideally, the ones who recognize that this is a team effort, that we are there to help the patient. That we aren’t operating in the middle of the night because there’s nothing on the telly.
Everything That Makes Us Human Page 1
