All the while we’ve been prepping, the sounds of my Spotify techno-dance playlist are echoing around the room. I’ve got a different playlist for different procedures. Downstairs, where we tend to work more on facial reconstruction, we play more rock music, but that’s because the plastics guys can’t cope with too much electronica. Upstairs, where we are now, and about to tackle a tumour with a difference, techno and dance seem to help me to work better. Something about the beats per minute lets me zone out of the real world, so I’m only seeing the work. But you never know until you get going.
And finally, we’re ready.
Our patient is a one-year-old girl with a brain tumour that’s taking up half of her head. It’s unusual to say the least. Not because tumours can’t grow to hideous proportions – but because she doesn’t seem to have noticed. It really is incredible. I’ve seen the CT scans and the MRIs plenty of times. Even so, looking at them projecting from the computer, I’m shaking my head as I did the first time I saw it.
She first came to our attention at eight weeks old. The obvious action back then was to schedule tumour surgery. Get the bugger out. But despite being malignant, the tumour seemed to be largely inactive. By a stroke of luck, it was growing out of the brain and compressing it – rather than invading deep inside. To look at the scans you wouldn’t see a jumbled mess of interwoven strands; more like the half-and-half design of the yin and yang symbols. Two things growing side by side, like two people in the back of a small car – uncomfortable, but not interfering.
Years ago, when I started out, I would not have bet a penny on her still being alive today. But that’s because I’d rarely seen a tumour play so nicely before. To be fair, the brain should take its share of the credit. Because the tumour started throwing its weight around in utero, before she was even born, the girl’s brain has been adapting ever since. You normally put control of the left-hand side of the body over there? Tough. That space is taken. How about we squeeze it in here? It has literally relocated important nerve centres to more convenient places. The ability for children’s brains to rewire and reorganize themselves is remarkable. They have this amazing aptitude for plasticity. Trust me: any adult would have died a long, long time ago. Our brains get too fixed in their ways. This girl is a living, evolving masterpiece.
Even so, enough is enough. At the current rate of growth, our patient will soon find her brain compressed dramatically. Serious cerebral dysfunction will surely follow.
It’s one of the cleanest ops I’ve ever done. Four hours later and we have managed to remove the tumour virtually in its entirety. What’s left is a cavern, a space where usually half a fully grown brain would be. And yet not one important controlling function has been impacted. It looks weird, crazy even, but with all the nerve tissue still intact in the small half that’s left, it’s going to be business as usual almost as soon as she wakes up. And it was, almost. Just a tiny bit of weakness in one side, which got better and didn’t seem to affect her life.
Six years later, every time I see that little girl, it’s such a great feeling to think, Holy moly, I thought you were going to be dead within six months. Not only is she not dead, but she’s awesome. And she’ll certainly outlive me. Not that she knows who I am. To her I’m just the annoying man who bangs a small hammer on her knee once a year and bombards her with questions. I’m probably a right pain in her backside.
But do you know what? That’s fine with me. I’d take that result every single time.
CHAPTER TWO
CALL ME ‘MISTER’
The hands. It always starts with the hands.
It’s funny, really. A child might be at death’s door. As far as the parents are aware, I am the person who stands a chance of bringing their bundle of joy back from the brink. I’ve been doing this my entire adult life. I’ve saved hundreds of children with the exact same symptoms. But sometimes it doesn’t cross their minds to check that. They don’t ask for my CV. They don’t enquire about past success rates. They stare at my hands.
Does he have the hands of someone who could save our child?
I get it. I’m going to be putting my fingers inside their baby’s skull. Touching its brain, most likely. They want assurances that I’m worthy, that I’m not shaking, that I’m clean. We scrub our hands thoroughly before we operate, and of course we wear gloves for all procedures. There was a short-lived attempt to suggest that we only needed to do a full ‘surgical scrub’ – the kind you see on the telly – in the morning, and then just a simple handwash between each case that day. It didn’t happen, despite the evidence that was presented to us. Some things can’t be changed – surgeons and nurses have their routines, and we need to do them to keep our anxiety at bay. But it’s all about appearances. And appearances where desperate parents are concerned count for more than you think. It’s a lesson I’ve learned over more than fifteen years as a consultant and almost double that time as a doctor.
And yet not everyone sets great store on such things. Not everyone even notices what parents think. Some people, in fact, couldn’t care less. Which is why I am the man I am today and why I choose to work with children. And which is why I try to go the extra mile and place myself in not just the parents’ shoes, but those of my patients. How would I feel in their position? What would make my already horrific ordeal that bit better?
I like to think that I do what I can, and should, for my patients. But it wasn’t always like that. And it certainly wasn’t what I was always taught.
At the age of eighteen I went off to medical school. I chose St Mary’s in Paddington, London. I had thought about Oxford – my biology teacher said that this was clearly where I should go – but after having visited it, I felt that it seemed too quiet, too provincial for the teenage me. I wanted the grubby highlights of the big smoke. Interesting how this view was to change later on in my life. Six years of medical school is a long time, but you soon realize after qualification that even half a century of study would have left you feeling you had gaps in your knowledge. All these years later I’m still learning. Of course, that’s with the benefit of hindsight. At that age you think you know it all.
I was bright-eyed and bushy-tailed, full of enthusiasm and enough confidence to think I could change the world. A typical eighteen-year-old, in other words. It was a bit of a shock to learn that the whole profession had slightly lower aspirations. The father of modern medicine, Hippocrates himself, summed it up in a nutshell: ‘Do no harm.’ (Well, he didn’t actually make it up, but let’s not quibble – it simply paraphrased his ‘oath’ that doctors love so much.) In other words, don’t screw up. That’s it. That’s all doctors were expected to do. Don’t make things worse. Anything better than that is a bonus. Surely, we must have moved on from there?
Reality check aside, the course covered everything, and as much as it makes me sound nerdy, I liked it all. Whichever topic we covered that week became my new life’s ambition. I was like a kitten chasing beams of light. Ooh, sparkly. Ooh, new! Want it, chase it, want it.
It was only as we went through year five that I decided upon my future speciality. Or so I thought. In your penultimate year of being a medical student, essentially after nearly six years of hard slog and excessive drinking, they throw you a bone. You’re asked to do a three-month specialism with the bonus of the powers-that-be letting you choose where to do it. Most people pick Jamaica or Thailand or Australia, basically somewhere to chill.
I chose the National Hospital for Neurology and Neurosurgery in Queen Square in London. Just down the road. What a loser.
In my defence, they had a great reputation for my new favourite topic: neurology, the medical side of brain disorders. The passion had been growing for some time. Lots of people have a model of that phrenology bust on their shelves – the human head with the various parts of the brain marked off like prime cuts on a picture of a cow. You’d be forgiven for thinking that it is an accurate representation of what’s under the hood – and certainly in the early 19th century mos
t experts did – but it’s largely inaccurate. Having said that, as incredible as it sounds, there are some areas of the brain that were successfully associated with specific functions as far back as ancient Egyptian times.
An American collector of antiquities called Edwin Smith discovered an almost 4,000-year-old papyrus containing a fantastic collection of descriptions of what are clearly neurosurgical wounds alongside explanations of what should be done to make them better. Things like: ‘If the man has a wound to his temple, and cannot speak, this is a wound that cannot be treated’, because they obviously knew that the speech centres were in these areas. It lists different presentations of spinal injuries and gives a spookily accurate assessment of the prognosis for each. There are lots of nuggets like these, all born thousands of years ago from, one imagines, observations of people with battle injuries. It’s fascinating to consider the physicians working independently, but all their information has been pulled together over time. One doctor would look at a patient and say, ‘Okay, you can’t move. There’s a hole in this part of your head, so they must be connected.’ He would write that down and over time people would build on that knowledge.
Like so many advancements in science and technology today, the driving factor has been the effects of war rather than a thirst for health. But the ancient Egyptians weren’t the only ones on record to dabble in neurosurgery. There’s evidence from over 3,000 years ago in Central and South America, where they used to trepan – in other words, drill holes in skulls to let out the evil humours. It’s almost inconceivable that there was neurosurgery going on back then, but the fact that there was further sold it to me as a worthwhile career.
The great thing about any neurological condition, though, and this is why I was drawn to it, is that it takes a lot of thought. It’s a very deductive speciality. You examine patients, and you have to work out where the problem lies, at what level and which part of the function of that person is affected. It’s like doing a cryptic crossword. The clues are there, but can you make sense of them? You’re Dr Watson and Sherlock Holmes rolled into one. I absolutely loved it. It spoke to me. Challenged me. And, I guess, didn’t exactly hurt my ego.
It’s not for everyone. Many of my friends were drawn to orthopaedics. I wasn’t going to judge them, but where was the challenge in that? ‘You’ve got a broken leg. Here’s an X-ray, it shows me the leg is broken. Job done.’
Of course, now I know that orthopaedics can be incredibly intricate and challenging, but I didn’t see that side of these specialities back then – you only get two to three months at most, and sometimes much less, at medical school.
I didn’t want something that would give me answers on a plate. I wanted to have to sit and think and work stuff out. Be a calculator rather than a robot on the production line. But, I began to wonder, would that be enough?
The thing about Sherlock, of course, is that while he was the greatest deductive detective, he was also, like the Dark Knight, no slouch at the old fisticuffs. He could handle the practical as well as the theoretical side of crime-solving. Whereas I, in neurology, was being benched whenever the going got good. The problem with neurology as a discipline is that although it’s really good for all that deductive reasoning, the treatment options can be limited. I felt slightly powerless in that I was going to be giving patients some medicine and seeing if the medicine helped, rather than me helping personally. I may as well have been standing on that weird raised step in a pharmacy doling out ibuprofen for all the input I thought I’d be giving. It didn’t feel like I was actually part of the treatment – just a conduit for the drugs. I think it was all part of a rather youthful desire to be the centre of everything.
But, I reasoned, so what if I rarely break a sweat? This is the area I want to specialize in.
By the third month, however, it had got to me. I was in the dining hall at Queen Square queuing for something with chips, whatever the day’s special was, and I remember ranting to a couple of friends about the shortcomings of the area.
‘I never feel like I do anything. I got into medicine to help people, not read books. I want to get my hands dirty.’ I was talking to a group of neurology hopefuls, so I wasn’t going to get any sympathy from them. Nor, it turned out, from anyone else.
‘Stop fucking whingeing,’ said a voice from behind me. I turned to see that, according to his name tag, it was one of the university’s senior trainee neurosurgeons. ‘If you really want to get your hands dirty then stop moaning and do something about it. Join us. Be a brain surgeon. Ditch these losers. Become one of the elite.’
I don’t think I moved for about a minute as I was so shocked at being sworn at like that by a stranger. By the time I did, the lunch queue had shifted around me and the guy was already at the till. I was torn between grabbing the chilli option and running after him. In the end I tried to do both. Clutching my food, I chucked a fiver at the cashier and legged it after my new mentor. So what if he eavesdropped on other people’s conversations? I liked the cut of the guy’s jib. He had this arrogance I’d never seen in doctors before. It was intoxicating. It spoke to me. He was exactly everything I wanted to be.
‘Do yourself a favour,’ he said, barely looking at me when I caught up. ‘Come and see what we do. You’ve either got it or you haven’t.’ He explained that he was operating the following day and I was welcome to attend.
Eighteen hours later, I was watching him cut into a young woman’s head. I needed to become one of these guys. Of course I did. It was so obvious. This guy wasn’t just deducing the problem and prescribing a few pills. He was nailing the diagnostic bit and then providing the solution with his own two hands.
He’s not just dishing out the medicine. He is the medicine.
My future was fixed at that very moment. But before I got there, despite what it said at my graduation ceremony about being qualified, I needed to learn to become a real doctor.
All the theory in the world can’t prepare you for what lies outside the college doors. After qualifying, you used to do a year’s basic medicine and surgery, basically a bit of everything, before you could even think of sub-specializing. In other words, you’re let loose on the public. Again I eschewed the glamour spots of the world for Ealing Hospital. Like all newbies, I thought I had all the answers. Like all newbies, I was soon put in my place. I knew nothing.
There was six months of general surgery and another six of general medicine. That’s really when you learn how to be a doctor. And it’s a steep learning curve. During my first ‘on-call’ shift as a doctor, I was asked to ‘write up’ some paracetamol. There happened to be a box near me in the drug cupboard, so I broke a couple of tablets out and handed them over.
‘What are you doing, lad?’ the nurse in charge asked. ‘You can’t just hand out medicine. You have to prescribe it.’
‘Okay,’ I said, and I duly wrote down ‘two paracetamol’. ‘There you go.’
She rolled her eyes and laughed. ‘You can’t write “two tablets”. You have to write “one gram”.’
‘Really? Six years and no one told me that?’
‘That’s why you’re here.’
Measuring tablets in weight was just the start of it. There were so many idiosyncrasies not covered in the textbooks and of course the only way to learn was to have first-hand experience. I examined hundreds of patients, processed thousands of blood tests, listened to countless heartbeats. It was baffling how so many people of the same species suffering the same conditions could have such different bodies. At med school all the practice dummies looked the same. Still, all part of the learning process.
The lack of time and resources in the NHS means there’s no room for slowcoaches. As nice as most people were, carrying a newbie passenger wasn’t something anyone enjoyed. They made that clear enough. And why not? They’d had to get up to speed sharpish back in the day. There was no reason I shouldn’t either.
You had to learn quickly. There just wasn’t the time for anything else. I was basically o
nly shown anything once. If it didn’t stick, you didn’t dare ask again. The whole culture was summarized succinctly by one of the doctors in the following words: ‘See one, do one, teach one.’ That was workable when you were writing out prescriptions. When we moved onto the surgery half of the year, the risks got a little higher and Hippocrates’ words finally made sense. You’re dealing with someone’s internal organs. It’s not Lego, it’s not Stickle Bricks. If anything it’s Jenga. One slip and you can wreck everything. Surgeons aren’t magicians. As one of them said, ‘We don’t deal in miracles. If in doubt, do nothing at all.’
Do no harm.
Every fledgling doctor has to pass the whole year. Whether you’re aspiring to become a GP, a gynaecologist or the future of oncology, it all begins with this cold immersion into reality. These days it’s spread out over two years. Even double that, I would suggest, couldn’t begin to prepare you comfortably for the world outside.
The surgery aspect only confirmed my decision to focus on neurosurgery, but I still had two more years of hurdles to overcome before I could even begin. Now promoted to Senior House Officer, ‘Dr Jay’ was expected to turn his hand to everything at the hospital of his choice and I elected Kingston in Surrey.
Everything That Makes Us Human Page 2
