Everything That Makes Us Human

by Jay Jayamohan

  My first stint was in A&E. If I thought doling out painkillers was an ordeal, then this was something else. If you’ve ever gone into A&E and thought the treating doctor looked a little scared, you’re right. I honestly didn’t know what I was doing quite a lot of the time. If you gave me rare and seemingly random symptoms as part of an exam, I’d ace it. ‘Erratic behaviour in a patient with sweet-smelling urine and ear wax? That must be a metabolic condition known as branched-chain ketoaciduria. I think that patient is suffering from Maple syrup urine disease, sir.’ (That’s a real thing, by the way.)

  But staring into the eyes of a real-life human being at 1 o’clock on a Sunday morning, trying to unpack the truth from the confused guesses the patient has made about his or her condition, the pressure was slightly different. So many variables, so many red herrings. Thankfully, there are the nurses. These people saved my backside countless times, and are the absolute backbone of the department. An experienced A&E nurse is worth more than sleep – and that was something I was sorely lacking.

  A&E really is the front line of medicine. You’re firefighting all the time. It’s a really worthy part of the system, but it wasn’t where I wanted to be. Nor was general surgery nor orthopaedic surgery, even after six months doing each. No, I thought, my future is in neurosurgery. I want to be a ‘Mr’.

  It’s a weird quirk of UK medicine – certainly it’s viewed as weird by international colleagues and, if I’m honest, most of my patients – that once you qualify as a surgeon you are elevated beyond the soubriquet of ‘doctor’. As a breed we’re quite passionate about the origins of the tradition. Like so many British oddities it has its roots in snobbery.

  To be a doctor in the 1700s required a medical degree. In theory, this was a sign of erudition. In practice, degrees were often acquired by charlatans cheaply, abroad or by post. It didn’t matter, as it bestowed upon them the title of ‘Dr’ and the right to prescribe medicines, albeit from a rather narrow range, and charge bills. Big bills.

  Occasionally, their diagnosis would require some bloodletting or bone-cutting, which is where the surgeon would come in. Except in those days, surgeons weren’t considered medical men. Far from it. They were butchers or, more accurately, barbers.

  If you needed a bladder stone removed or a tooth yanked out, you’d be sent along to the same place where you got your hair cut. This is why, if you look outside barbershops today, you’ll often see a pole of red-and-white stripes. It signifies the blood and bandages of their forefathers’ ‘other’ jobs.

  It was considered such a ghastly side of health care that doctors weren’t going to perform surgery themselves. All that blood and gore was considered beneath them. Not only were surgeons not required to have qualifications as doctors, all they really needed was muscle, something no man of learning would possess. If a doctor diagnosed a gangrenous foot, for example, then your local Vidal Sassoon would basically stick a leather strap in your mouth and four big blokes would hold you down while the barber got the saw out. Doctors wanted absolutely nothing to do with it.

  It was only in the 1800s, with the advent of antisepsis and some element of anaesthetic, that surgery began to lose its tag of human torture and people would voluntarily go to the surgeon and say, ‘I think there’s something wrong with me.’ As it evolved as an occupation and became more skilled and more licensed – and less deadly – the medical profession made moves to bring this former black sheep of the family under its own roof, which of course made sense. But even as they became ‘legit’ members of the industry, surgeons wanted nothing to do with those quacks who’d once treated them like dog mess on their shoes, so they refused the title of ‘Dr’. And which is why, out of solidarity with our predecessors, surgeons in the UK still do the same today. Myself included.

  After six years of struggle to become a ‘Dr’, I couldn’t wait to get rid of it.

  It was at a hospital in leafy Wimbledon where I finally got my chance to practise neurosurgery and, from the moment I passed my junior surgeon exams, my title changed as well. It gave me an inordinate amount of pleasure to ask people to ‘Call me “Mister”.’ It sounds really childish, but this title had cost me so much time and effort, and all the surgeons I knew got a kick out of this name change.

  I worked with half a dozen neurosurgeons, some more closely than others. They were a mix of consultants and senior trainees who were basically at the end of their training. They all had their strengths and weaknesses. Some would let me do more than run errands and watch them in theatre, but they might be unpleasant personally. Others were charm personified, but always, I felt, holding me back from contributing anything worthwhile. What they all had in common, however, was this unerring belief that they were operating – pun intended – at the top of the medical profession. The swagger wasn’t just reserved for the guy at Queen Square who’d helped to change my career path. They all had it coursing through them. As one of them admitted to me during an operation, ‘All doctors have a God complex – but we’re the only ones who deserve it.’

  I could see what they meant. Your heart is important but, at the end of the day, it’s basically a pump. A fancy irrigation system. Whereas the brain is network control. You want anything done, speak to the brain – oh wait, you can’t because the brain controls speech.

  I admit it. I was falling for the hype hook, line and sinker. In the meantime, my big brother was training to be a heart surgeon. We had a vague sort of competition going on between our specialities. He never gave an inch. Never doubted his side of the great divide. And, when we both experienced one of his colleagues close up, I could see why.

  I still remember the day I got the call from my dad telling me that he required a triple heart bypass. He was youngish, relatively fit and had never smoked, so it was a shock. Despite all three of us being in the medical game, the waiting list for Dad’s operation was some months after they predicted he would likely suffer a heart attack. That seemed a bit back to front. Fortunately, Dad had health insurance. I’d never understood why a doctor would get insurance but, given the waiting-list issues, it was all suddenly clear – he knew exactly what pressures the NHS was under and, given the predictions, we all knew this was the only way to go. So, given that we were paying, my cardiac surgery trainee brother knew exactly who he wanted to conduct the operation.

  On the morning of the operation, my brother and I were at the hospital to give moral support to my mum. Dad was in bullish spirits and, as he was wheeled away, so was I. As the hours passed, that confidence began to slip. Despite all my training, the thought of a stranger with his hands inside our dad’s chest was unsettling.

  I remember asking my brother, ‘I know you were his registrar, but are you sure about this guy?’

  ‘I’ve told you,’ he said. ‘He’s the best. You wouldn’t want anyone else.’

  ‘Let’s hope you’re right.’

  It was a long and painful five hours of waiting and waiting. I must have covered every inch of the floor in the first sixty minutes alone. Apart from a quick dash down to the supermarket in the lobby, the rest of the time I’d spent gazing absent-mindedly out of the window. Eventually, though, I had to ask, ‘What’s taking so long?’

  ‘I’m sure everything is fine,’ my brother said. ‘They’re just being thorough.’

  ‘Yeah, I suppose you’re right. You wouldn’t want them to rush – hey! Wait a minute.’ I called him over to the window. ‘Is that who I think it is?’

  A few floors down below was the unmistakable figure of my father’s surgeon, climbing into a car. ‘What the hell’s he doing out there?’ I asked.

  ‘He must have finished,’ he replied.

  ‘And he didn’t bother to come and tell us how it went? You were his fucking registrar!’

  Despite his defence of the guy, my brother was just as offended as I was that no contact had been made. We’d been waiting for nearly six hours and literally didn’t know where our dad was, alive or not. I’d had enough. I went running down the
hall and was just about to give someone a piece of my mind when the anaesthetist from the operation walked out. He too had been handpicked.

  ‘There you are,’ he said. ‘I was just coming to find you.’

  ‘Is Dad all right?’ I asked.

  ‘Should be fine. The next twenty-four hours, as you know, are crucial, but the op itself went like clockwork.’

  ‘Thank you,’ I replied. ‘Although it would have been nice to hear that from the surgeon.’

  ‘Oh, don’t worry about that,’ the guy said, ‘he’s not so good with families. All that matters is what he does in theatre, right?’

  ‘Yeah,’ I said, ‘I guess.’ But for the first time in my career, I wasn’t so sure.

  As it turned out, Dad developed renal failure the following day. Nothing to do with the level of skill shown by our errant surgeon – he’d been brilliant, you’d have to say. Not that I could ever tell him that. Never once during the following days did he show his face anywhere near us or even my dad. The anaesthetist, by contrast, was in and out like a nosy neighbour.

  My brother was as worried as I was, obviously, but he wouldn’t let a word be said about his former boss. An attack on the surgeon was an attack on the whole cardiac family.

  ‘Your lot are just the same,’ he insisted. ‘Probably worse.’

  ‘You don’t know what you’re talking about,’ I said. ‘I’ve never known a neurosurgeon care so little about his patient or their family.’

  He laughed. ‘Well, you will, I’m sure of it.’

  And, unfortunately, it wasn’t long before he was proved right. What this did teach me was about how it feels to be sitting on the cheap sofa, drinking crap coffee and sweating – in other words, being the relative. It was bad enough with my dad as the patient. The amplified terror of it being your baby – you wouldn’t want to experience that too often in your life. I knew that part of my job was going to involve trying to manage that fear in other people whenever I could.

  Surgery is very much an apprenticeship. You can’t learn that much from a book, hence the seemingly never-ending training. At the start, as a junior trainee you spend time examining patients – lots and lots of them – taking care of all the ward work, basically getting to grips with how things are done as much as anything. You’re allowed in the operating theatre, but it’s a fairly ‘no touching’ deal. It is a rude demotion compared to the level of operating we did as juniors in other specialities. I was able to do a fair few abdominal procedures almost single-handed, but neurosurgery training puts you right back down again.

  After a year of that, you start contributing to some procedures, learning how to close wounds, operating the suction, getting a bit more hands-on. It’s very low risk. There’s always either a senior trainee or the consultant surgeon – often both – guiding every move. You’re nervous as hell the first time you do anything and, though they don’t admit it, so are your bosses. But you get through it and the next time they only watch you with one eye.

  It was late at night. I was the designated dogsbody on duty, basically there to answer the bleep in case of emergency. But as it turned out, there was an emergency and I duly called the senior trainee who was on call with me. He took the patient to theatre. The whole process worked as smoothly as could be hoped. But then the bleep rang again. I took the verbal history and results over the phone from a harassed registrar in some other hospital, no doubt harassed to the extreme also.

  I phoned out again to run through the details with my boss, as the senior registrar was busy. Consultants are on call on top of their full-time day duties – so they are at home and are available for advice and assistance. I fully expected him to say, ‘Check the patient over – I’m coming in.’ But he didn’t.

  ‘You’ve seen this procedure before?’ he said.

  ‘Yes.’

  ‘Good, I think you will manage to do this quite fine.’

  ‘Do this? You mean on my own?’

  ‘You want to be a surgeon, don’t you?’

  ‘Well, yes, of course.’

  ‘Then he’s yours. Let me know how you get on.’

  I hung up the phone in shock. At last. It was happening. After all the years of dreaming and waiting, I was finally being allowed to work on my own patient. I was so excited. So ready for my big moment. So determined that this person – this fellow human being – whose life had been placed in my hands, was about to benefit from surely the greatest surgeon the UK would ever see!

  I was prepared. I was confident.

  Perhaps too confident.

  CHAPTER THREE

  SEE ONE, DO ONE, TEACH ONE

  I’m looking at a patient absolutely riddled with tumours. He has a lymphoma that’s spread throughout his body. He’s knackered. This is the last roll of the dice. Quite why he has only just appeared on our radar I have no idea. It’s clearly been an ongoing problem, but one about to end imminently. I reckon he has no more than twenty-four hours left to live unaided, maybe a few weeks regardless of what we do. Someone would have to operate immediately to give him a fighting chance of having those precious extra days with his family. And that someone, rather unexpectedly, is me.

  My boss doesn’t seem overly inclined to come in. The senior trainee is already wrists deep in his own surgery. It’s time for me to step up.

  See one, do one, teach one. The words repeat through my mind. I’ve seen it, I can do it. It’s how it’s always been.

  I look around and see the anaesthetist who I’ve worked with before. She looks calm. The scrub nurse has assisted around the operating table for more than twenty years. Just because I’m new, it doesn’t mean that there aren’t some serious experts in the room.

  I’ve probably seen the operation five times and assisted on it twice. It’s fairly straightforward. I need to insert a tube into the man’s skull to drain away the excess fluid. The scans show it building up in the ventricles – the fluid spaces we all have in the middle of our brain. If I go in from the patient’s right near the front, there’s little there of import. All the major speech functions are in the left part of the brain. It’s the ‘least worst’ option, as we are often forced to choose. I’ve seen and read it many times as being the best entry point.

  The patient is covered in green linen drapes. We used to use these for years – washed and reused ad nauseam. Increasing numbers of patches appearing over their lifespan, but only thrown away once they resembled some of my ‘battleship-grey’ underpants – you know the ones, with extra ‘comfort holes’ worn in them. Nowadays, it’s all disposable. It saves on washing and transport, but I am not sure about the eco-friendliness of all the paper being used. Not my choice any more.

  Anyway, I digress. The man’s head is partially exposed. Cleaned. Waiting. Ready.

  I look to the anaesthetist. ‘He’s all yours,’ she says. ‘We’re good our end.’

  The scrub nurse hands me my scalpel. I make a horseshoe-shape incision around the entry point, then peel back the area of skin. It flaps down, revealing the bone I need to drill through. I look to the scrub nurse. She already has my drill in her hand. She anticipates my every move.

  It’s crucial not to go too far – to plunge into the brain. Not if you don’t want to cause irreparable damage. I set the machine up as I’ve always seen it done. The power will cut off if I accidentally overstep the distance. It’s foolproof.

  We’re set. We’re ready. Deep breath.

  Anyone who’s ever drilled into a plasterboard wall will recognize that familiar lurch when the drill bit breaks through the board and into air. As slowly as I was going, it still came as a shock to suddenly meet no resistance. Except in this case I wasn’t drilling air. I’d entered the skull cavity. The drill now off, I opened the fibrous bag around the brain – the dura.

  Next, Wendy (the scrub sister) hands me the ventricular drain – the tube I need to pass into the brain to get to the fluid in the middle. Think of it like putting a straw in a coconut to get to the milk inside. I check the marking
s on the side of the tube as I pass it in: 4 cm; another one to go. I have seen them inserted 5 cm deep before. Now we’re in the danger zone. I have to keep moving perfectly forwards. Any deviation could take us away from the fluid and into very sensitive territory. As I read this, it all seems a bit melodramatic. But that’s after many years in the job. That initial terror of looking around and realizing there is no cavalry coming – realizing, in fact, that you are the one wearing the fancy blue outfit, coming to save the day. It’s hard to forget.

  I keep my eyes fixed on the tube’s depth markings. It takes less than a second to cover the remaining distance. I can’t afford a mistake. A man’s life depends on me. I have little experience and all the nerves in the world. It is not his fault that I am the one assigned to saving his life. But it is my privilege. I’m operating on a man’s brain. I have the opportunity to save a life, to make a difference. I’ve dreamed of this moment for so long.

  We hit the 5-cm mark and I hear myself sigh with relief. There is a central wire that keeps the tube stiff while I pass it in. I remove it. Fluid starts to come out, and I am utterly relieved. We should see improvements pretty soon.

  ‘We just have to wait till he wakes up,’ the anaesthetist says.

  I wash up, change out of my scrubs and can barely contain my delight as I leave. If I could have got away with a Fred Astaire-style ankle kick I’d have gone for it. I am buzzing. My first operation. My first test. My first shot at the big time.

  Yes, my hands were shaking. All of me was. That wasn’t important. What mattered was that I didn’t falter during the op. I was Steady Eddie. Cool as a cucumber. Did everything textbook. I was buzzing, on top of the world. Not quite ‘God complex’ levels but, even if I did say so myself, I’d just tapped into a man’s brain – his very soul – and saved his life.