This is what I was born for.
Getting back into the normal swing of things was hard. Apparently, the world hadn’t moved on as much as I had.
‘Hey, I just performed my first operation.’
‘Yay, great – now pass me those suppositories and a sick bowl – this guy’s in for a double ender …’
About an hour afterwards, I popped down to the Intensive Care Unit (ICU) to check up on my guy. I was expecting to see my patient upright and chomping on grapes with his loved ones. As it turned out, the mood at the bedside was slightly more sombre. Understandably so.
‘When’s he going to wake up?’ the patient’s wife asked. ‘When can we take him home?’
What to say? I honestly thought he’d have come round already. ‘Well, obviously he’s had a serious operation. It went well, but everyone recovers at their own rate. Plus, of course, he was pretty sick from the cancer, so that may mean he will take longer to wake up. But the fluid is draining out, so that should have normalized the pressure in his brain.’
We did overnight on call in addition to the daytime work, so I seamlessly moved from the night emergency cover work into regular daytime stuff. I had a ton of dogsbody chores to plough through for the senior trainee – discharge summaries, referrals back to other hospitals and other low-level work. I dealt with it as best I could, but all the while my mind was in one place: that bed, that man, that operation. That footnote in history.
When my boss announced that he was conducting ward visits, I dumped everything to join in. He hadn’t been the one who had been on call and who I’d rung the night before, but I really wanted to show him my proud achievement. For ninety minutes we wandered around the various extremities of the hospital. Finally, we entered ICU. My patient. My reputation.
When the consultant looked at the man’s charts he recognized my name. But by then I wasn’t particularly paying attention. ‘Do you think he should be awake by now?’ I asked.
He checked the info. ‘Hmm, you would hope so, yes.’
He rattled off questions for the accompanying nurses and his entourage of trainees, and requested further information. He also asked for a new scan. We finished the rest of the round, and then went to look at the scan.
After what seemed like forever, with me standing there fit to burst, he pulled me aside – a generous action as it turned out. ‘I don’t think he’s going to wake up,’ he said matter-of-factly, but out of the family’s earshot.
‘That’s not possible,’ I spluttered. ‘I was the operating surgeon. I did everything right.’
‘And yet,’ the consultant explained, ‘your man is still never going to wake up.’
It was the shittiest moment of my life. I wanted to curl up in a bed alongside my patient and have my own life support switched off.
The patient’s scan told a terrible story. Yes, the fluid pressure had been treated, but this had then led to a rapid drop in the pressure of the fluid around the tumour-addled brain. Without that pressure (which was, you will remember, trying in its own evil way to kill the guy), the tumour’s blood vessels suddenly felt released and, indeed, released a load of blood into his brainstem – the centre of consciousness and just about everything that keeps you alive. It was a massive bleed. It wasn’t my fault and I had had to do the operation. But it didn’t stop me feeling incredibly guilty about the whole thing.
‘Well, you couldn’t have foreseen this, clearly. Seriously, it’s not your fault. And in any case,’ he added, still staring at the notes, ‘he only had days to live anyway. If anything you saved him from a world of suffering.’
I ran up to the neurosurgery floor to find my other boss, the one who had instructed me – and trusted me – to conduct the procedure. As I knocked on the office door I was already writing my speech of resignation. After all, I’d performed an operation which, by the looks of it, was going to shorten a man’s life. In other words, the exact opposite of Hippocrates’ ‘Do no harm’ ethos.
I ran through everything I’d done and the horrific outcome. When I finished, the consultant just paused and stroked his chin. ‘These things happen,’ he said.
‘Yes, but it was my fault.’
‘It WAS NOT your fault. You did everything right. He was lucky you were there to at least try to save him. His time was up, I’m afraid. Learn from it and move on.’
I was shocked at how forgiving everyone was being.
I left his office, stunned. Relieved, of course, that I hadn’t been dragged across the coals. Devastated that the man had died but also confused as to why my bosses didn’t seem to be angry. If we were working at a paper-clip factory and I’d mislaid a shipment, then okay, tell me to get over it. But we were surgeons. We were people trusted by the public to save their lives. Surely that should make a difference?
I thought back to my father’s case. I remembered how crap we’d all felt being bypassed by the surgeon. It’s like we were irrelevant to him. It really is a God complex, I thought. They really think they don’t need to answer to anyone.
With a nauseous gut, and a super supportive senior registrar, I went down to tell the family what had happened. That I had done the operation, but there had been ‘unforeseen complications’. It’s a peculiarly British method of understatement in the face of a complication that opened the door to death. They listened, thanked me for my honesty and for trying to help. His wife said that he was going to die without the operation and so at least we had given it a go. And that was it.
The shadow of that operation never went away. I didn’t want it to in case I forgot the lessons it had taught me. But life in Wimbledon was too full-on to have that much time to dwell on it. Several of the other consultants went out of their way, I felt, to keep me occupied. I was given handfuls of new cases to prep and consult upon. I really got into the nitty gritty of new patients’ requirements, and immersed myself in keeping them and their families up to date right up until the point of surgery.
If I’m honest, I felt like I was being kept busy a bit like a naughty child. Then I realized these other bosses were really just trying to show me that there was always another patient. That I had to be able to cope with these things. Neurosurgery isn’t an easy speciality. I needed to learn how to walk the tightrope of caring for my patients, while not becoming paralysed by every complication and knockback. There would be plenty – and some of them could be by my hand. I simply had to learn to accept this and move on, or my career would grind to a halt, with tumours incompletely removed for fear of the consequences and hydrocephalus untreated, plus many other conditions that carried risks dealt with overcautiously. There is a reason that the consent form is chock-full of the potential complications of even the most ‘straightforward’ brain-surgery operation.
Suck it up, Jayamohan – at least you aren’t the patient …
About three weeks after my first solo op, I was due to observe in theatre with a different consultant. The patient looked as though he had a type of tumour called a glioblastoma, something I’d seen a lot of. It was the most malignant type of brain tumour, and almost all of the patients died within nine months to a year, and that was with surgery and radiotherapy. I’d ‘worked this patient up’ – done all the preoperative tests and assessments – and talked to them and really got to know them on the ward, and I guess my boss du jour knew this. We were virtually ready to go when she said, ‘Look, you’ve done all the work, do you want to do this op with me? I’ll take you through it.’
‘Really? I’d love to.’
I never expected to work on a tumour so early in my career. They’re the big bad wolves of so much of our work. Being given a chance to operate on it was amazing. The fact I was being trusted to do anything after the last time seemed like a miracle. But this boss was incredible. She guided me every step of the way and the operation went like clockwork. The patient woke up and everything was still working for him.
‘Not bad at all,’ she said afterwards. ‘Now, would you like the honour of telling the f
amily?’
‘It would be my genuine pleasure. Thank you.’
‘A few more dozen of those and maybe – just maybe – you’ll be ready to teach one.’
Too soon, boss, too soon …
CHAPTER FOUR
JUST ANOTHER SATURDAY NIGHT
PUMP. PUMP. PUMP.
The sweat is pouring off me. But it’s nothing to the ravines of perspiration seeping down the brow of the anaesthetist. He’s the one doing the work. The real work. For now, anyway.
‘John,’ I shout, ‘get in here!’
John is a porter. He lifts, he pushes, he carries all day. He’s strong. Fit. Fitter than the anaesthetist. Anaesthetists are some of the most valuable people in a hospital, but you wouldn’t want them representing you in a battle. Not when you have porters.
John rushes in. His colleague Dave is behind him. They both know what to do. Taking turns, they pump down on the young man’s chest, just as the anaesthetist has been doing. John pumps, he waits, he pumps, he waits. The familiar beads of sweat form on his brow, too. But he can handle it. For now.
PUMP. PUMP. PUMP.
I don’t remember the patient’s name. All I know for sure is that he’s young and he’s male. And he’s been dead for three minutes.
He was alive when he came in. Just. His pupils were dilated and his head showed signs of massive trauma. He’d been beaten to a pulp outside a pub an hour earlier – just another Saturday night. A scan in A&E had identified a blood clot on the brain and so they’d shipped him across to me. They didn’t hold out much hope, but even as they handed over the trolley one of them said, ‘Hope you’ve got your miracle-worker shoes on for this one.’
It’s a running joke. Everyone knows that neurosurgeons believe themselves to be the top of the medical tree. That’s what we like to tell ourselves – and anyone else who’ll listen. No one believes it, until you get a mashed-up mess like this and then it’s time to try to live up to the myth.
PUMP. PUMP. PUMP.
The patient’s heart stopped the second we got him on the operating table. ‘Oh, bugger.’
Everyone thought or said the same thing as the heart monitor ceased beeping and hit that all-too-familiar continuous eerie note. But it was the anaesthetist who said it loudest. The heart’s his domain in theatre. I might be the one with the magic knife, but he’s in charge of keeping the patient breathing till I’m done. Whichever way you look at it, a ‘flatliner’ doesn’t sit well on anyone’s scorecard.
Before anyone else had reacted, he’d gone straight into chest compression mode with his hands. Electric paddles can sometimes jump-start a heart, but that takes time to set up, and there were enough bits of metal equipment around the patient to electrocute a few of us in the process.
So, manual stimulation it was. It’s nothing like what you see in the movies. Unless you’re close to breaking the patient’s ribs, you’re not doing it right. And pressing hard enough to do that, again and again and again, is exhausting. Hence the call to the boys.
PUMP. PUMP. PUMP.
‘Four minutes, Jay,’ the anaesthetist says, just about keeping it together.
Four minutes? The guy’s been gone longer than it takes some people to run a mile. When, I wonder, does a person turn from a patient into a corpse? It’s odd the things you think about in such moments.
After what seems like an interminable amount of time, we get a pulse, and a blood pressure, of sorts. The patient was still super rickety and could go down again at any time. We discuss what to do. Ideally, we would want to spend some time getting him on various medicines in the ITU – the intensive care unit – to support his heart. But it had stopped because of the blood clot in his beaten-up brain – without me getting the clot out, he was a goner anyway. So, we decide that I will operate and they will keep his heart going with medicines and hands, depending on how it goes.
There are two ways to open a person’s head. The pretty way and the quick way. Usually, I shave the hair, use a scalpel to nick the skin, then apply an electrocautery device to burn down to bone level. It’s a slow, precise method and it leaves almost no scarring. But it takes time. Time, the incessant beeping note of the heart monitor reminds me, I don’t have. The fastest way is the only option.
‘For God’s sake, Jay, get him open, get the clot. Let’s go, go, go!’
I don’t need to be told, but again the anaesthetist is only saying what everyone else is thinking. I plant the knife blade against the man’s skin and press down. It goes deep and I feel it connect with the bone. I make the incision in the shape of a question mark. I drag back the skin and muscle, and I stare at the bone. It wasn’t a neat-looking procedure, but was the quickest way in. If I don’t do something now, there is no future. Not for this guy.
Five minutes have gone by.
It’s in an emergency like this that you appreciate the value of a great scrub nurse. The good ones know what I need before I do. The really good ones have it ready as soon as I put out my hand. But the great ones place the tool in my hand exactly how I want it, so I don’t need to take my eyes from the patient for a second. Jill is one of the best. She hands me the drill.
‘What’s taking so long?’
More cheerleading from the anaesthetist. I love the night-shift team spirit. It’s more like squabbling siblings – we bitch at each other, but always have each other’s backs.
The drill is calibrated to puncture the skull then cut out before it damages the brain. It’s just as well, the speed I’m hammering the first hole. One down, two to go. Again and again I lean into the device, wincing instinctively as the fine shards of bone spiral into the ether.
Two. Three. Now it’s time to join the dots.
‘Six minutes.’
Jill plants the jigsaw into my outstretched palm, trigger perfectly aligned to my forefinger and thumb. I clutch the saw, insert the thin blade inside one of the holes and power up. It’s hard work. Being up against the clock makes everything tougher, every tool heavier. But I lean into the angle and feel my hand dip slightly as the first connection is made.
The next two lines take another minute or so. As I drag the blade across for the final time, I’m aware of the fear in the room being replaced by a palpable tension. We’re nearly there. Make or break time.
‘Eight minutes, Jay. Hurry up, for Christ’s sake.’
I nod imperceptibly. It’s all that’s required. He knows I’ve heard. He also knows I don’t need to be told. But he’s a solid guy. Sometime before, I had moved up to Glasgow to further my training, we have both been registrars there for a couple of years, and have done many a night on call together. We trust each other, and that’s worth more than anything in this situation.
If I’ve done my sums right, the bleeding clot shutting down the messages to the heart – and everything else – should be directly underneath the rough pentagon shape I’m carving out. Given the circumstances, I’ve made the hole bigger than usual. At small palm size, I should be able to find what I’m looking for below. I’m as anxious as anyone to get there.
The scrub nurse takes the saw almost before I hold it out to her. Seconds later, my fingers are prising out the five-sided island I’ve cut out of bone. Now it’s my turn to sweat.
‘Come on, come on …’
My fingers seem to swell with every passing second, but suddenly I make contact and the jagged piece of skull lifts clean off in my hand. The dura is roughly sliced open with a knife, then cut with big scissors – no time for mucking about here. Below it, I should see a brain. In its place, all I can make out is a bloody lump covered in what appears to be jam. It’s the clot, and it’s massive.
The anaesthetist is shouting now, desperate. But his voice is not what I’m listening to. I’m ignoring the porters’ exhausted grunts, too. What’s grabbing my attention isn’t in fact a noise at all. It’s the absence of one. The lack. Is it my imagination or has the piercing repetitive noise of the heart monitor stopped?
The anaesthetist suddenly not
ices, too. ‘Come on, you bastard.’
We all know what should happen next, but the wait is excruciating.
Then it comes, faintly at first. Beep. Beep.
Then stronger. BEEP. BEEP. BEEP. BEEP.
I smile. I can’t help it. The act of removing a portion of the skull has been sufficient to alleviate the pressure on the brain. Communication channels to the heart and lungs are restored. As is normal service among my colleagues.
I keep working as the patient stabilizes. There’s still work to be done. I need to suction out the blood and remove any damaged brain that is too far gone to ever work again. Then I plate the skull back together and replace the patient’s skin as neatly as I can. But we’ve done it. We’ve achieved the impossible. We’ve brought a man back from the dead. Interfered with the natural order of things and turned a corpse back into a patient.
I smile again as I rejoin the skull. I realize that this is what I want to do forever.
Just another Saturday night in Glasgow …
You never stop learning. When you’re a junior, you basically operate all the time because you work for several bosses, and as soon as you’re free you just operate on the next patient. That’s why within six years you go from not being able to pick up a knife, to becoming a consultant. At least, that’s the dream. It’s a very intense process. I had two years at Ealing and Wimbledon as a junior surgeon, then known as the ‘Senior House Officer’. I was notching up many, many more operations – increasingly unsupervised and much more rewarding. They were of differing specialities, but all increased my skills.
The goal was to reach the level of neurosurgical registrar. To my mind those were – and are – the guys who run the hospital. You’re with the patients all the time. You live on the ward. You know everything about everyone coming in. Some consultants will rely entirely on your notes when they conduct their assessments. Some will get more involved and press the flesh with the families and the patients. But, as I already knew to my cost, all that touchy-feely stuff was purely optional for the grands fromages with the scalpels. So it’s the registrar who is essential to the process. I couldn’t have been looking forward to it more.
Everything That Makes Us Human Page 4
