One of the things I most admire about the parents of the children in my care is their optimism. Baby’s parents weren’t just brilliantly attentive, always ready to fight her corner and look after her every special need. They asked me one day, ‘Do you think we should risk having another child?’
I would never, ever give advice about whether two people should have another baby or not. It’s not my place. But I will and do and did point out the risks. However, since we have one of the world’s most famous craniofacial geneticists on the payroll at John Radcliffe, I’m able to say, ‘Don’t take my word for it …’ Such experts can give a percentage chance of a second or third child suffering the same condition as Baby.
Some families won’t take any risks. They stick, as it were. Others twist. Ask to be dealt another card. Usually it’s because they just want to bring children into the world. One family, however, told me they needed a healthy child to look after its brother when they were gone. It seems harsh on the younger, as yet unborn, sibling. But I can understand the logic, I think. I’ve seen enough of families to know nothing is guaranteed with siblings. Bloodlines alone don’t always impel people to take care of their own family. Until it happens, you’ll never know.
It doesn’t exist in neurosurgery, but I’ve certainly read about parents of children with metabolic conditions, who need stem cells or organ transplants for example, who will genuinely have another child for the sole purpose of creating a potential donor. It doesn’t happen often, but enough to register in the news. It’s a very interesting ethical position to be in. I guess some people may think it’s terrible, but unless you’re in that position, you have no idea how you’d react. Maybe these parents were always planning on having another child. Who can be sure?
If I’ve learned anything from a lifetime in medicine and two decades in neurosurgery, it’s that people are completely unpredictable with regard to their reactions. Some of the most sensible people who cross my path make the most irrational decisions. Others, often really young, seemingly quite immature parents, stun me by their totally logical approach that embraces all that is thrown at them.
I don’t know if I could survive the unbelievable turmoil that some of them go through. Lots of my families do not come through it as a cohesive group. The separation and divorce rate among my parents is very high. Occasionally, couples are just holding onto a relationship, and then on receiving some difficult news about their child, it’s less a case of a straw breaking the camel’s back and more of someone landing a whole bunch of cement bags on the camel. So, no surprise there. But other families arrive rock hard and get destroyed by the emotional stress. It’s either guilt or anger at the other partner for something they did or didn’t do. I’ve actually heard some mothers say to their husbands, ‘If I hadn’t had this baby with you he wouldn’t have had this condition.’ Harsh, in every possible way. But health problems for children trump everything, even common sense.
Years later, I saw ‘Baby’, now a young lady, in clinic. ‘Well,’ I said. ‘How did it go?’
She stared at her feet. Mum looked about to burst with pride.
‘Well, she was in the shop for half an hour. I was beginning to get worried. But out she came with a bag full of sweets and ice lollies and the biggest smile. No one looked, no one stared.’
I smiled. Baby had passed the Tesco test.
CHAPTER TEN
SHE’S CONING
If you think about high-speed traffic that drives towards a town on a motorway, as it gets closer to the town the roads get smaller and smaller and the speed gets slower and slower. Then, as you drive out of the town, the road gets bigger again and the speed of the vehicles picks up and then you hit the motorway and you’re driving at the limit. That’s how the blood travels to and from the brain. As it gets into those intricate nooks and crannies to supply the oxygen, it’s like a side road, the little street where people pootle along at 20 miles per hour. When it leaves, it’s doing the equivalent of 70 mph, flat out.
That’s the theory and, for most people for the majority of the time, that’s the reality. But what if overnight someone builds a big bypass right into the centre of the town so you don’t have to go down those tiny, windy roads? Nice in theory, but your car is going to hurtle in doing 70 mph and hit the centre without slowing down.
It’s the same story if the blood to the brain doesn’t have a chance to slow down from the full pressure of being pushed from the heart before it gets funnelled through the small, dainty blood vessels designed for lighter traffic. The good news is that road-traffic changes could never happen so quickly. With the brain, though, it’s a very real possibility.
An arteriovenous malformation (AVM) occurs when there is a change to the way that vessels develop in the body. This results in high-pressure blood flowing straight into small arteries. This in turn results in unsustainable pressure on the vessels, which can cause rupture. It doesn’t happen often in such a dramatic way – headaches or seizures are common ways of leading to a diagnosis. On this occasion, however, it was a full collapse.
My registrar took the call from one of our satellite A&E departments and ran straight to my office, collecting Tim, my senior trainee, en route.
‘We’ve got a four-year-old girl coming in, unconscious. Scans are reported to show bleeding in the middle of the brain.’
‘Have we got the scans?’
‘On their way. But there’s another thing. One pupil dilating.’
‘Crap.’
A single pupil enlarging is a really bad neurological sign. When we shine a light into your pupil it’s to monitor brain function inside. If you see both pupils appearing large and then shrinking with the light, that’s a positive – it’s what it is meant to do. It is the equivalent of squinting your eyes when looking at the sun – to stop too much light getting in. But if they become sluggishly reactive to light, that’s a bad sign. If they don’t react and stay large in size, it can mean that the patient is at risk of death.
‘Okay, we’re not going to have much time here. Are you up for this, Tim?’ I asked. It was the old ‘see one, do one, teach one’ ethos at work. The only way for trainees to learn the hard stuff is to do the hard stuff. Obviously, I’d be standing right at his shoulder.
Tim nodded. ‘Yup.’
‘Great. Then you get a team ready. I’m going for a pee.’ If there’s the potential for a long operation, make sure the old preparation adage is remembered: empty bladder, empty colon, full stomach. I just needed one bit sorted.
According to dispatch, the ambulance was less than twenty minutes out. The scans arrived and confirmed a massive haemorrhage. A blood clot had formed in the middle of her brain and blocked off the path for the brain fluid. I could make out the abnormal collection of blood vessels from the AVM. It looked severe but we didn’t need to deal with it straight away – it was the raised pressure that was the risk. If we didn’t get a drainage tube in to deal with the build-up, the little girl was looking at devastating brain damage – if she lived. With every minute waiting for the ambulance, the prospects of survival were looking less and less positive.
What would normally happen in this scenario – scary as it was – is this. The anaesthetists would have everything ready on their side. The moment the ambulance gurney comes flying through the double doors, they’d be primed to go. The girl would be lifted onto their bed and the paramedics would fade back, their role done. All checks completed, the anaesthetists would wheel the patient the 30 feet into the operating theatre where we’d get her onto the table, position her carefully and begin prepping. We’d put a safety drape over her head to ensure it’s all nice and clean and that we’re not touching the skin, then we’d drape the whole body and give her antibiotics. Next, we look at the scans. Do they match the last ones we saw? Is it the correct identity? The whole first thirty minutes is all about providing as safe, aseptic and clean an environment as you can – and ensuring it’s the right patient. There’s always extra worry when people are com
ing in from outside, as all the usual preparations and inspections that would have been carried out on the wards haven’t been done.
Checks completed, we would begin with the full anaesthesia, the precise incisions, the peeling back of the skin and run a bipolar electrocautery charge to minimize scarring afterwards. So many things we would do if we had the time. But from the second the ambulance guys burst through our double doors, I realized that was precisely what we didn’t have.
‘Pretty sure she’s coning,’ one of the paramedics calls out.
Damn. ‘Coning’ is shorthand for the clot piling up so much pressure that the heart rate centre at the base of the brain is being squashed. As it gets compressed, the heart rate drops and drops and drops. It’s only a matter of time before irreversible dysfunctions arise.
‘Heart rate?’ I ask.
‘Thirty-five and dropping.’ He checks again. ‘Thirty-four.’
Heart rate dropping so precipitously means one thing: imminent death. We’re against the clock.
‘Okay, guys, change of plan. We haven’t got time to eff about here,’ I say to the anaesthetist. ‘The second you tell me, we’re going in.’ I am seriously worried that the time and movement involved in getting her onto the operating table will be enough to finish this poor girl off.
‘We don’t have time for theatre,’ I tell my registrar. ‘Get everyone here.’
Suddenly, it’s a circus. The trolley crashes through the doors of the anaesthetic room. The gasmen are trying to keep the girl stabilized. Tim and I are splashing antisepsis on our hands, and all over the girl’s head. I’m just in my blues. The room isn’t sterile, there are people who’ve literally run in off the street. But none of that will matter to this little girl if we don’t get going.
The anaesthetist has never worked so quickly. It doesn’t matter that the girl is in a coma. We have no idea if her pain receptors are awake. She still has to be kept under like anyone else. And that takes time. The calculations are done on weight, but the standard amount of morphine and opiate sometimes isn’t right for everyone. He needs to rely on his years of skill to estimate how much she needs and ensure that there is enough, plus probably a bit more.
Tim is alongside me. ‘Sorry, mate,’ I say. ‘I have to jump in here.’
‘Totally,’ he says.
We both know the score. In any normal situation, Tim would have performed the op with me observing and no one would have batted an eyelid. He could even handle what was needed here, but in an emergency, with risk of death a near-certainty, the head honcho is expected to step in. If something does go horribly wrong – if the child doesn’t make it – then the parents take some comfort from knowing that the ‘best’ people were on the job. And that means the senior person there. Me.
The truth is, my trainee is as capable of doing what needs to be done as I am. But my career is up and running. My reputation is made. The last thing I want to do is to expose him to the wrath of grieving parents, or lawyers, for something that is not his fault.
The ambulance guys step away. They’re not getting their trolley back any time soon. This is happening now.
The anaesthetic room isn’t built for visitors. It’s tiny. It’s already got the anaesthetist, his assisting ODP (operating department practitioner), plus me, Tim and now my scrub nurse squeezing in from the other side, dragging in the most essential theatre equipment. But it doesn’t matter where we are. I’m still looking at a human head. This is all the room I need.
The second I get the all-clear, I make a stab incision at the top of her head, on the right side and to the front. It’s the less dominant side and it doesn’t tend to influence speech, so it’s far less likely to suffer lasting damage from an invasion. There’s no point in saving a child’s life if she has no life worth living afterwards.
I make an emergency drill hole through the skull. Then I can see the dura – the fibrous bag enclosing the brain. I cut a hole and pass a ventricular drain – a silicone rubber tube – into the brain. I have to get to the fluid spaces which have been pushed over by the clot. We don’t have scans in front of us. I’m doing it by memory. Muff this up and the game is over.
‘We’re in,’ I say, as I feel the telltale change in resistance as the tube goes in from the school blancmange of the brain into the water of the ventricle.
The second the first drop of liquid hits the end of the tube, I glance at the monitors. Worst-case scenario: no change and we’re too late. Best-case scenario: instant reaction. Which is exactly what we get.
‘Heart rate rising,’ the anaesthetist confirms, ‘and the blood pressure is dropping.’
His voice sounds matter of fact, but his face is as elated as mine. Then the smiles fade and the mental exhaustion kicks in. Adrenaline is a wonderful thing, but when it crashes it really crashes. It’s a more subdued room as we finish up. By the time we’re done, the emergency is averted but the little girl is still unconscious.
‘Now,’ I say, ‘it’s time to meet the parents.’
Half an hour from start to finish. Transferring her to theatre would have taken another twenty minutes minimum, which is vital extra time that I guarantee the little girl did not have. Our mission was to save her life. The crash-bang-wallop-style procedure appeared to have achieved that. When she became stronger we would have to look at the ongoing cause, the AVM, and sort out the tangle of blood vessels. But that was for another day. First, she needed to live.
She was taken to the Intensive Care Unit (ICU). Often the registrar or trainee will do the handover, but as operating surgeon I wanted to complete the journey myself. After all, that was where the parents would be able to see her.
The ICU is its own department, just as mine is. It’s not somewhere I would expect to waltz into and start barking orders, even though some surgeons still think they could. I handed over my patient and my notes and we went through everything we’d done, all that had taken place and, crucially, everything I would ideally like to happen next. For example, blood pressure kept at certain levels, heart rate regulated, coma induced – there are many options. They can only ever be requests, however, because patients don’t always behave as you’d like – even those under anaesthetic or in induced comas – so the doctors and nurses on hand will make the calls they need to make. A lung problem or something else might reveal itself and they’ll have to change tack. All the different specialities have to work as a team. At the end of the day, everyone has the same goal in mind.
In this instance, I suggested an ideal blood pressure, plus the obvious monitoring of brain pressure. Despite the coma, we had her under full sedation to help recovery. I suggested trying to rouse her within the next twelve to twenty-four hours, whenever they felt conditions were best. That was, I said, if she made it through the night.
Having explained it matter-of-factly to my colleagues, I then had to find different words to help the little girl’s mum and dad understand what had happened and, more importantly, what still might.
Mum had been at home when the girl had slumped. She travelled in the ambulance and Dad had joined them at A&E. From that moment, I don’t think they’d stopped crying or asking, ‘Why?’ It was almost a relief when they asked me the same question, because the answer is one of simple medical fact. I explained how the AVM had delivered the blood right into the sensitive blood vessels in the middle of the brain and how this had caused them to rupture and flood the area. I explained how we’d drained out the excess fluid and were monitoring their child.
But I also had to be honest about her current situation: ‘Your daughter is not out of the woods yet. The next few hours are crucial.’
‘What are you saying?’
Obviously, the girl had arrived in a very precarious state, which they knew. If I were to be totally frank with them, I’d have said that her chances of survival were 50/50 at best. Things could go very wrong very fast because the vascular malformation was still in there. Not only could she succumb to the pressure she’s already endured, but
she could re-bleed again. With the brain already sick, then it could be a real disaster.
But those aren’t the terms that parents want to hear. They deserve better chosen, more human words. ‘I’m saying I’m really, really worried about her. If you’ve got other members of family who would want to be here, I recommend you call them tonight.’
‘Are you telling us she is going to die?’
‘I can’t predict what might happen. She might die. She is very ill. We’ve done all we can for the moment. Now it’s up to her.’
It takes a while to switch off after a traumatic evening, but the forty-minute drive home helps. That rubbish-filled car is my decompression chamber. By the time I step through the front door I’m almost ready to face being a husband and dad again. Even so, the first thing my wife asks me is never, ‘How was your day?’ She knows to skip that question until the first ten minutes is out of the way, just in case …
Obviously, between dinner and TV and playing with the kids and hanging out with my wife, the tiny flashes of memory of the day’s emergency replay from time to time. I’ve no doubt that we did all we could. That’s not the issue. So, I find myself thinking about how she is going to fare. I can’t possibly know. It makes no sense fretting. It’s not like I can do anything now. Of course, if something should develop, I’d want to be the first person my team called in an emergency. But fortunately no call came.
Driving into Oxford the following morning, I started to plot my day. Of all the patients I needed to see, there was one who I was most interested in at that moment. No news could equal bad news. I wouldn’t know until I arrived.
Everything That Makes Us Human Page 12
