Everything That Makes Us Human

by Jay Jayamohan

  I quickly got up to speed in the handover that occurs every morning. The real information would only come when I saw her myself. Ward rounds are the thing of myths in movies. In reality, they can be quite chaotic, as juniors try to catch up with results, listen to what we are saying to patients and think about potential grilling questions. Consultants couldn’t do without these rounds because we need to be personally involved in the day-to-day progress of our patients, and face-to-face meetings are the best way.

  I already knew before I approached her bed that our four-year-old patient had yet to wake up. But, as I said to the anxious parents and their gathered clan, it was great news that she had survived the night. The plan from here on in was to give her another twelve hours, then accelerate the waking process.

  The great news, in my opinion, was that both pupils were now responding to light. The brain imbalance had settled. It wasn’t quite the rise of Lazarus that the family was expecting, but I did my best to reassure them.

  ‘We have to take the small victories,’ I said. ‘Just getting through the night was a massive achievement.’

  I returned twice more throughout the day. I wanted to see with my own eyes what, if anything, was happening. The fact that I couldn’t do anything more didn’t impact on the family’s gratitude that I was there. It’s just human nature. In fact, nurses were checking on her and altering medication every half an hour. I, however, was the one they wanted to see. It’s a lot of pressure, but something I don’t mind doing. The family are my patients, too.

  I swung by once more on my way out. There had been no change. ‘I think you’re safe to go home and get some sleep,’ I suggested to Dad. ‘We’re just waiting for her to wake up now. I don’t think anything is going to happen immediately.’

  The following morning, I arrived to learn there had been no change overnight, so in that prediction I’d been right. I was beginning to worry that there should have been more progress, though. I spoke with the ICU doctor and the anaesthetist, and we discussed reducing the sedation levels further. The next day there had still been no change. Now I was beginning to get concerned. I ordered another brain scan. It showed a much healthier scene. There seemed little reason for the girl to still be unconscious.

  A week passed with no further developments. Two more scans confirmed an angry-looking brain – swollen and showing signs of injury from the initial terrible event – but, crucially, no deterioration. Again, it’s not exactly something families are equipped to deal with.

  ‘Well, at the moment what we do know is that your daughter hasn’t got worse.’ Yeah, that never gets the champagne corks popping.

  Day eight came and went, and I fully feared that day nine would be the same. I was consulting on another case when my beeper went off. When I checked the call, I burst into the largest grin. It was news of my young coma patient. She hadn’t suddenly leapt out of bed and started doing the can-can. She hadn’t begun reciting the Greek alphabet. She hadn’t demanded pizza and pop. She had, however, brought up her hand – which is what we call localizing – and moved when the nurse was adjusting her breathing tube.

  On the face of it, what’s a hand movement? But the family and nurses knew. It was the first thing that had emanated from the young patient – their young daughter, niece, granddaughter – in more than a week that wasn’t the product of drugs or machinery. It is a very visceral human reaction to discomfort. The little lady was feeling something. She was waking up.

  I was as pleased as anyone. All the important brain signals were beginning to spike into life. ‘I think we’re ready to bring her out,’ I said. ‘How long do you think it’ll take to get her fully off the sedation?’

  ‘Hopefully within forty-eight hours,’ the anaesthetist said. ‘We’re going to take it slowly.’

  The waking-up process for an adult, let alone a child after that time period, is a slow one. The ICU doctors and anaesthetists still need to okay the heart function. They’re in charge, so I step back. Waiting and waiting, just like the family.

  The next twenty-four hours were excruciating. We all hoped for another sign of consciousness and we were all disappointed. Had it been a one-off? Was it a glitch after all? Why had nothing else happened? I was actually on my rounds the following morning when the next sign materialized. And that sign was historic. She was fighting the tubes that were sticking out of her, anxious to sit up. In other words, being a terrible patient – and no one could be happier. Distress at the tube in her throat indicated that she was able to breathe unaided. She was drowsy, but awake and engaged. Within another three days she was eating and speaking.

  I have to say, Mum and Dad could not thank me enough. They spoke of me in front of their daughter as though I was someone just between Santa Claus and God. Now, I am well aware that in real life I am probably somewhere between Mr Greedy and Mr Grumpy, but still I would be lying if I said that we don’t love getting compliments. We don’t believe them, sure, but these positives are what we stash away to tide us over the next, inevitable, dark time around the corner. The truth is, that little darling on the bed didn’t know me from Adam. She had no idea I’d touched her brain. No idea of anything, in fact, since her collapse a fortnight earlier.

  I was happy to leave it that way. After everything she had been through why burden her with unnecessary information? She’d discover who I was soon enough when she came back for us to remove the AVM problem once and for all. Until then, however, I was happy just being another random grown-up.

  CHAPTER ELEVEN

  CSI OXFORD

  Golf can be very dangerous for your health. Depending on the company, that is.

  During my time in Glasgow I came to recognize the differences between a driver, an iron and a putter. Not from playing the game or even watching it on TV. I really had very little interest in those days, preferring bars and parties. No, back then my entire knowledge of golf clubs stemmed from identifying the telltale impression that each one left when it was smacked into a person’s head.

  It was the start of an interesting sideline to my day-to-day job – giving medicolegal advice to courts and investigations involving neurosurgical areas of expertise. I’ve been called upon more than once to give expert evidence in court about weapons used for assault or murder. Golf clubs are reasonably easy to identify. They leave a certain distinctive blunt trauma site in the scalp, skull and brain. Other implements require a little more investigation.

  I was once called upon to look over evidence from a particularly nasty torture and murder in Newcastle. Four men had been arrested. CCTV showed them all attacking the victim, but each of them was wielding a different type of weapon: one had a hammer, one an axe, one a samurai sword, of all things, and one had a knife. The question was: which one had delivered the fatal blow?

  Without a single person to accuse, there was a strong possibility that all four men would get off the murder charge. At least that was the angle the defence teams were playing. If the prosecution didn’t realistically think that they could prove which of the group was the one responsible, then there was apparently no way they could prosecute successfully to the level they wanted to.

  I was called in to provide some thoughts. Very clearly all four weapons had played their part in the victim’s horrific last moments. The broken bones in the arms were caused by the hammer. The missing fingers were consistent with the sharp blade of the samurai sword. As for what had caused the massive damage to the head, however, that was unclear. Photographic evidence suggested it could have been the hammer or the handle of the sword or the back of the axe. The problem was, the head was so damaged in places that it was impossible to get a reading on what had gone on. Which is where my new toy came in.

  I have special software which I can use to feed in the scans and reconstruct the original skull and brain shape. At the time, it was not widely used, although of course technology moves forward rapidly and now it’s quite standard practice. It was very CSI Oxford for its day. I was able to ‘rebuild’ the skull
and brain at the point of injury. I found a very clear trauma tract in the skull and brain caused by a single blow consistent with the size, shape and weight of … the hammer. It fitted very well with the opinion of the pathologist who did the post-mortem. In such cases, it is really helpful to have different sorts of evidence that all agree – thus minimizing the risk of making a mistake with the medical interpretations.

  Sometimes I just review evidence remotely and provide a paper report – especially if my evidence contributes to a decision not to move forward with an investigation. If there is a case to answer, often I ‘appear’ in court via a video link. Other times I go in person. Most barristers think that juries respond better to ‘real’ people. Several cases, I think, have been dependent either way on my evidence. I think that I have developed the skills to address a court as a result of my day job. We have to explain medically complex conditions to very stressed families, so we get used to going slowly, using non-technical language and picking up on when things aren’t clear to people unfamiliar with medical matters. You can see its effects ripple across the room as everyone thinks, ‘Yeah, I understand now.’

  Case in point: a student in Manchester had the misfortune to get into altercations twice in one night. Again, pub cameras caught both incidents. You can clearly see him being punched around 8 p.m. and then again about 10 p.m. by a different person in a different bar. Only the second time he didn’t get up.

  The second attacker was charged with murder. His defence asserted that the punch wasn’t hard enough to be fatal and that it was the earlier fracas which had ‘triggered’ the death. It was a persuasive argument. Certainly one to cause ‘reasonable doubt’ when considering the severity of the charge. I could see it written on the jurors’ faces.

  I was able to show that, from the scans, the victim had sizable areas of trauma. There was no way, I said, that he could have functioned if these had been caused by the first blow. No way he could have walked into the next pub, let alone ordered and drunk a beer.

  As I delivered my evidence, I could see and feel the jury listening. By the time I had concluded that it was indeed the second event which was responsible for the killer blow, I think I had all twelve men and women either understanding why I believed that, if not agreeing with me.

  Of course, when giving evidence, I am not trying to win a case. That’s the job for the barristers. I am there to give the medical facts and then my opinion about what happened. After that, it’s all down to the jury and the court.

  Another week, another case. I was asked to investigate a mugging that had apparently got out of hand. Two men had been found with the victim’s belongings. While they weren’t denying assault and theft, they completely swore that the murder wasn’t on them. ‘Oh yes, we punched him and took his phone, but that was it. Someone else must have killed him.’

  Interestingly, the evidence from the scans supported their version of events. While the victim had a bleed on the surface of the brain, he didn’t have any kind of external signs of injury on that side of the head at all. The only oddity was a tiny little puncture wound on the opposite side.

  The post-mortem report gave no further help. It cited a brain problem as cause of death, but stated it was very difficult to narrow down what actually was the weapon or method that was involved. Something wasn’t right.

  I reconstructed the scan using my 3D system. Once it was complete, I found I could draw a line from the very small puncture wound on one side of the head through the brain to the injury on the other side. En route, the line passed a very important artery – now bisected. Clearly that was the cause of death. This tract was not visible on the scans when he was brought in, and obviously the treating doctors weren’t involved in the investigation. By the time the post-mortem was done, the brain tract had collapsed and disintegrated to a point where it could not be followed through the gelatinous, partially destroyed brain. However, the line of trauma became visible when I altered all the angles of the slices of the scans. Now it was a matter of the police proving how this had happened.

  I advised the police to look for a certain shape of object. I predicted they’d find something like a narrow knife or another implement with a fine blade. In the end, they discovered a very thin 6-inch screwdriver in a bin. Basically, it turned out that the aggressors had meant to threaten the victim, but he’d fought back and the tool had gone into his head. Clearly with some force, but it had been clean. One puncture straight in, straight out. Not only had it passed through the skull, but also the brain. The tragedy was that it had gone all the way through with minimal damage – but had just nicked a blood vessel on the other side.

  To be fair, the post-mortem had discovered the entry point, but with the blood vessel on the other side of the brain the pathologist hadn’t spotted the connection. Neither had I – it just slowly became visible as I played with the scans, turning them around on the screen. I had a long chat with the pathologist afterwards and we talked about how independent but confluent bits of work had come together so well. This is an important thing to bear in mind as cost cutting continues to affect both NHS and legal services in the UK.

  Playing Poirot is all well and good, but my main specialism, the thing I’m most known for in medicolegal fields, is something far more tricky. As a paediatric neurosurgeon, the medicolegal cases I’m going to see are never nice.

  There is a difference between medicine and law. My job is not to say whether somebody’s guilty or not guilty, but rather to explain what I think is the cause of death or likely cause of injury. I can say, ‘This injury is consistent with a traumatic assault that took place between ten and twelve o’clock this morning.’ If that timing happens to narrow down the number of suspects, then all the better for justice, but that’s not why I’m there. In fact, equally important is looking for any medical or ‘innocent’ causes or contributions to brain and spinal injuries.

  The majority of cases involving children are heard at the Family Court. There’s no jury, just a judge. Usually I’ll appear via video link and I won’t be the only expert witness. I have taken part in trials where there have been four or five of us on the stand together, chattering away, which is known as ‘hot-tubbing’. More standard practice, however, is each of us giving evidence separately. It has the benefit of you not being swayed by the arguments of your colleagues.

  I’m usually the only neurosurgical expert involved in a case. There’s an eye expert, an X-ray expert and a general paediatric expert, all looking at the same evidence. It’s paid work and it’s interesting. Most of all, it’s important. Currently, there are only a few paediatric neurosurgeons in the country doing this sort of thing – worries about being cross-examined or not wanting to read pretty unpleasant material or occasional disgruntlement about the legal aid board or CPS fees all serve to put medical professionals off this vital strand of medicolegal work.

  If it’s a case that’s got as far as court, then you can imagine the degree of scrutiny that has already been levelled at the family and carers. There will be stories of previous histories of drug and alcohol abuse, domestic violence and even injuries sustained by other children in the family. I can’t get invested in that, though. Although statistics suggest that such circumstances may make it more likely that a person would commit an offence, it doesn’t prove it medically, in terms of the actual injury I am looking at. Otherwise we could just decide that once you have a criminal past you will be guilty of any charge brought against you. Guilt or innocence is for the judge and jury to decide. As soon as you start getting involved in the emotional side of it, you’ve lost your position as an independent witness and expert.

  Luckily, there’s a lot of good material available these days to help us. A doctor in Germany in the 1980s conducted some incredible research into this area. Somehow he obtained permission from the parents of recently deceased babies to allow him to ‘experiment’ on their bodies, which involved dropping them from different heights in order to measure the level and area of fractures o
n the skull. Through his work, he showed that babies could sustain a fracture from a fall from a much lower height than had been previously thought. It sounds an absolutely grotesque way to conduct medical research, but not only was it legitimate and correctly organized, I’m convinced that its findings have been used to help prove the innocence or guilt of hundreds of people in these sorts of cases. One wonders if the parents know the difference their babies have made in this field, and whether that may give them some comfort.

  It’s such a common occurrence, sadly. This is just one story. It begins with a woman and a baby – although technically the woman is really still a child. She has a boyfriend who is not the baby’s father. He comes and goes, doesn’t help around the house and resents the baby interfering with his sex life. Much of his time is spent smoking skunk and drinking. Eventually, Mum persuades him to look after Baby for a couple of hours while she goes out with the girls for the first time since the birth. She’s looking forward it. So desperate for a change of scene that she maybe ignores the warning signs.

  While the mother is out the baby is, quote unquote, being played with when it suddenly collapses, goes into a respiratory arrest – it stops breathing and clearly becomes exceedingly unwell. An ambulance is called, Baby is taken to hospital and found to have a variety of intracranial injuries – bleeding on the surface of the brain and injury within the substance of the brain itself. There is blood in the spine as well. The ophthalmologists look and find bleeding behind the eyes. They state that these are clear evidence of injuries. There are long bone injuries to the limbs, and multiple ages of rib fractures.

  By the time the notes of the case are passed to me, many other people have come to their conclusions. I’m not interested in those. I’m being paid for my expertise as a neurosurgeon, not my ability to parrot someone else’s opinion. It’s clear that the treating doctors think this child has experienced a recent traumatic event on a background of old abusive events. They believe that this one was not just ‘out of the blue’.