Do No Harm: Stories of Life, Death and Brain Surgery

by Henry Marsh

  ‘Let’s get on with it!’

  I scrubbed up again and climbed back into my operating chair, settled my elbows on the armrests and got back to work on the tumour. Each brain tumour is different. Some are as hard as rock, some as soft as jelly. Some are completely dry, some pour with blood – sometimes to such an extent that the patient can bleed to death during the operation. Some shell out like peas from a pod, others are hopelessly stuck to the brain and its blood vessels. You can never know for certain from a brain scan exactly how a tumour will behave until you start to remove it. This man’s tumour was, as surgeons say, cooperative and with a good surgical plane – in other words, it was not stuck to the brain. I slowly cored it out, collapsing the tumour in on itself away from the surrounding brain. After three hours it looked as though I had got most of it out.

  Since pineal tumours are so rare one of my colleagues came into my theatre from his own operating theatre, to see how the operation was going. He was probably a little jealous.

  He peered over my shoulder.

  ‘Looks OK.’

  ‘So far,’ I said.

  ‘Things only go wrong when you’re not expecting them,’ he replied as he turned to go back to his own theatre.

  The operation continued until I had removed all of the tumour without injuring any of the surrounding vital architecture of the brain. I left Mike to close the wound and walked to the wards. I had only a few in-patients, one of them the young mother I had left paralysed a week earlier. I found her on her own in a side-room. When you approach a patient you have damaged it feels as though there is a force-field pushing against you, resisting your attempts to open the door behind which the patient is lying, the handle of which feels as though it were made of lead, pushing you away from the patient’s bed, resisting your attempts to raise a hesitant smile. It is hard to know what role to play. The surgeon is now a villain and perpetrator, or at best incompetent, no longer heroic and all-powerful. It is much easier to hurry past the patient without saying anything.

  I went into the room and sat down in the chair beside her.

  ‘How are you?’ I asked lamely.

  She looked at me and grimaced, pointing wordlessly with her good left arm to her paralysed right arm and then lifting it up to let it fall lifeless onto the bed.

  ‘I’ve seen this happen after surgery before, and the patients got better, although it took months. I really do believe you will get largely better.’

  ‘I trusted you before the operation,’ she said. ‘Why should I trust you now?’

  I had no immediate reply to this and stared uncomfortably at my feet.

  ‘But I believe you,’ she said after a while, although perhaps only out of pity.

  I went back to the theatres. The pineal patient had been transferred from the table to a bed and was already awake. He lay with his head on a pillow, looking bleary-eyed, while one of the nurses washed the blood and bone dust left from the operating out of his hair. The anaesthetists and theatre staff were laughing and chatting as they busied themselves around him, rearranging the many tubes and cables attached to him, in preparation for wheeling him round to the ITU. If he had not woken up so well they would have been working in silence. The nurses were tidying the instruments on the trolleys and stuffing the discarded drapes and cables and tubes into plastic rubbish bags. One of the porters was already mopping the blood off the floor in preparation for the next case.

  ‘He’s fine!’ Mike happily shouted to me across the room.

  I went to find his wife. She was waiting in the corridor outside the ITU, her face rigid with fear and hope as she watched me approach her.

  ‘It went as well we could hope,’ I said, in a formal and matter-of-fact voice, playing the part of a detached and brilliant brain surgeon. But then I could not help but reach out to her, to put my hands on her shoulders, and as she put her hands on mine and we looked into each other’s eyes, and I saw her tears and had to struggle for a moment to control my own, I allowed myself a brief moment of celebration.

  ‘I think everything’s going to be all right,’ I said.

  2

  ANEURYSM

  n. a morbid dilatation of the wall of a blood vessel, usu. an artery.

  Neurosurgery involves the surgical treatment of patients with diseases and injuries of the brain and spine. These are rare problems so there are only a small number of neurosurgeons and neurosurgical departments in comparison to other medical specialties. I never saw any neurosurgery as a medical student. We were not allowed into the neurosurgical theatre in the hospital where I trained – it was considered too specialized and arcane for mere students. Once, when walking down the main theatre corridor, I had had a brief view through the small port-hole window of the neurosurgical theatre’s door of a naked woman, anaesthetized, her head completely shaven, sitting bolt upright on a special operating table. An elderly and immensely tall neurosurgeon, his face hidden by a surgical facemask and a complicated headlight fixed to his head, was standing behind her. With enormous hands he was painting her bare scalp with dark brown iodine antiseptic. It looked like a scene from a horror film.

  Three years later I found myself in that same neurosurgical operating theatre, watching the younger of the two consultant neurosurgeons who worked in the hospital, operating on a woman with a ruptured cerebral aneurysm. I had been qualified as a doctor for one and a half years by then and was already disappointed and disillusioned with the thought of a career in medicine. I was working at the time as a senior house officer, or SHO for short, in my teaching hospital’s intensive care unit. One of the anaesthetists who worked on the ITU, seeing that I looked a little bored, had suggested that I come down to the operating theatre to help her prepare a patient for a neurosurgical operation.

  It was unlike any other operation I had seen, which had usually seemed to involve long, bloody incisions and the handling of large and slippery body parts. This operation was done with an operating microscope, through a small opening in the side of the woman’s head using only fine microscopic instruments with which to manipulate her brain’s blood vessels.

  Aneurysms are small, balloon-like blow-outs on the cerebral arteries that can – and often do – cause catastrophic haemorrhages in the brain. The aim of the operation is to place a minute spring-loaded metal clip across the neck of the aneurysm – just a few millimetres across – to prevent the aneurysm bursting. There is a very real danger that the surgeon, working at several inches’ depth in the centre of the patient’s head, in a narrow space beneath the brain, will inadvertently burst the aneurysm while he dissects it free from the surrounding brain and blood vessels and tries to clip it. Aneurysms have thin, fragile walls, yet they have high pressure, arterial blood within them. Sometimes the wall is so thin that you can see the swirling dark red vortices of blood within the aneurysm, made enormous and sinister by the magnification of the operating microscope. If the surgeon ruptures the aneurysm before he can clip it the patient will usually die, or at least suffer a catastrophic stroke – a fate than can easily be worse than death.

  The staff in the theatre were silent. There was none of the usual chatter and talk. Neurosurgeons sometimes describe aneurysm surgery as akin to bomb disposal work, though the bravery required is of a different kind as it is the patient’s life that is at risk and not the surgeon’s. The operation I was watching was more like a blood sport than a calm and dispassionate technical exercise, with the quarry a dangerous aneurysm. There was the chase – the surgeon cautiously stalking his way beneath the patient’s brain towards the aneurysm, trying not to disturb it, to where it lay deep within the brain. And then there was the climax, as he caught the aneurysm, trapped it, and obliterated it with a glittering, spring-loaded titanium clip, saving the patient’s life. More than that, the operation involved the brain, the mysterious substrate of all thought and feeling, of all that was important in human life – a mystery, it seemed
to me, as great as the stars at night and the universe around us. The operation was elegant, delicate, dangerous and full of profound meaning. What could be finer, I thought, than to be a neurosurgeon? I had the strange feeling that this was what I had wanted to do all my life, even though it was only now that I had realized it. It was love at first sight.

  The operation went well. The aneurysm was successfully clipped without causing a catastrophic stroke or haemorrhage and the atmosphere in the operating theatre was suddenly happy and relaxed. I went home that night and announced to my wife that I was going to be a brain surgeon. She looked a little surprised, given that I had been so undecided about what sort of doctor I should be, but she seemed to think the idea made sense. Neither of us could have known then that my obsession with neurosurgery and the long working hours and the self-importance it produced in me would lead to the end of our marriage twenty-five years later.

  Thirty years and several hundred aneurysm operations later, re-married and only a few years away from retirement, I cycled in to work on a Monday morning with an aneurysm to clip. A heat wave had just ended and heavy grey rain clouds hung over south London. It had poured with rain during the night. There was little traffic – almost everybody seemed to be away on holiday. The gutters at the entrance to the hospital were flooded so that the passing red buses sent cascades of water over the pavement and the small number of staff walking to work had to jump to one side as the buses swept past.

  I rarely clip aneurysms now. All the skills that I slowly and painfully acquired to become an aneurysm surgeon have been rendered obsolete by technological change. Instead of open surgery, a catheter and wire is passed through a needle in the patient’s groin into the femoral artery and fed upwards into the aneurysm by a radiology doctor – not a neurosurgeon – and the aneurysm is blocked off from the inside rather than clipped off from the outside. It is, without a doubt, a much less unpleasant experience for patients than being subjected to an operation. Although neurosurgery is no longer what it once was, the neurosurgeon’s loss has been the patient’s gain. Most of my work is now concerned with tumours of the brain – tumours with names like glioma or meningioma or neurinoma – the suffix ‘-oma’ coming from the ancient Greek word for tumour and the first part of the word being the name of the type of cell from which the tumour is thought to have grown. Occasionally an aneurysm cannot be coiled, so every so often I find myself going to work in the morning in that state of controlled anxiety and excitement that I knew so well in the past.

  The morning always starts with a meeting – a practice I began twenty years ago. I had been inspired by the TV police soap Hill Street Blues, where every morning the charismatic station police sergeant would deliver pithy homilies and instructions to his officers before they set off onto the city streets in their police cars with their sirens wailing. It was at the time when the government was starting to reduce the long working hours of junior hospital doctors. The doctors were tired and overworked, it was said, and patients’ lives were being put at risk. The junior doctors, however, rather than becoming ever more safe and efficient now that they slept longer at night, had instead become increasingly disgruntled and unreliable. It seemed to me that this had happened because they were now working in shifts and had lost the sense of importance and belonging that came with working the long hours of the past. I hoped that by meeting every morning to discuss the latest admissions, to train the juniors with constant teaching as well as to plan the patients’ treatment, we might manage to recreate some of the lost regimental spirit.

  The meetings are very popular. They are not like the dull and humourless hospital management meetings where there is talk of keeping in the loop about the latest targets or of feeling comfortable about the new Care Pathways. Our neurosurgical morning meeting is a different sort of affair. Every day at eight o’clock sharp, in the dark and windowless X-ray viewing room, we shout and argue and laugh while looking at the brain scans of our poor patients and crack black jokes at their expense. We sit in a semi-circle, a small group of a dozen or so consultants and junior doctors, looking as though we were on the deck of the Starship Enterprise.

  Facing us is a battery of computer monitors and a white wall onto which brain scans are projected, many times larger than life-size, in black and white. The scans are of patients admitted as emergencies over the preceding twenty-four hours. Many of the patients will have suffered fatal haemorrhages or severe head injuries, or have newly diagnosed brain tumours. We sit there, alive and well and happy in our work, and with sardonic amusement and Olympian detachment we examine these abstract images of human suffering and disaster, hoping to find interesting cases on which to operate. The junior doctors present the cases, giving us the ‘history’ as it is called – the stories of sudden catastrophe or of terrible tragedy that are repeated each day, year in, year out, as though human suffering would never end.

  I sat down in my usual place at the back, in the corner. The SHOs are in the front row and the surgical trainees, the specialist registrars, sit in the row behind them. I asked which of the junior doctors had been on call for the emergency admissions.

  ‘A locum,’ one of the registrars replied, ‘and he’s buggered off.’

  ‘There were five doctors holding the on-call bleep over twenty-four hours on Friday,’ one of my colleagues said. ‘Five doctors! Handing over emergency referrals to each other every four point two hours! It’s utter chaos . . .’

  ‘Is there anything to present?’ I asked. One of the juniors got up from his chair and walked to the computer keyboard on the desk at the front of the room.

  ‘A thirty-two-year-old woman,’ he said tersely. ‘For surgery today. Had some headaches and had a brain scan.’ As he talked a brain scan flashed up on the wall.

  I looked at the young SHOs and to my embarrassment could not remember any of their names. When I became a consultant twenty-five years ago the department had just two SHOs, now there are eight. In the past I used to get to know them all as individuals and take a personal interest in their careers, but now they come and go as quickly as the patients. I asked one of them to describe the scan on the wall in front of us, apologizing for not knowing who she was.

  ‘Alzheimer’s!’ one of the less deferential registrars shouted from the darkness at the back of the room.

  The SHO told me that she was called Emily. ‘This is a CTA of the brain,’ she said.

  ‘Yes, we can all see that. But what does it show?’

  There was an awkward silence.

  After a while I took pity on her. I walked up to the wall and pointed to the scan. I explained how the arteries to the brain were like the branches of a tree, narrowing as they spread outwards. I pointed to a little swelling, a deadly berry, coming off one of the cerebral arteries and looked enquiringly at Emily.

  ‘Is it an aneurysm?’ Emily asked.

  ‘A right middle cerebral artery aneurysm,’ I replied. I explained how the woman’s headaches had in fact been quite mild and the aneurysm was coincidental and had been discovered by chance. It had nothing to do with her headaches.

  ‘Who’s doing the exam next?’ I asked, turning to look at the row of specialist registrars who all have to take a nationally organized exam in neurosurgery as they reach the end of their training. I try to grill them regularly in preparation for it.

  ‘It’s an unruptured aneurysm, seven millimetres in size,’ Fiona – the most experienced of the registrars – said. ‘So there’s a point zero five per cent risk of rupture per year according to the international study published in 1998.’

  ‘And if it ruptures?’

  ‘Fifteen per cent of people die immediately and another thirty per cent die within the next few weeks, usually from a further bleed and then there’s a compound interest rate of four per cent per year.’

  ‘Very good, you know the figures. But what should we do?’

  ‘Ask the radiologists if they can c
oil it.’

  ‘I’ve done that. They say they can’t.’

  The interventional radiologists – the specialist X-ray doctors who now usually treat aneurysms – had told me that the aneurysm was the wrong shape and would have to be surgically clipped if it was to be treated.

  ‘You could operate . . .’

  ‘But should I?’

  ‘I don’t know.’

  She was right. I didn’t know either. If we did nothing the patient might eventually suffer a haemorrhage which would probably cause a catastrophic stroke or kill her. But then she might die years away from something else without the aneurysm ever having burst. She was perfectly well at the moment, the headaches for which she had had the scan were irrelevant and had got better. The aneurysm had been discovered by chance. If I operated I could cause a stroke and wreck her – the risk of that would probably be about four or five per cent. So the acute risk of operating was roughly similar to the life-time risk of doing nothing. Yet if we did nothing she would have to live with the knowledge that the aneurysm was sitting there in her brain and might kill her any moment.

  ‘So what should we do?’ I asked.

  ‘Discuss it with her?’

  I had first met the woman a few weeks earlier in my outpatient clinic. She had been referred by the GP who had organized the brain scan but his referral note told me nothing about her other than that she was thirty-two years old and had an unruptured aneurysm. She came on her own, smartly dressed, with a pair of sunglasses pushed back over her long dark hair. She sat down on the chair beside my desk in the dull outpatient room and put her elaborate designer bag down on the floor beside her chair. She looked anxiously at me.

  I apologized for keeping her waiting and hesitated before continuing. I did not want to start the interview by immediately asking her about her family circumstances or about herself – it would sound as though I was expecting her to die. I asked her about the headaches.