by Henry Marsh
As the tumour was at the base of the man’s brain, and as there was the risk of heavy blood loss, I had decided to carry out the operation in what is called, simply enough, the sitting position. The unconscious patient’s head is attached to the pin headrest which in turn is connected to a shiny metal scaffold, attached to the operating table. The table is then split and the top half hinged upwards, so that the patient is sitting bolt upright. This helps reduce blood loss during surgery and also improves access to the tumour, but involves a small risk of anaesthetic disaster as the venous blood pressure in the patient’s head in the sitting position is below atmospheric room pressure. If the surgeon tears a major vein air can be sucked into the heart, with potentially terrible consequences. As with all operating, it is a question of balancing risks, sophisticated technology, experience and skill, and of luck. With the anaesthetists, the theatre porters and U-Nok, Fiona and I positioned the patient. It took half an hour to make sure his unconscious form was upright with his head bent forward, that there were no ‘pressure points’ on his arms or legs where pressure sores might develop, and that all the cables and wires and tubes connected to his body were free and not under tension.
‘Well, let’s get on with it,’ I said.
The operation went perfectly with scarcely any blood loss at all. This type of tumour is the only time in brain tumour surgery that you have to remove the tumour ‘en bloc’ – in a single piece – since if you enter the tumour you will be instantly faced by torrential bleeding. With all other tumours in brain surgery you gradually ‘debulk’ it, sucking or cutting out the inside of it, collapsing it in on itself, away from the brain, and thus minimizing damage to the brain. With solid haemangioblastomas, however, you ‘develop the plane’ between the tumour and the brain, creating a narrow crevice a few millimetres wide by gently holding the brain away from the surface of the tumour. You coagulate and divide the many blood vessels that cross from the brain to the tumour’s surface, trying not to damage the brain in the process. All this is done with a microscope under relatively high magnification – although the blood vessels are tiny, they can bleed prodigiously. One quarter of the blood pumped every minute by the heart, after all, goes to the brain. Thought is an energy-intensive process.
If all goes well the tumour is eventually freed from the brain and the surgeon will lift the tumour out of the patient’s head.
‘All out!’ I shout triumphantly to the anaesthetist at the other end of the table, and wave the scruffy and bloody little tumour, no bigger than the end of my thumb, in the air at the end of a pair of dissecting forceps. It hardly looked worth all the effort and anxiety.
With the day’s operating finished I went to see the patient on the Recovery Ward. He looked remarkably well and wide awake. His wife was beside him and they expressed their heartfelt gratitude.
‘Well, we were lucky,’ I said to them, though they probably thought this was false modesty on my part, which I suppose to an extent it was.
As I left, dutifully splashing alcoholic hand gel on my hands on my way out, James the registrar on-call for emergencies came looking for me.
‘I think you’re the consultant on call today,’ he said.
‘Am I? Well, what have you got?’
‘Forty-six-year-old man with a right temporal clot with intraventricular extension in one of the local hospitals – looks like an underlying AVM. GCS five. He was talking when he was admitted.’
An AVM is an arterio-venous malformation, a congenital abnormality which consists of a mass of blood vessels that can, and often do, cause catastrophic haemorrhages. The GCS is the Glasgow Coma Scale and a way of assessing a patient’s conscious level. A score of five meant that the man was in coma, and close to death.
I asked him if he had seen the scan and if the patient was already on a ventilator.
‘Yes,’ James replied, so I asked him what he wanted to do. He was one of the more senior trainees and I knew that he could deal with this case himself.
‘Get him up here quickly,’ he said. ‘There’s a bit of hydrocephalus so I’d stick a wide bore drain in and then take out the clot, leaving the AVM alone. It’s deep.’
‘Carry on,’ I said. ‘He’s potentially salvageable so make sure they send him up the motorway pronto. You might point out to the local doctors that there’s no point sending him if they don’t do it quickly. Apparently they need to use the magic phrase “Time Critical Transfer” with the ambulance service and then they won’t mess about.’
‘It’s already done,’ James replied happily.
‘Splendid!’ I said. ‘Just get on with it.’ And I headed off downstairs to my office.
I cycled home, stopping off at the supermarket to get some shopping. Katharine, the younger of my two daughters, was staying with me for a few days and was to cook supper. I had agreed to do the shopping. I joined a long queue of people at the check-out.
‘And what did you do today?’ I felt like asking them, annoyed that an important neurosurgeon like myself should be kept waiting after such a triumphant day’s work. But I then thought of how the value of my work as a doctor is measured solely in the value of other people’s lives, and that included the people in front of me in the check-out queue. So I told myself off and resigned myself to waiting. Besides, I had to admit to myself that soon I will be old and retired and then I will no longer count for much in the world. I might as well start getting used to it.
While I was standing in the queue my mobile phone went off. I experienced an immediate flash of alarm, instantly frightened that this would be my registrar calling to say that there was a problem with the brain tumour case but instead I heard an unfamiliar voice as I scattered my shopping over the counter while struggling to answer the phone.
‘Are you the consultant neurosurgeon on call?’
Emergency calls are usually all sent to the on-call registrar so I answered warily.
‘Yes?’ I said.
‘I am one of the A&E SHOs,’ said the voice self-importantly. ‘My consultant has told me to ring you about a patient here. Your on-call registrar is not answering his bleep.’
I was immediately annoyed. If the case was so urgent why didn’t the A&E consultant ring me himself? There used to be a certain etiquette about ringing a colleague.
‘I find that hard to believe,’ I said, as I tried to gather up the hot cross buns and clementines I had dropped. A&E were probably just trying to shift patients quickly to meet their target for waiting times. ‘I was just speaking to him ten minutes ago . . .’
The A&E SHO didn’t seem to be listening.
‘It’s a sixty-seven-year-old man with an acute on chronic subdural . . .’ he began.
I interrupted him and told him to ring Fiona, who was not on call but I knew was still in the building and then switched the phone off, giving an apologetic smile to the puzzled check-out girl.
I left the supermarket feeling anxious. Perhaps the patient was desperately ill, perhaps James had failed to answer his bleep so I rang Fiona on her mobile. I explained the problem and said that I was worried that maybe just for once it really was an urgent referral and not just an attempt to get a patient out of A&E.
I went home. She rang me half an hour later.
‘You wait until you hear this one,’ she said, laughing. ‘James had answered the call and was already on his way to A&E. The patient was perfectly well, he was eighty-one not sixty-seven and they’d completely misinterpreted the brain scan, which was normal.’
‘Bloody targets.’
By the time that I had got home it had started to rain. I changed into my running clothes and reluctantly headed for the small suburban park behind my home. Exercise is supposed to postpone Alzheimer’s. After a few laps round the park my mobile phone went off.
‘Bloody hell!’ I said, dropping the wet and slippery phone as I tried to pull it out of my tracksuit and answer the
call.
‘James here. I can’t stop the oozing,’ a voice said from the muddy ground.
‘What’s the problem?’ I asked, once I had managed to pick the phone up.
‘I’ve taken the clot out and put a drain in but the cavity is oozing a lot.’
‘Not to worry. Line it with Surgicel, pack it and take a break. Go and have a cup of tea. Tea is the best haemostatic agent! I’ll look by in thirty minutes or so.’
So I finished my run, had a shower, and made the short journey back to the hospital, but in my car, because of the rain. It was dark by now, with a strong wind, and there had been heavy snowfalls in the north, even though it was already April. I parked my car in the scruffy delivery bay by the hospital basement. Although I am not supposed to park there, it does not seem to matter at night and it means that I can get up to the theatres more quickly than from one of the official car parks which are further away.
I put my head past the doors of the theatre. James was standing at the end of the operating table, holding the patient’s head in his hands as he wound a bandage around it. The front of his gown was smeared with blood and there was a large pool of dark red blood at his feet. The operation was clearly finished.
‘All well?’ I asked.
‘Yes. It’s fine,’ he replied. ‘But it took quite a while.’
‘Did you go and have a cup of tea to help stop the bleeding?’
‘Well, no, not tea,’ he said, pointing to a plastic bottle of Coca-Cola on one of the worktops behind him.
‘Well, no wonder the haemostasis took so long!’ I said with mock disapproval and all the team laughed, happy that the case was over and that they could now go home. I went briefly to check on the tumour patient who was now on the ITU for the night as a matter of routine.
The ITU had had a busy week and there were ten patients in the large and brightly-lit warehouse of a room, all but one of them unconscious, lying on their backs and attached to a forest of machinery with flashing lights and digital read-outs the colour of rubies and emeralds. Each patient has their own nurse, and in the middle of the room there is a large desk with computer monitors and many members of staff talking on the phone or working on the computers or snatching a plastic cup of tea in between carrying out the constant tasks that are needed in intensive care.
The one patient who was not unconscious was my brain tumour case, who was sitting upright in bed, still looking red-faced, but wide awake.
‘How are you feeling?’ I asked.
‘Fine,’ he replied with a tired smile.
‘Well done!’ I replied, as I think patients need to be congratulated for their surviving just as much as the surgeons should be congratulated for doing their job well.
‘It’s a bit of a war zone here, I’m afraid,’ I said to him, gesticulating to the depersonalized forms of the other patients and all the technology and busy staff around us. Few – if any – of these patients would survive or emerge unscathed from whatever it was that had damaged their brains.
‘I’m afraid you won’t get much sleep tonight.’
He nodded in reply, and I went downstairs to the basement in a contented frame of mind.
I found my car with a large notice stuck to the windscreen.
‘You have been clamped,’ the notice said, and there was a long list beneath this accusing me of negligence and disrespect and so on and so forth, and telling me to report to the Security Office to pay a large fine.
‘I really can’t take this anymore!’ I burst out in rage and despair, shouting at the concrete pillars around me but when I furiously marched round my car, to my surprise I found that none of the wheels had been clamped and then, when I came round to the notice again, I noticed that added in ballpoint to the notice were the words ‘Next time’ with two large exclamation marks.
I drove home torn between impotent rage and gratitude.
4
MELODRAMA
n. a sensational, dramatic piece with crude appeals to the emotions and usu. a happy ending.
I was recently asked to talk to the script-writing team for the TV medical drama Holby City. I took the train from Wimbledon to Boreham Wood at the opposite end of London and went to the well-appointed country house hotel where they were meeting. There were at least twenty people sitting round a long table. They were thinking of adding a neurosurgical ward, they told me, to the fictional Holby City General Hospital, and wanted me to talk to them about neurosurgery. I talked for almost an hour without stopping, something I don’t find very difficult to do, but I probably concentrated too much on the grim and tragic aspects of my work.
‘Surely you have some more positive stories to tell, which our viewers would like?’ somebody asked and then I suddenly remembered Melanie.
‘Well’ I said,’ Many years ago I did once operate on a young mother who was just about to have a baby and was going blind . . .’
There were three patients for surgery on that Wednesday – two women with brain tumours and a young man with a disc prolapse in his lumbar spine. The first patient was Melanie – a twenty-eight-year-old woman in the thirty-seventh week of pregnancy who had started to go blind over the preceding three weeks. She had been referred as an emergency to my neurosurgical department from the ante-natal clinic of her local hospital on Tuesday afternoon. A brain scan had shown a tumour. I was on call for emergencies that day so she was admitted under my care. Her husband had driven her to my hospital from the ante-natal clinic; when I first saw them on the Tuesday afternoon he was guiding Melanie down the hospital corridor towards the ward with one hand on her shoulder and the other hand holding a suitcase. She had her right arm stretched out in front of her for fear of bumping into things and her left hand was pressed onto the unborn child inside her as though she was frightened she might lose it just as she was losing her eyesight. I showed them the way to the ward entrance and said that I would come back later to discuss what should be done.
The brain scan had shown a meningioma – a ‘suprasellar’ meningioma growing from the meninges, the membrane that encases the brain and spinal cord – at the base of her brain. It was pressing upwards onto the optic nerves where they run back from the eyes to enter the brain. These particular tumours are always benign and usually grow quite slowly, but some of them have oestrogen receptors and, very occasionally, the tumours can expand rapidly during pregnancy when oestrogen levels rise. This was clearly what was happening in Melanie’s case. The tumour did not pose a risk to the unborn child, but if it was not removed quickly Melanie would go completely blind. It could happen within a matter of days. An operation to remove a tumour like hers is relatively straightforward but if the visual loss before surgery is severe it is by no means certain it will restore vision and there is some risk it will make it worse. I have once left one person completely blind with a similar operation. Admittedly he was already almost blind before the operation – but then so was Melanie.
When I went to the ward an hour or so later I found Melanie sitting up in her bed, with a nurse beside her completing the admission paperwork. Her husband, looking desperate, was on a chair next to the bed. I sat down on the end of the bed and introduced myself. I asked her how it had all started.
‘Three weeks ago. I scraped the side of the car on the garage gates when I was coming home from my ante-natal class,’ she said. ‘I couldn’t understand how I had managed to do it but a few days later I realized that I couldn’t see properly out of my left eye.’ As she spoke her eyes moved restlessly with the slightly unfocused look that people have when they are going blind. ‘It’s been getting worse and worse since then,’ she added.
‘I need to examine your vision a bit,’ I said. I asked her if she could see my face.
‘Yes,’ she replied. ‘But it’s all blurry.’
I held up my hand in front of her face with the fingers outstretched. I asked her how many fingers she could se
e.
‘I don’t really know,’ Melanie said with a note of desperation ‘I can’t see . . .’
I had brought an ophthalmoscope, the special torch used for looking into eyes, from my office. I fiddled with the dial on the ophthalmoscope, put my face close up to hers, and focused on the retina of her left eye.
‘Look straight ahead,’ I said. ‘Don’t look into the light since it makes your pupil smaller.’
The eyes are said by poets to be the windows to the soul but they are also windows to the brain: examining the retina gives a good idea of the state of the brain as it is directly connected to it. The miniature blood vessels in the eye will be in a very similar condition to the blood vessels in the brain. To my relief I could see that the end of the optic nerve in her eye still looked relatively healthy and not severely damaged, as did the retinal blood vessels. There was some chance surgery would get her better rather than just stop her going completely blind.
‘Doesn’t look too bad,’ I said, after looking into her right eye.
‘My baby! What will happen to my baby?’ Melanie asked me, clearly more troubled about her child than her eyesight.
I reached out and held her hand and I told her that her baby would be fine. I had already arranged with the obstetricians that they would come and perform a Caesarean section and deliver the baby once I, so to speak, had delivered the tumour. It could all be done under the same anaesthetic, I said. I hoped that surgery would improve her eyesight as well, but had to warn her and her husband that I could not guarantee this. There was also some risk, I told them, that the operation might leave her blind. It was all a question of whether the tumour was badly stuck to the optic nerves or not, which I would not know until I had operated. All that was certain, I said, was that she would go completely blind without surgery. I added that I had seen many patients in poor countries like Ukraine and Sudan who had indeed gone completely blind with tumours such as hers because of delays in treatment. I asked her to sign the consent form. Her husband leant forward and guided her hand with the pen. She scribbled something illegible.
