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

by Henry Marsh

  After finishing my year as a houseman I returned to my teaching hospital in north London to work as a senior house officer on the Intensive Care Unit. I had decided, with diminishing conviction, to try to train as a surgeon and working in intensive care was seen as a useful first step. The job mainly involved filling up forms, putting up drips, taking blood and occasionally more exciting invasive procedures, as they are called, such as inserting chest drains or IVs into the large veins of the neck. All the practical instruction was given by the more experienced junior doctors. It was while working on the ITU that I had gone down to the operating theatres and seen the aneurysm operation that prompted my surgical epiphany.

  Now that I knew exactly what I wanted to do my life became much easier. A few days later I went to find the neurosurgeon I had watched clipping the aneurysm and told him I wanted to become a neurosurgeon. He told me to apply for the neurosurgical SHO job in his department which was shortly to be advertised. I also spoke to one of the senior general surgeons on whose firm I had been as a student. An exceptionally kind man – the kind of surgical teacher I came close to worshipping – he immediately arranged for me to go and see two of the most senior neurosurgeons in the country both to make myself known as a would-be brain surgeon and to plan my career. Neurosurgery was a small world in those years, with fewer than a hundred consultants in all of the UK. One of the senior surgeons I went to see was at the Royal London in the East End. A very affable man, I found him in his office smoking a cigar. The walls were lined with photographs of Formula 1 racing cars since he was, I learned, the doctor for Formula 1 racing. I told him of my deep desire to be a neurosurgeon.

  ‘What does your wife think about it?’ was his first question.

  ‘I think she thinks it’s a good idea, Sir,’ I said.

  ‘Well, my first wife couldn’t stand the life so I changed her for a different model,’ he replied. ‘It’s a hard life, you know, training in neurosurgery.’

  A few weeks later I drove down to Southampton to see another senior neurosurgeon. He was equally friendly. Balding, with red hair and a moustache, he looked more like a jovial farmer than what I expected a neurosurgeon to look like. He sat at a desk covered in piles of patients’ notes that almost hid him from view. I told him about my ambition to become a neurosurgeon.

  ‘What does your wife think about it?’ he asked. I assured him that all would be well. He said nothing for a while.

  ‘The operating is the easy part, you know,’ he said. ‘By my age you realize that the difficulties are all to do with the decision-making.’

  7

  MENINGIOMA

  n. a benign tumour arising from the fibrous covering of the brain and spinal cord; usu. slow-growing, produces symptoms by pressure on the underlying nervous tissue.

  On Monday morning I had awoken at seven, to the sound of heavy rain. It was February and the sky, seen dimly though my bedroom windows, was the colour of lead. There was a long operating list ahead of me but I doubted if I would be able to finish it since I knew that the hospital was overflowing once again, and that there was a shortage of beds. The day would end with the misery of my having to apologize to at least one patient, who would have been kept waiting all day, nil-by-mouth, starved and anxious, on the off-chance that a post-operative bed might become available, to be told that their operation would have to be postponed.

  So, cursing the weather, with the wind and rain against me, and cursing the hospital’s bed state, I cycled to work. I was late for the morning meeting and sat down next to one of my colleagues, a neuroradiologist whose interpretation of brain scans – a very difficult skill – is second to none and on whose advice I depend to save me from making mistakes. I asked Anthony, the registrar who had been on call for emergency admissions overnight to present the admissions. He was sitting at the computer at the front of the room and had been waiting for me to arrive. Anthony was quite junior and tended to be a bit gung-ho, not an unusual characteristic in a surgeon, but one which most neurosurgeons lose as they become more experienced.

  ‘There was nothing very interesting last night,’ he replied.

  I looked at him and irritably told him that the simple, everyday problems were often the most important ones.

  He looked hurt by my criticism, and I momentarily regretted my bad manners.

  ‘This is a ninety-six-year-old woman who has been living independently and has been starting to fall at home,’ he said. ‘She’s got severe aortic stenosis – you can hear the cardiac murmur from the end of the bed. She’s got a left hemiparesis and can’t walk but is fully orientated.’

  I asked one of the most junior doctors sitting in the front row for the most likely diagnosis.

  ‘The only condition we might treat in somebody that age would be a chronic subdural,’ he replied confidently.

  I asked him about the significance of the aortic stenosis.

  ‘It means that a general anaesthetic would probably kill her.’

  I told Anthony to show us the scan. He turned to the computer keyboard. He typed in a number of passwords but it took several minutes before the website linking us to the local hospitals, from where most of our patients come, appeared. While he fiddled with the computer the other junior doctors laughed and joked about the hospital’s IT systems, while trying to help him locate the patient’s scans.

  ‘The software for transferring scans is complete crap . . . Try refreshing, Anthony – no, go to View, then tile – doesn’t seem to be working. Drag it over to the left. It’s useless. Try going back to login . . .’ Eventually the old woman’s brain scan suddenly flashed up on the wall in front of us. It showed a thick layer of fluid between the inside of her skull and the surface of her brain, distorting the right cerebral hemisphere.

  It was yet another old person with a chronic subdural – the commonest emergency in neurosurgery. The rest of the brain didn’t look too bad for her age, and much less shrunken than for most ninety-six-year-olds.

  ‘My father died at that age with Alzheimer’s,’ I said to the trainees. ‘His brain on his brain scan looked like a Swiss cheese plant, there was so little left.’

  ‘So, Anthony,’ I continued, ‘what’s the problem?’

  ‘It’s an ethical problem. She says she would rather die than have to leave her home and end up in a nursing home.’

  ‘Well, that’s not unreasonable. Have you ever worked on a psycho-geriatric ward or nursing home?’

  ‘No,’ he replied.

  I started to talk about how I had once worked as a psycho-geriatric nursing assistant. Looking after a ward of twenty-six doubly incontinent old men was not easy. As the population gets older and older there are going to be more and more scandals in the media about abuse in old people’s homes. By 2050 a third of the population of Europe will be over sixty. My first boss in general surgery – a lovely man – ended his days in a nursing home because of dementia. His daughter told me he kept on saying that he wanted to die but he was terribly fit and it took ages. He used to have a cold bath every morning when he was younger.

  ‘Well we can’t just let her die,’ one of the registrars in the back row said, interrupting my monologue.

  ‘Why not?’ I said. ‘If that’s what she wants.’

  ‘But she might be depressed. She might change her mind.’

  We discussed this for a while. I pointed out that his comments applied well enough to younger people who had many years of life ahead of them if they didn’t commit suicide, but I was uncertain if it applied to somebody aged ninety-six who had little chance of getting home again.

  I asked Anthony what he thought were the chances of her returning to an independent life in her own home if we operated.

  ‘Not very good, at her age,’ he replied. ‘Though I suppose she might get back for a while but she’ll still end up in a nursing home sooner or later if the aortic stenosis doesn’t finish her
off first.’

  ‘So what should we do?’ I said to the room. There was an uncomfortable silence. I waited for a while.

  ‘The only next of kin is a niece. She’s coming in this morning,’ Anthony told us.

  ‘Well, any decisions will have to wait until then.’

  My radiological colleague leant over towards me and spoke quietly.

  ‘I always find these cases by far the most interesting,’ he said. ‘The young ones,’ he nodded towards the row of junior doctors, ‘all want to operate, and want big, exciting cases – that’s fair enough at their age, but the discussions about these everyday cases are fascinating.’

  ‘Well, I was just like that once upon a time,’ I replied.

  ‘What do you think will happen to her?’ he asked.

  ‘I don’t know. She’s not my case.’ I turned to the assembled doctors. ‘There’s ten minutes left,’ I said. ‘Shall we look at one of the cases on my list for today?’ I gave the patient’s name to Anthony and he summoned up a brain scan onto the wall, with greater success than with the first case. The scan showed a huge tumour – a benign meningioma – pressing on the left side of the patient’s brain.

  ‘She’s eighty-five years old,’ I began. ‘When I went in to neurosurgery thirty-two years ago, when you lot were probably still in trainer pants, we just didn’t operate on people this old. Anybody over the age of seventy was simply considered too old. Now there doesn’t seem to be any age limit.’ So I gave them the history, the story about the patient.

  I had first seen Mrs Seagrave several weeks earlier in the outpatient clinic. She was the highly articulate widow of an eminent doctor and she came accompanied by her three very professional and equally articulate middle-aged children – two daughters and a son. I had to go to another room to bring in some extra chairs. The patient, a short and dominating woman with long grey hair, well turned out and looking younger than her age, marched into the room in an authoritative way. She sat in the chair beside my desk and her three children sat in a row facing me, a polite but determined chorus. As with most people with problems affecting the front of the brain she had little insight, if any, into her difficulties.

  Having introduced myself I asked her, with the wary sympathy of the doctor anxious to help but anxious also to avoid the emotional demands patients make of their doctors, to tell me about the problems that had led to her having a brain scan.

  ‘I’m perfectly all right!’ she declared in a ringing tone. ‘My husband was the professor of gynaecology at St Anne’s. Did you know him?’

  I said that I did not – that he had been rather before my time.

  ‘But it’s just outrageous that they,’ she gestured towards her children sitting opposite her, ‘won’t let me drive. I really can’t manage without a car. It’s all so sexist . . . If I was a man they’d let me drive.’

  ‘But you are eighty-five years old . . .’ I said.

  ‘That has nothing to do with it!’

  ‘And there is the matter of the brain tumour,’ I added, pointing to the monitor on my desk. ‘Have you seen your brain scan before?’

  ‘No,’ she said. ‘Well, isn’t that interesting.’ She looked thoughtfully at the scan for a while, showing the large mass, the size of a grapefruit, compressing her brain. ‘But I really must be allowed to drive. I can’t manage without it.’

  ‘If you’ll excuse me,’ I said, ‘I would like to ask your children a few questions.’

  I asked about the difficulties their mother had had in recent months. I think they were a little reticent about drawing attention to her problems in her presence – and she constantly interrupted, disputing what they said and, above all, complaining about the fact they would not let her drive. Between the three of them they gave me to understand that their mother had become confused and forgetful. At first, naturally enough, they had attributed this to her age but her memory became steadily worse and she was seen by a geriatrician who had arranged a brain scan. Brain tumours like hers are a rare but recognized cause of dementia and can be surprisingly large by the time they start to cause problems. It was always possible, however, that she was suffering from Alzheimer’s disease as well as having a brain tumour and an operation to remove the tumour, I therefore told them, was not guaranteed to make her better. It also came with a very real danger of making her much worse. The only sure way of knowing whether the tumour was responsible for her problems, however, would be by removing it. The problem, I told them, was that it was impossible to predict from the scan just how great the risk was of making her worse. It is a question of how stuck the surface of the tumour is to the surface of the brain and until you operate you cannot tell how easy or difficult it will be to separate the tumour away from the underlying brain. If it is stuck, the brain will be damaged and she could be left paralysed down the right side of her body and unable to communicate, as each half of the brain controls the opposite side of the body and the function of speech is on the left side of the brain.

  ‘Can’t you just remove part of the tumour,’ one of the daughters asked, ‘and leave the part stuck to the brain?’

  I explained that this rarely worked since these tumours are often quite solid and if you leave a rigid shell of tumour behind, the brain remains compressed and the patient doesn’t get any better. And the tumour can grow back again.

  ‘Well, how often is the tumour stuck to the brain?’ the other daughter asked.

  ‘Well, it’s a bit of a guess, but I suppose twenty per cent.’

  ‘So there’s a one in five chance of making her worse?’

  In fact it was probably slightly more than that because every time you open somebody’s head there’s a one to two per cent risk of catastrophic haemorrhage or infection, and that risk is probably slightly greater in somebody her age. The only certainty was that she would slowly get worse if we did nothing – but, I added hesitantly, hoping that Mrs Seagrave herself would not notice, one might argue that given her age it was best simply not to operate and accept that she would slowly deteriorate before she died.

  One of the daughters asked if any treatment other than surgery might help. With Mrs Seagrave continuing to interrupt, complaining about the monstrous injustice of her not being allowed to drive, I explained that radiotherapy and chemotherapy were of no use with tumours of this type. It was fairly obvious that their mother was not capable of following the conversation.

  ‘What would you do if it were your mother?’ the son asked.

  I hesitated before I answered because I was not sure of the answer. It is, of course, the question that all patients should ask their doctors, but one most are reluctant to ask since the question suggests that doctors might choose differently for themselves compared to what they recommend for their patients.

  I replied slowly that I would try to persuade her to have the operation if we – and I gestured to the four of them as I spoke – all felt she was losing her independence and heading for some kind of institutional care. But I said that it was very difficult – that it was all about uncertainty and luck. I was sitting with my back to the window with the three children in front of me as I spoke, and wondered if they could see through the window behind me the large municipal cemetery in the distance beyond the hospital car park.

  I concluded the meeting by telling them that there was no need to make an immediate decision. I gave them my secretary’s phone number and suggested they let me know what they wanted to do in due course. They trooped out, and I removed the three chairs and then went to collect the next patient from the waiting area. I heard a few days later from my secretary Gail that they had decided – how much persuasion the patient herself had required I do not know – that I should operate.

  She was admitted to the hospital for the operation three weeks after the outpatient appointment. The evening before the operation, however, the anaesthetist – a rather young and inexperienced one – had request
ed a test called an echo-cardiogram. She might, the anaesthetist said, have a problem with her heart because of her age, although she had no symptoms of heart disease. This test was almost certainly unnecessary but as a surgeon, with only minimal knowledge of anaesthesia, I was in no position to argue. I told my juniors to beg the cardiac staff to get the test done first thing the next morning. Instead of operating I had therefore spent much of the day dozing angrily on the sofa in the surgeon’s sitting room, watching the dull sky through the high, viewless windows, waiting for the test to be done. The occasional pigeon flew past, and sometimes I could see airliners in the distance nosing their way through the low clouds towards Heathrow.

  The test, despite my juniors’ pleas, was not done until four in the afternoon. Since the operation might well take several hours and I am only supposed to operate on emergencies out of hours I had to explain to the distressed and tearful patient, when she finally arrived outside the operating theatres in a wheelchair with an angry daughter, that I would have to cancel the operation. I promised to put her first on my next list so she was wheeled back to the ward and I bicycled home in a bad temper. Adding her to my next list would very probably mean having to cancel some of the other operations already planned for the day.

  After I had discussed her case with the junior doctors at the Monday morning meeting I went to the reception desk outside the operating theatres. The anaesthetist – a different one from the one who had ordered the echo-cardiogram – was standing there with my registrar Mike, who looked gloomily at me.

  ‘Mrs Seagrave’s growing MRSA on the swabs which were taken when she was admitted last week and her operation was cancelled,’ Mike said. ‘The theatre will have to have a one-hour clean after her operation. We won’t be able to get the list done if we do her first so I rearranged the list so that she’s at the end of the list.’