by Henry Marsh
‘Well, I suppose we’ll have to break my promise to her that we’d do her first,’ I replied. ‘It doesn’t make much sense though does it? They test her for MRSA the day before the operation and don’t get the results back for several days. If we had operated as planned last week we wouldn’t have done a one-hour clean would we?’
‘Mrs Seagrave’s daughter was threatening to sue us last night,’ he said. ‘She said we were all hopelessly disorganized.’
‘I’m afraid she’s right but suing us isn’t going to help, is it?’
‘No,’ he replied. ‘It just puts one’s back up. And it’s quite upsetting.’
‘Why the fuss?’
‘The anaesthetist turned up and said she’d have to be cancelled.’
‘Oh for Christ’s sake, why?’ I exploded.
‘Because she’s been put at the end of the list and therefore we won’t finish before five o’clock.’
‘Which bloody anaesthetist?’
‘I don’t know. A slim blonde – I think she’s the new locum.’
I walked the few feet to the anaesthetic room and put my head through the door. The anaesthetist Rachel and her junior were leaning against the side of the worktop lining the wall of the anaesthetic room, drinking coffee from polystyrene cups, waiting for the first patient to arrive.
‘What’s all this about cancelling the last case?’ I asked. The anaesthetist was indeed a new one – a locum recently appointed to replace my regular anaesthetist who was on maternity leave. We had done a few lists together and she had seemed competent and pleasant.
‘I’m not starting a big meningioma at 4 p.m.,’ she declared, turning towards me. ‘I’ve got no childcare this evening.’
‘But we can’t cancel it,’ I protested. ‘She was cancelled once already!’
‘Well I’m not doing it.’
‘You’ll have to ask your colleagues then,’ I said.
‘I don’t think they will, it’s not an emergency,’ she replied in a slow and final tone of voice.
For a few moments I was struck dumb. I thought of how until a few years ago a problem like this would never have arisen. I always try to finish the list at a reasonable time but in the past everybody accepted that sometimes the list would have to run late. In the pre-modern NHS consultants never counted their hours – you just went on working until the work was done. I felt an almost overwhelming urge to play the part of a furious, raging surgeon and wanted to roar out, as I would have done in the past:
‘Bugger childcare! You’ll never work with me again!’
But it would have been an empty threat since I have little say in who anaesthetizes my patients. Besides, surgeons can no longer get away with such behaviour. I envy the way in which the generation who trained me could relieve the intense stress of their work by losing their temper, at times quite outrageously, without fear of being had up for bullying and harassment. I spun on my heel and walked down the corridor trying to work out how to solve the problem. The solution appeared immediately in the form of Julia the bed manager who was coming down the theatre corridor looking for me.
‘We’ve admitted the two routine spines to the Day Room for your list today but we haven’t got any beds to put them in afterwards, there were so many emergency admissions last night. What do you want to do?’ she asked, looking strained. She was clutching her diary with its long list of patients who needed to be admitted, discharged or transferred and the phone numbers of the bed managers in other hospitals, who would probably be equally stressed and would be reluctant to accept them because they also were short of beds.
‘If we haven’t got any beds to put them in after the operation,’ I said, inwardly rejoicing as this meant Mrs Seagrave’s operation would now start early enough to mean I might finish by five o’clock, ‘I can’t very well operate, can I? You’ll have to send them home. At least they’re fairly minor ops.’
So the operating list was now sufficiently truncated. Two patients, starved from midnight in preparation for their frightening operations would be given a cup of tea in consolation and sent home.
I reluctantly walked to the Day Room on the ward where the patients to be operated upon that day were waiting. Since the hospital is chronically short of beds, more and more patients are brought in for surgery on the morning of their operation. This is standard practice in private hospitals and works very nicely since there will be a room and bed into which each patient can be put. In an over-stretched hospital like mine, however, this is not the case, so when I entered the small Day Room I found fifteen patients, all awaiting major surgery, all squeezed into a room the size of a small kitchen, still wearing their coats, wet with the February rain, which steamed in the cramped conditions.
Mike was on his knees in front of the patient who would be first on the list, since Mrs Seagrave’s operation would now have to be done in the afternoon. He was explaining the consent form to him. He has rather a loud voice so all the other patients must have heard what he was saying.
‘I have to warn you that there are some risks to the operation and these include death, a major stroke, major haemorrhage or serious infection. Just sign here please.’ He handed the consent form – a document that has become so complicated of late that it even has a table of contents on its front cover – to the patient with a pen and the man quickly scribbled his signature without looking at it.
I apologized to the two women whose spinal operations had been cancelled. I explained that there had been several emergency admissions during the night and they politely nodded their understanding, though I could see that one of them had been crying.
‘We’ll try to bring you back as soon as possible,’ I said. ‘But I’m afraid that at the moment I don’t know when that will be.’
I dislike telling patients that their operation has been cancelled at the last moment just as much as I dislike telling people that they have cancer and are going to die. I resent having to say sorry for something that is not my fault and yet the poor patients cannot very well be sent away without somebody saying something.
I spoke briefly to the man with facial pain whose case I would do first and then to Mrs Seagrave, who was waiting in a corner with her daughter beside her.
‘I’m so sorry about last week,’ I said. ‘And I’m sorry that I can’t do your operation first but I promise to get it done this afternoon.’ They looked a little dubiously at me.
‘Well, let’s hope so’ said her daughter with a grim expression. I turned to face all the patients crammed into the little room.
‘I’m sorry about all this,’ I said to them, waving my arm round the crowded room, ‘but we’re a bit short of beds at the moment.’
As I said this, suppressing the urge to deliver a diatribe about the government and hospital management, I wondered, once again, at the way in which patients in this country so rarely complain. Mike and I left for the theatres.
‘Do you think I have said sorry enough?’ I asked him.
‘Yes,’ he replied.
The first case was a microvascular decompression – known as an MVD for short. It was the same operation as the one I had been filmed carrying out in Kiev. The man had suffered from trigeminal neuralgia for many years and the standard pain-killing drugs had become increasingly ineffective. Trigeminal neuralgia is a rare condition – victims suffer excruciating spasms of pain in one side of the face. They say it is like a massive electric shock or a having a red hot knife pushed into their face. In the past, before effective treatment became available, it was well-recognized that some people who suffered from it would commit suicide because of the pain. When I introduced the operation to Ukraine in the 1990s several of the patients I treated, since they could not afford the drug treatment, told me that they had indeed come close to killing themselves.
The operation involves exposing one side of the brain through a very small opening in the skul
l behind the ear and gently displacing a small artery off the sensory nerve – the trigeminal nerve – for the face. The pressure of the artery on the nerve is responsible for the pain though the exact mechanism is not understood. It is fairly exquisite microscopic surgery but, provided you know what you are doing, technically straightforward. Although Mike had been right to frighten the man with the consent form – and I had mentioned the same risks to him when I had seen him in my outpatient clinic a few weeks earlier – I have had only a few problems out of several hundred such operations and I did not seriously expect any difficulties.
Once I had entered his head and started to use the operating microscope I found an abnormally large vein blocking access to the trigeminal nerve. When I started to approach the nerve, deep in the part of the skull known as the cerebello-pontine angle, the vein tore and a torrential haemorrhage of dark purple venous blood resulted. I was operating at a depth of six or seven centimetres, through a two-centimetre diameter opening, in a space only a few millimetres across, next to various vital nerves and arteries. The bleeding hides everything from view and you have to operate by blind reckoning, like a pilot lost in a cloud, until you have controlled the bleeding point.
‘Suction up!’ I shouted to the circulating nurse, as I tried to clear the blood with a microscopic sucker and identify from where the bleeding was coming.
It was not exactly a life-threatening emergency but it proved very difficult to stop the bleeding. You have to find the bleeding point and then pack it off with small pieces of haemostatic gauze which you press on with the tips of microscopic instruments which have angled handles so that your hands don’t block the view, waiting for the vein to thrombose.
‘It’s not cool to lose your cool over venous haemorrhage,’ I said to Mike as I gazed a little anxiously into the swirling pool of blood through the microscope. ‘It will always stop with packing.’ But as I said this I began to wonder if this might prove to be my second fatality with this operation. More than twenty years ago I had operated on an elderly man with recurrent trigeminal neuralgia and he had died from a stroke several weeks later as a result of the operation.
After twenty minutes, despite my efforts, the large sucker bottle at the end of the table was filled to its brim with dark red blood and Jenny, the circulating nurse, had to change it for an empty one. The patient had lost a quarter of all the blood circulating in his body. Eventually, with my instruments pressed against it, the packed off vein sealed and the bleeding stopped. As I stood there, my hands immobile as they held the microscopic instruments pressed onto the ruptured vein, I was certainly worried about the bleeding but I was equally worried that there now would not be enough time to get Mrs Seagrave’s operation done. The thought of cancelling her operation a second time, and having to face her and her daughter again, was not a good one. Aware that I was starting to feel under pressure of time I felt forced to take even longer than perhaps was necessary to make sure that the bleeding had stopped. If it started again after I had closed his head, the result would almost certainly be fatal. By two o’clock I was happy with the haemostasis, as surgeons call the control of bleeding.
‘Let’s send for the next case,’ I said to the anaesthetist, ‘You’ve got an experienced registrar with you so she can start the next case in the anaesthetic room while we’re finishing in here.’
‘I’m afraid we can’t,’ she replied, ‘we have only one ODA’ – ODAs being the technicians who work with the anaesthetists.
‘Oh bloody hell, just send for the patient can’t you?’
‘The ODA manager has made a new rule that you cannot start the next case until the first case is off the table. It’s not safe.’
I groaned and pointed out that we had never had any problems overlapping cases in the past.
‘Well, there’s nothing you can do about it. Anyway, you should plan more realistic operating lists.’
I could have explained that there was no way in which I could have predicted the unusual bleeding. I could have explained that if I only planned operating lists that allowed for the unexpected I would hardly get any work done at all. But I said nothing. It was now unlikely that we would get Mrs Seagrave’s operation started in less than an hour after finishing the first case. I was going to have to operate in a hurry if I was to finish by 5 p.m., something I hate doing. If the operation did go on beyond 5 p.m. the theatre staff would have to stay, of course, but if I ‘over-run’ too often it means that in future it will become even more difficult to start cases towards the end of the day. The thought of cancelling the operation yet again, however, was even worse.
We finished the first case, and the anaesthetist started to wake the man up.
‘I think we can send now,’ she said to one of the nurses, who went outside to pass the message on. I knew that there would be some delay before Mrs Seagrave was on the table so I went down to my office to get some paperwork done. I returned to the theatres after twenty minutes and looked into the anaesthetic room expecting to see the anaesthetists busy at work on Mrs Seagrave. To my dismay I saw that the room was empty apart from an ODA, whom I did not recognize.
I asked him what had happened to the patient but he just shrugged and said nothing in reply so I headed off to the Day Room to see what had happened to Mrs Seagrave.
‘Where’s Mrs Seagrave?’ I asked the nurse.
‘She’s gone to get changed.’
‘But why wasn’t she changed already?’
‘We’re not allowed to.’
‘What do you mean?’ I asked in exasperation. ‘Who doesn’t allow it?’
‘It’s the government,’ the nurse replied.
‘The government?’
‘Well the government says we can’t have patients of different sexes sitting in the same room in theatre gowns.’
‘Why not put them in dressing gowns?’
‘We suggested that ages ago. The management said the government wouldn’t allow it.’
‘So what should I do? Complain to the prime minister?’ The nurse smiled.
‘Here she is,’ she said, as Mrs Seagrave appeared, being pushed along the corridor in a wheelchair by her daughter. She was dressed in one of those undignified hospital gowns that scarcely cover one’s buttocks, so perhaps the government was right after all.
‘She had to change in the toilet,’ said her daughter, rolling her eyes.
‘I know. There are no separate facilities for the patients who come in on the morning of the operation,’ I said. ‘Anyway, we’re running out of time. I’ll take her to theatre myself.’ So I took hold of the wheelchair and rolled her rapidly down the corridor.
The ward nurse came running down the corridor after me clutching Mrs Seagrave’s notes.
By now it was three o’clock and the anaesthetist was looking distinctly unhappy.
‘I’ll do it all myself,’ I hurriedly assured her. ‘Skin to skin.’ Mike was disappointed that I would be elbowing him aside – earlier in the day I had told him that I would assist him doing it. Now he would have to assist me.
‘It looks very straightforward. It’s going to be easy,’ I added. This was a lie and I did not expect Rachel to believe it. Few anaesthetists believe what surgeons tell them.
And so, at half past three, we started.
Mike bolted the patient’s head to the operating table and shaved the left side of her head.
‘These are operations where one really doesn’t know what’s going to happen,’ I muttered to Mike, not wanting Rachel to hear. ‘She might bleed like a stuck pig. The tumour might be horribly stuck to the brain so it will take hours and at the end we’re left with the brain looking a horrible mess and she’s crippled, or the tumour might just jump out and scamper round the theatre.’
With scalpels, drills and clips, together we worked our way steadily through the scalp and skull of the late eminent gynaecologist’s widow. After forty
minutes or so we were opening the meninges with a small pair of scissors to expose her brain and the meningeal tumour pressing into it.
‘Looks pretty promising,’ said Mike, bravely hiding his disappointment at not doing the operation himself.
‘Yes,’ I agreed. ‘Not bleeding much and looks as though it will suck nicely.’ I picked up my metal sucker and stuck it into the tumour. It made an unattractive sucking sound as the tumour started to disappear, peeling gently off the brain as it shrank.
‘Awesome!’ said Mike. After a few minutes I shouted out happily to Rachel: ‘Forty minutes to open her head. Ten minutes to remove the tumour! And it’s all out and the brain looks perfect!’
‘Wonderful,’ she said, though I doubted if I was forgiven.
I left Mike to close up the old lady’s head and sat down in a corner of the theatre to write an operating note. It took another forty minutes to finish the operation and the patient was being wheeled off to the Intensive Care Unit by 5 p.m.
Mike and I left the theatres and walked round the wards to see our inpatients. Apart from the two surgical cases we had just done there were only a few patients, recovering uneventfully from relatively minor spinal operations done two days earlier so the ward round took only a few minutes and we ended up on the ITU. Examining patients at the end of the operating list, making sure that they are, as the jargon has it, ‘awake and fully orientated with a GCS of 15’, is an important part of the neurosurgeon’s day.
Mrs Seagrave was sitting half-upright in her bed, with drip-stands and syringe pumps and monitors with flashing displays beside her. With so much technology it is hard to believe that anything can go wrong but what really matters is that a nurse wakes the patient up every fifteen minutes to make sure they are alert and not slipping into a coma caused by post-operative bleeding. A nurse was cleaning blood and bone dust from her hair. I had finished the operation in a hurry and had forgotten to wash and blow-dry her hair, something I usually do with female patients.
