by Henry Marsh
‘But that was never discussed with us. Does our opinion about what is best for patients count for nothing?’ I asked.
Her utter lack of interest in what I said was very obvious and she did not bother to reply. I started to deliver an impassioned denunciation of the dangers of having trainee surgeons working only forty-eight hours a week.
‘You can send me an email setting out your views,’ she said, interrupting me, and the meeting came to an end.
I went round to the theatres where my registrar was starting the spinal case. He had done a fair number of these cases on his own before, and although not the best of my trainees in terms of operating ability, he was certainly one of the most conscientious and kindest juniors I had had for a long time. The nurses all adored him. It seemed safe enough to let him start and probably do all the operation himself. The patient’s extreme anxiety had, however, made me anxious in turn, so I changed and went into the theatre, when usually I would have stayed outside in the red leather sofa room, readily available but not overlooking everything he did.
As it was a spinal procedure the patient, rendered anonymous by light blue sterile drapes, was lying anaesthetized face down on the table, a small area of skin over the lower spine exposed as a rectangle, coloured yellow by the iodine antiseptic and brilliantly illuminated by the big, dish-shaped operating lights suspended on hinged arms from the ceiling. In the middle of this rectangle was a three inch incision through the skin and into the dark red spinal muscles, which were held open by steel retractors.
‘Why such a large incision?’ I asked irritably, still enraged by the manager and her complete indifference to what I had said. ‘Haven’t you seen how I do these? And why are you using the big bone rongeurs? That shouldn’t be necessary at L5/S1.’ I was annoyed but not alarmed – the operation had scarcely begun, the scan had showed a simple disc prolapse and he would not yet have reached the more difficult part of the operation, which is to expose the trapped nerve root within the spine.
I scrubbed up and came over to the operating table.
‘I’ll have a look,’ I said. I picked up a pair of forceps and looked into the wound. A long shiny white thread, the thickness of a piece of string – four or five inches long – came up out of the wound in my forceps.
‘Oh Jesus fucking Christ!’ I burst out. ‘You’ve severed the nerve root!’ I threw the forceps onto the floor and flung myself away from the operating table to stand against the far wall of the theatre. I tried to calm myself down. I felt like bursting into tears. It is, in fact, highly unusual for gross technical mistakes like this to occur in surgery. Most mistakes during operations are subtle and complex and scarcely count as mistakes. Indeed, in thirty years of neurosurgery I’d never witnessed this particular disaster, although I have heard of it happening.
I forced myself to return to the operating table and looked into the bloody wound, cautiously exploring it, dreading what I might find. It became apparent that my registrar had completely misunderstood the anatomy and opened the spine at the outer rather than the inner edge of the spinal canal and hence had immediately encountered a nerve root, which, even more incomprehensibly, he had then severed. It was an utterly bizarre thing to have done, especially as he had seen dozens of these operations done before, and done many unsupervised on his own.
‘I think you’ve cut straight through the nerve – a complete neurotmesis,’ I said sadly to my dumb-struck assistant. ‘He’ll almost certainly be left with a permanently paralysed ankle and a life-long limp. That’s not a minor disability – he’ll never be able to run again, or to walk on uneven ground. So much for the mountain bike championships.’
We completed the rest of the operation in silence.
I redirected the opening into the spine and quickly removed the disc prolapse without any difficulty – the simple and quick operation I had more or less promised him as he lay looking so frightened in the anaesthetic room earlier that morning.
I went out of the theatre where Judith, my anaesthetist for many years, joined me in the corridor.
‘Oh it’s so terrible,’ she said. ‘And he’s so young. What will you tell him?’
‘The truth. It’s just possible that the nerve is not completely cut through and I suppose he might just recover, though if he does it will take months. To be honest, I doubt if he will, but I suppose there’s some hope . . .’
One of my consultant colleagues passed by and I told him what had happened.
‘Bloody hell,’ he said. ‘That’s bad luck. Do you think he’ll sue?’
‘I think it was reasonable enough for me to let my registrar start – he’s done these operations before. But I got it wrong. He was less experienced than I realized. It really was staggeringly incompetent . . . but then I am responsible for his operating.’
‘Well, it’s the Trust that gets sued anyway – it doesn’t really matter whose fault it was.’
‘But I misjudged his abilities. I’m responsible. And the patient will blame me anyway. He’d put his trust in me, not in the bloody Trust. In fact, assuming he doesn’t recover, I’ll tell him to sue.’
My colleague looked surprised. Litigation is not something we are supposed to encourage.
‘But my duty is to him, not to the Trust – isn’t that what the GMC piously tells us doctors?’ I said. ‘If he’s been left crippled and somebody’s made a mistake – he ought to get some financial compensation, shouldn’t he? The irony is that if we hadn’t had to have that meeting with that fatuous manager I’d have been in theatre sooner and this disaster probably wouldn’t have happened. I wish I could blame the manager,’ I added. ‘But I can’t.’
I went off to write an operating note. It’s quite easy to lie if things go wrong with an operation. It would be impossible for anybody to know after the operation in what way it had gone wrong. You can invent plausible excuses – besides, patients are always warned that nerve damage can happen with this operation, even though I have scarcely ever seen it happen. I know of at least one very famous neurosurgeon, now retired, who covered up an even more major mistake on a very eminent patient with a dishonest operating note. I wrote down, however, an exact and honest account of what had happened.
I left the theatre and thirty minutes later saw Judith leaving the recovery ward.
‘Awake?’ I asked.
‘Yes. He’s moving his legs . . .’ she said a little hopefully.
‘It’s the ankle that matters,’ I replied gloomily, ‘not the legs.’
I went round to see the patient. He was only just awake, and was not going to remember anything I said so soon after the operation, so I said little to him and just sadly confirmed my worst fears: he had complete paralysis of lifting the left foot upwards – a foot drop as it is called in the trade – and, as I had told my junior, it is a very disabling condition.
I went to see him two hours later after he had returned to the ward and was fully awake. His wife was sitting anxiously beside him.
‘The operation was not straightforward after all,’ I said. ‘One of the nerves for your left ankle was damaged and that’s why you can’t bend the foot up at the moment. It might get better – I really don’t know. But if it does I’m afraid it will be a slow process that takes months.’
‘But it should get better?’ he asked anxiously.
I told him that I didn’t know and could only promise to always tell him the truth. I felt quite sick.
He nodded in numb agreement, too shocked and confused to say anything. The anger and tears, I thought as I walked away, and dutifully squirted alcohol gel on my hands from a nearby bottle on the wall, will come later.
I went downstairs to my office and dealt with mountains of unimportant paperwork. There was a huge box of chocolates on my desk from a patient’s wife. I took them through to Gail’s office in the next room as she likes chocolates more than I do. Her office, unlike mine, has a w
indow, and I noticed that it was pouring with rain in the hospital car park outside. The pleasant smell of rain on dry earth was filling her office.
‘Have some chocolates,’ I said.
I cycled home in a furious temper.
Why don’t I just stop training juniors? I said to myself as I angrily turned the pedals. Why don’t I just do all the operating myself? Why should I have to carry the burden of deciding whether they can operate or not when the fucking management and politicians dictate their training? I’ve got to see the patients every day on the ward anyway as the juniors are so inexperienced now – on the few occasions when they’re actually in the hospital, that is. Yes, I shall no longer train anybody, I thought with a sudden sense of relief. It’s not safe. There are so many consultants now that having to come in occasionally at night wouldn’t be a great hardship . . . The country’s massively in debt financially, why not have a massive debt of medical experience as well? Let’s have a whole new generation of ignorant doctors in the future. Fuck the future, let it look after itself, it’s not my responsibility. Fuck the management, and fuck the government and fuck the pathetic politicians and their fiddled expenses and fuck the fucking civil servants in the fucking Department of Health. Fuck everybody.
15
MEDULLOBLASTOMA
n. a malignant brain tumour that occurs during childhood.
There was a child – Darren – who I had operated on many years ago for a malignant tumour called a medulloblastoma when he was twelve years old. The tumour had caused hydrocephalus and although I had removed the tumour completely the condition continued to be a problem and a few weeks after the operation I had carried out a ‘shunt’ operation, implanting a permanent drainage tube into his brain. My son William had undergone the same operation after his tumour had been removed for the same reason. William has been fine ever since but Darren’s shunt had blocked on several occasions – a frequent problem with shunts – and he had required several further operations to revise the shunt. He was treated with radiotherapy and chemotherapy and as the years passed it appeared that he had been cured. Despite the problems with the shunt Darren had otherwise done very well and he went on to study accountancy at university.
He had been at university, away from home, when he started to develop severe headaches. He was brought to my hospital while I was on sick leave with a retinal detachment. A brain scan showed that the tumour had recurred. Although tumours such as Darren’s can and do recur it is usually within the first few years after treatment. For the tumour to come back after eight years – as with Darren – is very unusual and nobody had expected it. Recurrence is inevitably fatal although further treatment can postpone death by a year or two with luck. The plan was that one of my colleagues would operate again in my absence but the evening before the operation Darren suffered a catastrophic haemorrhage into the tumour – an entirely unpredictable event that happens occasionally with malignant tumours. Even if he had been operated upon successfully before the haemorrhage it is unlikely that he would have had long to live. His mother had been with him when he had suffered the haemorrhage. He had been placed on a ventilator on the ITU but he was already brain dead and the ventilator was switched off a few days later.
I had got to know Darren and his mother well over the years and I had been very upset to hear of his death when I got back to work, though it was not the first time a patient of mine had died like this. As far as I could make out his treatment once he arrived in my department had been entirely appropriate but his mother was convinced he had died because of my colleague’s delay in operating upon him. I received a letter from his mother requesting an appointment with me. I arranged to see her in my office rather than in one of the impersonal consulting rooms of the outpatient clinic. I brought her into the room and sat her down opposite me. She burst into tears and started to tell me the story of her son’s death.
‘He suddenly sat up in bed and clutched his head. My son cried out “Help me, help me, Mummy!”’ she said, in torment as she told me. I remembered how once a patient of mine, dying from a tumour, had cried out for help to me and how awful and helpless I had felt. How much worse, I thought, how utterly unbearable it must be if it were one’s own child crying for help, and if one could not help them.
‘I knew that they should have operated but they just wouldn’t listen to me,’ she said.
She went over the sequence of events over and over again. After forty-five minutes I threw my hands up in the air and shouted in some desperation.
‘But what do you want me to do? I wasn’t there.’
‘I know it wasn’t your fault but I was hoping for some answers,’ she replied.
I told her that as far as I could tell the haemorrhage could not have been predicted and it had been perfectly reasonable to plan on operating the next day. I said that the doctors and nurses who had been looking after Darren were terribly upset about what had happened.
‘That’s what they said on the ITU when they wanted to turn the ventilator off,’ his mother said, her voice choking with anger. ‘That keeping him on the ventilator was upsetting for the staff. But these people are paid, they are paid, to do their job!’ She became so angry that she rushed out of the room.
I followed her out of the hospital into the afternoon sunlight to find her standing in the car park opposite the main entrance
‘I’m sorry that I shouted,’ I said. ‘I find this all very difficult.’
‘I thought you would be furious when you heard about his death,’ she said to me in a disappointed voice. ‘I know that it’s difficult for you . . .’ – she waved her arm at the building behind us – ‘You have a duty to the hospital.’
‘I’m not trying to cover up for anybody,’ I replied. ‘I don’t like this place and have no loyalty to it whatsoever.’ As we talked we had started to walk back to the steel and glass front entrance to the hospital. The constant passage of people coming and going through the automatic doors made it feel like a railway station.
I took her back to my office, past the threatening notice at the entrance to the outpatient clinic over which I had once got into trouble for denouncing on the radio. ‘This Trust’ – states the notice – ‘operates a policy of withholding treatment from violent and abusive patients . . .’ It was ironic, I thought, how the notice expressed the hospital management’s distrust of patients, and it was a corresponding lack of trust in the hospital which was now tormenting Darren’s mother. She collected her bag from my office and left without saying anything more.
I went back up to the wards. I met one of my registrars on the staircase.
‘I’ve just seen Darren’s mother,’ I said to him. ‘It was pretty grim.’
‘There had been a lot of problems when the boy was dying on the ITU,’ he replied. ‘She wouldn’t let us turn the ventilator off, even though he was brain dead. I had no problem with that, but some of the anaesthetic staff got pretty difficult over the weekend and some of the nurses were refusing to look after him since he was brain dead . . .’
‘Oh dear,’ I said.
I remembered how angry I had been myself many years ago, at how my own son had almost died due to what I felt had been the carelessness of one of the doctors looking after him when he had been admitted to hospital with his brain tumour. I also remembered how, after I had become a neurosurgeon myself, I had operated on a young girl with a large brain tumour. The tumour was a mass of blood vessels, in the way that some brain tumours can be, and I had struggled desperately to stop the bleeding. The operation became a grim race between the blood pouring out of the child’s head and my poor anaesthetist Judith pouring blood back in through the intravenous lines as I tried, and failed, to stop the bleeding.
The child, a very beautiful girl with long red hair, bled to death. She ‘died on the table’ – an exceptionally rare event in modern surgery. As I completed the procedure, stitching together the scalp of
the now dead patient, there was utter silence in the operating theatre. The normal sounds of the place – the chatter of the staff, the hissing of the ventilator, the bleeping of the anaesthetic monitors – had suddenly stopped. All of us in the theatre avoided each other’s eyes in the presence of death and in the face of such utter failure. And as I closed the dead child’s head I had to think about what to tell the waiting family.
I had dragged myself up to the children’s ward, where the mother was waiting to see me. She would not have been expecting to hear this catastrophic news. I had found it very difficult to talk, but managed to convey what had happened. I had no idea how she might react, but she reached out to me and held me in her arms and consoled me for my failure, even though it was she who had lost her daughter.
Doctors need to be held accountable, since power corrupts. There must be complaints procedures and litigation, commissions of enquiry, punishment and compensation. At the same time if you do not hide or deny any mistakes when things go wrong, and if your patients and their families know that you are distressed by whatever happened, you might, if you are lucky, receive the precious gift of forgiveness. As far as I know Darren’s mother did not pursue her complaint but I fear that if she cannot find it in her heart to forgive the doctors who looked after her son in his final illness she will be haunted forever by his dying cry.
16
PITUITARY ADENOMA
n. a benign tumour of the pituitary gland.
By the time that I became a consultant in 1987 I was already an experienced surgeon. I was appointed to replace the senior surgeon at the hospital where I had been training and as the senior surgeon wound down his career he had delegated most of his operating to me. Once you become a consultant you are suddenly responsible for your patients in a way that you never were as a junior and trainee. You come to look back on your years of training as an almost carefree time. As a trainee the ultimate responsibility for any mistakes that you might make are ultimately borne by your consultant and not by yourself. As I get older I find the self-assurance of many of my trainees, for whose mistakes I am responsible, a little irritating but I was no different myself once. This all changes when you become a consultant.
