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

by Henry Marsh

  PHOTOPSIA

  n. the sensation of flashes of light caused by mechanical stimulation of the retina of the eye.

  Illness is something that happens only to patients. This is an important lesson you learn early on as a medical student. You are suddenly exposed to a terrifying new world of illness and death, and you learn how terrible illnesses often start with quite trivial symptoms – blood on the toothbrush might mean leukaemia, a small lump in the neck might mean cancer, a previously unnoticed mole might be malignant melanoma. Most medical students go through a brief period when they develop all manner of imaginary illnesses – I myself had leukaemia for at least four days – until they learn, as a matter of self-preservation, that illnesses happen to patients, not to doctors. This necessary detachment from patients becomes all the greater when you start working as a junior doctor and you have to do frightening and unpleasant things to patients. It starts with simple blood-taking and inserting drips, and progresses over time – if you train as a surgeon – to ever more radical procedures, cutting and slicing into people’s bodies. It would be impossible to do the work if you felt the patients’ fear and suffering yourself. Besides, the increasing responsibility that comes as you climb the career ladder brings greater anxiety that you will make a mistake and that patients will suffer. Patients become objects of fear as well as of sympathy. It is much easier to feel compassion for other people if you are not responsible for what happens to them.

  So when doctors fall ill themselves they tend to dismiss their initial symptoms and find it hard to escape the doctor–patient relationship, to become mere patients themselves. It is said that they are often very slow to diagnose their own illnesses. I took little notice of the flashing light in my eye. It had started when I returned to work in September after a late summer holiday. I noticed that every time I walked down the brightly lit, factory-like corridors of the hospital an odd little flashing light would momentarily appear in my left eye. It was hard to pin down and after a fortnight it disappeared. A few weeks later, however, I noticed that there seemed to be a flashing arc, just beyond my line of vision in my left eye, which would come and go for no apparent reason. I became a little pre-occupied by this but since the symptoms were almost subliminal I dismissed them, although I could not help but think of the patients I see whose brain tumours can sometimes first declare themselves with rather similar subtle visual symptoms. I attributed them instead to anxiety about the meeting to which I had been summoned with the hospital chief executive, probably to be told off for causing trouble again.

  One evening, while driving my car, there was a sudden shower of flashing lights in my left eye, as swift as shooting stars. When I got home I found that my eye seemed to have filled with a swirling black cloud of Indian ink. It was rather alarming but quite painless. I had paid little attention to ophthalmology as a student and didn’t have a clue as to what was happening but a few minutes on the internet revealed that I had suffered a vitreous detachment. The vitreous – the transparent jelly that fills the eye behind the lens – had broken away from the wall of the eyeball. Since I am very short-sighted I learned that I was at risk of the vitreous detachment progressing to a retinal detachment which might result in my losing vision in that eye.

  A major advantage of being a doctor is that you can get immediate medical help from your friends without the misery that our patients face of queuing in the local Accident and Emergency department, in a GP’s surgery or, worse still, trying to get hold of a GP out of hours. I rang up an ophthalmic colleague. He arranged to see me early next morning, a Sunday. So next day I drove to the hospital where we both work, the roads empty, the vision in my left eye intermittently blurred by the floating cloud of black blood. He examined my eye and told me that I had the beginnings of a detached retina. It was in the days when I still had a large private practice and could afford private medical insurance so it was arranged for me to see a specialist vitreo-retinal surgeon in one of the central London private hospitals the following day.

  I knew by now that retinal detachment can occur quite suddenly – the retina can simply peel off the eyeball, like old wallpaper off a damp wall – and I lay that night in my dark bedroom, my wife Kate beside me as anxious as I was, opening and closing my eye, checking if I could see, wondering if the eye might go blind, watching the dim shape of the blood-cloud performing its dance across the night sky seen through the windows. It turned and twisted slowly, quite elegantly, a little like a computer screen saver. To my surprise I eventually got to sleep and could see well enough in the morning to go to work – the appointment with the vitreo-retinal surgeon was for the afternoon.

  Surgeons can fall ill just like anybody else but it can be difficult to judge whether one is well enough to operate. You cannot cry off operating just because you are feeling a little out of sorts but nor would anybody want to be operated upon by a sick surgeon. I learned a long time ago that I can operate perfectly well despite being tired, as when I am operating I am in an intense state of arousal. Sleep deprivation research has shown that people make mistakes if moderately deprived of sleep when they are carrying out boring, monotonous tasks. Surgery – however trivial the operation – is never boring or monotonous. I carried out one operation – ironically enough under local anaesthetic on the visual area of a man’s brain – and quite forgot my own anxieties until, as I started to put his skull back together again, I remembered that I was soon to be a patient myself.

  Suddenly fearful, I left the hospital in a hurry, and ordered a mini-cab to take me to the Harley Street Clinic in central London.

  The retinal surgeon was a little younger than me but I recognized myself in his surgical manner – affable and business-like, with that wary sympathy all doctors develop, anxious to help but worried that patients will make difficult emotional demands of us. I knew that he would dislike having to treat a fellow surgeon – it is both a compliment and a curse when your colleagues ask you to treat them. All surgeons feel anxious when treating colleagues. It is not a rational anxiety – their colleagues are much less likely to complain than other patients if things go badly, as they know all too well that doctors are fallible human beings and not entirely in control of what is going to happen. The surgeon treating a fellow surgeon feels anxious because the usual rules of detachment have broken down and he feels painfully exposed. He knows that his patient knows that he is fallible.

  He examined my retina again. The light was especially bright and I flinched a little.

  ‘There’s fluid starting to build up under the retina,’ he said. ‘I’ll operate tomorrow morning.’

  I walked out of the building twenty minutes later in a state of panic. Rather than take the tube or a taxi home I walked the six miles back to my house rehearsing all the terrible things that might happen to me – starting with having to abandon my career (I did, in fact, know two surgeons who had had do this because of retinal detachments) and going on to complete blindness, which was possible, since I had been told I had early changes predictive of detachment in my other eye as well. I cannot remember how my thoughts ran as I walked but, to my surprise, by the time I got home I was strangely reconciled to the problem. I would accept whatever happened but hoped for the best. I had forgotten that I had turned off my mobile phone when in the clinic and I shamefacedly found a panic-stricken Kate waiting at home, fearing the worst, unable to contact me.

  At the hospital the next morning a smart receptionist was expecting me. The paperwork was quickly dealt with and I was taken to my room. The porters and attendants wore black waistcoats like page boys, the corridors and rooms were all carpeted and quiet with muted lighting. The contrast with the large public hospital where I work couldn’t have been greater. The surgeon re-examined my left eye and told me that I needed an operation called a gas-bubble vitrectomy in which several large needles are inserted into the eyeball, the vitreous jelly is sucked out and the retina plastered back into place with an ice-cold cryo-probe.
The eyeball is then filled with nitrous oxide gas to keep the retina in place for the next few weeks.

  ‘You can have the operation under local or general anaesthetic,’ the surgeon told me, in a slightly hesitant voice. It was clear that he did not find the idea of operating on me under local anaesthetic appealing and neither did I, though I felt a coward when I thought of how I subject many of my patients to brain surgery under local anaesthetic.

  ‘General anaesthetic please,’ I said to his evident relief and then his anaesthetist, who must have been waiting outside with his ear to the door, bounced into the room like a jack-in-the-box and quickly checked my fitness for an anaesthetic. Half an hour later, dressed in one of those absurd gowns that for some obscure reason fasten at the back, rather than at the front, usually leaving one’s buttocks exposed, with paper knickers, white anti-embolism stockings and a pair of well-used slippers, I was being escorted to the operating theatres by one of the nurses. As I walked into the anaesthetic room I almost burst out laughing. I must have walked into operating theatres thousands of times, the all-important surgeon, in charge of his little kingdom, and here I now was as the patient, dressed in gown and paper knickers.

  I had always dreaded becoming a patient yet when, at the age of fifty-six, I eventually did I found it remarkably easy. This was, quite simply, because I realized how lucky I was compared to my own patients – what could be worse than having a brain tumour? What right did I have to complain when others must suffer so much more? Perhaps it was also because I was using my private health insurance and so avoided the loss of privacy and dignity to which most NHS patients are subjected. I could have a room to myself, with a carpet and with my own loo – details that are very important to patients but not to NHS administrators and architects. Nor, I am afraid to say, do many doctors care about these things, until they become patients and come to understand that patients in NHS hospitals rarely get peace, rest or quiet and never a good night’s sleep.

  I was anaesthetized and woke up a few hours later back in my room with a bandage over my eye, completely pain-free. I spent the evening drifting in and out of sleep, watching a fascinating light show in my blinded left eye, enhanced by morphine. It was as though I was flying over a pitch-black desert at night with brilliant fires burning in the distance. It reminded me of watching bush-fires at night when I had worked as a teacher in West Africa many years earlier – long walls of flame driven across the savannah grasslands by the harmattan wind off the Sahara, burning on the horizon beneath the stars.

  The surgeon came to see me very early next morning, on his way to his NHS hospital. He took me round to the treatment room and removed the bandage from my left eye. All I could see with it was a vague dark blur – a little like being underwater.

  ‘Bend forward and hold your watch close up to your left eye,’ he said. ‘Can you see anything?’

  The face of my watch, hugely magnified, like the moon rising over the sea at night, swam into view.

  ‘Yes,’ I told him.

  ‘Good,’ he said cheerfully. ‘You can still see.’

  I was effectively blind in my left eye for the next few weeks. The gas bubble in my eye was at first like the horizon of a great planet over which I could only see a thin glimpse of the outside world. It gradually shrank and vision slowly returned – the inside of my eye was like one of those gaudy lava lamps, the bubble slowly rolling and bouncing whenever I moved my head. I was unable to operate for a month but, rather reluctantly, started doing outpatient clinics a week after my own operation. I found it quite tiring. I wore a black patch over my eye which gave me a nicely piratical look although I felt a little embarrassed that my patients could see that I was not in perfect health. When I went to see the eye surgeon a few days after the operation, sporting my eye patch, he looked dubiously at me.

  ‘Drama queen,’ he said, but otherwise reported himself to be happy with the state of my eyeball.

  I had fully recovered within a matter of weeks but one of the consequences of a vitrectomy is that the lens in the eye becomes progressively damaged and needs to be replaced. This is a simple, straightforward operation, more commonly carried out for cataracts, which I underwent three months later. I was on call for emergencies for the weekend after that second, minor operation.

  If it had not been raining on the Sunday afternoon perhaps I would not have fallen down the staircase and broken my leg. Perhaps my eyesight was still out of true. After a busy Saturday night, Sunday morning was quiet. I had had to go in to operate at midnight since the on-call registrar was new and had needed help with a relatively simple operation on a middle-aged man with a cerebellar stroke. The operation had gone easily enough and I spent Sunday morning, feeling rather tired, working in my small, overgrown and ramshackle back garden.

  I had driven to the Wandsworth recycling dump with plastic bags full of garden refuse, and joined the queue of polished estate cars and SUVs waiting to take part in this Sunday morning ritual. Into the huge containers of the dump people were busy throwing rubbish – the future archaeology of our civilization – broken armchairs, sofas, washing machines, hi-fi equipment, cardboard boxes, beds and mattresses, last year’s lawnmowers, pushchairs, computers, televisions, bedside lamps, magazines, plasterboard fragments and rubble. There is a furtive, guilty air to these places – people avoid each other’s eyes, like men in a public toilet, and hurry to get back into the privacy and luxury of their shiny cars and drive away. Whenever I go to the dump I always leave with a great sense of relief, and on this occasion decided to reward myself with a visit to the local garden centre on the way home. It was while I was walking happily between the rows of plants and shrubs, looking for something to buy, that it started to rain. A low ragged rain cloud, looking like ink spreading in clear water, raced overhead and the rain poured down, driving the shoppers indoors and leaving the garden centre suddenly deserted. I found myself standing alone among the green plants and shrubs. My mobile phone rang. It was Rob, the on-call registrar from the hospital.

  ‘I’m very sorry to disturb you,’ he said, going through the usual polite litany my juniors always recite whenever they call me, ‘but could I discuss a case with you please?’

  ‘Yes, yes, of course,’ I said, hurrying off to find shelter in a warehouse full of terracotta pots.

  ‘This is a thirty-four-year-old man who fell from a bridge . . .’

  ‘A jumper?’

  ‘Yes. Apparently he’d been depressed for some time.’

  I asked if he had landed on his head or on his feet. If they hit the ground feet first they fracture their feet and spines and end up paralysed and if they hit their head first they usually die.

  ‘He landed on his feet but he hit his head as well,’ came the reply. ‘He’s a polytrauma case – he’s got a fractured pelvis, bilateral tib and fibs and a severe head injury.’

  ‘What does the scan show?’

  ‘A large haemorrhagic contusion in the left temporal lobe and the basal cisterns are gone. He’s had a big, fixed pupil on the left for five hours now.’

  ‘And his motor response?’

  ‘None, according to the ambulance men.’

  ‘Well, what do you want to do?’

  Rob hesitated, reluctant to commit himself.

  ‘Well, I suppose we could pressure monitor him.’

  ‘What do you think is his prognosis?’

  ‘Not very good.’

  I told Rob that it would be better to let him die. He would probably die whatever we did, and even if he did survive he’d be left terribly disabled. I asked him if he had seen the family.

  ‘No, but they’re coming in,’ he replied.

  ‘Well, spell it out to them,’ I said.

  While we were speaking, the rain had stopped and the sun had come out from behind the broken clouds. The plants around me glittered with reflected light. The shoppers emerged from the shelter of the
shop and the pastoral scene of the garden centre resumed – happy gardeners walked between the rows of plants and trees, stopping to examine them, and wondering which to buy. I bought myself a Viburnum paniculata with little starbursts of white flowers and drove home with it perched in a friendly sort of way on the passenger seat beside me.

  I could have operated on this poor suicidal man and possibly saved his life, but at what cost? Or so I told myself as I started to dig a hole in the back garden for the viburnum. Eventually I felt forced to go in to the hospital to look at the scan myself and to see the patient – despite my best efforts I found it difficult to deliver a death sentence, even on a jumper, on the basis of hearsay evidence alone.

  My shoes had become soaking wet in the downpour and I changed them for a new pair, recently re-soled, before driving in to the hospital.

  I met Rob in the dark X-ray viewing room. He summoned up a brain scan on the computer screens.

  ‘Well,’ I said as I looked at the CT scans, ‘he’s wrecked.’ It was a relief that the scan looked even worse than Rob’s description of it over the phone. The left side of the man’s brain was smashed beyond repair, his brain darkened on the scan by oedema and flecked with white, the colour of blood on CT brain scans. His brain was so swollen that there was no hope of survival, even in a disabled state, even if we operated.

  ‘There are two great benefits to medicine as a career,’ I said to Rob. ‘One is that one acquires an endless fund of anecdotes, some funny, many terrible.’

  I told him about a jumper I had treated years ago, a pretty young woman in her twenties who jumped under a tube train. ‘She had to have a hindquarter amputation of one leg – the leg removed completely at the level of the pelvis – I suppose the train had run lengthwise over her hip and leg. She’d also suffered a compound depressed skull fracture which was why she was sent over to us after the local hospital had done the amputation. We sorted her head out and she slowly woke up over the next few days. I remember telling her she’d lost her leg and she said “Oh dear. It doesn’t sound very nice, does it?” But she was quite happy at first, obviously couldn’t remember all the unhappiness that had made her throw herself under the train. But as she recovered from her head injury, as she got better, so to speak, she got worse since her memory started to return and every day you could see her become more and more depressed and desperate. When her parents eventually turned up you could see why she had tried to kill herself. It was very sad to watch.’