by Henry Marsh
I went to find a sympathetic staff nurse.
‘I’ve just told poor Mr Mayhew he’s going to die,’ I told her apologetically. ‘He’s dying for a cigarette. Can you help?’
She nodded quietly.
When I later left the ward, as I walked down the corridor, I saw two of the nurses lifting him into a wheelchair. He was shouting as they manhandled him off his bed.
‘He’s just told me I’m going to die! I’m going to die . . . I don’t want to die.’
There must be some secret place in the hospital where they can wheel the paralysed patients for a smoke. I was happy to know that common sense and kindness had not yet been completely beaten out of the nurses.
Three years ago I built a roof extension in the attic of my house. I installed sloping skylights with French windows opening out onto a small enclosed balcony, cut into the roof-space at the back of the house, and around this I built a short balustrade. There is room for a single chair and a few pot plants and I like to sit there in the summer evenings when I get home from work. So I sat there after returning from the hospital, with a gin and tonic, with a typical south London vista of chimney pots and slate roofs and a few tree tops, stretching away from me into the distance. I could see the garden birds flitting in the fading light between the trees of the back gardens below me, and my three bee-hives in front of my workshop. I thought of my patients. I thought of my colleague, and of the man to whom I had just read out a death sentence. I thought of how he had immediately understood that he would never get home, that his estranged family would never visit him, that he would die in the care of strangers in some impersonal place. I thought of how I had walked away – but what else could I have done? As the sun set I could hear a blackbird on the neighbouring roof singing its heart out.
The three operations, which I carried out next day, were simple and straightforward. It turned out that the woman with a meningioma had been on one of the other wards on the Sunday evening after all.
A few days later, after I had operated on the alcoholic Mr Mayhew, and after he had been discharged from my ward, I saw him in the distance as I was coming into the hospital. A nurse was pushing him in a wheelchair towards the hospital coffee shop. He waved his good arm to me and it was difficult to know if it was in greeting or in farewell. I did not see him again.
25
ANAESTHESIA DOLOROSA
n. severe spontaneous pain occurring in an anesthetic area.
It was the summer when I had broken my leg falling down the stairs. There had been a heatwave which had come to an end with a brief thunderstorm early in the morning. I lay happily in bed listening to the thunder rolling and crashing over the silent city. My plaster cast had been removed the day before and replaced by a large plastic and Velcro inflatable boot that looked as though it belonged to an Imperial Trooper from Star Wars. It was very clumsy, but at least I could walk again and take it off at night. It was strange to be reunited with my leg and to see it again after six weeks’ absence, encased as it had been in a fibreglass cast. I stroked my leg and rubbed it as I lay in bed listening to the rain pouring down and tried to make friends with it again. It was stiff, purple and swollen, scarcely recognizable and felt oddly detached from me. Recent neuroscientific research has shown that even within a few days of a limb being lost or immobilized the brain starts to re-wire itself, with other areas of the brain taking over the redundant area for the lost or immobilized limb. My slight feeling of estrangement from my leg was almost certainly an aspect of this phenomenon – the phenomenon of ‘neuroplasticity’, whereby the brain is constantly changing itself.
After a month off, I could now start cycling to work again, proudly displaying my Star Trooper boot to the passing traffic. This first day back at work was a Thursday, my outpatient day, so after the morning meeting I would be in the outpatient clinic.
Once again, the SHOs at the morning meeting were new and I did not recognize any of them. One of them presented the first case.
‘There was only one admission last night,’ he said, looking at the X-ray screen. ‘Not very interesting,’ he added. He was sprawled back in his chair, his back turned to us, trying to appear cool but looking instead like an awkward teenager.
‘Don’t ever say that!’ I said. ‘Who are you, by the way? And what do you want to be when you grow up?’ – a standard question I ask all the new doctors.
‘Orthopaedic surgeon,’ he told me.
‘Sit up straight and look us in the eye when you talk,’ I said. I told him that the progress of his medical career was going to depend largely on how well he presented himself and his cases at meetings like this one.
I turned to the registrars, and asked if they agreed and they laughed in polite agreement. I told the chastened SHO to tell us about the patient admitted during the night.
He turned a little sheepishly to face us.
‘This is a seventy-two-year-old woman who collapsed at home.’ As he spoke he fiddled with the keyboard in front of him and a brain scan started to appear on the wall.
‘Hang on!’ I said. ‘Let’s have a little more history before we look at the scan. Do we know her previous medical history, was she fit and independent for her age? In what way did she collapse?’
‘Apparently she lived on her own and was self-caring and self-ambulating.’
‘Self-catering as well?’ I asked. ‘And self-cleaning like an oven? Does she wipe her own bottom? Come on, speak English, don’t talk like a manager. Are you trying to tell us that she looks after herself and can walk unaided?’
‘Yes,’ he replied.
‘So what happened?’
‘Her daughter found her on the floor when she went to visit her. It’s not clear how long she had been there.’
‘So what’s the differential diagnosis for collapse in the elderly?’
The new SHO reeled off a long list of causes and conditions.
‘And where was she on the Glasgow Coma Scale?’
‘Five.’
‘Don’t use numbers! They’re meaningless. What was she actually doing?’
‘No eye opening to pain, no sounds and flexing.’
‘That’s better,’ I said approvingly. ‘I can actually see what she was like. Did she have a neurological deficit when you saw her last night on admission?’
He looked embarrassed.
‘I didn’t look.’
‘How did you know her coma scale then?’ I asked.
‘It was what the doctors at the local hospital said . . .’ His voice trailed off in embarrassment.
‘You should have examined her yourself. But,’ I added, feeling the need to wield a carrot after the stick, ‘you’re here to learn.’
I turned to the registrars who were enjoying the ritual of teaching by teasing of the new SHO.
‘Who was on last night?’
David, one of the registrars nearing the end of his six years’ training, called out that he had been on call for emergencies.
‘She had a right hemiplegia,’ he said. ‘Her neck was a bit stiff too.’
‘What are the other possible signs on examination if she’d had a subarachnoid haemorrhage?’
‘They can have subhyaloid haemorrhage in the eyes.’
‘Did she?’
‘I didn’t look. The ward ophthalmoscope was lost ages ago . . .’
The woman’s brain scan flashed up in front of us.
‘Bloody hell!’ I said as I looked at it. ‘Why on earth did you accept her? It’s a massive bleed into the dominant hemisphere, she’s seventy-two, she’s in coma – we’re never going to treat her, are we?’
‘Well, Mr Marsh,’ David replied a little apologetically, ‘the referring hospital said she was sixty-two. She’d been a university lecturer. Pretty smart, the daughter said.’
‘Well she’s not going to be smart any longer,�
� my colleague sitting next to me said.
‘Anyway,’ David said, ‘we had some empty beds and the bed managers were trying to put some non-neuro patients in them . . .’
I asked if there had been any other admissions.
‘The oncologists referred a woman with melanoma,’ Tim, one of the other registrars, said, walking to the front of the room to take over from the SHO. He put a brain scan up on the wall in front of us. The scan showed two large and ragged tumours in the brain which were clearly inoperable. Multiple brain tumours are almost always secondary tumours – known as metastases – from cancers that have started elsewhere, such as cancers of the breast or lung or, as in this case, of the skin. Their development signifies the beginning of the end, although in some cases treatment can prolong life by a year or so. ‘The referral letter says she drinks 140 units of alcohol a week,’ Tim told us. I saw one of the SHOs in the front row doing some rapid mental arithmetic.
‘That’s two bottles of vodka a day,’ she said in slight amazement.
‘She had a cerebral met removed at another hospital eighteen months ago,’ Tim said. ‘And radiotherapy afterwards. The oncologists want it biopsied.’
I asked him what he had told them.
‘I said they were inoperable and a biopsy was unnecessary. They are obviously melanoma mets. They might as well make the diagnosis post mortem.’
‘I love your positive attitude,’ my colleague sitting next to me said. ‘So what’s the message back to the oncologists?’
‘Keep on drinking!’ somebody shouted happily from the back of the room.
With no more cases to discuss we filed out of the viewing room to start the day’s work.
I stopped at my office to collect my dictation machine.
‘Don’t forget to remove your tie!’ Gail shouted at me through the door to her office.
The new chief executive for the Trust, the seventh since I had become a consultant, was especially keen on the twenty-two-page Trust Dress Code and my colleagues and I had recently been threatened with disciplinary action for wearing ties and wristwatches. There is no evidence that consultants wearing ties and wristwatches contributes to hospital infections, but the chief executive viewed the matter so seriously that he had taken to dressing as a nurse and following us on our ward rounds, refusing to talk to us and instead making copious notes. He did, however, wear his chief executive badge – I suppose just in case somebody asked him to empty a bedpan.
‘And your watch!’ Gail added with a laugh as I stomped off to see my outpatients.
The outpatients wait in a large and windowless room on the ground floor. There are many patients, sitting in obedient silence in rows as there are many clinics going on all at once in the new, centralized outpatient department. The place has all the charm of an unemployment benefits office although with the added detail of a magazine rack holding leaflets on how to live with Parkinson’s disease, prostatism, irritable bowel syndrome, myasthenia gravis, colostomy bags and other unpleasant conditions. There are two large abstract paintings, one purple, one lime green, which had been hung on the walls by the hospital arts officer, an enthusiastic woman in black leather trousers, on the occasion of a visit by one of the royals for the official opening of the new building a few years ago.
I made my way past the waiting patients who watched me as I walked to the consulting room. My first sight on entering the consultation room was a Babel-like tower of multi-coloured folders containing the patients’ notes – a pile rarely less than two feet high – a tower of sheets of paper, bursting out of dog-eared files, in which the recent relevant results have rarely been filed, and if they have been filed, have been filed in such a way that it is usually very difficult to find them. I can learn – usually in entirely random order – about my patient’s birth history, and perhaps their gynaecological, dermatological or cardiological conditions but rarely find information such as when I had operated on the patient, or the analysis of the tumour I removed. I have learnt that it is usually much quicker to ask the patient instead. The Trust has to devote ever-increasing numbers of staff and resources to the constant tracking, searching and transporting of medical notes. The greater part of the notes, I should explain, consist of nursing charts recording the patient’s passing of bodily fluids on previous admissions and are no longer of any interest or importance. There must be many tons of such notes being carried around NHS hospitals every day in a strange archival ritual which brings dung beetles to mind, devoted to the history of patients’ excretions.
My outpatient clinic is an odd combination of the trivial and the deadly serious. It is here that I see patients weeks or months after I have operated on them, new referrals or long term follow-ups. They are wearing their own clothes and I meet them as equals. They are not yet in-patients who have to submit to the depersonalizing rituals of being admitted to the hospital, to be tagged like captive birds or criminals and to be put into bed like children in hospital gowns. I refuse to have anybody else in the room – no students, no junior doctors or nurses – only the patients and their families. Many of the patients have slowly growing brain tumours, too deep in the brain to operate upon and yet not growing fast enough to justify the palliative cancer treatment of radiotherapy or chemotherapy. They come to see me once a year for a follow-up scan to see if their tumour has changed or not. I know that they will be sitting outside the consultation room, in the dark and dreary waiting area, sick with anxiety, waiting to hear my verdict. Sometimes I can reassure them that nothing has changed, sometimes the scan shows that the tumour has grown. They are being stalked by death and I am trying to hide, or at least disguise, the dark figure that is slowly approaching them. I have to choose my words very carefully.
Since neurosurgery deals with diseases of the spine as well as of the brain, part of any neurosurgical outpatient clinic is spent talking to patients with back problems, only a few of whom need surgery. With one patient with a brain tumour I will be trying to explain that his or her life is probably coming to an end, or that they require terrifying surgery to their brain, whereas with the next I will be telling them, struggling to appear sympathetic and uncritical, that their backache is perhaps not as terrible a problem as they feel it to be and that life can perhaps be worth living despite it. Some of the conversations I have in the clinic are joyful and some absurd and others can be heart-breaking. They are never boring.
Having looked at the pile of notes with a feeling of slight despair, I sat down and turned on the computer. I returned to the reception desk to look at the list of patients for the clinic and find out who had arrived. All I could see were several blank sheets of paper. I asked the receptionist for my clinic list. He looked a little embarrassed as he turned over one of the blank sheets of paper to reveal another sheet beneath with a list of the patients coming to see me.
‘Corporate outpatient management has said we must keep the patient’s names covered to preserve confidentiality,’ he said. ‘There’s some target for it. We’ve been told to do it.’
I called out the name of the first patient in a loud voice, looking round at the assembled patients waiting to see me. A young man and an elderly couple hurriedly got up from their chairs, anxious and deferential in the way we all are when we go to see doctors.
‘How’s that for confidentiality?’ I muttered to the hapless receptionist. ‘Maybe the patients should be identified only by numbers like in a VD clinic?’
I turned away from the reception desk.
‘I’m Henry Marsh,’ I said to the young man as he came up to me, becoming a kind and polite surgeon, instead of an impotent and angry victim of government targets. ‘Please follow me.’ We walked round to the office, his elderly parents following us.
He was a young policeman who had suffered an epileptic fit several weeks ago – suddenly, out of the blue, changing his life forever. He was taken to his local A&E department where a brain scan showed a tumour.
He had recovered from the fit, and as the tumour was a small one, he was sent home and a referral made to the regional neurosurgical centre. It took a while for the referral letter to be passed on to me so he had to wait two weeks before we finally met – two weeks waiting to hear, in effect, whether he would live or die since none of his local doctors would have known enough about brain tumours to be able interpret the scan with any confidence.
‘Do please sit down,’ I said, indicating the three chairs in front of my desk, with its tower of notes and slow computer.
I went over the history of the fit briefly with him and his family. As is usually the case with epilepsy it had been more frightening for his mother, who had witnessed the fit, than for the man himself.
‘I thought he was going to die,’ she said. ‘He stopped breathing and his face went blue though he was better by the time the ambulance came.’
‘I just remember waking up in the hospital. I then had the scan,’ the young policeman said. ‘I’ve been fearing the worst since then.’ His face was desperate with the hope that I could save him, and the fear that I might not.
‘Let’s look at the scan,’ I said. I had seen it two days earlier but I see so many scans every day that I have to have them immediately in front of me whenever I see a patient if I am not to make a mistake.
‘This may take a while,’ I added. ‘The scans are on the computer network of your local hospital and this is then linked over the net to our system . . .’ As I spoke I typed on the keyboard looking for the icon for his hospital’s X-ray network. I found it and summoned up a password box. I have lost count of the number of different passwords I now need to get my work done every day. I spent five minutes failing to get into the system. I was painfully aware of the anxious man and his family watching my every move, waiting to hear if I would be reading him his death sentence or not.
‘It was so much easier in the past,’ I sighed, pointing at the redundant light-screen in front of my desk. ‘Just thirty seconds to put an X-ray film up onto the X-ray screen. I’ve tried every bloody password I know.’ I could have added that the previous week I had had to send four of the twelve patients home from the clinic without having been able to see their scans, so that the appointments had been entirely wasted and the patients made even more anxious and unhappy.
