Admissions

  ADMISSIONS

  A Life in Brain Surgery

  Henry Marsh

  To William, Sarah, Katharine and Iris

  ‘Neither the sun nor death can be looked at steadily’

  La Rochefoucauld

  ‘We should always, as near as we can, be booted and spurred, and ready to go…’

  Michel de Montaigne

  ‘Medicine is a science of uncertainty, and an art of probability…’

  Sir William Osler

  CONTENTS

  Title Page

  Dedication

  Preface

  1The Lock-Keeper’s Cottage

  2London

  3Nepal

  4America

  5Awake Craniotomy

  6The Mind–Brain Problem

  7An Elephant Ride

  8Lawyers

  9Making Things

  10Broken Windows

  11Memory

  12Ukraine

  13Sorry

  14The Red Squirrel

  15Neither the Sun Nor Death

  Acknowledgements

  By Henry Marsh

  Copyright

  PREFACE

  I like to joke that my most precious possession, which I prize above all my tools and books, and the pictures and antiques that I inherited from my family, is my suicide kit, which I keep hidden at home. It consists of a few drugs that I have managed to acquire over the years. But I don’t know whether the drugs would still work – they came with neither a ‘Use By’ nor a ‘Best Before’ date. It would be embarrassing to wake up in Intensive Care after a failed suicide attempt, or to find myself having my stomach pumped out in Accident and Emergency. Attempted suicides are often viewed by hospital staff with scorn and condescension – as failures in both living and dying, and as the agents of their own misfortune.

  There was a young woman, when I was a junior doctor and before I started training to be a brain surgeon, who was saved from a barbiturate overdose. She had been determined to die in the wake of an unhappy love affair, but had been found unconscious by a friend and taken to hospital, where she was admitted to the ITU – the Intensive Therapy Unit – and ventilated for twenty-four hours. She was then transferred to the ward where I was a houseman – the most junior grade of hospital doctor – when she started to wake up. I watched her regain consciousness, coming back to life, surprised and puzzled at first still to be alive, and then not quite sure whether she wanted to return to the land of the living or not. I remember sitting on the edge of her bed and talking with her. She was very thin, and was obviously anorexic. She had short, dark-red hair, which was matted and dishevelled after a day in a coma on a ventilator. She sat with her chin resting on the hospital blanket over her drawn-up knees. She was quite calm; perhaps this was still the effect of the overdose, or perhaps it was because she felt that here, in hospital, she was in limbo, between heaven and hell – that she had been given a brief reprieve from her unhappiness. We became friends of a kind for the two days that she was on the ward and before she was transferred to the care of the psychiatrists. It turned out that we had acquaintances in common from Oxford in the past, but I do not know what happened to her.

  I have to admit that I’m not at all sure that I would ever dare to use the drugs in my suicide kit when – and it may well happen quite soon – I am faced with the early signs of dementia, or if I develop some incurable illness such as one of the malignant brain tumours with which I am so familiar from my work as a brain surgeon. When you are feeling fit and well, it is relatively easy to entertain the fantasy of dying with dignity by taking your own life, as death is still remote. If I don’t die suddenly, from a stroke or a heart attack, or from being knocked off my bicycle, I cannot predict what I will feel when I know that my life is coming to an end – an end which might well be distressing and degrading. As a doctor, I cannot have any illusions. But it wouldn’t entirely surprise me if I started to cling desperately to what little life I had left. Apparently, in countries where so-called doctor-assisted suicide is legal many people, if they have a terminal illness, having initially expressed an interest in being able to die quickly, do not take up the option as the end approaches. Perhaps all that they wanted was the reassurance that if the end was to become particularly unpleasant, it could be brought to a quick conclusion and, in the event, their final days passed peacefully. But perhaps it was because, as death approached, they started to hope that they might yet still have a future. We develop what psychologists call ‘cognitive dissonance’, where we entertain entirely contradictory thoughts. Part of us knows, and accepts, that we are dying but another part of us feels and thinks that we still have a future. It is as though our brains are hardwired for hope, or at least that part of them is.

  As death approaches, our sense of self can start to disintegrate. Some psychologists and philosophers maintain that this sense of self, of being coherent individuals free to make choices, is little more than a title page to the great musical score of our subconscious, a score with many obscure, often dissonant voices. Much of what we think of as real is a form of illusion, a consoling fairy story created by our brains to make sense of the myriad stimuli from inside and outside us, and of the unconscious mechanics and impulses of our brains.

  Some even claim that consciousness itself is an illusion – that it is not ‘real’, that it is a trick played on us by our brains – but I do not understand what they mean by this. A good doctor will speak to both the dissonant selves of a dying patient – the part that knows that it is dying, and the part that hopes that it will yet live. A good doctor will neither lie nor deprive the patient of hope, even if the hope is only of life for a few more days. But it is not easy, and it takes time, with many long silences. Busy hospital wards – where most of us are still doomed to die – are not good places in which to have such conversations. As we lie dying, many of us will keep a little fragment of hope alive in a corner of our minds, and only near the very end do we finally turn our face to the wall and give up the ghost.

  1

  THE LOCK-KEEPER’S COTTAGE

  The cottage stands on its own by the canal, derelict and empty, the window frames rotten and hanging off their hinges and the garden a wilderness. The weeds were as high as my chest and hid, I was to discover, fifty years of accumulated rubbish. It faces the canal and the lock, and behind it is a lake, and beyond that a railway line. The property company that owned it must have paid somebody to clear out the inside of the cottage, and whoever had done the work had simply thrown everything over the old fence between the garden and the lake, so the lake side was littered with rubbish – a mattress, a disembowelled vacuum cleaner, a cooker, legless chairs and rusty tins and broken bottles. Beyond the junk, however, lay the lake, lined by reeds, with two white swans in the distance.

  I first saw the cottage on a Saturday morning. A friend had told me about it. She had seen that it was for sale and knew that I was looking for a place where I could establish a woodworking workshop in Oxford to help me cope with retirement. I parked my car beside the bypass and walked along the flyover, deafening cars and trucks rushing past me, to find a small opening in the hedge, almost invisible, at the side of the road. There was a long line of steps covered in leaves and beechmast, under a dark archway formed by the low, bending branches of beech trees, leading down to the canal. It was as though I was suddenly dropping out of the present and returning to the past. The roar of the traffic became abruptly muted as I descended to the quiet and still canal. The cottage was a few hundred yards away along the towpath, over an old, brick-built humpback canal bridge.

  There were several plum trees in the garden, one of them growing up through an obsolete and rusty old machine with reciprocating blades like a hedge-trimmer, for cutting heavy undergrowth. It had two
big wheels with Allens and Oxford stamped on the rims in large letters. My father had had exactly the same model of machine, which he used in the two-acre garden and orchard where I had grown up less than one mile away in the 1950s. He once accidentally ran over a little shrew in the grass of the orchard as I stood watching him, and I remember my distress at seeing its bleeding body and hearing its piercing screams as it died.

  The cottage looks out over the still and silent canal and the heavy black gates of the narrow lock. There is no road access – it can only be reached along the towpath on foot or by barge. There is a brick wall with drinking troughs for horses along one side of the garden, facing the canal – I found later the metal rings to which the horses which towed the barges along the canal would have been tethered. A long time ago the lock-keeper would have been responsible for the gates, but the lock-keepers’ cottages along the canal have all been sold off and the gates are now left to be operated by whoever is on the passing barges. I am told that a kingfisher lives here and can be seen flashing across the water, and that there are otters as well, even though only a few hundred yards away there is the roar of the bypass traffic crossing the canal on the high flyover on its concrete stilts. But if I turn away from the road, all I can see are fields and trees, and the reed-lined lake behind the house. I can imagine that I am in ancient, deep countryside, as it was when I was growing up nearby, before the bypass was built sixty years ago.

  The young woman from the estate agents was sitting on the grass bank in the sunshine beside the entrance to the cottage, waiting for me. She opened the bolted and padlocked front door. I stepped over a few letters on the floor inside, covered in muddy footprints. The estate agent saw me looking down at them and told me that an old man had lived here by himself for almost fifty years – the deeds for the property described him as a canal labourer. When he died the property developers, who had bought the house some years ago, put it up for sale. She did not know whether he had died here or in hospital or in a nursing home.

  The place smelt damp and neglected. The cracked and broken windows were covered by torn, dirty lace curtains and the window sills were black with dead flies. The rooms had been stripped out and had the sad and despondent air of all abandoned homes. Although there was water and electricity, the facilities were primitive, and there was only an outside toilet, smashed into pieces, with the door off its hinges. The dustbin by the front door contained plastic bags full of faeces.

  The ancient farmouse nearby where I had spent my childhood was said to have been haunted – at least, according to the Whites, the elderly couple who lived across the road and whom I liked to visit. An improbable tale of a sinister coach and horses in the yard at night and also of a ‘grey lady’ in the house itself. It was easy to imagine the old man’s ghost haunting the cottage.

  ‘I’ll take it,’ I said.

  The girl from the estate agents looked at me sceptically.

  ‘But don’t you want to get a survey?’

  ‘No, I do all my own building work and it looks OK to me,’ I replied confidently, but wondering whether I was still capable of the physical work that would be required and how I would manage without any road access. Perhaps I should stop being so ambitious and abandon my obsessive conviction that I must do everything myself. Perhaps it no longer mattered. I ought to employ a builder. Besides, although I wanted a workshop, I wasn’t sure that I wanted to live in this small and lonely cottage, with a possible ghost.

  ‘Well, you’d better make an offer to Peter, the manager in our local office,’ she replied.

  I drove back to London the next day – with the uneasy thought that perhaps this little cottage would be where I myself would eventually end my days and die, and where my story would end. Now that I am retiring, I am starting all over again, I thought, but now I am running out of time.

  I was back in the operating theatre on Monday – I was in my blue theatre scrubs, but expected to be only an observer. In three weeks’ time I was to retire – after almost forty years of medicine and neurosurgery. My successor, Tim, who had started off as a trainee in our department, had already been appointed. He is an exceptionally able and nice man, but not without that slightly fanatical determination and attention to detail that neurosurgery requires. I was more than happy to be replaced by him and it seemed appropriate to leave most of the operating to him, in preparation for the time when – and it would probably be something of a shock for him – he suddenly carried sole responsibility for what happened to the patients under his care.

  The first case was an eighteen-year-old woman who had been admitted for surgery the previous evening. She was five months pregnant but had started to suffer from severe headaches, and a scan showed a very large tumour – almost certainly benign – at the base of her brain. I had seen her as an emergency in my outpatient clinic a few days earlier; she came from Romania and her English was limited, but she smiled bravely as I tried to explain things to her via her husband, who spoke a little English. He told me that they came from Maramures, the area of northern Romania on the border with Ukraine. I had been there myself two years ago on a journey from Kiev to Bucharest with my Ukrainian colleague Igor. The landscape was exceptionally beautiful, with ancient wooden farms and monasteries – it seemed that the modern world had scarcely caught up with the place at all. There were haystacks in the fields and hay wagons drawn by horses on the roads, with the drivers wearing traditional peasant costumes. Igor was outraged that Romania had been allowed to join the European Union whereas Ukraine had been kept out. My Romanian colleague, who had come to collect us from the border with Ukraine, wore a tweed cloth cap and leather driving gloves, and drove us at high speed on the terrible roads in his son’s souped-up BMW all the way to Bucharest, almost without stopping. We did, however, spend a night on the way at Sighisoara, where the house still stood where Vlad the Impaler – the prototype for Dracula – had been born. It was now a fast-food joint.

  The operation on the woman was not an emergency in the sense that it did not need to be done at once, but it certainly had to be done within a matter of days. Such cases do not fit easily into the culture of targets which now defines how the National Health Service in England is supposed to function. She was not a routine case but nor was she an emergency.

  My own wife Kate, a few years ago, had fallen into the same trap when awaiting major surgery after many weeks of intensive care at a famous hospital. She had been admitted as an emergency and underwent emergency surgery without any difficulty, but then needed further surgery after several weeks of intravenous feeding. I became accustomed to the sight of a large foil-wrapped bag of glutinous fluid hanging above her bed, dripping into her central line – a catheter inserted into the great veins leading to her heart. Kate was now no longer an emergency but nor was she a routine admission, so there was no provision for her to undergo surgery. For five days in a row she was prepared for surgery – very major surgery, with all manner of frightening potential complications – and each day by midday the operation was cancelled. Eventually, in despair, I rang her surgeon’s secretary. ‘Well, it’s not really up to Prof as to who goes on the routine operating lists,’ she explained apologetically. ‘It’s a manager – the List Broker. Here’s the number to ring…’

  So I rang the number only to receive a message that the voice mailbox was full and I could not leave a message. At the end of the week the decision was made to make Kate into a routine case by sending her home with a large bottle of morphine. She was readmitted a week later, presumably now with the List Broker’s permission. The operation was a great success, but I mentioned the problem we had encountered to one of my neurosurgical colleagues at the same hospital when we met at a meeting shortly afterwards.

  ‘I find it very difficult being a medical relative,’ I said. ‘I don’t want people to think my wife should get better treatment just because I’m a surgeon myself, but it really was getting pretty unbearable. Having your operation cancelled is bad enough – but five days in
a row!’

  My colleague nodded. ‘And if we can’t look after our own, what about Joe Bloggs?’

  So I had gone to work on Monday morning worried that there would be the usual shambles of trying to find a bed for the young girl into which she could go after surgery. If her condition was life-threatening I would be able to start the operation without having to seek the permission of the many hospital staff involved in trying to allocate an insufficient number of beds to too many patients, but her condition was not life-threatening – at least not yet – and I knew that I was going to have a difficult start to the day.

  At the theatre reception area there was an animated group of doctors and nurses and managers looking at the day’s operating lists sellotaped to the top of the desk, discussing the impossibility of getting all the work done. I saw that several of the cases were routine spinal operations.

  ‘There are no ITU beds,’ the anaesthetist said with a grimace.

  ‘Well why not just send for the patient anyway?’ I asked. ‘A bed always turns up later.’ I always say this, and always get the same reply.

  ‘No,’ she said. ‘If there’s no ITU bed I will end up having to recover the patient in theatre after the op and it could take hours.’

  ‘I’ll try to go and sort it out after the morning meeting,’ I replied.

  There was the usual collection of disasters and tragedies at the morning meeting.

  ‘We admitted this eighty-two-year-old man with known prostate cancer yesterday. He had gone first to his local hospital because he was going off his legs and was in retention of urine. They wouldn’t admit him and sent him home,’ Fay, the on-call registrar, told us as she put up a scan. This was met with sardonic laughter in the darkened room.

  ‘No, no, it’s true,’ Fay said. ‘They catheterized him and wrote in the notes that he was now much better. I have seen the notes.’