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  ‘It might bleed a bit,’ I said to Heidi, ‘and the brainstem might be a problem.’ Sudden and alarming changes in the patient’s heart rate and blood pressure, even cardiac arrest, can occur if you get into trouble with the lower part of the brainstem, known as the medulla oblongata.

  ‘Not to worry,’ said Heidi. ‘We’re prepared. Big IV and plenty of blood cross-matched, ready in the fridge.’

  Peter was wheeled into the operating theatre and, having assembled the theatre staff, we rolled him off the trolley face-down onto the operating table with Samih holding his head.

  ‘Prone, neutral position, head well flexed,’ I told him. ‘Get him in the pins. Midline incision with the craniectomy more to the left and take out the back of CI. Give me a shout when you’ve done that and you’re down to the dura and I’ll come and join you.’

  I left the operating theatre and went round to the surgeons’ sitting room for the regular Monday morning meeting with my consultant colleagues. The meeting had already started, with our two line managers in attendance – both of whom, I might add, I liked and got on well with. The meetings were to discuss the day-to-day business of the neurosurgical department and the managers would sometimes tell us about the department’s ‘financial position’. Much of the meeting was spent letting off steam about all the petty frustrations and inefficiencies of working in a large hospital. There was a sky-blue cushion in the shape of a brain that had been given to me by the sister of one of my American trainees and sometimes we would throw it around the room as we talked, rather like holding the conch shell in Golding’s Lord of the Flies. Sean, the senior of the two managers, was talking. He declined to hold the cushion when I threw it at him.

  ‘I’m afraid that this last year we made only one million pounds’ profit for the Trust whereas the year before we made four million, even though we did not do any more work. We used to be one of the most profitable departments in the Trust but that is no longer the case.’

  ‘But where on earth did the three million go?’ somebody asked.

  ‘It’s not very clear,’ Sean replied. ‘We spent a lot on agency nurses. And you’re spending a lot more on putting metalwork into people’s spines and you’re doing too many emergencies – we get only thirty per cent payment if you exceed the target for emergency work.’

  ‘It’s so bloody ridiculous,’ I snorted. ‘What would the public say if they knew we got penalized for saving too many lives?’

  ‘You know the reason,’ Sean said. ‘It’s to stop hospitals making cases into emergencies when they’re not emergencies and over-claiming.’

  ‘Well, we never did that,’ I replied.

  I should explain that ‘profit’ in an NHS department is not profit in the usual sense – instead it is whether we have exceeded our ‘financial target’ or not, which is based on previous performance and is an arcane process that I find entirely incomprehensible. Any ‘profit’ that we make goes to prop up less profitable parts of the Trust, so, despite the introduction into the NHS of the incentives and penalties so loved by economists, there is little real motive at a clinical level, on the shop floor, to work more efficiently. Besides, whenever there does seem to be any extra money, it all appears to be spent on employing more and more members of staff, as though to encourage the existing members of staff to do less work.

  The conversation meandered on for a while, discussing the problem of spinal implants. There is no easy answer to this question. As intracranial neurosurgery has declined, replaced by non-surgical methods such as the radiological treatment of aneurysms and highly focused radiation for tumours, neurosurgeons (and there are ever-increasing numbers of them, all keen to operate) have moved into spinal surgery. This is largely about inserting all manner of very expensive titanium nuts and bolts and bars into people’s backs, for cancer or for backache, although the evidence base and justification for such surgery, at least for back pain, are very weak. Even with the cancer patients – metastatic cancer often spreads to the spine – it can be a moot point as to whether to operate or not as the poor patient is going to die anyway, sooner or later, from the underlying cancer. Spinal implant surgery is major surgery and is a six-billion-dollar-a-year business in the US. It is a prime example of the ‘over-treatment’ that is a growing problem in modern health care, and especially in commercial, marketized health-care systems such as in America.

  I stopped doing such surgery myself some years ago in order to concentrate on brain surgery, so I was happy to abandon the conversation when I was summoned back to the operating theatre, where Samih had started the operation.

  ‘Let’s have a look,’ I said, and I leant forward, taking care not to touch the sterile drapes, to peer into the large hole in the back of Peter’s head. ‘Very good,’ I commented. ‘Open the dura and I’ll go and put some gloves on. Jinja,’ I said to the circulating nurse (the nurse who is not scrubbed up and does the fetching and carrying while the operation proceeds), ‘can you get the scope in please?’

  While Jinja shoved the heavy scope up to the operating table I scrubbed up at the large sink in the corner of the room – a soothing and deeply familiar act, although always accompanied by a feeling of tension in the pit of my stomach. I must have done this many thousands of times over the years and yet now I knew that it was soon to end – at least in my home country.

  Jinja came and tied up the laces at the back of my blue gown and I marched up to the table where Peter lay hidden under the sterile blue drapes, with only the gaping and bloody hole in the back of his head to be seen, brilliantly lit by the operating lights. Samih opened the dura – the leathery, outer layer of the meninges – with a small pair of scissors while I watched. I then took over. I sat down on the operating chair with its arm rests. The first rule of microscopic surgery, I tell my trainees, is to be comfortable, and I usually sit when operating, although in some departments this is not considered to be very manly, and the surgeons stand throughout the procedure, often for very many hours on end.

  It was easy enough to find the tumour – a bright-red ball shining in the microscope’s light – a few millimetres beneath the back part of the brain, the cerebellum. To the left would be the all-important brainstem, and to the right and deep down the lower cranial nerves, scarcely thicker than thread; but all this was hidden by the tumour. I would not be able to see them until the very end of the operation, when I had removed most of the tumour. As soon as I touched the tumour with the sucker, blood spurted up out of it.

  ‘Heidi,’ I said, ‘it’s going to bleed.’

  ‘No problem,’ came the encouraging reply, and I settled down to attack the tumour.

  ‘If the blood loss gets too much,’ I said to Samih, ‘your anaesthetist might ask you to stop and pack the wound, but then you worry you might damage the brain with the packing. If it looks as though the patient is going to bleed to death – to exsanguinate – sometimes you just have to operate as quickly as possible, get the tumour out before the patient dies and just hope you haven’t damaged anything. The bleeding usually stops once the tumour is all out.’

  ‘I saw you do a case like that when you came to Khartoum,’ Samih commented.

  ‘Ah yes. I’d forgotten that. He did OK though…’

  It took four hours of intense concentration to get the tumour out. Down the three-centimetre-wide hole in Peter’s head, all I could see was bright-red arterial blood, welling endlessly upwards. There was no way I could see the brain and no way I could delicately dissect the tumour off it. To my disappointment I did not enjoy the operation, which I think I would have done in the past. I should have arranged to do the operation jointly, I told myself, with a colleague. This greatly reduces the stress of operating, but I had not expected the tumour to bleed quite so much, and it is always difficult as a surgeon to ask for help, as bravery and self-reliance are seen as such an important part of the job. I would hate my colleagues to think that I was getting old and losing my nerve.

  ‘Look, Samih,’ I said, ‘the dam
n thing did separate away.’ With the tumour finally removed and the bleeding stopped, we could see the brainstem, and the lower cranial nerves and the vertebral artery all perfectly preserved. It made me think of the moon, appearing from behind clouds and transforming the night. It was a good sight.

  ‘We were lucky,’ I said.

  ‘No, no,’ said Samih, obeying the first rule for all surgical trainees, flattering me. ‘That was fantastic.’

  ‘Well, it didn’t feel it,’ I replied, and then shouted across to the far end of the table, ‘Heidi, what was the blood loss?’

  ‘Only a litre,’ she said happily ‘No need to transfuse him. His haemoglobin is still one hundred and twenty.’

  ‘Really? It felt like a lot more,’ I said, thinking that maybe I had been unnecessarily nervous during the operation. I consoled myself with the thought that perhaps all the years of experience counted for something after all. But Peter was going to be all right and that was all that mattered, and his young children would be happy that I had cured their Daddy’s headaches.

  ‘Come on, Samih,’ I said, ‘let’s close.’

  Peter awoke well from the operation. His voice was hoarse but I checked that he could cough, so I was not worried that he was at risk of aspiration.

  I went back to the hospital late in the evening to see the post-op cases. I went in most evenings: I live nearby so it was easy for me and I knew that my patients liked seeing me on the evenings both before and after their surgery. It was also a private protest against the way in which doctors now are expected to work shifts with fixed hours, and medicine is no longer perceived as a vocation, a true profession. Many doctors now seem to have the same expectation.

  I walked onto the ITU and found Peter among the two long lines of beds on either side of the warehouse-like room, each with its own nurse at the foot end, and a little forest of high-tech monitoring equipment at the head end.

  ‘How is he?’ I asked the nurse.

  ‘He’s OK,’ came the reply. There are so many ITU nurses that I know only a few of them and I did not recognize this one. ‘We had to put a nasogastric down in case he aspirated…’

  To my surprise, when I looked at Peter, who was sitting upright in his bed, wide awake, I saw that somebody had indeed put a nasogastric tube up his nose and then taped it to his face. I was angry that he had been subjected to the unpleasant procedure of having the tube inserted; it should not have been done, as he did not need it. The tube is pushed up the nose and then down the back of the throat into the stomach – a very unpleasant experience, I am reliably informed by my wife Kate, who has personal experience of it. Nor is it an entirely harmless procedure, and cases have been recorded of the end of the tube getting into the lungs and causing aspiration pneumonia and death, or even getting into the brain. These are, admittedly, rare complications, but after such a difficult but successful operation I was furious that it had been done. The decision to insert it had been made by one of the ITU doctors, clearly less experienced than I was, and the doctor on duty on the ITU for the night denied all knowledge of it. There seemed little point in blaming the nurse. I asked Peter how he felt.

  ‘Better than I expected,’ he said in a slightly hoarse voice, and then proceeded to thank me again and again for the operation. I bid him goodnight and told him that we’d remove the wretched nasogastric tube in the morning.

  I went into work next morning, and immediately went with Samih to the ITU. There was a different nurse at the end of Peter’s bed whom, once again, I did not recognize. Peter was awake and told me that he’d managed to sleep a little – quite an achievement in all the inhuman noise and bright lights of the ITU. I turned to the nurse.

  ‘I know you didn’t insert the nasogastric tube, but please take it out,’ I said.

  ‘I’m sorry, Mr Marsh, but he will have to be checked by SALT.’

  SALT are the speech and language therapists who some years ago started to assume responsibility for patients with swallowing problems as well as speech difficulties. I had had several disagreements with speech therapists in the past when they had refused to sanction removal of nasogastric tubes which in my opinion the patients did not need. As a result several patients had been kept in hospital being unnecessarily tube-fed, despite my protests. I was not the speech therapists’ favourite neurosurgeon.

  ‘Take the tube out,’ I said, between gritted teeth. ‘It should never have been inserted in the first place.’

  ‘I’m sorry Mr Marsh,’ the nurse replied politely, ‘but I won’t.’

  I was seized by a furious wave of anger.

  ‘He doesn’t need the tube!’ I shouted. ‘I will take responsibility. It is perfectly safe. I did the operation – the brainstem and cranial nerves were perfectly intact at the end, he’s got a good cough… take the bloody tube out.’

  ‘I’m sorry Mr Marsh,’ the hapless nurse began again. Overcome with rage and almost completely out of control, I pushed my face in front of his, took his nose between my thumb and index finger and tweaked it angrily.

  ‘I hate your guts,’ I shouted, turning away, impotent, furious and defeated, to wash my hands at the nearest sink. We are supposed to clean our hands after touching patients, so I suppose the same applies to assaulting members of staff. Years of frustration and dismay at my steady loss of authority, at the erosion of trust and the sad decline of the medical profession, had suddenly exploded – I suppose because I knew I was to retire in two weeks’ time and suddenly could no longer restrain my rage and feeling of intense humiliation. I stormed off the ward followed by Samih, leaving a little group of amazed nurses standing at the end of Peter’s bed. I do not often lose my temper at work and have certainly never laid a hand on a colleague before.

  I slowly calmed down and returned later in the day to the ITU to apologize to the nurse.

  ‘I’m very sorry,’ I said. ‘I shouldn’t have done that.’

  ‘Well, what’s done is done,’ he replied, though I did not know what he meant and wondered whether he would be making an official complaint – to which I felt he was fully entitled. Towards the end of the day I received an email from the matron for the ITU saying that she had learnt that there had been an ‘incident’ on the ITU and asking me to come and talk to her the next day.

  I went home in a state of craven and abject panic, the like of which I had scarcely ever known before. It took me a long time to calm down – I was so pathetically frightened by the prospect of some kind of official disciplinary action being launched against me. Where’s the brave surgeon now? I asked myself as I lay on my bed, shaking with fear and anger. It’s time to go, it really is.

  Next morning I duly reported to the ITU matron – a colleague I knew well and had been working with for many years. It brought back memories of being summoned to the headmaster’s office at school for some misdemeanour in the past, and of my intense anxiety as I waited outside the door. Sarah, the ITU matron, and I had been together at the old hospital which had been closed twelve years earlier. It had become something of an anomaly: a single-specialty hospital, with a staff of about 180, dealing only with neurosurgery and neurology in a garden suburb surrounded by trees and gardens. There were some good clinical reasons for integrating us into the major hospital where we now work, with a staff of many thousands; and the site of the old hospital, Atkinson Morley’s in Wimbledon (AMH), was of course far too beautiful to be a mere hospital. It was sold for commercial development and the hospital turned into apartments that now cost millions of pounds.

  But we lost a lot as well – above all the friendly working relationships that can come when you work in a small organization where everybody knows each other on a personal level and work together on the basis of personal obligation and friendship. The efficiency of the hospital was a perfect illustration of Dunbar’s number – that magic number of 150. The size of our brain, Robin Dunbar, an eminent evolutionary anthropologist at Oxford University, has argued (and the brain size of other primates), is determined by the si
ze of our ‘natural’ social group, when humans and their brains evolved in small hunting and gathering groups. We have the largest brains among primates, and the largest social group. We can relate to about 150 people on an informal, personal basis, but beyond that leadership, impersonal rules and job descriptions become necessary.

  So Sarah knew me quite well. Some of the comradely atmosphere of the old hospital had been preserved, despite the best efforts of the management to merge our department into the anonymous collective of the huge hospital where we now worked. I think anybody else in the nursing hierarchy of the hospital would have initiated some kind of formal disciplinary procedure against me.

  ‘I’m ashamed of myself,’ I told her. ‘I suppose it happened partly because I know I’m leaving…’

  ‘Well, he wasn’t to know that SALT for you is like a red rag to a bull. He doesn’t want to make a formal complaint but he said you were very frightening and it brought back memories of an assault he suffered some months ago.’

  I hung my head in shame and remembered how my first wife had told me how terrifying I could look, as our marriage fell apart with furious arguments.

  ‘He handled me very well and kept admirably calm,’ I said. ‘Please thank him when you next see him. It won’t happen again,’ I added with a slight smile. Sarah knew well enough that I was about to retire. I left her office and went round to the men’s ward where Peter had been sent the previous evening. At least the senior nurse there had been happy to remove the wretched nasogastric tube at my request and it was nice to find Peter drinking a cup of tea without any problems, although he certainly had a very hoarse voice.