I’m looking at a patient absolutely riddled with tumours. He has a lymphoma that’s spread throughout his body. He’s knackered. This is the last roll of the dice. Quite why he has only just appeared on our radar I have no idea. It’s clearly been an ongoing problem, but one about to end imminently. I reckon he has no more than twenty-four hours left to live unaided, maybe a few weeks regardless of what we do. Someone would have to operate immediately to give him a fighting chance of having those precious extra days with his family. And that someone, rather unexpectedly, is me.
My boss doesn’t seem overly inclined to come in. The senior trainee is already wrists deep in his own surgery. It’s time for me to step up.
See one, do one, teach one. The words repeat through my mind. I’ve seen it, I can do it. It’s how it’s always been.
I look around and see the anaesthetist who I’ve worked with before. She looks calm. The scrub nurse has assisted around the operating table for more than twenty years. Just because I’m new, it doesn’t mean that there aren’t some serious experts in the room.
I’ve probably seen the operation five times and assisted on it twice. It’s fairly straightforward. I need to insert a tube into the man’s skull to drain away the excess fluid. The scans show it building up in the ventricles – the fluid spaces we all have in the middle of our brain. If I go in from the patient’s right near the front, there’s little there of import. All the major speech functions are in the left part of the brain. It’s the ‘least worst’ option, as we are often forced to choose. I’ve seen and read it many times as being the best entry point.
The patient is covered in green linen drapes. We used to use these for years – washed and reused ad nauseam. Increasing numbers of patches appearing over their lifespan, but only thrown away once they resembled some of my ‘battleship-grey’ underpants – you know the ones, with extra ‘comfort holes’ worn in them. Nowadays, it’s all disposable. It saves on washing and transport, but I am not sure about the eco-friendliness of all the paper being used. Not my choice any more.
Anyway, I digress. The man’s head is partially exposed. Cleaned. Waiting. Ready.
I look to the anaesthetist. ‘He’s all yours,’ she says. ‘We’re good our end.’
The scrub nurse hands me my scalpel. I make a horseshoe-shape incision around the entry point, then peel back the area of skin. It flaps down, revealing the bone I need to drill through. I look to the scrub nurse. She already has my drill in her hand. She anticipates my every move.
It’s crucial not to go too far – to plunge into the brain. Not if you don’t want to cause irreparable damage. I set the machine up as I’ve always seen it done. The power will cut off if I accidentally overstep the distance. It’s foolproof.
We’re set. We’re ready. Deep breath.
Anyone who’s ever drilled into a plasterboard wall will recognize that familiar lurch when the drill bit breaks through the board and into air. As slowly as I was going, it still came as a shock to suddenly meet no resistance. Except in this case I wasn’t drilling air. I’d entered the skull cavity. The drill now off, I opened the fibrous bag around the brain – the dura.
Next, Wendy (the scrub sister) hands me the ventricular drain – the tube I need to pass into the brain to get to the fluid in the middle. Think of it like putting a straw in a coconut to get to the milk inside. I check the markings on the side of the tube as I pass it in: 4 cm; another one to go. I have seen them inserted 5 cm deep before. Now we’re in the danger zone. I have to keep moving perfectly forwards. Any deviation could take us away from the fluid and into very sensitive territory. As I read this, it all seems a bit melodramatic. But that’s after many years in the job. That initial terror of looking around and realizing there is no cavalry coming – realizing, in fact, that you are the one wearing the fancy blue outfit, coming to save the day. It’s hard to forget.
I keep my eyes fixed on the tube’s depth markings. It takes less than a second to cover the remaining distance. I can’t afford a mistake. A man’s life depends on me. I have little experience and all the nerves in the world. It is not his fault that I am the one assigned to saving his life. But it is my privilege. I’m operating on a man’s brain. I have the opportunity to save a life, to make a difference. I’ve dreamed of this moment for so long.
We hit the 5-cm mark and I hear myself sigh with relief. There is a central wire that keeps the tube stiff while I pass it in. I remove it. Fluid starts to come out, and I am utterly relieved. We should see improvements pretty soon.
‘We just have to wait till he wakes up,’ the anaesthetist says.
I wash up, change out of my scrubs and can barely contain my delight as I leave. If I could have got away with a Fred Astaire-style ankle kick I’d have gone for it. I am buzzing. My first operation. My first test. My first shot at the big time.
Yes, my hands were shaking. All of me was. That wasn’t important. What mattered was that I didn’t falter during the op. I was Steady Eddie. Cool as a cucumber. Did everything textbook. I was buzzing, on top of the world. Not quite ‘God complex’ levels but, even if I did say so myself, I’d just tapped into a man’s brain – his very soul – and saved his life.
This is what I was born for.
Getting back into the normal swing of things was hard. Apparently, the world hadn’t moved on as much as I had.
‘Hey, I just performed my first operation.’
‘Yay, great – now pass me those suppositories and a sick bowl – this guy’s in for a double ender …’
About an hour afterwards, I popped down to the Intensive Care Unit (ICU) to check up on my guy. I was expecting to see my patient upright and chomping on grapes with his loved ones. As it turned out, the mood at the bedside was slightly more sombre. Understandably so.
‘When’s he going to wake up?’ the patient’s wife asked. ‘When can we take him home?’
What to say? I honestly thought he’d have come round already. ‘Well, obviously he’s had a serious operation. It went well, but everyone recovers at their own rate. Plus, of course, he was pretty sick from the cancer, so that may mean he will take longer to wake up. But the fluid is draining out, so that should have normalized the pressure in his brain.’
We did overnight on call in addition to the daytime work, so I seamlessly moved from the night emergency cover work into regular daytime stuff. I had a ton of dogsbody chores to plough through for the senior trainee – discharge summaries, referrals back to other hospitals and other low-level work. I dealt with it as best I could, but all the while my mind was in one place: that bed, that man, that operation. That footnote in history.
When my boss announced that he was conducting ward visits, I dumped everything to join in. He hadn’t been the one who had been on call and who I’d rung the night before, but I really wanted to show him my proud achievement. For ninety minutes we wandered around the various extremities of the hospital. Finally, we entered ICU. My patient. My reputation.
When the consultant looked at the man’s charts he recognized my name. But by then I wasn’t particularly paying attention. ‘Do you think he should be awake by now?’ I asked.
He checked the info. ‘Hmm, you would hope so, yes.’
He rattled off questions for the accompanying nurses and his entourage of trainees, and requested further information. He also asked for a new scan. We finished the rest of the round, and then went to look at the scan.
After what seemed like forever, with me standing there fit to burst, he pulled me aside – a generous action as it turned out. ‘I don’t think he’s going to wake up,’ he said matter-of-factly, but out of the family’s earshot.
‘That’s not possible,’ I spluttered. ‘I was the operating surgeon. I did everything right.’
‘And yet,’ the consultant explained, ‘your man is still never going to wake up.’
It was the shittiest moment of my life. I wanted to curl up in a bed alongside my patient and have my own life support switched off.
The patient’s scan told a terrible story. Yes, the fluid pressure had been treated, but this had then led to a rapid drop in the pressure of the fluid around the tumour-addled brain. Without that pressure (which was, you will remember, trying in its own evil way to kill the guy), the tumour’s blood vessels suddenly felt released and, indeed, released a load of blood into his brainstem – the centre of consciousness and just about everything that keeps you alive. It was a massive bleed. It wasn’t my fault and I had had to do the operation. But it didn’t stop me feeling incredibly guilty about the whole thing.
‘Well, you couldn’t have foreseen this, clearly. Seriously, it’s not your fault. And in any case,’ he added, still staring at the notes, ‘he only had days to live anyway. If anything you saved him from a world of suffering.’
I ran up to the neurosurgery floor to find my other boss, the one who had instructed me – and trusted me – to conduct the procedure. As I knocked on the office door I was already writing my speech of resignation. After all, I’d performed an operation which, by the looks of it, was going to shorten a man’s life. In other words, the exact opposite of Hippocrates’ ‘Do no harm’ ethos.
I ran through everything I’d done and the horrific outcome. When I finished, the consultant just paused and stroked his chin. ‘These things happen,’ he said.
‘Yes, but it was my fault.’
‘It WAS NOT your fault. You did everything right. He was lucky you were there to at least try to save him. His time was up, I’m afraid. Learn from it and move on.’
I was shocked at how forgiving everyone was being.
I left his office, stunned. Relieved, of course, that I hadn’t been dragged across the coals. Devastated that the man had died but also confused as to why my bosses didn’t seem to be angry. If we were working at a paper-clip factory and I’d mislaid a shipment, then okay, tell me to get over it. But we were surgeons. We were people trusted by the public to save their lives. Surely that should make a difference?
I thought back to my father’s case. I remembered how crap we’d all felt being bypassed by the surgeon. It’s like we were irrelevant to him. It really is a God complex, I thought. They really think they don’t need to answer to anyone.
With a nauseous gut, and a super supportive senior registrar, I went down to tell the family what had happened. That I had done the operation, but there had been ‘unforeseen complications’. It’s a peculiarly British method of understatement in the face of a complication that opened the door to death. They listened, thanked me for my honesty and for trying to help. His wife said that he was going to die without the operation and so at least we had given it a go. And that was it.
The shadow of that operation never went away. I didn’t want it to in case I forgot the lessons it had taught me. But life in Wimbledon was too full-on to have that much time to dwell on it. Several of the other consultants went out of their way, I felt, to keep me occupied. I was given handfuls of new cases to prep and consult upon. I really got into the nitty gritty of new patients’ requirements, and immersed myself in keeping them and their families up to date right up until the point of surgery.
If I’m honest, I felt like I was being kept busy a bit like a naughty child. Then I realized these other bosses were really just trying to show me that there was always another patient. That I had to be able to cope with these things. Neurosurgery isn’t an easy speciality. I needed to learn how to walk the tightrope of caring for my patients, while not becoming paralysed by every complication and knockback. There would be plenty – and some of them could be by my hand. I simply had to learn to accept this and move on, or my career would grind to a halt, with tumours incompletely removed for fear of the consequences and hydrocephalus untreated, plus many other conditions that carried risks dealt with overcautiously. There is a reason that the consent form is chock-full of the potential complications of even the most ‘straightforward’ brain-surgery operation.
Suck it up, Jayamohan – at least you aren’t the patient …
About three weeks after my first solo op, I was due to observe in theatre with a different consultant. The patient looked as though he had a type of tumour called a glioblastoma, something I’d seen a lot of. It was the most malignant type of brain tumour, and almost all of the patients died within nine months to a year, and that was with surgery and radiotherapy. I’d ‘worked this patient up’ – done all the preoperative tests and assessments – and talked to them and really got to know them on the ward, and I guess my boss du jour knew this. We were virtually ready to go when she said, ‘Look, you’ve done all the work, do you want to do this op with me? I’ll take you through it.’
‘Really? I’d love to.’
I never expected to work on a tumour so early in my career. They’re the big bad wolves of so much of our work. Being given a chance to operate on it was amazing. The fact I was being trusted to do anything after the last time seemed like a miracle. But this boss was incredible. She guided me every step of the way and the operation went like clockwork. The patient woke up and everything was still working for him.
‘Not bad at all,’ she said afterwards. ‘Now, would you like the honour of telling the family?’
‘It would be my genuine pleasure. Thank you.’
‘A few more dozen of those and maybe – just maybe – you’ll be ready to teach one.’
Too soon, boss, too soon …