The three underpinnings of any sort of diagnosis are: take a history, examine the patient, do some tests. Occasionally, the history and the investigation can completely fight against each other.
A baby was brought in one day with head trauma. A couple of trainees had passed on it as they preferred the tumours. I was next in line. The child was unwell, clearly. The problem I had wasn’t with the injury, but the parents. The story changed half-hourly.
‘She fell.’
‘This basket toppled on her.’
‘The dog pushed her over.’
‘She was hiding under a table and looked up too quickly.’
Some of the explanations you could rule out by age alone. Baby was eight months old. She can’t walk, so she’s not falling. Dog knocked her over? It would have had to pick her up first. The others were suspicious simply because of the many other stories. I was convinced something had happened that the family wasn’t telling us about.
These two people were allegedly with the child throughout and yet they couldn’t say what had happened. Even they had to see how bad that looked. But they didn’t.
Usually people come in saying, ‘Little Johnny’s been vomiting, gone off his feet, he’s wobbly, his arm is twitching’ – something that gives us an idea of where to start looking. We do the investigation, we find the abnormalities, we treat. Things progress in a fairly predictable manner. Throw in the extra variable of wondering whether people are telling the truth or not and everything becomes very unpredictable indeed.
At thirty-three, I was at the stage where I knew I was going to qualify as a paediatric neurosurgeon and I would be looking for a job within the year. You have a little bit of a swagger at this time. Perhaps some overconfidence about what you know. You’ve dedicated your whole life and a lot of money to get to where you are – and I don’t just mean Canada. It comes with the territory that you’re so certain about things.
And I was certain that this family was lying. Absolutely. Cast-iron guarantee. Interrogating them, however, wasn’t my job. Not my real job. My duty was to ascertain the nature of the injury and treat it as quickly and effectively as possible. I could report the parents to the social services once the child was safe.
The injury was, I thought at the time, a very classic trauma event. I couldn’t work out what else it could be. I operated, removing the swelling in the brain by drilling into the skull. Two hours in and out. As I stitched her up, I questioned the point of it all. Was I just patching the child up so she could be abused another day? Maybe. Maybe not.
One of my colleagues found me afterwards. ‘We’ve got the investigation results,’ she said, waving a batch of papers. ‘It turns out Baby has a bleeding disorder.’
‘Let me see that.’ I scanned through the notes and there in black and white was the bald fact that this child had a propensity to bleed with far less cause than was common for most people. So this could explain the condition, the bleeding within the skull causing brain dysfunction, but not the dodgy behaviour of the parents.
‘You know something’s really fishy about them, don’t you?’ I said.
‘Sure do.’
‘Why would they be like that if they’re innocent?’
She shrugged.
The whole episode made me pull up short. I’d been so confident of one scenario having played out, but in all likelihood there was an alternative explanation. I didn’t want to make the same mistake again. Jumping to conclusions helps nobody, least of all the patient.
I began reading as much around the subject as I could. A pathologist called Dr John Plunkett wrote an article in The British Medical Journal about child abuses. Plunkett is somebody who does not believe in shaken baby syndrome. He doesn’t accept that you can shake a baby to death without causing profound neck injury, and supplied page after page of reasoned argument and evidence. It was certainly food for thought.
I’d been educated to believe that facts were immutable. Medical school is full of facts – we learnt them and put them into practice. Easy-peasy it seemed to us, in our innocence (or naivety, depending on your view). Now, it seemed, they were only part of a puzzle. Context had to be considered as well. It wasn’t long, however, before I realized that even this could be manipulated.
I left Canada a few months later, never really knowing whether my patient’s flaky parents had something to hide or not. I was taking up a neurosurgical post at the John Radcliffe Hospital in Oxford. More importantly, at the age of thirty-four, I had finally achieved my goal of becoming a consultant.
But if Canada had taught me anything, it is that you never stop learning. I was a consultant, but a junior one. Ahead of me was my mentor and, very quickly, my friend Peter Richards. Peter was a great senior person to have around. He’d been there, done that, got the T-shirt, worn it out and bought another one. By coincidence he also was – is – one of the UK’s most experienced neurosurgeons, looking at cases of alleged child abuse in the legal field. When he learned I had a burgeoning interest in that side of things he said, ‘If you want to look at some of my cases, let me know.’
‘I’d like that.’
‘But I warn you: it’s not a world to enter lightly.’
I soon discovered what he meant. I was referred by Peter to offer advice in a case where a two-year-old had died of trauma to the head. There was video evidence of the mother’s boyfriend repeatedly hitting the child. He actually recorded himself. It took me several attempts to finish each clip. I’m a surgeon, I’m not squeamish and I’m certainly not afraid of blood. But I do what I do because I want to heal. To fix. Having to watch and listen to this criminal savagery was harrowing.
The jury certainly thought so. There was silence in the courtroom as the videos were played. You could hear a pin drop. The only sounds were the agonizing screams of the poor little mite – and the occasional gasp and retching noise as jurors’ stomachs turned.
Undoubtedly, the boyfriend was an animal. Clearly, he had subjected an innocent child to unimaginable pain for the entirety of its short life. But – the defence team wanted to know – was he responsible for the baby’s death? And that is where things got tricky.
There was overwhelming evidence to indicate that the man was a monster. A child abuser. A bully. There was no doubt he had caused injury upon injury. But, his barrister asked, ‘Can you, in your expert opinion, honestly say that you see a fatal blow being delivered?’
As much as I wanted to say yes, I had to be honest. ‘No.’
‘Can you say, definitively, that the defendant is the only person to have struck the child?’
Well, who else? I thought. But again the answer was, ‘No.’
‘Could it, possibly, have been the child’s mother who delivered the fatal blow? Or someone else?’
And then it became clear. The defence’s argument wasn’t that the boyfriend hadn’t abused the child – that was all caught on tape, there was no denying it. Rather it was that he couldn’t be proven to have murdered him. They were going for reasonable doubt.
However, it didn’t work. The defendant was found guilty of murder by a sickened jury. But I left the court with more questions than answers. For all my great leaps forward in Toronto, learning not to judge a book by its cover, I had to face a new realization: that even facts and accuracy and truth can be distorted if you squint hard enough.
Work on legal cases had to be squeezed in around clinical work. Before I joined, Peter’s department was just him. My arrival doubled the consultant staff and the workload. In the early days we’d do the ward rounds together, so he could get me up to speed. We were inseparable. Maybe a bit too inseparable.
‘You know what the nurses are calling us?’ he said, one day.
‘Nothing good, I imagine.’
‘Batman and Robin.’
‘That’s not so bad,’ I said. ‘But which one of us is Batman?’
He burst out laughing. ‘I don’t know, Robin. You tell me.’
The John Radcliffe Hospital’s very own Bruce Wayne was pretty old school in a lot of ways, but he didn’t have the ego that, in my experience, often went with it. Along with the ridiculous workload, he was happy to share the credit. More importantly, when stumped, he wouldn’t just go with our joint best guess for the sake of looking clever.
Case in point: I had a child with a difficult vascular malformation, a lesion on the brain. I say ‘I’ because Peter let me take every case that I wanted. He was in a position in his life where he didn’t need to take on any more cases to build up experience, so it worked really well. Of course, the fact that you’ve just become a consultant doesn’t mean suddenly you know everything. You’re the same chump that you were the day before, when you were the senior registrar. The first years (or even the first decade) as a consultant can then be spent building up a large list of cases. Doctors have a great ability to remember things, but now, as consultants, we can get rid of the ‘stupid’, rare diseases we had to learn about as students and would never see, and fill the memory banks with relevant, well-indexed experience – the stuff with which we could go into battle against the diseases and conditions encountered in whichever specialism we had chosen.
The type of vascular malformation in front of me now wasn’t anything I’d encountered before, so naturally I asked Peter. Not surprisingly, he had seen it and dealt with it before but, because it was so rare in kids, not for a very long time. ‘I can check my notes,’ he said.
‘What about if I ask my old bosses in Toronto?’ I asked. ‘I know one of them has got a particular interest in this area.’
The idea of asking an outside source – and a foreign one at that – for help would be enough to ruin some of the ‘old school’ people I’d trained with. But not Peter. ‘Splendid idea. Let me know what they say. Quite probably things have moved on since I last treated it anyway.’
I fired off an email to Toronto and thus began a series of transatlantic ping-pong as ideas flew back and forth between us. I told them my observations and my planned line of attack, and they, very gently, told me better alternatives. They never said: ‘Don’t do that, you idiot.’ It was more: ‘Have you considered …?’ or ‘Ever think about this approach?’
It was a really collegiate atmosphere, very respectful and, in the long term, exceptionally influential. It’s how I swore I would always try to treat anyone who ever had the misfortune in the future to work for me. It doesn’t always work because there are some people who are too uncaring or lazy to have become doctors in the first place – something that drives me bonkers as a teacher.
The long and short of it was that everyone in the loop agreed on one idea, so I took it to Peter.
‘That sounds like a great plan. Let’s do that,’ he confirmed.
We did and it worked. Even if it hadn’t, it was still the best way forward. Like I said, you never stop learning. You never stop wanting to improve. You never stop wanting to help.
Sometimes, though, that isn’t enough. In fact, sometimes those instincts can cause more problems than they solve. As I was about to find out.