Everything That Makes Us Human

by Jay Jayamohan

  And they were terrible, because of course not all trauma cases are accidental. In fact, in my experience in adult neurosurgery, they were quite often not accidents at all.

  Ah yes, but that was in Glasgow, I thought, as I looked at the scan of my new patient’s battered brain. That was with stupid, drunken, blinkered men. This is a six-month-old baby. No one would do that intentionally.

  I glanced at the parents. Or would they?

  CHAPTER FIVE

  BATMAN AND ROBIN

  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 an
d 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.

  CHAPTER SIX

  THAT’S NOT FAT

  Eight months. It’s no age. No age to die. No age to be born. Not like this.

  Not even eight months old. This is eight months BC – Before Caesarean. Before Coming into this world. It’s tragic.

  The baby had popped up on my radar antenatally, after Mum complained of not feeling any kicks or movements or any of those other things that pregnant women can sense and enjoy. Her local hospital did a scan of the foetus. Often it turns out to be something that’s fixable. That’s what they were looking for. In this instance they found that Baby had a brain tumour.

  Breaking that news to the parents of a five-year-old is hard enough. But telling expectant parents that the unborn child they haven’t even met yet might have a terminal disease is crushing.

  ‘A tumour?’ Mum says, her face white in shock. Her husband clutches her hand. It won’t help either of them to learn that the condition is relatively rare. That there were just over 400 brain tumours in under-eighteen-year-olds in 2018 – in the UK. Maybe this was the only baby to be diagnosed at this stage in the whole country. It’s all irrelevant to them.

  Dad looks at his wife, his hand drifts to her tummy. He looks at me, then back to them. ‘Oh my God,’ he says, ‘our baby’s got cancer.’

  You can’t blame him. When people hear the word ‘tumour’ they automatically think of the ‘Big C’. It’s understandable, but not what the word means.

  A tumour is a lump. An area of tissue that has experienced accelerated growth. If the tumour is the sort that tends to stay in the same location and slowly gets bigger within the same place, and just pushes the brain out of the way, that tends to be what we call benign. As opposed to the tumours which can move around the bloodstream or the cerebrospinal fluid between the brain and the spinal cord. These tumours have the ability to detach a portion of themselves off, float off, reattach in various locations and start to grow there as well. Those are what we call cancer cells.

  There are lots and lots of different types of cells that work together to form the brain. It’s not all just nerve cells. These are very delicate and require an elaborate scaffolding of supporting – or glial – cells to give them the ability to make the connection with each other. There are supporting cells and insulating cells, cells that are there to supply energy and oxygen, and cells that the neurons themselves hang onto.

  The texture and the appearance of a tumour will very much depend on which cell type it comes from. Tumours in the nerve cells are actually relatively rare. The most common are tumours of the glial cells – they make the scaffolding for the nerves. These are cells which tend to replicate and grow over time, replacing each other. In most people it all goes to plan. Occasionally, the cells replicate but misread the recipe book, forget to add an ‘off switch’ and just keep growing into what becomes a tumour.

  With neonatal cases there’s an added layer of confusion. At that age cells are still in a state of flux, they’re literally growing right in front of you. What you have to ask yourself is: are you looking at rapidly growing cancer cells or just cells that are growing because they’re still supposed to be in utero? There’s much we still don’t understand.

  MRI scans revolutionized medical treatment. In the case of tumours, however, they can only do so much. You can’t tell a malignant tumour from a benign one just by looking. A tumour comprising 10 per cent of the brain can prove more toxic than one covering 20 per cent. Or, in this instance, 50 per cent. Whether they’re highly malignant or benign, there’s no way of knowing at first glance. Bottom line: they all look bad till you get inside.

  Still, there are always options.

  The later you leave a termination, the harsher it is for the carrier. You can dress it up however you like, but basically the medical team will often end the baby’s life, with the mother still needing to deliver the body. I can’t think of a much more traumatic scenario than a mother having to give birth to a child whose medical condition was so serious, she agreed to terminate their life. There’s no hearing the first cry, there’s no first feed. It’s unimaginably distressing. But sometimes it’s the way that parents choose to go.

  This baby was just past eight months of development when her condition was flagged. Way past the ‘normal’ dates when mothers decide to have an abortion. But these conditions were anything but normal. In situations where birth can be injurious to the health of the mother, or a baby is really
sick, then termination remains an option throughout pregnancy.

  But the mother needs to decide. Although fathers are often involved in such a momentous decision, legally it is only the mother who can make the final call either way.

  Baby’s mum hears the evidence, takes in the severity of her unborn child’s condition, understands the real likelihood of her baby dying, if not in childbirth then shortly after. She hears it all and, after discussion with her husband, decides to press ahead with the pregnancy anyway.

  I’m there at the birth, a month after the dreadful news had been broken. The mother had to go through that four weeks in constant stress and anxiety – every time she couldn’t feel the baby move, she must have been so worried.

  Scans can only tell you so much. I need to see with my own eyes what I will be dealing with later. Will I have to operate tonight or do I have a couple of weeks to prep the case properly and study the baby?

  We recommended a birth by Caesarean section as we weren’t really sure how Baby’s head would cope with the pressure of standard delivery. Her tumour accounted for a significant part of the brain mass and there were too many variables to risk.

  The birth goes well and Baby emerges breathing and functioning as you would hope. No way had that been a given. Such a large tumour could easily have pressed hard enough on the brain to block vital passageways. On top of that, the pressure outside the womb is different to inside. There was no telling how she was going to react physically, but not only is she functioning, she is thriving. Watching Mum hold her, you would have no idea there was a problem.

  But we both knew there was. From my point of view, I could see I had time to fully explore what had to be done. To get blood cross-matched for a transfusion, to do MRI scans, to really get a sense of what we were dealing with.

  If things hadn’t gone to plan, we weren’t exactly on DEFCON 1 but we were prepared. We would have had theatre ready within the day. We could have drained any fluid build-up inside the head, any number of things. It isn’t necessary. Even so, Baby is sent to SCBU – Special Care Baby Unit – while I request the MRI.