Admissions

by Henry Marsh

  I showed his opinion to Dev.

  ‘Isn’t the internet wonderful!’ I said. ‘We can get a world-class opinion so quickly.’

  ‘We’d better get the child back and talk to the family,’ he replied, but the girl and her family had disappeared.

  While the patients come and go, the day outside grows dark. The high Himalayan foothills on the horizon disappear. The ragged leaves of the banana tree in the paddy field next to the hospital start to shake and flap in the wind. A flock of small birds is suddenly flung up into the sky like a handful of leaves, to be quickly swept from sight. The windows of the outpatient room are open – the room fills with the intoxicating smell of wet earth and the patients’ notes in front of me blow off the table. There are frequent power cuts and every so often the room plunges into darkness for a few minutes. Thunder crashes directly overhead, to echo away into the distance.

  ‘Patient is sixty-five-year-old man with numbness in his fingers.’

  The MRI scan shows slight compression of the sixth cervical nerve roots in his neck.

  ‘How much is he troubled by his symptoms?’

  ‘He has difficulty climbing trees and milking buffalo, sir.’

  We decide to continue with conservative treatment.

  ‘It is proxy case, sir. Father has brought scan. His two-month-old daughter is in other hospital. They have diagnosed bacterial encephalomeningitis. Child is fitting, and they grew enterobacter in the blood. They have recommended three weeks of IV antibiotics. He wants to know if the treatment is right.’

  The CT scan was of poor quality and I found it difficult to interpret, but it looked as though the child might have suffered extensive brain damage.

  ‘He wants to know if it is good idea to spend money treating the child.’

  ‘How many other children does he have?’

  ‘Three, sir.’ But then we worked out that two of them had already died.

  I looked at the scan for a long time, not knowing what to recommend.

  ‘I think I’d get an MRI scan,’ I eventually said. ‘If it shows severe brain damage, perhaps it is better to let the child die.’

  Jaman, the excellent MO, spoke to the father.

  ‘It is economic problem for the MRI scan,’ he told me.

  ‘Then it’s very difficult,’ I said.

  I left Jaman and the other MOs to have a long conversation with the father. I don’t know what was decided, but the father said ‘Namaste’ to me very politely as he left.

  ‘Patient is forty-year-old lady who has had headache for twenty years, sir.’

  My heart sinks a little.

  ‘Well, tell me more about the headache.’

  We discuss this for a few minutes. The patient has been on a long list of drugs over the years.

  ‘She suffers from panic attacks. She finds diazepam helps, sir.’

  I deliver a little lecture on the evils of diazepam and the way that millions of housewives became addicted to it in the past in Europe and America. It is very difficult to know what to suggest.

  ‘Do you know the word stigma?’

  ‘Yes, sir.’

  ‘Is there stigma in Nepal against seeing psychiatrists?’

  ‘Yes, there is, sir.’

  ‘I think you should suggest she sees a psychiatrist. I find it helps if I tell patients that I had psychiatric treatment myself once. It was invaluable.’

  There was a rapid exchange in Nepali.

  ‘She wants MRI scan, sir.’

  ‘It’s a waste of her money.’

  ‘But she lives in Nepalgunj.’

  ‘How far away is that?’

  ‘Two days by bad road.’

  ‘Oh all right, get an MRI scan then… it won’t show anything but I suppose she hopes that somehow it will make her unhappiness real.’

  Afterwards the MO tells me that the patient has already tried to kill herself twice.

  ‘How do people kill themselves in Nepal?’

  ‘Usually by hanging, sir.’

  The patients come from all over Nepal, often from remote mountain villages accessible only on foot. They come to the clinic hoping for an instant cure, and with an exaggerated faith in medicines, perhaps connected to their belief in prayer and sacrifice. The idea that drugs can have side effects, that there is a balance to be struck between cost and benefit, seems very alien to them. It is impossible to treat effectively chronic problems such as headache, epilepsy, raised blood pressure or low back pain on the basis of a single visit. So the patients end up on a bewildering variety of different drugs that they either acquire themselves or from different doctors over the years. They come with plastic bags full of shiny foil blister packs of coloured tablets of many shapes and sizes, which they spread out on the table in front of me and the MOs.

  ‘She is thirty-year-old lady with headache, sir.’

  Oh dear, I thought, not another one. She sat diffidently in front of me with her husband beside her.

  ‘And she cannot stop laughing, sir.’

  ‘Really? Pathological laughter? That’s interesting.’

  I was handed the scan. It was indeed very interesting, but very sad.

  ‘What do you see, Salima?’

  After a while, Salima, with my help, worked out that we were looking at a huge brain tumour – technically a petroclival meningioma. I had once had a similar case in London who also had the very rare symptom of uncontrollable, pathological laughter. I had operated, and had left her in a persistent vegetative state. It was one of the larger headstones in my inner cemetery.

  ‘Tell them to come back tomorrow when Prof is here,’ I said.

  Once she had left the room I told the MOs that without surgery the poor young woman would die within a matter of years – slowly, probably from aspiration pneumonia. She already had difficulties swallowing, from the pressure of the tumour on the cranial nerves that controlled her throat, a sure harbinger of death. But surgery, I told them, was almost impossibly difficult – at least, it was very difficult to operate without, at best, inflicting lifelong disability on the patient. So what was better? To die within the next few years, or face a longer life of awful disability?

  ‘Prof needs to talk to them,’ I said, but she never came back.

  ‘All is well apart from the child… the baby where we tried to do an endoscopic ventriculostomy yesterday.’ This had been another patient, a baby only a few months old, with a huge hydrocephalic head.

  ‘In what way?’

  ‘Not doing well…’

  ‘Does the mother have other children?’

  ‘Yes.’

  ‘It’s best if we let her die, isn’t it?’

  Dev said nothing but silently conveyed his agreement.

  ‘In England we wouldn’t be allowed to do that,’ I said. ‘We’d raise heaven and earth and spend a fortune to keep the child alive even though she will have a miserable future with severe brain damage and a head the size of a football. My old boss, at the children’s hospital where I trained, sometimes said to me, after we had operated on a particularly hopeless case who was doomed to live a miserable and disabled life, that he wished he could tell the parents to let the child die and go and have another one. But you’re not allowed to say that.’

  ‘The child died during the night,’ the registrar told me when he saw me next morning looking at the space where she had been. The child had gone, leaving only a sad little huddle of sheets on the bed, as the nurses had not yet had time to change the bedding.

  I had some difficulties setting up a patient for an MVD, an operation for facial pain which involves microscopically manipulating a small artery off the trigeminal nerve, the nerve for sensation over the face. It is an operation I have done hundreds of times in London – but doing it here feels very different. Turning the patient was somewhat problematic.

  ‘In London we say one, two, three and then turn the patient,’ I said. ‘Do you do that here?’

  ‘Yes, sir,’ the registrar assured me happily.
r />   ‘One,’ I said, and he grabbed the patient and started pushing him off the trolley.

  ‘No! No!’ I shouted. ‘One, two, three… and then roll.’

  It felt more like a rugger scrum than a coordinated manoeuvre, but we managed to get the patient safely face-down onto the table.

  *

  It was a twenty-minute drive from Neuro Hospital to the Bir, past a few small demonstrations with heavily armed police in attendance. Nepal is in a constant state of political chaos. The civil war only ended a few years ago. The monarchy collapsed four years after the royal massacre. The democratically elected Marxist government which replaced it is riven by continuous political infighting. The streets around the hospital were packed with pedestrians and motorbikes. An emaciated young woman was selling a few halved cucumbers, daubed with a red relish, from an empty oil drum that served as a stall, at the hospital entrance. There was a row of ramshackle pharmacies across the road from the entrance, with crowds of people standing in front of them.

  ‘That was the first pharmacy in Nepal,’ Dev said, pointing to an old brick building behind the pharmacy shacks with wide cracks in its walls from the recent earthquake.

  The hospital itself was more like a dirty old warehouse. It reminded me of some of the worst hospitals I had seen in Africa and rural Ukraine. It had been built in the 1960s by the Americans, and although some of the wards had plenty of windows, it was a typical example of the style of architecture that treats hospitals as being little different from factories or prisons, with long, dark corridors and lots of gloomy spaces. The wards were very crowded and everything felt sad and neglected. Dev was greeted with many delighted smiles and ‘Namastes’ by the staff, but he told me afterwards that he had been deeply upset by the visit.

  ‘I created my own neurosurgical unit here,’ he told me. ‘The first in Nepal. We had to build everything from scratch with second-hand equipment. I used to do my own cerebral angiograms by direct carotid puncture in the neck. Jamie Ambrose at AMH had shown me how to do it. We painted the ward every year – I paid for the paint myself – we had a painting party. And look at it all now! All gone, filthy, neglected.’

  ‘When I came back here from the UK,’ he continued, ‘nobody would work after two in the afternoon. So I sat in the office by myself, the only senior doctor in the building. Eventually everybody else stayed as well. We had no money then. I was working all the time.’

  We left the hospital and stood outside, waiting for Dev’s driver. Dev was recognized by many people – he is famous throughout Nepal, let alone at the hospital where he used to work – and while he chatted and joshed with them I stood and watched the endless flow of people coming and going. There was a large pool of dirty water from a leaking water main, and rubbish and broken bricks – probably left over from the earthquake – in the gutter opposite. And yet, as the women picked their way across the road in their brilliantly coloured and elegant clothes, I thought, with a slight feeling of shame, that the scene was rather beautiful.

  As Ramesh, Dev’s driver, manoeuvred the car past the long and chaotic queues outside the petrol stations, Dev returned to the subject of the Bir.

  ‘I need a rest after what I have just been through. It was terrible, terrible… people would come to appreciate just how good a ward could be… all gone. That floor was something different. Nice working environment. It was recognized by the Royal College in England for training. All gone, all gone.’

  A few months later I met an English neurosurgeon in New Zealand who, when a medical student, had visited Dev’s department at the Bir. He fully confirmed just how different the department had been from the rest of the hospital.

  ‘It was a beacon of light in the darkness,’ he said.

  ‘We came back here with such high hopes,’ Madhu told me over supper that evening, ‘and everything has got so much worse.’

  7

  AN ELEPHANT RIDE

  We set off for the Terai – the flat lowlands in the south of Nepal, bordering India – early in the morning, just after dawn, the air very still and humid and hot. I was in a cheerful mood: the day before, I had received the pathology report on the skin tumour I had had removed before setting out for Nepal. The tumour was indeed cancerous but the ‘excision margins were clear’ – in other words, I had been cured and would not need further treatment.

  There is an entire tourist village centred on elephant rides adjacent to the Chitwan National Park. Tourism in Nepal had suffered badly because of last year’s earthquake and the nearby tourist town of Sauraha, with many bars and small hotels, looked almost empty when we drove through it.

  ‘What will they live off?’ I asked Dev.

  ‘Hope,’ he said, with a shrug.

  There were only a few Western people to be seen, easily identified by their baggy shorts and T-shirts. I always wear a long-sleeved shirt and trousers, not just to be different but because the Catholic missionaries I lived with in Africa fifty years ago, when I was working as a volunteer teacher, taught me that this shows respect for the local people.

  We were taken to the government elephant station at the edge of the jungle. We walked beneath tall, widely spaced trees, through patches of sunlight. It was remarkably quiet. There was a group of elephant-high, ramshackle shelters – roofs of battered and rusty corrugated-iron sheets on four posts, surrounded by tattered electric fencing. In the centre of each shelter there was a massive wooden pillar, with heavy chains and shackles hanging down. There were no elephants to be seen.

  ‘They used to keep the elephants chained at night but an Englishman showed them they could use electric fencing,’ Dev told me.

  Beyond the sheds were a few low buildings, and in one with an open front two European teenage girls were sitting cross-legged in very short shorts on the ground next to a dark-skinned elderly Nepali man. They were rolling up handfuls of rice mixed with sweets – the plastic wrappers were carefully removed – into a ball, wound around with long grass, a packed lunch for elephants. They held the ball with one foot and used their hands to bind the long grass around the rice. The girls were very absorbed and everybody was silent. When I asked them where they came from, they smiled and said they came from Germany. I wasn’t quite sure what to think about seeing these children of the affluent West playing at being peasants.

  And then, slowly, coming out of the surrounding jungle, a huge elephant appeared with a mahout perched high on her neck, his feet behind her ears. The creature was enormous, solemn and stately, and strangely graceful for such a massive beast. The last of the megafauna on land to survive mankind.

  ‘That’s the one we’ll be going on,’ Dev told me.

  The mahout brought the great creature to where we were waiting, and the elephant bent her huge knees and settled awkwardly down on the ground, back legs pointing backwards and front legs forward. The mahout and his helpers then spent some time fitting a wooden frame over a mattress onto the elephant’s back, kept in place with a wide girth, which they heaved on with ropes to get it tight. While they did this I walked up to the elephant and looked into her small, thoughtful eyes and she looked back at me. She had elegantly curled the end of her trunk over her left foreleg. The day before I had been reading about elephants – of the 40,000 muscles in their trunks, and of their great brains, the largest brain of all land mammals. They are intensely social, with a complex social life. They can console each other, mourn the dead and have a language of sorts. They can also recognize themselves in mirrors (which is generally considered to mean that they have a sense of self).

  Nobody knows how many brain cells are needed for consciousness. Recent work on insects suggests that even they might be capable of it; their brains show similarities to the midbrain of reptiles and mammals, where some authorities think conscious experience arises. To ask if a creature is conscious is equivalent to asking if it can feel pain, and nobody knows at what point pain arises in nervous systems. If you deliver a painful stimulus to one of a lobster’s claws, it will rub the p
ainful area with the other claw. Is this a mere reflex? It seems more likely that it feels pain. We boil lobsters alive, of course, before eating them.

  When patients are unconscious, for instance after a head injury, we assess the depth of their coma by hurting them. You either squeeze the nail bed of one of their fingers with a pencil, or press very hard with your thumb over the supraorbital nerve just above one of the eyes. If they respond purposefully to the pain – trying to push you away or, just like the lobster, trying to get one of their hands to the painful area – we assume there is some kind of conscious perception of pain going on, even if the patient has no memory of it afterwards. On the other hand, if the patient is in deep coma, they do not move in response to the pain at all, or move their limbs in a reflex, purposeless way. We assume, then, that there is no conscious element to the response and that the patient is deeply unconscious.

  And then there is the wonderful mystery, at the other end of the scale from insects, as to why whales have brains which are so much larger than ours. It is true that there are structural differences (whales lack our cortical layer IV and most of them have a much higher ratio of supportive glial cells to neuronal cells than we do), but nobody knows why they have evolved such massive brains, and to what use they are put. In recent years the floodgates have opened with new research into animal intelligence: cows have friends among other cows, pilot whales (a species of dolphin) have more neuronal cells in their brains than any other creature, manta rays can recognize themselves in mirrors, fish can communicate and work together when hunting. We are moving further and further away from Descartes’s separation of mind from matter, and his dreadful claim that animals are mere automata.