Admissions

by Henry Marsh

  ‘It’s easier now that she’s on a ventilator, isn’t it?’ I replied, because it would be kinder if she died anaesthetized on a ventilator than from bed sores and infection on a bed in the hospital or back in her home – not that she was likely ever to get home.

  On the morning round next day I noticed a group of doctors and nurses round the girl’s bed. She was groaning terribly as an anaesthetist pushed a flexible, fibre-optic bronchoscope down her trache tube. Her chest X-ray looked awful. We watched the intriguing view of the ringed and ridged inside of her lungs’ bronchi on the small monitor attached to the bronchoscope, while she groaned piteously as the anaesthetist tried to clear the fluid from her lungs. We agreed she was better off dying, but Dev was in an impossible situation. Should he have refused to operate and left the woman with her dislocated, broken neck untreated, leaving her to die without any treatment? The family would almost certainly have refused to accept this. Should he have left them to take her to another hospital where she would have undergone surgery that probably would not have been done as well as it would have been in his hospital? I had never had to face problems like this in my own career.

  We get so used to most of our patients having brain damage and being unconscious that we forget that some of the paralysed patients on ITUs are wide awake, suffering horribly but unable to show it. Or perhaps it is wilful blindness on our part. I was painfully aware that I had found some of these cases so distressing during my career that I tended to avoid them and walk past them on the ward round. What do you say to somebody who is completely paralysed from the neck down, but awake, on a ventilator, so that they cannot talk?

  I remembered an identical case in Ukraine many years ago. My colleague Igor was still working in the government emergency hospital at the time. He was very proud of the fact that he had managed to keep the patient alive, but on a ventilator.

  ‘First case of long-term ventilation in Ukraine,’ he declared.

  The young man was in a bleak little side room and lived there for three years. Many religious icons surrounded him on the otherwise bare walls. He was equipped with a speaking tracheostomy tube and each time I visited Igor’s department I would go and see him. His brother looked after him and spoke some English, so I communicated with the patient through him. Each time I saw him he had wasted away a little more. At the time of the injury – breaking his neck diving into shallow water – he had been quite heavily built, but by the time he died he was skin and bones. At first I was able to have quite rational conversations with him, but it became more difficult with each visit. At least, he started to ask me about religious miracles and salvation, which he spoke about with intense passion (to the extent that you can speak passionately with a speaking tracheostomy tube), to which I had no answer. I was relieved on a later visit to see that the little side room was empty.

  The young Nepali woman had fallen and broken her neck during Dasain, the most important of the many Nepali festivals, when upwards of fifty thousand goats and hundreds of buffalo are sacrificed to the goddess Durga. Blood is smeared everywhere in honour of the goddess, including, I noticed, on Dev’s gold-coloured Land Rover. Animal rights activists, I read in a local newspaper, have recently suggested that the goats be replaced with pumpkins.

  The festival goes on for two weeks. Two days earlier Dev had told me to accompany him to the gates in front of his house. A police jeep was parked there with a uniformed policeman standing beside it. Another policeman appeared, leading a beautiful goat with long, floppy ears on a rope from behind the garage.

  ‘I give the local police a goat every year for Dasain,’ Dev told me. The goat was bundled into the back of the jeep but immediately jumped out. So it was put back in, but now with a police escort. They drove away with the goat looking mournfully out at me over the tailgate, the policeman beside it.

  ‘That goat will feed a hundred policemen,’ Dev said approvingly.

  ‘Nobody is in the mood for Dasain, this year, what with the earthquake and now the blockade and fuel crisis,’ Dev commented as we drove back to Kathmandu from a visit to a nearby town. Yet in several places we passed the beautiful high swings – known as pings – which are a traditional part of Dasain celebrations. They are made simply of four bamboo poles lashed together, more than twenty feet high and decorated with colourful flags. I saw Nepalis – both adults and children – laughing ecstatically as they swung happily to great heights, although I thought the pings looked a little precarious.

  The next day I sat in the library teaching the juniors and discussing how we could improve the MOs’ jobs.

  ‘I am going back to London tomorrow,’ I told the new cohort of MOs, freshly out of medical school and, it seemed to me, pretty well out to lunch.

  ‘You are good doctors. We want to make you better. I hope the registrars’ – I looked pointedly at them – ‘will try to continue the morning meetings in this spirit. Teasing, yes, but no bullying.’ Pleased with this little speech, I then went down to Dev’s office and was about to go downstairs to start the clinic when there was a sudden flurry of activity in the corridor outside.

  I found Dev, looking grim, surrounded by several of his juniors at the theatre reception desk, all looking equally serious.

  ‘The girl with a broken neck has just died,’ Protyush told me. ‘The husband is very angry.’

  ‘Is Dev waiting to talk to him?’

  ‘Yes, but we need backup – here in Nepal the families can assault us. We’re waiting for the security guards.’

  Thirty minutes later, I stood in a corner of the theatre reception area where I had a view into the counselling room, and I could see Dev, but not the angry husband. Dev listened to a long outburst in silence and spoke quietly in reply. I crept away, not liking to eavesdrop on so much tragedy and unhappiness.

  ‘I wish I still worked for the NHS,’ Dev said to me that evening, as we sat in the garden. ‘Or at least that I was still the only neurosurgeon here, or that I didn’t have to worry about keeping the hospital afloat financially. It’s yet to make a profit, you know, even after ten years. Twenty years ago I could simply have said that there was nothing to be done and the family would have accepted it.’

  ‘How did the meeting with the family go?’ I asked.

  ‘Oh – the usual stuff. It happens now every few months. Never happened in the past. The husband said I had killed his wife by doing a tracheostomy. Nonsense of course – and in fact, in six months’ time, he’ll probably have a new wife. If she had survived it would have been terrible for both of them. And I spent so long, every morning, trying to explain. And he was so polite, as though I was a god, but now I’m a devil. But I’m sure you’ll find there’s another neurosurgeon in town who’s told them that if he had treated her she’d have been OK.’

  ‘You can’t expect people to be reasonable immediately after a death like this one,’ I said, trying to be helpful.

  ‘Nepal is different,’ Dev replied. ‘I worry for the boys, when they become seniors, having to work in a country like ours where the people are so uneducated – they won’t have my authority. All the hospitals have a permanent plainclothes policeman stationed twenty-four hours a day because of problems like this. They said they would get all the other patients’ families to blockade the hospital. Said they would burn it down. They want money. I know a lot of other doctors here who have had money extorted from them. That’s the problem with having to run a private hospital – “We paid you to treat her,” they said, “and now she’s dead.” It was so much easier in the past when I worked at the Bir. But the government medical service here now is terrible, almost completely broke. And so when I first see a patient the initial question is not what treatment would be best for them but “What can you afford?” You’re so lucky to work in the NHS.’

  ‘Well, she’s better off dead,’ I said.

  It was sad to see Dev – usually so cheerful and enthusiastic – suddenly silent, looking grim.

  ‘You can’t really share it with an
yone. It would only upset and frighten my wife,’ he added.

  ‘Only neurosurgeons understand,’ I said, ‘how difficult it is to be so hated, especially when you haven’t even done anything wrong, and only tried to do your best.’

  I remembered one of my first catastrophes as a consultant. A child who died as a result of my postponing an operation that should have been done urgently. I had thought it was safe to wait until the morning, but I had been wrong. I had to attend an external investigation. I did not have to meet the parents face to face but passed them in the corridor. The look of silent hatred the mother gave me was not easy to forget.

  ‘You start,’ he said, pointing to the bottle of beer I had already got out. ‘The woman’s MP might come round to the hospital – I don’t want to smell of alcohol.’

  I was summoned to supper two hours later. To my surprise, all the managerial team of the hospital were present – six people including the driver, all there to support Dev. I was rather touched. I’d never had support like this for my disasters.

  Over a large Nepali dinner there was much animated discussion, most of it lost on me as they spoke in Nepali. But I was told that the family were threatening a hunger strike and a press conference, and planned to get the other patients’ families to join them.

  ‘Seven point five,’ I heard the manager, Pratap, suddenly say – he had been looking at his smartphone. This, it turned out, was the strength of an earthquake that had just hit Afghanistan and Pakistan. The catastrophic earthquake that had hit Nepal six months before my visit had been 7.8. This was discussed for a while, and then they resumed the conversation about the dead girl’s family and what might happen.

  ‘It’s all because we now work for money,’ Madhu, who was sitting next to me, said. ‘We didn’t want to, but had no choice. We can’t provide free treatment to everybody.’

  Next morning, the morning of my departure from Nepal, I sat drinking coffee in the garden, in Dev and Madhu’s little Shangri-La. The pigeons were cooing and gurgling, the cocks were crowing, the hooded crows were quarrelling again in the camphor tree, although in truth for all I knew they might have been discussing their marital problems or the presence of the brown mongoose which can sometimes be seen, sinuous and graceful, running swiftly across the garden. Or perhaps they were excited about the prospect of the first day of the festival of Tihar in two weeks’ time, the day of kaag tihar, when crows are worshipped and little dishes of food are put out for them. I probably understand as much about the crows as I do about the impenetratable complexities of Nepali society. Two birds with feathery trousers I couldn’t identify waddled busily about on the small lawn in front of the gazebo.

  I set off for work as usual but as it was the tenth and most auspicious day of Dasain, there was little traffic on the road. I passed women wearing their finest clothes – brilliants reds and blues and greens, decorated with gold and silver and paste jewels which flashed in the sunlight. They picked their way cautiously over the puddles and around the rubbish and stinking, open drains. When I got to work I found that there were twelve uniformed policemen with long iron-shod sticks in front of the hospital, sitting in the sunshine on the grass mound by the magnolia tree. The dead woman’s family and supporters stood nearby. Dev and I looked down at them from his office window.

  ‘How much longer will this go on for?’ I asked.

  ‘Oh, until the weather gets colder,’ he said with a laugh, his cheerful good humour having returned.

  ‘I’m not even sure the story about cutting grass on a cliff was true. Her husband has money – it’s unlikely she’d be out gathering grass off a cliff,’ he said. ‘I’m pretty suspicious that it was another ping accident.’

  We had admitted a sixty-five-year-old man two days earlier, also completely paralysed, with a broken neck, who had fallen from a ping.

  ‘Happens all the time during Dasain,’ Dev said.

  I noticed that behind the policemen, the waiting outpatients and the dead woman’s angry family, in the rice paddy next to the hospital, people were harvesting the rice – a picturesque and medieval sight, although in the background there was a long queue of dirty old trucks waiting at the petrol station. In the distance, the high Himalayas, beyond the foothills, were hidden.

  8

  LAWYERS

  I had to return to London from Nepal earlier than I had originally planned because I was due to appear in court. A patient was suing me. The case had been dragging on for four years. I had operated for a complex spinal condition causing progressive paralysis, and the patient had been initially left worse than he had been before the operation. As far as I could tell he had eventually ended up better than before the operation, but apparently he was deeply aggrieved. A neurosurgeon – justly famous for the very high opinion he had of himself, although less famous for his medico-legal pronouncements – was of the opinion that I had acted negligently. Just for once, I was as certain as I could be that I had not, and I had reluctantly felt obliged to defend myself. It was just like Nepal, I thought. All these surgeons attacking each other. I had had to attend various meetings about the case and many thousands, probably hundreds of thousands, of pounds must have been spent in legal fees. At the last moment, after I had come all the way back from Nepal, the claimant and his lawyers abandoned the case two days before the trial was due to start. The solicitor handling my defence was most apologetic about the waste of my time.

  ‘But it’s better than needing twelve policemen,’ I replied cheerfully, without explaining what I meant.

  Many doctors do what is called medico-legal work, providing reports for lawyers in cases involving personal injury or medical negligence. It is a lucrative but time-consuming business. I did a few such reports myself when I became a consultant, but quickly gave it up. I preferred operating and dealing with patients to the many meetings and lengthy paperwork which medico-legal work requires. I only became involved with lawyers if I was being sued myself – always a very distressing experience, whether I felt guilty or not.

  This occurred four times during my career, including the case which had forced me to return from Nepal and which had now collapsed. The other three cases had all been settled, as I blamed myself for what had happened and did not want to defend myself. One case had been for a retained swab after a spinal operation (in the days when swab counts were not being done in the old hospital) which had not caused any severe injury, and the other two were cases where I had been slow to diagnose serious, although almost uniquely rare, post-operative infections. One of those patients had come to serious harm, the other to catastrophic harm.

  But a few years ago I was subpoenaed to give evidence in a personal injury compensation case, which I regarded as an absurd and complete waste of my time. So I attended reluctantly, a series of High Court orders having been served on me over the three days before the hearing. The men serving them had never been able to serve them on me in person – which, strictly speaking, I believe the law requires. The first attempt had been made while I was operating and the second when I was away from London the following day. I returned the following evening to find that a copy of the order had been pushed through the letterbox of the front door of my home. I was operating the day after that until the evening, and came out of the theatre to be told that earlier in the morning a man had walked up to the hospital reception desk and had thrown down yet another copy of the High Court order in front of the receptionist and then stalked off.

  This barrage of court orders had been unleashed upon me by a solicitor in a huge City law firm which was acting on behalf of an American law firm, which in turn was acting for the defendants in the compensation case.

  An English woman had been involved in a minor car accident in the USA while on holiday, and had subsequently seen me as a patient about her ‘whiplash’ symptoms. I had confirmed with an MRI scan that there were no significant injuries to her neck and reassured her that she would get better in time. In practice it is not at all clear whether these whiplash s
yndromes do get better. Patients develop an array of aches and pains and altered sensations in their necks and arms which do not correspond to any known pathological processes such as bone fractures or torn muscles or trapped nerves, and do not spontaneously improve in the time it takes most proven ‘soft-tissue’ injuries to heal and become painfree. It is well known that these syndromes do not occur in countries which do not have any legal recognition of whiplash injury as a consequence of minor car crashes.

  The particular type of accident which is alleged to produce ‘whiplash injury’ is a ‘shunt’, when a car is driven into from behind by another car. These are typically low-speed accidents, where the driver or passengers are subjected to relatively slight forces, never enough to cause any obvious injuries, but which seem to produce severe and lasting symptoms without any evidence of injury such as bruising or swelling or changes on an X-ray or MRI scan. It has been pointed out that driving dodgem cars on fairgrounds involves near-continuous shunting as the cars are deliberately driven into each other, and yet there are no reports of whiplash symptoms afterwards. This discrepancy between the severity of the symptoms and the apparent triviality of the injury has been attributed to a putative ‘whiplash’ effect. The victim’s neck is supposed to be cracked like a whip – something that has never in fact been demonstrated and is probably fallacious.

  I used to see many of these patients every year in my outpatient clinic and it was clear to me that most of them were not consciously malingering – instead they were the willing, perhaps hapless, victims of a ‘nocebo’ effect, the opposite of the placebo effect. With the placebo effect, which is well understood, people will feel better, or suffer less pain, simply as a result of suggestion and expectation. With ‘whiplash injury’, the possibility of financial compensation for the victims, combined with the powerful suggestion that they have suffered a significant injury, can result in real and severe disability, even though it is, in a sense, purely imaginary. They are more the victims of the medico-legal industry and of the dualism that sees mind and brain as separate entities than of any physical injury outside the brain. It is the modern equivalent of the well-attested phenomenon of a witch doctor in tribal society casting a spell on somebody, causing the victim to fall ill, merely through the power of suggestion and belief. There was a further significant irony in this case, which I had mentioned in my original letter about the patient: the victim’s husband was a lawyer specializing in personal injury compensation.