Admissions

by Henry Marsh

  I slept badly, waking frequently, hoping against hope, like a rejected lover, that all would be well, that when the dawn came Vlad would ring me to say that she was showing signs of recovery, but the phone remained silent. I went into work next morning and up to the ITU. The ITU consultant was standing beside the patient’s bed.

  ‘She’s no better,’ he said, and launched into a technical account of how he was managing the patient’s complicated metabolic problems. He had always struck me as being a bit of a heartless technician.

  ‘I couldn’t sleep at all last night,’ he suddenly said.

  ‘It’s not your fault.’

  ‘I know that,’ he replied. ‘But it just feels so awful.’

  The family were waiting outside the ITU, and we went to talk to them, and prepare them for the worst. There was still some hope, I told them. I said that she might survive but that it was also possible that she might die.

  ‘She might have suffered a catastrophic stroke before I operated. It’s too early to tell,’ I told them. I went on to explain that if she had suffered a catastrophic stroke, it would only show up clearly on a scan done the next day. So I said we would get a scan later in the day.

  I went in that evening. In the X-ray viewing room I looked at the woman’s brain scan on the computer screens. It was mottled and dark – clear evidence of catastrophic damage. Her brain had obviously swollen so badly while her diabetic coma was treated that she had suffered a major stroke. The operation had been too late. I walked round to the ITU where all the family were gathered in the interview room, waiting for me. Their eyes were fixed on me as I told them that there was no longer any hope. I told them that her death had been avoidable, because her blood sugar hadn’t been checked on admission. I promised that this would be investigated and that I would report back to them in due course.

  As I said this I wanted to scream to high heaven that it was not my fault that her blood sugar had not been checked on admission, that none of the junior doctors had checked her over, and that the anaesthetists had not realized this. It was not my fault that we were bringing patients into the hospital in such a hurry that they were not being properly assessed. I thought of the army of managers who ran the hospital, and their political masters, who were no less responsible than I was, who would all be sleeping comfortably in their beds tonight, perhaps dreaming of government targets and away-days in country house hotels, and who rarely, if ever, had to talk to patients or their relatives. Why should I have to shoulder the responsibility for the whole damn hospital like this, when I had so little say in how the hospital was run? Why should I have to apologize? Was it my fault that the ship was sinking? But I kept these thoughts to myself, and told them how utterly sorry I was that she was going to die and that I had failed to save her. They listened to me in silence, fighting back their tears.

  ‘Thank you, Doctor,’ one of them said to me eventually, but I left the small waiting room feeling all the worse for it.

  I left the ITU staff to turn off the ventilator the next day.

  I had told the family to sue the hospital – what had happened was indefensible – but they did not. Probably because of my apology.

  I wish the authorities responsible for regulating doctors in the UK understood just how difficult it is for a doctor to say sorry. They show little sign of it. The General Medical Council recently produced a document on the Duty of Candour, which is now a statutory obligation. It orders us to tell patients whenever a mistake has been made, both in person and in writing. It would, the document told us, usually be the duty of the senior clinician responsible for the patient to do this, and to apologize, irrespective of who had made the mistake. It went on to add helpfully: ‘for an apology to be meaningful it must be genuine,’ seemingly unaware of the contradiction between an apology being compulsory and yet at the same time genuine. There was no discussion of how this contradiction can be resolved. It is resolved, of course, if senior doctors like myself feel trusted and respected, and if they have authority, and if they are not compelled to do meaningless things like asking patients to fill in a questionnaire about their behaviour. And if they are given the resources with which to do their work effectively.

  I agree with everything in the document about the importance of honesty and apology, but I view with sadness and anger the increasing alienation and demoralization of doctors in England. The government, driven as always by the latest tabloid headlines, has set up an increasingly complex system of bureaucratic regulation based on distrust of the medical profession and its professional organizations. Of course doctors need regulating, but they need to be trusted as well. It is a delicate balance and it is clear to me that in England the government has got it terribly wrong.

  14

  THE RED SQUIRREL

  The two patients with acoustics were waiting for us in Igor’s small and cramped office. One was a woman in her fifties, the other in her thirties. Both tumours were very large and both women were starting to lose their balance as a result of the tumours pressing on the brainstem. Patients with tumours this size gradually deteriorate, becoming more and more disabled, and will eventually die – but it can take many years. Surgery, if done competently, has a low risk of killing the patient, but, with the very large tumours, a high risk of leaving them with half their face paralysed, which is very disfiguring and for most people is a life-changing experience.

  By this time I had operated on several acoustic tumours with Igor and there had been no disasters, so I was not too troubled about agreeing to operate. The older woman was certain she was happy to proceed with surgery, the younger was very frightened and indecisive. We spent almost two hours talking to her – all of it in Ukrainian, of course, and I spoke little. There was no question that she needed surgery, but she could choose between surgery done by Igor and myself and going to the State Institute. I was in no position to judge how our results compared to theirs.

  ‘What would it cost to have the operation in Germany?’ she asked me, Germany being a popular place for wealthy Ukrainians to go for medical treatment.

  ‘At least thirty thousand dollars, probably much more.’

  Although she did not say as much, it was clear she could not raise the money to go abroad, but I couldn’t deny that probably it would be safer if she did. After two hours of discussion, it was agreed that we would operate. We would do the older patient on Monday and the younger one on Tuesday. There were a few other patients to see, but as it was a Sunday the outpatient clinic was quicker than usual. One was a young woman from a village in the west of the country, with a huge suprasellar meningioma compressing her optic nerves. She had long hair and a very pale face. I was told that she was losing her eyesight, but the details were a little vague.

  ‘She’ll go blind without surgery,’ I told Igor when I looked at her brain scan. ‘But the risks of surgery making her blind are also very high.’

  ‘Oh, I have done several suprasellar meningiomas with good results. You show me how,’ he declared confidently.

  ‘Igor, this tumour is enormous. It’s the biggest I’ve ever seen. It’s a completely different problem from the usual, smaller ones.’

  Igor said nothing in reply, but he looked unconvinced and was obviously itching to operate.

  The first acoustic operation next day went well. I cannot remember the details – my memory has been so overlaid by what was to happen later. But I remember that the operation took many hours and, as usually happens when I work with Igor, we were not home until after nine o’clock in the evening.

  ‘It is wonderful when you come!’ Igor said to me as we drove back home, the van bumping over the cobbled street that leads down to the Dnieper. ‘It is like holiday for me. I scrub my brain. Recharge my batteries!’ I was tempted to reply that my batteries felt correspondingly discharged and flat, and my brain-scrubbing brush worn and bent, but I kept quiet.

  I sleep on a sofa bed in the living room of Igor and Yelena’s apartment. It’s not exactly comfortable but I a
lways sleep well. It is on the sixteenth floor of a typical Soviet apartment block. The sofa bed once opened up in the middle of the night and deposited me on the floor. The view from the window is grimly impressive: a huge circle of identical, shabby high-rise blocks, with a dilapidated school and health centre in the middle of the ring – a Soviet Stonehenge. There is a large flat-screen television in the room, a few religious icons on the wall and a glass-fronted bookcase containing mainly medical books. Like the rest of their apartment, it is very plain and tidy and almost puritanical. Yelena is also a doctor, and works as a cardiologist in the Kiev Emergency Hospital, where I first met Igor in 1992. The family’s life is devoted to work.

  I usually rise early, woken by the hollow rumbling of the apartment block’s battered elevator going up and down as people set off early for work. We get up at six and drive to work forty-five minutes later. The traffic is already very heavy but moves quite quickly, over the high Moskovskyi suspension bridge across the Dnieper. In the west I can see the golden domes of the churches of the Lavra Monastery shining, and to the east the rising sun is reflected in the windows of the garish apartment blocks built in the years of the property boom before the crash of 2007.

  We go to see the woman with the acoustic tumour we operated on the day before. She is remarkably well and her face is not paralysed. I am always amazed at how tough the Ukrainians are – she is already standing out of bed, albeit unsteadily. We all laugh and smile happily. In the bed next to her is the young woman with long hair.

  ‘Suprasellar meningioma for surgery tomorrow!’ Igor announced. ‘The second acoustic patient has sore throat. There is law in this country, if sore throat you not allowed to operate.’

  So the day was spent seeing outpatients. In the late afternoon Igor drove me to an empty field on the outskirts of Trojeschina, the bleak suburb of Soviet apartment blocks where he lives. He had bought the field some years ago with a view to building his own hospital there, but then came the financial crash of 2007 and the site remained undeveloped. He was now instead converting an apartment block in the west of the city into a hospital, but had also bought himself a large, unfinished house. I wondered whether his increasingly grim expression was because he had started to overreach himself. The grass was still brown from the winter, burnt black in places, but with a few green shoots to be seen. There was rubbish everywhere. In the distance were the drab buildings of Trojeschina and the tall chimney of a power station. There was a small and dirty stream, partly blocked with plastic bags and tin cans and lined by weary-looking, bare willow trees. Igor produced a breadknife from his jacket pocket and proceeded to cut off a willow branch and stick it in the ground.

  ‘Will that really grow?’ I asked sceptically.

  ‘Yes, one hundred per cent,’ he replied, waving at the dozen or so willows along the litter-covered bank which had grown over the last ten years.

  Opposite us, on the other side of the filthy stream, were a concrete ruin and a restaurant, with piles of rubbish and a dog which barked furiously when it saw me.

  ‘Local people tell me how to do. People cut them down,’ he said, pointing to the many stumps and burnt trunks. ‘You have to plant five trees if one to live.’

  As he planted more willow branches he discussed his endless problems with corrupt bureaucracy.

  ‘This is land of losted possibilities,’ he stated. ‘First problem is Russia and second is corrupt Ukrainian bureaucrats. Everybody leave,’ meaning that young people with any ambitions or dynamism have emigrated. ‘I love and I hate this country. It is why I plant trees.’

  The next day we operated on the girl who was losing her eyesight. One of the most difficult aspects of working with Igor is that it seems impossible to start the major cases until well after midday. I often complained to him that this was a serious problem as it meant that we ended up doing some of the most difficult and dangerous parts of the operation in the evening, when I, at least, was starting to feel tired. Dangerous and delicate brain surgery can be very intense and intensely draining. But Igor said it was impossible to get the theatre started sooner.

  ‘I must do everything. Check equipment,’ he said. ‘If nurses or my doctors prepare case, they will make mistakes.’

  When I suggested he should delegate more, and that by not trusting his team he was actually creating the problem, he disagreed violently.

  ‘This is Ukraine,’ he said. ‘Silly people, silly country,’ in his characteristically declamatory and assertive style. I had noticed over the years that few doctors or nurses lasted in his department for long. I still don’t know if he was right and I was wrong, but I hated these late starts to difficult and dangerous operations.

  By one o’clock he was finally starting to open the young woman’s head. I viewed the prospect of the operation continuing until late in the evening with dismay. I braved the guards at the entrance to the hospital and escaped for a walk round a small nearby park, something I have only dared to do since Maidan. The weather had turned suddenly mild and I slithered and slid over melting ice under the dull, grey sky. A red squirrel with high, pointed ears ran in circles around me, occasionally taking fright when I came too close, and darted up the nearest tree. I told the squirrel that I was finding it increasingly difficult to help Igor with these very major operations. I went back to the hospital, showed the guards my passport, and returned to the operating theatre.

  The patient’s head was almost open and Igor was scrubbed up at the table. I took my usual place on the hard trolley in the corner of the anaesthetic room. The door to the operating theatre was open and I could hear Igor shouting at his staff from time to time. He used a garage compressor for the air-powered drill I gave him nine years ago, used for cutting the bone of the skull to open the patient’s head, and the compressor was next to the trolley I was lying on. It went off with a deafening explosion every few minutes when more compressed air was needed. I drifted in and out of sleep, woken at regular intervals by the compressor. It was half past two and they had only just started the bone work! Not for the first time, I told myself that this was the last visit. I had done this often enough before, but I knew it was not a good way to operate… And was it really necessary? Did Igor really need to do the occasional difficult case like this? I couldn’t go on like this, I told myself, being angry all the time. It was like working in my hospital back in London.

  Eventually Igor asked me to take over. He had been slow and careful, but had been unable to find the left optic nerve and needed my help. Once I had settled down in the chair my anger quickly dissipated and the operation seemed to go rather well. I felt happy and concentrated, full of fierce anxiety and excitement – full of the intense joy of operating. It took me several hours of delicate dissection to find the left optic nerve, working in a space only a centimetre wide. When I did, I realized I had wasted my time – it had been so thinned by the tumour that the woman could not possibly have had any vision in her left eye.

  ‘Was she blind in the left eye?’ I asked Igor and his staff. All I had been told was that she had only 20 per cent of her vision. But nobody knew. I realized at once that I had made a serious mistake. I should have asked about the nature of her visual loss before the operation. If I had known she was already blind in the left eye I would not have spent hours tiring myself out, trying to find and preserve the left optic nerve

  After three hours of intense operating there was a fairly simple lump of tumour left, but I was tired – it was late, and I thought it would be easy for Igor to remove this last part. He had done pretty well so far, although a few of his comments later made me realize that I had not explained the anatomy of the optic nerves as clearly as I should have done. I went off to have a sandwich. When I came back I found that Igor had removed the tumour but had damaged the vital optic chiasm, the area where the two optic nerves meet and cross over. It was entirely my mistake – I should have stayed when Igor was removing that last part of the tumour, or done it myself.

  I looked miserably
down the microscope.

  ‘She’s going to be blind,’ I said.

  ‘But right optic nerve OK,’ Igor said in surprise.

  ‘But the chiasm has been damaged,’ I replied. ‘Well, it might well have happened if I had done that last part myself,’ I added. This was certainly true, but at least I would then have felt I had done my best.

  Igor said nothing. I don’t think he believed me.

  We had finished by nine o’clock, and her head had been stitched back together again. She was still anaesthetized when we left but the pupils of both her eyes were large and black and did not react to light – a certain sign of blindness that Igor found hard to accept.

  ‘Maybe she be better tomorrow.’

  ‘I doubt it,’ I replied.

  Leaving somebody completely blind after surgery – it has happened to me twice – is a peculiarly unpleasant experience. It feels worse than leaving them dead: you cannot escape what you have done. Granted that in all these cases the patients were going to go blind without surgery and had already lost most of their vision, but it is a deeply painful experience to stand next to the patient at the bedside and see their blank, blind eyes fruitlessly casting about. Some of them at first go into a hallucinatory state and think that they can still see, and almost manage to persuade you that they can. You hesitate to disabuse them by demonstrating that they can’t – the simplest test is to push your fist suddenly up to their eyes. They do not blink.

  We sat at breakfast next morning, as we have done for many years.

  ‘Did you sleep well?’ Igor asked me.

  ‘No.’

  ‘Why not?’

  ‘Because I was upset.’

  He said nothing.

  We made our way to work as usual. I went upstairs with Igor to see the young woman – there was no question that she was completely blind. I found it very hard to look at her while Igor leant over her with a bright desk lamp for a torch, trying to convince himself that her pupils still reacted a little to light, so I left the room.