by Henry Marsh
‘What happened to her?’ Rob asked.
‘I haven’t a clue. We sent her back to the local hospital and I heard no more.’
‘What is the second benefit of a career in medicine?’ Rob asked politely.
‘Oh, just that if one falls ill oneself one knows how to get the best care.’ I waved at the brain scan on the monitor in front of us. ‘I’ll go and talk to his parents.’
I left the X-ray viewing area and walked along the dull and overlit hospital corridor to the ITU. The hospital was still very new. It felt like a high-security prison – doors could only be opened with a swipe card and if the doors were left open for more than a minute an ear-splitting alarm would sound. Fortunately since then most of the alarms have broken or been sabotaged, but our first few months in the new building were spent with the almost constant sound of alarms going off – an odd phenomenon for a hospital full of sick people, one might think. I walked into the ITU. Lined around its walls were the forms of the unconscious patients on ventilators surrounded by machinery, with a nurse at each bed.
The nurses at the central desk pointed to one of the beds when I asked about the new admission and I walked over to it. I was taken aback by the fact that the poor jumper was immensely fat. For some reason I didn’t expect a suicide to be fat, so fat that from the end of the bed I could not see his head at all – only the great pale mound of his naked belly, partly covered by a clean sheet, and beyond it the monitors and machinery and syringe drivers at the head of the bed, with their flashing red LEDs and digital read-outs. An elderly man was sitting on a chair at the bedside and got up when he saw me. I introduced myself and we shook hands.
‘Are you his father?’ I asked.
‘Yes,’ he said quietly.
‘I’m very sorry,’ I said, ‘but there’s nothing we can do to help.’ I explained that his son would die within the next twenty-four hours. The old man said nothing other than to nod his head. There was little expression on his face – whether he was too stunned, or too estranged, I do not know. I never got to see his son’s face, and I do not know what human tragedy lay behind the pathetic, dying bulk that lay on the hospital bed beside us.
I went home and climbed up the stairs to the attic room I had built the previous year to where Kate was lying on a sofa, recovering from a particularly bad relapse of her Crohn’s disease. I had made the staircase of oak myself and had sanded and polished the steps to a high finish. We discussed the need for an extra handrail on the stairs since she Kate slipped on the stairs and bruised herself quite badly two nights earlier. We have both always been a little dismissive of the Health and Safety culture that increasingly dominates our risk-averse society but decided that a handrail was probably a good idea. I set off downstairs, down the handmade oak stairs, each tread and riser carefully made by myself, to finish planting the viburnum in the back garden. My newly soled shoes slipped on the over-polished oak, I lost my balance, heard the horrible, explosive crack of my leg breaking and my foot dislocating and fell down the stairs.
Although breaking one’s leg is indeed very painful it is surprisingly easy to tolerate – it is well known, after all, that soldiers in battle rarely feel great pain if they are seriously wounded – the pain comes later. You’re too busy working out how to save yourself to think much about the pain.
‘Bloody hell! I’ve broken my leg,’ I shouted. Kate at first thought I was joking until she found me at the bottom of the stairs, with my left foot twisted round at an improbable angle. I tried to pull my foot out straight with my hands but started to pass out with the pain so Kate called our neighbours who put me on the back seat of their car and took me to A&E at my own hospital. A wheelchair was found and soon I was in a short queue at the reception desk, manned by two fierce-looking women behind what looked like bullet-proof glass. I sat there patiently, gritting my teeth, my broken leg sticking out in front of me. After a short delay I was facing one of the receptionists.
‘Name?’ she asked.
‘Henry Marsh’.
‘Date of birth?’
‘Five three fifty. Actually I’m the senior consultant neurosurgeon at this hospital.’
‘Religion?’ she asked in reply, without batting an eyelid.
‘None,’ I replied, crestfallen but thinking that at least my hospital was truly egalitarian.
The interrogation went on for a short time and I was then rescued by one of the Casualty sisters who promptly established that my foot was dislocated and that it needed reducing. I was very gratified at how quickly this was done, and painlessly at that, thanks to IV morphine and midazolam and Entonox. My last memory, before the drugs rendered me unaware of everything around me is of my trying to persuade the enthusiastic sister not to take an enormous pair of scissors to my brand new, green corduroy trousers.
When I started to come round in a happy haze from the drugs, and reflected on what it would have been like to have had a fracture like mine reduced in the past, without any anaesthetic at all, I found my orthopaedic colleague standing at the end my trolley. I had called him on my mobile from the backseat of my neighbours’ car on the way to A&E.
‘It’s a fracture dislocation,’ he said ‘They’ve reduced it nicely but it will need an operation – internal fixation. I could do that tomorrow at the private hospital.’
‘I’ve got insurance,’ I said. ‘Yes, let’s do that.’
‘We’ll have to get a private ambulance,’ said the sister.
‘Don’t worry,’ said my colleague, ‘I can take him myself.’
So I was wheeled out of A&E, my left leg in a long plaster back-slab and helped into my colleague’s red Mercedes sports car. Thus I was taken in some style to the private hospital three miles away, where the fracture was duly fixed the next day. My colleague insisted on keeping me in hospital for five days on the grounds that I was a doctor and would not listen to his medical advice that I should rest my leg for the first few days after surgery. So I spent much of the following week in bed, with my leg propped up in the air, looking at a rather fine oak tree outside the window of my room, reading P.G. Wodehouse and reflecting on the way in which many of the government’s so-called ‘market-driven reforms’ of the NHS seemed to be driving the NHS even further away from what went on in the real market of the private sector, in which I was once again a patient. I could occasionally hear my colleagues going to visit their patients in the rooms next to mine, their voices full of charm and polite encouragement.
On the morning of my discharge I went down to the outpatient area to wait to have the plaster changed. I watched the many outpatients coming and going.
My colleagues, in smart dark suits, would emerge from time to time from their consulting rooms to bring in the next patient waiting to see them. Some of them knew me and looked somewhat startled to see me disguised as a patient in a dressing gown with a leg in plaster. Most of them stopped and commiserated and laughed with me at my bad luck. One of them, a particularly pompous physician, stopped for a moment and looked surprised.
‘Fracture dislocation of the left ankle,’ I said.
‘Oh dear,’ he said in a very prim voice, as though he disapproved of the vulgar way in which, by allowing my leg to be broken, I had become a mere patient, and he quickly returned to his room. I was summoned to the plaster room where my orthopaedic colleague removed the old dressing and carefully studied the two incisions, one on either side of my ankle. He declared himself happy and then, taking my leg in his hands, re-dressed the wounds and placed a new plaster back-slab against my foot and leg, holding it in place with a crepe bandage. I thought rather wistfully of the huge gulf that separates this sort of medicine from what I practice as a neurosurgeon.
‘I rarely touch my patients, you know,’ I said to him. ‘Other than when operating on them, of course. It’s all just the history and the brain scan and long, depressing conversations. Not at all like this. This is rather ni
ce.’
‘Yes, neurosurgery is all doom and gloom.’
‘But our occasional triumphs are all the greater as a result . . .’ I started to say before he interrupted my philosophizing.
‘You have got to keep that foot up for the next few weeks ninety five per cent of the time because it’s going to become very swollen.’
I bade him goodbye and, picking up my crutches, hopped out of the room.
A few weeks later I suffered a vitreous haemorrhage and retinal tear in my other eye but it was easier to fix than the left eye had been. I was back at work within a matter of days. I had been lucky compared to my patients, and I was full of the profound and slightly irrational gratitude for my colleagues that all patients have for their doctors when things go well.
22
ASTROCYTOMA
n. a brain tumour derived from non-nervous cells. All grades of malignancy occur.
After the success of the trigeminal neuralgia operation Igor was keen that when I next went out to Ukraine I should operate on a number of patients with especially challenging brain tumours, which he assured me could not be treated safely in Ukraine by his senior colleagues. I did not share his enthusiasm and told him so, but when I arrived on my next visit there was a long queue of patients with quite dreadful brain tumours waiting to see me in the dingy corridor outside his office.
The outpatient clinics I have conducted over the years in Igor’s office have always been bizarre events, and quite unlike anything else I have ever done. As Igor’s fame grew, patients would come from all over Ukraine to consult him. There was no appointment system – patients would turn up at any time, and seemed to accept that this might involve waiting all day to be seen. On the occasion of my visits the queue of patients would stretch all the way down the long hospital corridor outside his office and disappear from view around a distant corner.
We would start at eight in the morning and continue until late in the evening without a break. There would often be several patients and their families in the small office all at once, some of them dressed, some of them undressed. There might also be journalists and TV crews conducting interviews, especially when Igor’s political situation was proving problematical. There were three telephones in the room and most of them were in constant use. There were rarely fewer than seven or eight people in the room at the same time. I found all this chaos exhausting and irritating and at first I blamed Igor for it, telling him that he should institute an appointments system, but he said that in Ukraine nobody would adhere to it and that it was best to let people turn up whenever they wished.
Igor’s manner with patients was somewhat brusque, although at times he seemed capable of sympathy. Since I do not speak Russian or Ukrainian I could only guess at what was being said, before it was translated by Igor, and I discovered that often I was entirely wrong. The patients brought their own brain scans, arranged previously, and without further ado I would be asked whether surgery was possible or not. In English medicine it is drilled into one at a very early stage that one should base one’s decisions on taking a history and examining the patient and that only at the end should one look at the ‘special investigations’ such as X-rays and brain scans. Here the whole process was reversed and compressed into a few minutes or even seconds. I felt like the emperor Nero at the Roman games. It was made all the more difficult by the fact that the brain scans were usually of poor quality. It was difficult to see clearly what was going on and this made me even more uneasy about having to make so many rapid life-or-death decisions.
On this particular visit, in the summer of 1998, it became clear that Igor’s many enemies in the medical establishment had brought pressure to bear on the hospital director who had welcomed the British ambassador the previous year. On the morning of the first outpatient clinic I learnt that I had been ‘banned’ from the operating theatres by the director, and also that he would not meet me. I was, in fact, quite relieved – the cases I had seen were daunting and I was frightened by the thought of operating on them in the primitive operating theatres.
The fact that I had been banned from the operating theatres was headline news and the outpatient clinic next day had more than its usual share of journalists and TV crews in attendance. Halfway through the morning, as I was being interviewed by a Ukrainian TV journalist, while simultaneously trying to decide whether somebody’s brain tumour was operable or not, the head of the hospital’s surgical department arrived and ordered the journalists and film crews out of the hospital. He wore a particularly tall chef’s hat, and an outsize pair of spectacles to go with it, and looked reassuringly absurd. It was difficult to take him seriously. We left the hospital and continued the interview outside, with the hospital in the background.
One of the patients I had just seen, and agreed – with considerable misgivings – to operate on, was also interviewed and asked what she felt about the fact that I was not going to be allowed to treat her. Ludmilla had come up from the south of the country to see a famous professor of neurosurgery in Kiev. She had become increasingly unsteady on her feet in recent months and a brain scan had shown a large and very difficult tumour at the base of her brain – an ependymoma of the fourth ventricle, a benign but often fatal growth. There was no question of her undergoing surgery in her home town. She arrived on time for her appointment but the professor was late. His junior doctors looked at her brain scan.
‘If you want to live, leave before the professor returns,’ one of them had said. ‘Go and see Kurilets. He has contacts with the West and may be able to help. If you let the professor operate, you will die.’ She quickly left and a few days later I saw her in Igor’s office.
We both appeared on the national nine o’clock television news that evening.
‘What do you want?’ the journalist was seen to ask Ludmilla.
‘I want to live,’ she replied quietly.
The urge to help, the planning of difficult and dangerous operations, of taking carefully calculated risks, of saving lives, is irresistible and even more so if you are doing it in the face of opposition from a self-important professor. When I met Ludmilla the next day I felt that I had no choice other than to tell her that, if she wished, I would arrange for her to come to London and I would operate on her there. Not surprisingly, she agreed.
It was the next day that I first saw Tanya. Igor wanted us to leave for the hospital by 6.30 in the morning but I overslept and once we had set off I quickly realized why Igor had been keen to leave early – the morning Kiev rush hour meant that a journey of thirty minutes took, instead, one and a half hours. We joined an endless queue of grubby cars and trucks, dull grey shapes in the fog, with red tail-lights turning their exhaust into small pink clouds, inching along the enormous wide roads towards the centre of Kiev. The roads are lined by huge advertisements for cigarettes and mobile phones, scarcely visible in the fog. Many cars queue-jump by mounting the pavements and weaving between the lamp posts. Heavy 4x4s leave the road altogether and career across the muddy patches of grass beside the road if it will get them ahead.
Tanya was near the end of the queue of patients with inoperable brain tumours. She was eleven years old at the time. She walked into Igor’s office, unsteadily, supported by her mother, with a scratched piece of X-ray film that showed an enormous tumour at the base of her brain that must have been growing for years. It was the largest tumour of its kind that I had ever seen. Her mother, Katya, had brought her all the way from Horodok, a remote town near the border with Romania. She was a sweet child, with the awkward long-legged grace of a foal, a page-boy haircut and a shy, lopsided smile – lopsided because of the partial paralysis of her face caused by the tumour. The tumour had been effectively deemed inoperable both in Moscow and Kiev and it was obvious that it was going to kill her sooner or later.
Just as it is irresistible to save a life, it is also very difficult to tell somebody that I cannot save them, especially if the pati
ent is a sick child with desperate parents. The problem is made all the greater if I am not entirely certain. Few people outside medicine realize that what tortures doctors most is uncertainty, rather than the fact they often deal with people who are suffering or who are about to die. It is easy enough to let somebody die if one knows beyond doubt that they cannot be saved – if one is a decent doctor one will be sympathetic, but the situation is clear. This is life, and we all have to die sooner or later. It is when I do not know for certain whether I can help or not, or should help or not, that things become so difficult. Tanya’s tumour was indeed the largest I had ever seen. It was almost certainly benign and, at least in theory, could be removed, but I had not tried to operate on such a large tumour in a child her age before, nor did I know anybody else who had tried. Doctors often console each other, when things have gone badly, that it is easy to be wise in retrospect. I should have left Tanya in Ukraine. I should have told her mother to take her back to Horodok, but instead I brought her to London.
Later that year I arranged for Tanya and Ludmilla to come to London and I had organized a mini-van to meet them at Heathrow and deliver them with their accompanying relatives at the entrance to my hospital. How proud and important I felt when I met them there! I carried out both the operations with Richard Hatfield, a colleague and close friend and who had often come out to Ukraine with me.