‘I know that on one level he meets none of the criteria,’ I said. ‘His symptoms are not intractable; in fact, he has no physical symptoms at all. But he’s living with the knowledge that, at any moment, torrential bleeding will begin that will be the certain death of him. And he’s in the worst possible place to spend what little time he has left – you know what a Surgical Emergency Unit’s like. Please give him his last few days with his family in a place that’s peaceful.’
There was a long pause. I held my breath. Then the consultant told me a bed had unexpectedly become available in the hospice that evening, and the bed was Major Ashdown’s. I put down the phone and slowly exhaled. I went to tell him and his family.
‘You can go to the hospice tonight, Robert,’ I told him. ‘There’s a bed there, and it’s yours.’
Sometimes when a man – in particular a military man whose whole being radiates strength and composure – breaks down and cries it can feel awkward, embarrassing, as though he’s let himself go. But, on this occasion, we all wept freely: the major, who would now enjoy fine wine with his last meals; the family, who would sit with him in tranquillity and comfort, sharing their precious final hours together; and the house officer, who had been enough of a bloody-minded irritant to be an effective advocate on her patient’s behalf.
I later learned he had died two days later, surrounded by his family, in a private room overlooking the hospice garden, where pheasants liked to peck at the grass. That weekend in the supermarket I selected the most expensive bottle of single malt whisky I could find on the shelves, my small contribution to the drinks trolley.
Saving lives is seductive. In my earliest days as a doctor, I loved discovering that I could do things. That I was no longer the floundering bookworm but a competent, capable doctor. I soon found, however, that the adrenaline highs of those early days, though intoxicating, were short-lived. The quiet moments of connection with patients were what I began to cherish. A hand held in mine, a darkest fear calmly heard, the tiniest acts that infused each day with meaning and fulfilment. What had started as an ordeal was beginning to feel like a privilege.
CHAPTER 4
BRILLIANCE
My earliest memories of Christmas involve timorous footsteps down hospital corridors. Every year, my siblings and I would rip open the contents of our stockings in an orgy of excitement, devour our special festive breakfast, then set off for the local cottage hospital in the car with my mother and father. This was the 1970s – before Margaret Thatcher had done away with the vast majority of these small, rural hospitals, some of them barely bigger than a townhouse, that enabled villagers to avoid huge treks to a county hospital and to be treated close to home by the one doctor, their local general practitioner, who was familiar with their lives and illnesses. I dare say that, financially, they were inefficient and that economies of scale mandated their closure. Nevertheless, as the NHS was centralised under Thatcher, rural patients lost something of incalculable value: the intimacy, and thus humanity, of their medical care of old.
My father, having travelled the world as a Royal Naval anaesthetist, had chosen to alight as a GP in a village near a small market town in the West Country within whose cottage hospital he still practised anaesthetics. Babies were born there, great-grandparents died there. My father knew every one of them. Each year, five or six of his patients, invariably men and women in their eighties or their nineties, would spend Christmas stranded in the cottage hospital. Without fail, he would visit them all with his young family in tow. I remember smiling nurses thrusting Quality Street upon us and wondering how many I could stuff away before Mum and Dad cottoned on. At barely five or six years old, what really frightened me was leaving the nurses to meet my father’s patients. We would move as a family unit from bedside to bedside, and I would hover uncertainly at a strange person’s side while Dad chatted away with them warmly and easily. Sometimes, his patients were so ancient and frail I thought they must be about to die. Iodine and bodily fluids, the staple smells of the hospital, made me feel light-headed. Rarely do I remember the patient’s own family being present at these elderly patients’ bedsides. Often it seemed as though the visit from their family doctor was the highlight, so far, of their Christmas Day.
For all my anxieties about what to say, how to behave and whether someone was about to gasp their terminal breath in front of me, one thing was perfectly clear. These faces, so wizened and haggard, would light up with sheer delight at my father’s arrival. I could see that a Christmas visit from their family doctor meant the world to them. And, when my siblings and I crept closer to their sides, often they would beam with joy at the chance to chat with a small child. Somehow I knew that, in spite of my awkwardness and fears, what we gave of our Christmas mornings was vastly eclipsed by what this meant to my father’s bedbound patients. Eventually, as I approached my teens, I’d look forward to our annual visitations. Like my father and mother, I appreciated the pleasure of making a difference, however small.
Like so many children of doctors and nurses, I discovered early the unadorned realities of medicine. When I broke my arm trying to swing on a rope across a river in the highlands of Scotland, landing shoulder first on the riverbed, my father reassuringly mentioned as he drove me to the hospital that the doctors there would probably cut into my arm and fix the broken bones with a metal pin. Coughs and colds never warranted a day off school. With medical parents, we had to be moribund to earn a sick day, and even then would invariably be dragged to my mother’s family planning clinic, to lie sweaty and miserable on an NHS couch while she advised the county’s youth on contraception.
No one had a mother with stories like mine. A former ophthalmic nurse at London’s Moorfields Eye Hospital, she would describe to our appalled delight the jars of medicinal leeches that sat tucked away out of sight. If a patient had bashed or inflamed their eyeball, how better to remove the blood trapped inside than to apply a creature honed by thousands of years of evolution to do one thing superlatively well: the imperceptible extraction of blood? Sometimes I’d lie awake at night, imagining a patient tucked up in their white cotton sheets, trying to sleep with a fat black bloodsucking slug squatting on their eyeball. Tellingly, far from being horrified, I only wished I could see it for myself.
Today, I observe this slightly skewed relationship with our bodies and their functions evolving in my own children. When he was four, my son was asked by his nursery teacher what happens if you do not drink enough water. Instead of replying that you become thirsty, he explained that you become dehydrated and this was very dangerous for your kidneys. Around the same time, he earned his first ever pocket money every few weeks by being a mock patient in my medical school’s paediatrics exams. Nervous students, often with minimal experience of children, would attempt to win him over into allowing himself to be examined. Everything hinged on whether or not he warmed to them. Once, a particularly awkward candidate adopted that slow, loud voice people sometimes think will endear them to tiny children, as though they were mentally incapacitated.
‘Hey, there, little guy, do you know what these are?’ he asked over-brightly, making the ends of his stethoscope perform a little jig around his neck. ‘These are my magic ears! Let’s use these cool magic ears, shall we?’
My son stared up at him balefully. ‘It is a stethoscope,’ he stated bluntly. ‘You use it to listen to my heart.’
Crushed by a four-year-old, the poor man was on the brink of tears. He never quite recovered.
As a child, I was torn between science and the arts. Once, when my mother had laboriously combed the nits from my long hair, I carefully preserved one on a specimen slide to inspect it closely under my microscope. At weekends, I liked to hunt for owl pellets while walking our dog in the countryside, then spend hours dissecting out the tiny rodent bones, obsessively mounting and labelling them on cardboard before writing melodramatic poems about the untimely demise of mice. One day, I found an entire cow’s skull in the undergrowth, half hidden under fer
ns and brambles, almost too heavy to lift. I managed to haul it several miles back home and, when my parents refused to allow me to keep a cow’s skull in my bedroom permanently, I donated it to the school art room so that generations of children hence would have the chance to map its contours.
Sharing with Jeremy Hunt a degree in Philosophy, Politics and Economics (PPE) – though we were not student contemporaries – I came to journalism full of lofty ideals about changing the world through the power of human stories. But even while making films about subjects such as Al-Qaeda’s rise in the UK, Tony Blair’s ‘sexed-up’ Iraq war dossier, the Monica Lewinsky scandal and the state of policing and the NHS in Britain, I kept hankering after medicine. Visiting home, I’d hang on my father’s every word as he told me stories from his practice that captured all the gore, ugliness and beauty of doctoring. Like him, I wanted to be able to read a human body like a book and apply hard science to fixing its frailties. Above all, I had a sneaking suspicion that in the cutthroat world of political and current affairs television – with all its ego, ambition and frequent ruthlessness – I wasn’t, and never would be, myself. The tough carapace I thought I wore to work fooled no one, least of all me. I was so busy trying to fake being Bob Woodward, I feared I might be missing out on the job I was born for.
‘What?’ asked my incredulous boss when I told him I was thinking of retraining. ‘Why on earth would you give up television just to end up being some kind of lowly, part-time GP? You’ll be bored out of your mind. You must be mad.’
He had a point. There is glamour, money and clout in television, even at the current-affairs end of the spectrum. I had travelled all over the world for work, interviewed cabinet ministers, rubbed shoulders with heads of state, enjoyed affluence and agenda-setting power far greater than any I would know again. Giving it all up to go back to school as a first-year medical student was either brave or crazy. But, though my metropolitan media life was superficially seductive, I wanted to do the thing you are never allowed to mention in your medical school interviews. I wanted to help people. Not indirectly, via media influence, but as a hands-on, everyday experience.
There is a vogue these days among some doctors to dismiss the notion of medical vocation as self-aggrandising claptrap. As one American doctor and writer, Louis Profeta, puts it, medicine ‘is just a job’, no more special and important than any other. He despises doctors who want ‘to be fawned over and congratulated on how compassionate they [are], and how they have the hardest jobs in the world, and that no one could possibly understand the work or appreciate how hard their jobs [are].’7 Clearly having one particular job or another makes no one better or more hardworking than their peers, and there are undoubtedly some doctors out there with superiority complexes the size of small planets, though personally I have met very few of these. But that misses the point. Medicine is ‘just a job’ only in the same way that birth, death, disability and bereavement are all just everyday stuff. Run-of-the-mill is losing one’s house key or being booked for speeding, not losing a limb or receiving a diagnosis of terminal cancer. Immersing oneself professionally in the world of human illness – other people’s suffering, pain, hopes and fears – has always seemed to me to be an honour and a privilege, be it as a nurse, doctor, dietician, midwife or hospital porter. And I am not ashamed to say that for me – perhaps inevitably, given all the doctors and nurses in my family – it felt like a calling.
I started moonlighting in the evenings to pass my science A levels and finally, just before my thirtieth birthday, I self-funded my way for five years through medical school by working as a freelance typist during term times and as an ad hoc documentary maker in the long summer holidays. It was hard to stay afloat financially while keeping up with my studies, but from day one I felt liberated, as though finally I was doing what I was meant to. I loved every single bit of it. The complicated science, the dissection room, the conversations with patients, the sense of steeping myself in the knowledge and rigour that would underpin my future practice, the sheer luxury of learning again.
Two years into my medical degree, my old and new lives collided happily when, during the long university summer holiday, I travelled to Phoenix, Arizona, to make a documentary about a remarkable feat of neurosurgery.
Brett Kehrer, a young farmer in his twenties from deepest rural Pennsylvania, had been plagued for years by excruciating headaches. Eventually, his insurance company had agreed to fund an MRI scan. What it revealed was devastating. Ballooning out from the side of one of the most important arteries in the human body – the basilar artery – was an aneurysm. Aneurysms typically start life as a small patch of weakness in the arterial wall against which blood pulsates relentlessly until the artery begins to billow outwards into a fragile, blood-filled sac. Its walls stretch ever more thinly until one day, inevitably, they cannot withstand the high pressures any longer. When an aneurysm bursts inside the brain, the haemorrhage unleashed is often catastrophic. Brett’s aneurysm was one of the largest ever found on MRI. Its sheer dimensions led several neurosurgeons to conclude it was simply inoperable. Brett was given no choice but to wait for the blow-out that would certainly kill him.
But his family refused to give up, their tenacity leading them to Robert Spetzler, one of America’s leading neurosurgeons. Spetz, as he was known in his hospital in Phoenix, gave a remarkable second opinion. He was willing to operate, indeed was confident of success, but only after he had halted Brett’s heartbeat and drained his body of blood in order to deflate the enormous aneurysm, creating a space in which to operate safely. The technique, one Spetz had pioneered twenty years previously, was known as hypothermic cardiac standstill. It relied on the principle that the colder the human brain becomes, the more sluggish its metabolic activity and so the lower its demands for oxygen. In the same way that a child can be submerged under ice for hours, yet miraculously wake up again afterwards, Spetz’s cardiac-standstill patients could be cooled on ice into a state of suspended animation, able to survive intact for up to an hour without a functioning heart, brain, blood or oxygen. The price of Brett’s one chance at life, in essence, was to experience death on a temporary basis.
I landed in Pennsylvania three days before Brett’s surgery. The Kehrer family’s whitewashed wooden farmhouses was nestled deep within fields of thigh-high wheat and barley. Brett towered a good foot above me, a gentle giant, all brawn and civility. Like his family and Ann, his childhood sweetheart turned fiancée, he exuded kindness and old-school Christian values. Without his faith, he told me, he would not have been able to bear the wait before his surgery. The day before he flew to Phoenix, his entire community came together in a Sunday afternoon open-air party, thrown for the benefit of their local boy. There were fiddlers, country dancing, hog roasts, barbecued corn cobs, haybale mountains for the children to scramble on, beer on tap for the adults. The celebration spanned four generations of locals, several hundred of whom had gathered to send Brett off in style, an extraordinary expression of community spirit. None of them knew if they would see him again. It was a scene saturated with poignancy and midsummer sunshine.
‘I’m lucky I have God to put my trust in,’ Brett told me as the night drew in. ‘I believe I am destined to marry Ann this fall. And I believe in Dr Spetzler.’
In the high-stakes world of neurosurgery, Spetz had a reputation for doing operations that others dared not attempt. When the outcomes of major brain surgery include disability so devastating it is potentially a fate worse than death, this was controversial. Spetz thrived on risk, hurling his surgeon’s hands down Arizona’s rocky peaks on his mountain bike and out of helicopters to ski the most extreme slopes in Alaska. Tall and thin, he had the rangy appearance of a mountaineer. He attributed his skill in the operating theatre in no small part to his physical stamina, being able to endure eight or more hours of surgery without a flicker of fatigue undermining the precision of his hand movements.
Aneurysms are the heli-skiing of neurosurgery. Their repair demands the kin
d of calm under pressure that would make most of us quake in our boots. The heart pumps a quarter of our blood through the brain – a litre of blood every minute – and, if the neurosurgeon accidentally tears an aneurysm’s paper-thin walls, their operating field will turn in seconds into a bloodbath. Handling a cerebral aneurysm must, I imagine, feel like bomb-disposal work – except that, in this case, one false move triggers not your own death, but your patient’s.
The basilar artery, Spetz explained on camera, supplied blood to the all-important brain stem, the portion of the brain responsible for controlling a person’s breathing, heartbeat, blood pressure, speech, swallowing, hearing and balance. If, during surgery, Spetz inadvertently interrupted this blood supply, Brett might awake to find himself a victim of the notoriously horrifying ‘locked-in syndrome’. Fully alert and conscious, locked-in patients cannot voluntarily move any part of their body apart from their eyes, the closest thing I could imagine to purgatory. The extraordinary lengths of hypothermic cardiac standstill were an attempt to minimise the chances of such catastrophic damage as the surgeon wielded his scalpel.
Filming Spetz and Brett discussing his operation the day before surgery, I witnessed a very different kind of skill. Somehow, even while candidly describing the most terrifying of worst-case scenarios, Spetz managed to convey both implacable confidence and kindness. I observed Brett and his parents almost visibly relaxing as Spetz answered their questions with quiet authority. He seemed entirely at ease with the risks. Even had they not had their faith in God, Spetz came across as the next best thing. He made you rush to place your trust in him.
I embraced Brett as we said goodbye, acutely aware that these might be the last words we would say to each other. The next morning, reunited beneath the glare of the theatre lights, I found him lying beneath green surgical drapes, eyes taped shut, head shaved and fastened to the operating table by metal pins drilled into his skull. The first phase of the surgery was under way. Spetz and his assistant had peeled back Brett’s scalp and were now cutting a window into his skull. As in all big surgeries, excitement and expectation crackled round the room. A crowd of doctors had gathered to watch. The case, in its own way as epic as King Lear, promised all the drama and suspense of every good theatre production. The electric saw hummed like a dentist’s drill as a scrub nurse sprayed water to keep the skull cool and catch the bone dust as it rose from the freshly sawn edge. My cameraman began to feel queasy as Spetz finally held aloft to the lens a large, intact piece of cranium before placing it, with a clink of porcelain on metal, into the waiting kidney dish.
Your Life In My Hands--a Junior Doctor's Story Page 6