Admissions: A Life in Brain Surgery

12

UKRAINE

Igor, as always, is waiting for me at the airport, his head in a tight woollen cap, bobbing up and down in the crowd outside the exit, trying to spot me. His characteristically stern expression breaks into a brief smile when he sees me, but in recent years the smile has become briefer and briefer. His serious enthusiasm, which had so impressed me when we first met, seems to have changed into something grim and rather different.

I awkwardly accept his kisses. We argue over who should carry my suitcase (often full of second-hand surgical equipment) and climb into his van. We drive into the city to the hospital, and Igor holds forth in his broken, staccato English. It was only when I heard Ukrainian spoken by the Ukrainian poet Marjana Savka in Lviv, in the west of the country, that I realized Ukrainian could be very beautiful, and not the rather harsh, declamatory language spoken by Igor.

‘Financial crisis terrible. Everybody have money problems. Everybody unhappy. Before crisis my doctors make maybe two thousand dollars in month, now only four, maybe five hundred.’ This monologue continues until we reach the hospital. I know that there will be a long queue of patients in the corridor outside the small, cramped office waiting to see me, almost all of them with large and terrible brain tumours and other, often hopeless, neurosurgical problems.

‘Two acoustics to see,’ he says, as we pass the tall and ugly apartment blocks on the city’s outskirts, looking bleak and unwelcoming in the winter mist. There is a thin layer of snow on the ground. I think, not for the first time, how grim Ukraine can be, and how tough its inhabitants have to be to survive. ‘Many interesting cases, Henry,’ he says happily.

‘Well, interesting for you,’ I reply grumpily.

‘You lose enthusiasm since you retire,’ he replies in a disapproving tone of voice.

‘Maybe I’m just getting old.’

‘No, no, no!’ he cries, and then, reverting to his favourite topic, goes on to tell me that twenty Ukrainian banks have collapsed in the preceding year.

We cross the great River Dnieper on one of the many massive bridges built during the Soviet era. The river is frozen, but only in places, and I can see below us the small figures of dozens of people on the shelves of ice, close to the oil-black water, fishing through holes they have cut.

‘People drown every day,’ Igor observes. ‘Twenty this year. It is disaster. It is silly.’

We drive up the steep cobbled street leading from the banks of the River Dnieper to the centre of Kiev and turn onto Institutskaya Street, where a few months earlier dozens of protesters had been killed by snipers in the Maidan demonstration. The SBU hospital where Igor rents space for his private clinic is just round the corner on Lipska Street. The SBU, once known as the KGB, being an important organ of the State, naturally had its hospital in the centre of Kiev. I had been in Kiev on several occasions during Maidan. I spent as much time as I could mingling with the thousands of demonstrators, proud to feel a small part of it.

I had first gone to Ukraine in 1992, just after the collapse of the Soviet Union. Entirely by chance I had met Igor in one of the hospitals I had visited. We became friends and I had been travelling to Ukraine for a few days each year ever since to help him with his surgery. At that time medicine in Ukraine was decades behind the West. I found many secondhand instruments and microscopes for him and taught him everything I knew. At first this was all spinal surgery, and Igor was soon probably the most accomplished spinal surgeon in Ukraine. As his fame spread, more and more patients came to his outpatient clinic with problems in the brain. He badgered me constantly to help him develop brain surgery, insisting that the large and difficult acoustic tumours he had seen me operating on in London could not be treated properly in Ukraine. In Ukraine, because of delays in diagnosis, these tumours are usually very large and the operations correspondingly difficult and dangerous. These are tumours which grow off the hearing nerves within the skull and can become large enough to compress the brain and slowly kill the patient. On my very first visit to Kiev in 1992 I went with two other colleagues from my hospital, one an anaesthetist and the other a pathologist. We visited the major State neurosurgical hospital, one of the two major centres for brain surgery in all of the Soviet Union, where we delivered lectures. My pathology colleague was taken on a tour of the pathology department and came back afterwards to tell us, looking a little shaken, of a series of buckets he had been shown containing the brains of patients who had died after surgery for acoustic tumours.

When Igor and his wife Yelena came to London to Kate’s and my marriage in 2004, all he could talk about was the need to develop acoustic neuroma surgery. Eventually Kate told him that she could stand it no longer. ‘Igor,’ she said, ‘I’m sorry, but we’re going to have a moratorium on the word acoustic. We have to talk about something else. We cannot spend every mealtime, every day, with you trying to persuade Henry to show you how to operate on acoustics.’ Just for once, Igor did what he was told for a few days. Even I found his intense enthusiasm for neurosurgery and utter commitment to it rather tiring at times. Eventually I agreed to help him, but not without misgivings, as the treatment of patients with brain tumours involves much more than just operating.

In the years before Maidan I would return to England and enthusiastically tell people: ‘Ukraine is a really important country!’

This was usually met with a puzzled expression.

‘It’s part of Russia, isn’t it?’

And I would then deliver a little lecture on how Ukraine was one of the great historical watersheds, where Europe met Asia, where democracy met despotism.

I think most of my colleagues and friends in England regarded my slight obsession with Ukraine as an eccentric hobby, but when Maidan started and all of Europe saw the images of the fighting between the demonstrators and the Berkut riot police, resembling medieval battle scenes with staves and shields and catapults, and blazing car tyres filling Independence Square with flames and black smoke, I think I could claim some prescience. Igor had had many problems during the twenty-four years we had been working together. He had been something of a medical revolutionary and dissident, using what he had learnt from me to try to improve neurosurgery in Ukraine. The medical system in Ukraine was as authoritarian as the political system and he made many enemies and had many difficulties. But his patients did very well and eventually his clinic became well established. The many attempts by senior colleagues and administrators to thwart him failed. There was something heroic about what he had achieved, and I felt that my work with him over the years was part of the same struggle against corrupt autocracy as the Maidan protests.

There is a turnstile in the small lobby at the entrance to the hospital. The tiled floor is wet with thawing snow brought in on people’s boots. Patients and their families can come and go quite freely, but as I am a foreign doctor I am regarded with suspicion by the SBU. When I arrive I have to show my passport to the unsmiling young soldiers behind the glass window next to the turnstile.

‘You might be terrorist!’ Igor says as the turnstile is unlocked and it clanks in an authoritarian sort of way as I push through it.

‘They are SBU soldiers, and hospital has no control of them,’ he added.

‘It must be an awfully boring job.’

‘No, no, no. They are happy not to be at frontline.’

I feel imprisoned once I am inside – imprisoned by my lack of Ukrainian or Russian, and intimidated by the soldiers at the entrance. It is probably quite unnecessary. I once arranged to wait for a film-maker to meet me at the entrance to the hospital. One of the soldiers had to keep me company on the pavement outside until she arrived. When she came she translated what the soldier had started to say to me. I thought he was threatening me with arrest or something similar, but apparently it was a long speech of thanks for my helping Ukrainian patients.

I look back with some shame on the years of my training. It is complete torment to assist a less experienced surgeon than yourself to do a difficult and dangerous operation. Some of the senior surgeons I had worked for simply couldn’t do it and left me to get on with it – the so-called ‘see one, do one’ method of surgical teaching which was one of the more egregious aspects of some English surgical training in the past. I look back with horror on some of the mistakes I made when I was a trainee and, even worse, on some of the mistakes made by my trainees – for which I must hold myself responsible – once I became a senior surgeon myself. But some of my trainers, I now realize, had shown great patience and kindness (and courage) in taking me through operations. I had not thought for a moment how difficult it might be for them, so self-important was I, and so engrossed in what I was doing. Igor, I now realize, is no different. I don’t think he ever saw how difficult I found the long outpatient clinics, which could easily last ten or twelve hours, or the agonies I went through as he operated on major brain tumour cases. The more I let him do, the more he would learn, but the greater the risk to the patient and the more anxious I would become. If it seems that it is safe for him to carry on, I retire to the recovery room next to the operating theatre and stretch myself out on the trolley by the window, resting my head on a cardboard box. I would be simultaneously bored and tense, going into the theatre at regular intervals to see how he was getting on and whether I should take over.

‘Do you want me to scrub up?’ I ask.

‘No, no, not yet,’ is the usual reply, but sometimes he asks for my help, and sometimes I insist that I take over.

On one previous visit in winter, some years before Maidan, the view through the window as I lay there was uncommonly beautiful – of fine snowflakes drifting down from a grey sky, and of the tall pine and silver birch trees in the hospital courtyard bending with the weight of the snow on their branches. The courtyard itself was virginal white, with only a few footprint tracks on the paths. We were doing a very difficult tumour in a young woman. Both Igor and I thought that I would have to help him, but in the event Igor did almost all of it and she awoke perfectly.

I had passed the long hours by the window watching the snow fall. I thought it was the crowning moment of the many years I had spent teaching him. But on one of my regular visits two years later I heard, only by accident, that the woman had died some months after the operation, from a post-operative infection in her brain. His silence over this, and the way in which he had not sought my advice when she fell ill after the surgery, made me furious and I came close to telling him that I would never return to Ukraine, but eventually I thought better of it. I was told later that he had thought I would refuse to come back to Ukraine if he did tell me, which was, of course, the complete opposite of the truth and showed how little he understood me. It reminded me of the long delays before the Soviet government admitted to the catastrophe at Chernobyl.

I told Igor how angry I was, and it was a long time before he grudgingly apologized, but the words of apology seemed almost to choke him, so difficult did he find it to speak them. I went on to tell him how I had once made a similar mistake myself with a post-operative infection, with catastrophic consequences for the patient, and had also failed to ask for help. I still have a photograph of the young Ukrainian woman, which I had taken when I first met her in the cramped little clinic room. She is looking pleadingly at me. Something died within me when I heard of her death, although I still wanted to come out to Ukraine – it had become such an important part of my life. It was only some years later that I understood how wilfully blind I had become. I came to regret bitterly that I had not left him then. I should never have agreed to help him with brain tumour surgery.