Admissions: A Life in Brain Surgery

13

SORRY

I had gone into work on Sunday as usual. I had been rather depressed about my work in recent weeks and, as I cycled down Tooting High Street in the dark, I decided that it was time to think more positively. Some of my patients came to grief, I told myself, but most did not, and I should remember the successes, not dwell on the failures. I had recently read an article which suggested that stress and anxiety made you more prone to develop Alzheimer’s, and also that positive thinking was good for your immune system. I therefore strode into the hospital that Sunday evening full of good intentions.

There were four patients waiting for me – all with brain tumours. I talked to the first three for quite a long time and it was late by the time I reached the fourth. This last patient was a diabetic Asian woman, a few years younger than myself. Her family had brought her to see me two weeks earlier. Her English was limited and the family told me that she had been behaving increasingly strangely over the preceding two years. She had now started to become very drowsy. I had been unable to get much of a history from her, and discussed her problem and its treatment with her family instead. The scan showed that she had a small and benign meningioma at the front of her brain which was producing a great deal of reactionary swelling in the brain, and it was this swelling – medically called oedema – that was causing her symptoms. Surgery would almost certainly cure her. She would return to being the woman she had been, before her brain had started to become oedematous and her personality to change. Brain-swelling can be a major problem with brain surgery for tumours, and it is standard practice to put patients on steroids before surgery to reduce the swelling. In severe cases, such as with this woman, I start the steroids a week before surgery, and I wrote to her GP asking him to do this and warning him that the steroids would make her diabetes worse.

It was ten o’clock at night by the time I came to her room and found her asleep. A little apologetically, I shook her gently. She woke quickly and looked confusedly at me.

‘It’s Mr Marsh,’ I said. ‘Is everything OK?’

‘Very sleepy,’ she said and rolled over away from me.

‘Are you OK?’ I asked again.

‘Yes,’ she said, and went back to sleep.

The on-call registrar was standing beside me and I turned to him.

‘She was pretty knocked off by the brain-swelling when I saw her two weeks ago,’ I said, shrugging. ‘And it’s late at night, so we’d better leave her alone. The family are in the picture.’

Anxiety is contagious – doctors dislike anxious patients because anxious patients make anxious doctors – but confidence is also contagious, and as I walked out of the hospital I felt buoyed up by the way the first three patients had all expressed such great confidence in me. It allowed me to dismiss the last patient’s sleepiness. I felt like the captain of a ship: everything was in order, everything was shipshape and the decks were cleared for action, for the operating list tomorrow. Playing with these happy nautical metaphors, I went home.

The next day got off to a good start. I had slept well and awoke feeling more enthusiastic and less anxious than I usually do on a Monday morning. The morning meeting went well; there were some interesting cases to discuss and I made a few good jokes at the patients’ expense, which had the junior doctors laughing. The list got off to a prompt start and the first three tumour operations all went perfectly.

I went into the operating theatre, where my registrar had just positioned the fourth patient on the operating table. As I came in the anaesthetist looked at me with an expression that managed to be both accusing and apologetic at the same time. She had the printout from the blood gas analysis done routinely once the patients are asleep, as doctors say, in her hand.

‘Do you know that her blood sugar is forty?’

‘Bloody hell!’

‘And her potassium is seven. And her pH is seven point two. She must be horribly dehydrated as well. Her diabetes is completely out of control.’

‘It must be the steroids – but what was her blood sugar when she came in last night?’

‘It seems that the night staff didn’t check it. Her blood sugar was only slightly up three days ago when she was seen in the pre-admission clinic.’

‘But it should have been checked yesterday anyway, shouldn’t it, since she was a known diabetic?’

‘Yes. It should have been. I thought she seemed a bit slow this morning when I saw her,’ the anaesthetist said, ‘but I thought it was because of the tumour, when I realize now it was because she was going into diabetic coma…’

‘I made the same mistake last night,’ I said unhappily. ‘But I’ve never, ever seen anything like this happen before. Presumably we’ll have to cancel the case?’

‘I’m afraid so.’

‘Bloody hell…’

‘We’ll get her round to the ITU and sort out her diabetes – it will take a few days. She needs to be rehydrated. To carry on with the operation now would be hopelessly dangerous.’

‘Well, she’s had a wacky haircut under GA, even though we haven’t removed the tumour,’ I said to my registrar as we unpinned her head from the operating table and admired the way he had shaved a couple of inches of hair off the front of her forehead.

‘It’s very typical of things going wrong in medicine,’ the anaesthetist commented from the other end of the operating table. ‘It’s lots of little things coinciding together… If she had spoken better English, if she hadn’t already been a bit confused because of the tumour, we’d all have realized that something was going wrong. The failure to check her glucose on admission wouldn’t have mattered so much then… And if she hadn’t been seen in the pre-admission clinic a few days earlier, and instead had just been clerked in and her bloods checked when she was admitted, as we used to do in the past…’

‘The management introduced the pre-admission clinic as an efficiency measure,’ I said.

‘But that was because of the lack of beds and increasing workload,’ she replied. ‘Patients were being admitted later and later on the evening before surgery and there was no time to clerk them in properly.’

‘Should we be doing anything about this?’

‘I think it’s an AIR rather than an SUI,’ she said.

‘A what?’

‘Adverse Incident Report as opposed to a Serious Untoward Incident.’

‘What’s the difference?’

‘An Adverse Incident is anonymous and gets filed somewhere.’

‘But where do you send it?’

‘Oh, some central office somewhere.’

‘But shouldn’t I just go and talk to the ward nurses? Do we really want the bloody managers beating them up?’

‘Well, you could do that. But it’s possible that this is a HONK coma and she might die.’

‘What the hell is HONK?’

‘Hyperosmolar non-ketotic diabetic coma.’

‘Oh,’ was all I could say in reply, realizing that my medicine was getting out of date.

So I went to find the nurses. The ward sister was very upset – she is the most conscientious of nurses, and looks perpetually anxious.

‘I’ll talk to the night staff about it,’ she said, looking desperately unhappy. I was worried that she might burst into tears. ‘She should have had her glucose checked.’

‘Don’t get upset,’ I said cheerfully. ‘These things happen. And the patient hasn’t actually come to any harm. Just talk to the night staff about it. Mistakes happen. We’re only human. I myself have started an operation on the wrong side you know… the important thing is not to make the same mistake twice.’

It had been many years earlier, before we had checklists – an operation on a man’s neck for a trapped nerve in his arm. The operation is done through a midline incision, and you dissect down onto one side of the spinal column to drill out the trapped nerve. As I walked down the operating theatre corridor a few hours later, something was nagging me. My heart lurched when I suddenly realized that I had operated on the wrong side. I could quite easily have covered up the mistake – the incision was midline and post-operative scans do not clearly show where you have operated. The pain is not always relieved by surgery, and I could have told the patient a few weeks later that I would have to operate again, without telling him why. I knew of many stories of surgeons lying to patients in similar circumstances. But instead I went to the ward to see the man. It was the old hospital, and he was in one of the few single rooms, which had a window looking out onto the hospital gardens. It was spring, and you could see the many daffodils I had planted some years earlier. I had planted them while in the throes of a passionate – but one-sided – adulterous love affair. It had quickly fizzled out but it laid the foundations for the end of my marriage three years later. I sat down beside his bed.

‘I’m afraid I’ve got some bad news for you.’ He looked questioningly at me.

‘And what’s that, Mr Marsh?’

‘I’m terribly sorry but I’ve gone and operated on the wrong side,’ I said.

He looked at me in silence for a while.

‘I quite understand,’ he then said. ‘I put in fitted kitchens for a trade. I once put one in back to front. It’s easily done. Just promise me you’ll do the right side as soon as possible.’

As I say to my juniors, when you make a stupid mistake, pick your patient carefully.

I went back to the operating theatre and looked up the phone numbers of the various patients’ relatives and rang them to report on the day’s events. The first three patients were all well: an old man with a pituitary tumour whose eyesight was already better, a monosyllabic garage mechanic on whom I had carried out an awake craniotomy and who had become less monosyllabic now that the operation was over, and a young woman with a tumour at the base of the skull who now had a stiff and painful neck but was otherwise surprisingly well. The last patient was on a ventilator on the ITU having her diabetic coma treated.

So I went home. The day had perhaps been a little chaotic, but none of the patients had come to serious harm. I remained determined that my resolution to see the positive side of neurosurgery should not be broken.

By eleven o’clock I was just about to go to bed when my mobile phone rang. I was upstairs brushing my teeth, and as I had left my phone charging on the kitchen table, I had to stumble naked down the stairs in a hurry, cursing and swearing. Neurosurgeons do not enjoy phone calls in the evening after a day’s operating – it usually means that something has gone seriously wrong. The phone had stopped ringing by the time I got to it. The landline phone then started ringing just as the mobile phone also started ringing again with a voicemail message, so I cursed even more as I answered the landline phone.

‘The meningioma has blown both her pupils – scan shows severe swelling,’ I heard the voice of Vlad, the on-call registrar, telling me.

For a moment I was too surprised to reply.

‘But I didn’t even operate! I was expecting the other patients to get into trouble…’

‘Maybe the diabetes, or the rehydration, made the brain swelling worse,’ Vlad said. ‘What do you want to do?’

‘I don’t know,’ I replied. I sat down on a kitchen chair, stark naked, completely lost for an answer.

‘Her biochemistry is OK now. The anaesthetists have corrected it,’ Vlad added.

‘She’s probably had it,’ I said after a while. ‘But I really don’t know what to do… if we operate, do a decompressive craniectomy to allow room for the swelling, she might survive but then be left wrecked – and if we don’t operate she might just pull through and we can operate at a later date. I don’t know what to do,’ I repeated.

Vlad didn’t comment as I stared vacantly at the kitchen wall.

‘It’s a unique set of circumstances,’ I said. ‘It’s a toss-up either way.’

I thought of the man with a hammer to whom everything tends to look like a nail.

‘We’re surgeons,’ I went on. ‘We tend to see surgical solutions to everything. It doesn’t necessarily mean operating is the right thing to do.’

Again Vlad said nothing, waiting for a decision. I sat silently for a while, willing my unconscious to tell me what to do, as the problem was far too unusual for reason and science to give me an answer, although an immediate decision was called for. Vlad was very experienced and shortly to become a consultant himself. The operation was well within his abilities. I could go to bed, I told myself.

‘Take her to theatre. Take the front of her skull off and remove the tumour. If the brain is hopelessly swollen leave the bone out.’

‘OK,’ Vlad said, pleased that a decision had been made and happy at the prospect of operating.

I remained on the kitchen chair for a long time, staring at the kitchen wall. There was no great need for me to go to the hospital, but I realized that I would not get to sleep with the thought that the operation was going on while I lay in bed, so I quickly dressed and drove the short distance, along dark and deserted streets, back to the hospital. I ran up the stairs to the operating theatres on the second floor, but to my annoyance found that the patient had not yet arrived. I went round to the ITU. The patient was lying unconscious on her bed, on a ventilator, surrounded by doctors and nurses.

‘Don’t bloody wait for the bloody porters!’ I said furiously. ‘I’ll take her to theatre.’ So there was the usual hustle and bustle as all the machinery connected to the patient – the syringe drivers, monitors, catheters, IV and arterial lines and ventilator – was disconnected or reconnected to portable equipment and then we set off, a clumsy procession of doctors and nurses, bent double, pulling the bed or pushing or carrying equipment down the long corridor to the operating theatre.

Once there, I had the poor woman’s head open within minutes. I rested my gloved finger on her brain.

‘Brain’s very slack,’ I muttered.

‘It’s probably the ventilation and the drugs she’s been given,’ Vlad said. ‘Look – the brain’s pulsatile.’ He pointed to the way that the yellow and light-brown mass, covered in blood vessels, that was her brain was gently expanding and contracting in synchrony with the bleeping of the cardiac monitor on the anaesthetic machine. ‘She’ll be OK.’

‘That’s what they say,’ I said. ‘But it doesn’t mean much in my experience. When she blew her pupils she might well have suffered catastrophic infarction and most of her brain died. That could be why it’s not swollen now. By tomorrow it may well start swelling again as it finally dies off. But she might just pull through…’ I added, hoping against hope. I picked up a dissector and sucker and it took only a matter of minutes to remove the tumour which had caused all the trouble. It was absurdly easy.

We finished the operation quickly. At the end of these emergency operations, the critical moment is when one anxiously holds open the unconscious patient’s eyelids to see if the pupils have started to constrict in reaction to light again. If they constrict, the patient will live.

‘I think the left pupil is reacting,’ the anaesthetist said happily, peering at the blank black pupil of the patient’s left eye. The right eye was hidden by the head bandage I had wound around the patient’s head after stitching up the scalp.

I looked. I had to look very closely, my face almost touching the woman’s, as I had forgotten to bring my reading spectacles with me in my hurry to get to the hospital.

‘I don’t think so,’ I replied. ‘Wishful thinking.’

I wrote a brief operating note, asked Vlad to ring the family once she was out of theatre, and drove home.

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.