Admissions: A Life in Brain Surgery

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 always 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.

We returned downstairs to Igor’s office to see some of the outpatients already queuing up in the corridor.

‘The acoustic woman we cancel is… oh!’ – Igor waved his arms in the air – ‘in terrible way. She hope very much you help with the operation and now you go away.’

After the long conversation and all the negotiations it seemed very cruel that her hopes – exaggerated although they might be – should be dashed and that I would not be involved in her operation after all. Besides, after the previous day’s disastrous operating, I felt all the more the need to supervise Igor.

I looked at the diary on my smartphone, resigning myself to the inevitable.

‘I can fly back in ten days’ time,’ I said, ‘to do the op. Just for one day, but then I must leave.’

Igor simply nodded his head, and I could not help but feel I was being taken a little for granted. On the way back from work that evening, my guilt and despair about the blind girl finally overcame me. I started shouting angrily at Igor, not blaming him for the operation but for the way I felt he showed no understanding whatsoever for how difficult I found it to help him, and how utterly insensitive he seemed to other people’s feelings. I ranted and raved for a while – we were crossing the Moskovskyi Bridge in the dark, and the black waters of the Dnieper, no longer frozen, were below us.

‘Oh, I’d better shut up,’ I finally said, worried that my outburst would distract him. He had never seen me behave like this before, and I was close to tears. ‘Or you’ll crash the car.’

‘No,’ he replied, in his best emphatic and Soviet style. ‘I concentrate on driving.’ And at that moment I felt an enormous gulf, as wide as the black river below, open up between us. But it was difficult not to be impressed by his apparent calm and detachment.

Later that week I went to the town of Lviv in the west of Ukraine. I had agreed to give a lecture at the Medical School. I spoke of how difficult it is for doctors to be honest. We learn this as soon as we put on our white coats after qualifying. Once we are responsible for patients, even at the lowest level of the medical hierarchy, we must start to dissemble. There is nothing more frightening for a patient than a doctor, especially a young one, who is lacking in confidence. Furthermore, patients want hope, as well as treatment.

So we quickly learn to deceive, to pretend to a greater level of competence and knowledge than we know to be the case, and try to shield our patients a little from the frightening reality they often face. And the best way of deceiving others, of course, is to deceive yourself. You will not then give yourself away with all the subtle signs which we are so good at identifying when people lie to us. So self-deception, I told the Ukrainians, is an important and necessary clinical skill we must all acquire at an early stage in our careers. But as we get older, and become genuinely experienced and competent, it is something we must start to unlearn. Senior doctors, just like senior politicians, can easily become corrupted by the power they hold and by the lack of people around them who will speak truth to power. And yet we continue to make mistakes throughout our careers, and we always learn more from failure than from success. Success teaches us nothing, and easily makes us complacent. But we will only learn from our mistakes if we admit to them – at least to ourselves, if not to our colleagues and patients. And to admit to our mistakes we must fight against the self-deception that was so necessary and important at the beginning of our careers.

When a surgeon advises a patient that they should undergo surgery, he or she is implicitly saying that the risks of surgery are less than those of not having the operation. And yet nothing is certain in medicine and we have to balance one set of probabilities against another, and rarely, if ever, one certainty against another. This involves judgement as much as knowledge. When I talk to a patient about the risks of surgery what I should really be talking about is the risks of surgery in my hands, in identical cases, and not just what is stated in the textbooks. Yet most surgeons are singularly poor at remembering their bad results, hate to admit to inexperience and usually underestimate the risks of surgery when talking to their patients. And even if the patient ‘does well’ and there are no complications after the operation, it can still be a mistake – it may well have been that the patient did not really need the operation in the first place and the surgeon, keen to operate, overestimated the risks of not operating. Over-treatment – unnecessary investigations and operations – is a growing problem in modern medicine. It is wrong, even if the patient comes to no obvious harm.

Critical to this is to understand that other people are better at seeing our mistakes than we are. As the psychologists Daniel Kahneman and Amos Tversky have shown, our brains are hardwired to fail to judge probabilities consistently. We are subject to many ‘cognitive biases’, as psychologists call them, which distort our judgement. We are too biased in our own favour and, under pressure, as doctors often are, we make decisions too quickly. However hard we try to admit to our mistakes, we will often fail. Safe medicine, I told them, is largely about having good colleagues who feel able to criticize and question us. As I said this, I thought of how difficult it is for surgeons like Igor and Dev who work, more or less, on their own.

I was told afterwards that for some of the Ukrainian audience this was almost a life-changing event – to hear a senior doctor admitting to fallibility, and stressing the importance of teamwork, of listening to criticism and of being a good colleague. It was an ironic counterpoint to my increasing problems with Igor.

It was a cold morning and the cars parked in the road outside my house were shrouded in frost that glittered in the moonlight as I bicycled to Wimbledon station nine days later. I sat on the train, wrapped in the heavy overcoat I wear when travelling to Ukraine in the winter, watching the sunrise over the slate roofs of south London alongside the railway line. I lost count many years ago of how many times I have made this journey. In the past I had been excited to return, but now I only felt the intense sadness and regret that you feel at the end of an affair. I felt obliged to keep my promise to operate on the second woman with an acoustic tumour, but I had decided that I could not go on helping Igor with these major cases. He was not the only surgeon doing these difficult operations in Kiev and I was pretty sure that the State Institute – a very large hospital compared to Igor’s small, independent clinic – was doing many more such cases, and that it had not stood still since I first visited it twenty-four years earlier. Complex brain surgery, for me at least, is a question of teamwork – having the patient ‘on the table’ early in the morning, with colleagues and assistants you trust, and with whom you can share some of the burden of post-operative care.

It is a painful truth in medicine that we must expose some patients to risk, for the sake of future patients. As an experienced surgeon I have an ethical duty to the patient in front of me, but also to the future patients of the next generation of surgeons whom it is my duty to train. I cannot train surgeons less experienced than myself without exposing some patients to a degree of risk. If I did all the operating myself, if I instructed my trainees in every move, they would learn nothing, and their future patients would suffer. I had been willing to help Igor do dangerous cases and inflict the torment on myself of supervising his operating, in the belief that he was creating a sustainable and viable future for his clinic and that Ukrainian patients and his own trainees would benefit from it. I also believed him when he gave me to understand that other surgeons in Ukraine could not do these operations. That had probably been true twenty years ago, but I had come to doubt if it was still the case. I had been naive, perhaps worse than that. My own vanity, my wish for what looked like heroic action by working in Ukraine, had distorted my judgement.

I arrived back in Kiev to find that Igor had cancelled the operation on the young woman with an acoustic for a second time. He did not make it entirely clear to me why he had done so. We had a very unsatisfactory meeting with some of his doctors, which I had asked for. I thought I might be able to improve the working relationships in his department by getting them to talk together, but I was wrong. Igor became very angry. He clearly felt that his doctors had no right to criticize him or to complain, and saw the meeting as a plot against him, though of his colleagues’ doing, and not mine. And I was a well-meaning but stupid outsider, interfering in a foreign country’s internal affairs, having completely failed to understand them.

I returned to London next morning. I subsequently wrote to Igor, trying to explain why I felt unable to go on working with him unless he changed the way he ran his department, so that I felt it had a future, but received no reply. I don’t know what happened to the young woman with the acoustic. I had been working with Igor for twenty-four years, for almost as long as my first marriage. In both cases I had clung to the wreckage for far too long, reluctant to open my eyes and admit that my marriage had ended, that my work with Igor no longer had a future. In both cases it was like waking from a nightmare, but one of my own making, and I felt ashamed.

Six months later I returned to Lviv as I had been invited to give some more lectures to the medical students. I talked once again of the importance of honesty and of being a good colleague. But I also told them how essential it is to listen to patients and how difficult it is to learn how to talk to patients as they will rarely, if ever, tell us whether we have spoken well to them or not, for fear of offending us. We get none of the negative feedback and criticism which is such an important part of learning how to do things better. I spoke to them of the importance of telling patients the truth, something most of us doctors find very difficult, as it often means admitting to uncertainty. I told them how the woman with the suprasellar meningioma whom we had left blind had heard I was in Lviv and had asked to come and meet me. I rather dreaded this but when she came, led into the room by her husband, she did not appear especially angry or unhappy. She told me how she had seen many doctors after the operation – it seemed that they had told her that she would have to wait longer for her eyesight to recover, and she wanted to know from me how long this might take.

‘What should I tell her?’ I asked the students rhetorically. ‘I know she is never going to see again. And should she have been informed of that right from the start?’

I told them that it had seemed cruel to deprive her of all hope immediately after the operation, though I had warned her and her husband – but Igor might have chosen not to translate it – that I thought the chances of recovery werevery small indeed. But after six months it seemed wrong to continue to lie to her. Up till then in the conversation she had been putting a brave face on things and even making a few jokes about her blindness. But then I told her, slowly, that I wanted her to know how sad I was that the operation had been such a disaster. And now she started crying, and her husband started crying, and I had difficulties not crying myself. And I told her that she never would see again and that she must learn to use a white stick and to read Braille. I delivered a little lecture on neuroscience – about how the visual areas of her brain would quickly be converting to the analysis of sound rather than vision, that blind people could lead almost normal lives, although it was very difficult. And so we talked, and at the end she asked when I was returning to Lviv, as she said she would like to come and talk with me again.

After three months of complete neglect, the weeds in the cottage garden had grown to an extraordinary size – there were stately thistles as tall as young trees, with purple flowers reaching over my head. The cow parsley was ten foot high. There were nameless, numberless plants, some with leaves as large as umbrellas. I was slightly ashamed that I did not know their names. The two rusted corrugated-iron sheds near the lake had almost disappeared under the wild, green tide pushing up against them. The abandoned garden had become an impenetrable jungle. There was a glorious, green freedom to the place, and I felt very reluctant to beat it into submission. But I wanted to know what had happened to the apple trees and single walnut tree I had planted in the winter – they had vanished.

Using my petrol-powered hedgecutter on a five-foot drive-shaft, I swept a path towards where I had planted the young walnut tree. At first, to my dismay, all I could see was a dead stalk surrounded by the overbearing, giant weeds – even though I had put black plastic sheeting down around the tree to suppress them. But once I had cleared the surrounding weeds I found, to my joy, that the little walnut tree was alive and well, with large, tender green leaves lower down the stem. I then cut a path to the five apple trees in the opposite corner of the garden, and these I also found to be flourishing – there were even some small apples on their branches.

I spent five hours starting to cut back the weeds and also the overgrown hedge in front of the cottage, which was starting to block the towpath. This was the first hard, physical work I had done for many months and I found, once again, that although exhausting, it was a wonderful panacea. I forgot all my anxieties and preoccupations, I stopped thinking about my future, and my shame, anger and despair over the referendum on Britain’s membership of the European Union. The air was full of the green scent of cut grass, the acrid smell of the giant cow parsley and crushed leaves. All I could think about was the next, painful sweep of the hedgecutter, which was balanced on a sling around my neck. My neck clicked and creaked as I worked, and there were constant showers of pins and needles into my right shoulder, from what I assume is a trapped nerve between the third and fourth vertebrae of my cervical spine – the problem has been troubling me for some months. My neck is so stiff that when I try to look up at the stars at night I tend to fall over backwards.

As my body ages, I notice all sorts of new symptoms. My left hip aches a little when I run, my right knee hurts when I sit cramped in airplanes. My prostatism wakes me at night. I am a doctor, so I know what these symptoms mean, and that they will get worse as I get older. I also know that sooner or later I will develop the first signs of a serious illness, which may well be my final illness. I will probably dismiss them at first, hoping that they will go away, but at the back of my mind I will be frightened. I was staying in an expensive hotel recently, and the multiple mirrors in the extravagant marble-clad bathroom not only showed me my elderly, sagging buttocks – a most offensive reminder of my age – but also a mole just in front of my right ear that I had not noticed before. It could not be seen in a single mirror, face-on. I lay in bed, convinced that I had developed melanoma – the most deadly of the skin cancers – and eventually had to get up and search through photographs on my laptop until I found one of myself in profile, which showed that the mole had been present years ago. Only then could I get back to sleep.

I came home from the cottage garden stiff and exhausted, and slept that night for nine hours. I lay in bed in the morning, my neck and back aching, and began to doubt whether I was still capable of all the work required to restore the cottage. I went back later in the day and started to cut out the broken glass from the windows smashed by the vandals. I had spent many hours one year earlier inserting the ogee-shaped glass panes with small nails – known as glazing sprigs – and putty and mastic.

It started to rain very heavily, and the green water of the usually still canal was so flailed by the rain that it seemed to be boiling. The sight distracted me, my hands slipped and I cut my left index finger badly, over the second metacarpal joint, on one of the glass fragments in the window frame, raising a flap of skin over the extensor tendons. It bled profusely, leaving a brilliant red trail on the window frame. I am so used to the sight of blood in the operating theatre that I had forgotten the fairy-tale beauty of its colour. I looked at it in wonder, until the rain started to wash it away. I probably should have taken myself off to hospital to have my finger stitched, but I did not like the thought of queuing for hours, so I went home with a bloody handkerchief wrapped around it. I improvised a repair with a series of plasters cut into strips, and a splint made with outsize matchsticks from an ornamental matchbox a friend had given me.