Admissions: A Life in Brain Surgery

2

LONDON

I had decided to resign from my hospital in London in a fit of anger in June 2014, four months before I came across the lock-keeper’s cottage. Three days after handing in my letter of resignation I was in Oxford, where I live with my wife Kate at weekends, running along the Thames towpath for my daily exercise. I was panic-stricken about what I would do with myself once I no longer had my work as a neurosurgeon to keep me busy and my mind off the future. It was in exactly the same place, on the same towpath, but walking, not running, many years earlier, in a much greater state of distress, that I had decided to abandon my degree in politics, philosophy and economics at Oxford University – much to my parents’ distress and dismay when they got to hear of it.

While I ran beside the river, I suddenly remembered a young Nepali woman with a cyst in her spine that had been slowly paralysing her legs. I had operated on her two months previously. The cyst turned out to be cysticercosis, a worm infection common in impoverished countries like Nepal but almost unheard of in England. She had returned to the outpatient clinic a few days earlier to thank me for her recovery; like so many Nepalis, she had the most perfect, gentle manners. As I ran – it was late summer, the river level was low and the dark-green water of the Thames seemed to be almost motionless – I thought of her and then thought of Dev, Nepal’s first and foremost neurosurgeon, more formally known as Professor Upendra Devkota. We had been friends and surgical trainees together in London thirty years ago.

‘Ah!’ I thought. ‘Perhaps I can go to Nepal and work with Dev. And I will see the Himalayas.’

Both decisions, separated by forty-three years – to abandon my first degree and to resign from my hospital – had been provoked by women. The first was a much older woman, a family friend, with whom I was passionately and wholly inappropriately in love. Although twenty-one years old, I was immature and sexually entirely inexperienced, and had had a repressed and prudish upbringing. I can see now that she seduced me, although only with one passionate kiss – it never went beyond that. She burst into tears immediately afterwards. I think she had been attracted by my combination of intellectual precocity and awkwardness. Perhaps she thought that she could help me overcome the latter. She probably later felt ashamed, and perhaps embarrassed, by my passionate, poetic response – the poems now long forgotten and destroyed. She died many years ago, but my intense embarrassment about this episode is still with me now, even though the kiss resulted in my finding a sense of meaning and purpose to my life. I became a brain surgeon.

I was confused and ashamed by the pangs of my frustrated and absurd love, and overwhelmed by feelings of both love and rejection. I felt there were two armies fighting within my head and I wanted to kill myself to escape them. I tried to compromise by pushing my hand through a window in the flat where I had student digs beside the Thames in Oxford, but the glass would not break or, rather, a deeper part of my self showed a sensible caution.

Unable to translate my unhappiness into physical injury, I decided to run away. I made the decision while walking along the Thames towpath in the early hours of the morning of 18 September 1971, having fortunately failed to hurt myself. The towpath is narrow, in summer dry and grassy, in winter muddy and with many puddles. It passes through Oxford and past Port Meadow, the wide flood meadow to the north of the city. My childhood family home was a few hundred yards away. I might even have seen it as I walked miserably along the river – the area was deeply familiar. If I had gone a little further and followed a narrow cut, linking the river to the Oxford canal, I would have come across the lock-keeper’s cottage, but I think I had already turned back by then, having made my decision. The old man, though young at that time, would already have been living there.

I abandoned my university degree for unrequited love, but it was also a rebellion against my well-meaning father, whose belief in the virtue of attending Oxford or Cambridge university was an article of faith. He had been an Oxford don before moving to London. He deserved better from me, but such rebellious behaviour is buried deep within the psyche of many young people; and my father, the kindest of men, but who had himself once rebelled against his own father, resigned himself to my decision. I left my predictable professional career path to work as a hospital theatre porter in a mining town north of Newcastle. I hoped that by seeing other people suffering with ‘real’, physical illness I would somehow cure myself. My subsequent life as a neurosurgeon was to teach me that the distinction between physical and psychological illness is false – at least, that illnesses of the mind are no less real than those of the body, and no less deserving of our help. A friend’s father, John Maud, was the general surgeon in the hospital, and although he had never met me, at his daughter’s request he got me a job in his operating theatre. I find it quite extraordinary that he did this, just as I find it remarkable that my Oxford college agreed that I could return after a year’s truancy. It is impossible to know how my life would have developed without so much help and kindness from others.

It was my experience as a theatre porter, watching surgeons operate, that led me to become a surgeon. It was a decision that came quite suddenly to me, while talking to my sister Elisabeth – a nurse by training – as she did her family’s ironing, when I returned to London for a weekend. I had gone to visit her to hold forth at great length about my unhappiness. It somehow became clear to me – I can’t remember how – that the solution to my unhappiness was to study medicine and become a surgeon. Perhaps Elisabeth suggested it to me. I took the train back to Newcastle on the Sunday evening. As I sat in the carriage, seeing myself reflected in the dark glass of the window, I knew that I had now found a sense of purpose and meaning. It would be another nine years, however, when I was already a qualified doctor, before I discovered the all-consuming love of my life – the practice of neurosurgery. I have never regretted that decision, and have always felt deeply privileged be a doctor.

I am not sure, however, if I would take up medicine or neurosurgery now, if I could start my career all over again. So many things have changed. Many of the most challenging neurosurgical operations – such as operating on cerebral aneurysms – have become redundant. Doctors are now subject to a regulatory bureaucracy that simply did not exist forty years ago and which shows little understanding of the realities of medical practice. The National Health Service in England – an institution I passionately believe in – is chronically starved of funds, since the government dares not admit to the electorate that they will need to pay more if they want first-class health care. Besides, there are other, more pressing problems now facing humanity than illness.

As I returned to Newcastle with my new-found sense of having a future, I read the first issue of a magazine called The Ecologist. It was full of gloomy predictions about what was going to happen to the planet as the human population continued to grow exponentially, and as I read it I wondered whether becoming a doctor, healing myself by healing others, might not be a little self-indulgent. There might be more important ways of trying to make the world a better place – admittedly less glamorous ones – than by being a surgeon. I have never entirely escaped the view that being a doctor is something of a moral luxury, by which doctors are easily corrupted. We can so easily end up complacent and self-important, feeling ourselves to be more important than our patients.

A few weeks later, back at work as a theatre technician, I watched a man undergoing surgery to his arm. He had deliberately pushed his hand through a window in a drunken rage and his hand had been left permanently paralysed by the broken glass.

The other woman who quite unintentionally played a pivotal role in my life – at the end of my neurosurgical career – was the medical director of my hospital. She was sent one day by the hospital’s chief executive to talk to the consultant neurosurgeons. I believe that we had the reputation of being arrogant and uncooperative. We were too aloof and not playing our part. I was probably considered to be one of the worst offenders. She came into our surgeons’ sitting room – the one with the red leather sofas that I had bought some years previously – accompanied by a colleague who was called, I think, the Service Delivery Unit Leader (or some similarly absurd title) for the neurosurgery and neurology departments. He was a good colleague and on several occasions had saved me from the consequences of some of my noisier outbursts. He was suitably solemn on this occasion, and the medical director was looking perhaps a little anxious at the prospect of disciplining eight consultant neurosurgeons. She sat down and carefully placed her large pink handbag beside her on the floor. Our Service Delivery Unit Leader made a little introductory speech and handed over to the medical director.

‘You have not been following the Trust dress code,’ she declared. Apparently this meant that the consultant neurosurgeons had been seen wearing suits and ties. I had always thought that dressing smartly was a sign of courtesy to my patients, but apparently it now posed a deadly risk of infection to them. A more probable, albeit unconscious, explanation for the ban – which came from high up the NHS hierarchy – was that the senior doctors should not look any different from the rest of the hospital staff. It’s called teamwork.

‘You have not been showing leadership to the juniors,’ the medical director continued. This meant, she told us, that we had not been making sure that the junior doctors had been completing the Trust computer work on time when patients were discharged. In the past we had had our own neurosurgical discharge summaries, which had been exemplary, and I had always taken some pride in them, but they had now been replaced by a Trust-wide, computerized version of such appallingly poor quality that I, for one, had lost all interest in making sure that the juniors completed them.

‘If you do not follow Trust policies, disciplinary action will be taken against you,’ she concluded. There was no discussion, no attempt to persuade us. The problem, I knew, was that the hospital was about to be inspected by the Care Quality Commission, an organization that puts great store by dress policy and the completion of paperwork. She could have said that she knew this was all rather silly, but could we please help the hospital, and I am sure we would all have agreed – but no, it was to be disciplinary action. She picked up her pink handbag and left, followed by the Service Delivery Unit Leader, who looked a little embarrassed. So I sent off my letter of resignation the next day, unwilling to work any longer in an organization where senior managers could demonstrate such a lack of awareness of how to manage well, although I prudently postponed the date of my departure until my sixty-fifth birthday so that my pension would not suffer.

It is often said that it is better to leave too early rather than too late, whether it is your professional career, a party, or life itself. But the problem is to know when that might be. I knew that I was not yet ready to give up neurosurgery, even though I was so anxious to stop working in my hospital in London. I hoped to go on working part-time, mainly abroad. This would mean that I would need to be revalidated by the General Medical Council if I were to remain a licensed doctor.

Aircraft pilots need to have their competence reassessed every few years and, it is argued, it should be no different with doctors, because both pilots and doctors have other people’s lives in their care. There is a new industry called Patient Safety, which tries to reduce the many errors that occur in hospitals and which are often responsible for patients coming to harm. Patient Safety is full of analogies with the aviation industry. Modern hospitals are highly complex places, and many things can go wrong. I accept the need for checklists and trying to instil a blame-free culture, so that mistakes and errors are identified and, hopefully, avoided. But surgery has little in common with flying an aircraft. Pilots do not need to decide what route to fly or whether the risks of the journey are worth taking, and then discuss these risks with their passengers. Passengers are not patients: they have chosen to fly, patients do not choose to be ill. Passengers will almost certainly survive the flight, whereas patients will often fail to leave the hospital alive. Passengers do not need constant reassurance and support (apart from the little charade where the stewardesses and stewards mime the putting-on of life jackets and point confusingly to the emergency exits). Nor are there anxious, demanding relatives to deal with. If the plane crashes, the pilot is usually killed. If an operation goes wrong, the surgeon survives, and must bear an often overwhelming feeling of guilt. The surgeon must shoulder the blame, despite all the talk about blame-free culture.

To revalidate doctors is important but not easy, and it took the General Medical Council in Britain many years to decide how to do it. As well as being ‘appraised’ by another doctor, I had to complete a ‘360-degree’ assessment by several colleagues, and one by fifteen consecutive patients. I was tempted, when instructed to provide the names of colleagues, to name ten people who disliked me (alas, not very difficult), but I chickened out, and instead listed various people who would be unlikely to find great fault with me. They ticked the online boxes, saying how good I was, and how I achieved a satisfactory ‘work–life balance’, and I returned the favour when they sent me their 360-degree forms.

I was provided with fifteen questionnaires to hand out to patients. The exercise was managed by a private company – one of the many profitable businesses to which much NHS work is now outsourced. These companies prey off the NHS like hyenas off an elderly and disabled elephant – disabled by the lack of political will to keep it alive.

I was told to ask the patients to complete the lengthy, two-sided form after I had seen them in my outpatient clinic and to have them return the forms to me. Not surprisingly, I was on my best behaviour. Besides, the patients would probably have been reluctant to criticize me to my face. My patients obediently filled in the forms. It seemed to me that whoever would be examining them might well suspect that I had fraudulently completed them myself, as all the completed forms were both eulogistic and anonymous. I was tempted to do this but to accuse myself of being impatient and unsympathetic – in short, of being a typical surgeon – and see if this made any difference to the absurd charade.

My first neurosurgical post had been as a senior house officer in the hospital where I had trained as a medical student. There were two consultant neurosurgeons, the younger one very much my mentor and patron. The senior surgeon retired shortly after I started working in the department. He rang me once at night when I was on call, seeking advice about a friend of his who had passed out at home, asking whether this might be due to his blood-pressure drugs. It was fairly obvious that the friend was himself. I remember once standing with him in front of an X-ray screen looking at an angiogram – an X-ray that shows blood vessels – of a patient with a difficult aneurysm, and him telling me to ask his younger colleague to take over the case.

‘By my age, aneurysm surgery is not good for the coronaries,’ he said. I knew that recently one of the senior neurosurgeons in Glasgow had clipped an aneurysm and then immediately collapsed with a major heart attack.

My senior consultant’s career ended gloriously with a successful operation on a large benign brain tumour in a young girl. She recovered perfectly and a few days later, still in her hospital gown and with a shaven head, came to his retirement party to present him with a bouquet of flowers. I believe that he died a few months afterwards. My own surgical career, thirty-four years later, was to end ignominiously.

I had two weeks left before retiring and I was looking at a brain scan with my registrar, Samih.

‘Fantastic case, Mr Marsh!’ he said happily, but I did not reply. Until recently, I would have said exactly the same myself. The difficult and dangerous operations were always the most attractive and exciting ones, but as my career approached its end I was finding that my enthusiasm for such cases, and for the risk of disaster, was rapidly diminishing. The thought of the operation going badly, and of my leaving a wrecked patient behind me after my retirement, filled me with dismay. Besides, I thought, as I am soon to give all this up, why must I go on inflicting it on myself? But the patient had been referred to me personally by one of the senior neurologists. Suggesting that one of my colleagues do the operation instead was out of the question: it was just not compatible with my self-esteem as a surgeon.

‘It should separate away from all the vital bits,’ I said to Samih, pointing to the tumour on the scan. The tumour was growing at the edge of the foramen magnum. Damage to the brainstem or the nerves branching off it can be catastrophic for the patient, including paralysis of swallowing and coughing. This can lead to fluid in the mouth getting into the lungs and causing a very severe form of pneumonia that can easily be fatal. At least the tumour appeared benign. It did not look as though it would be stuck to the brainstem and spinal nerves so, at least in theory, it should be possible to remove the tumour without causing severe damage. But you can never be certain.

It was Sunday evening and Samih and I were sitting in front of the computer at the nurses’ station on the men’s ward. We both regretted the fact that our work together was soon to end. The close relationship you can have with your trainees is one of the great pleasures of a surgeon’s life.

It was early March, and it was dark outside but the sky was clear; there was a very bright full moon, low over south London, which I could see through the ward’s long line of windows. There had been a scent of spring in the air as I had bicycled in to work, along the back streets, the moon cheerfully racing along beside me over the slate roofs of the terraced houses.

‘I haven’t met him yet,’ I said. ‘So we had better go and talk to him.’

We found the patient in one of the six-bed bays, the curtains drawn around the bed.

‘Knock, knock,’ I said, drawing the curtain aside.

Peter was sitting up. There was a young woman in the chair beside the bed. I introduced myself.

‘I’m so pleased to see you at last,’ he said, looking much happier than most of my patients when I first meet them. ‘The headaches have really been getting awful.’

‘Have you seen the scan?’ I asked.

‘Yes, Dr Isaacs showed it to me. The tumour looked huge.’

‘It’s not that big,’ I replied. ‘I have seen many bigger, but then one’s own tumour always looks enormous.’

Samih had pulled along one of the new mobile computer stations from the corridor and placed it at the end of Peter’s bed. He summoned up the brain scan while we talked.

‘That’s a centrimetric scale there,’ I explained, pointing to the edge of the scan. ‘Your tumour is four centimetres in diameter. It’s causing hydrocephalus – water on the brain – it’s acting like a cork in a bottle and trapping the spinal fluid in your head where it is supposed to drain out at the bottom of your skull. Without treatment – although I apologize for terrorizing you – you only have a few weeks to live.’

‘I can believe that,’ he said. ‘I’ve been feeling really lousy, though the steroids Dr Isaacs started me on helped a bit.’

We talked for a while about the risks of the operation – death or a major stroke were possible but unlikely, I said, and he might have difficulty swallowing. He nodded and told me that in recent weeks he had sometimes choked when eating. We talked also about his work, and about his children. I asked his wife what they knew about their father’s illness.

‘They’re only six and eight,’ she said. ‘They know their Daddy is coming to hospital and that you are going to make his headaches better.’

While we talked, Samih filled up the long consent form and Peter signed it quickly.

‘I’m not at all frightened,’ he said, ‘and I’m really glad I’ve got you to do it just before you retire.’ I let this pass – patients want to think their surgeon is the best and don’t particularly like it when I tell them that I am not and that I am dispensable. Samih noted his wife’s phone number down on the edge of the consent form.

‘I’ll ring you after the op,’ I said to Peter’s wife. ‘See you tomorrow.’ I waved to Peter and slipped out between the curtains. There were five other men in the room who looked up at me as I left – no doubt they had all listened to the conversation with great interest.

As I cycled to work next morning, I reflected on the strange fact that almost forty years of working as a surgeon were coming to an end. I would no longer have to feel constantly anxious, with my patients so often on the edge of disaster, yet for almost forty years I had never had to worry about what to do each day. I had always loved my work, even though it was often so painful. Every day was interesting; I loved looking after patients, I loved the fact that I was – at least in my own little hospital pond – quite important, indeed my work had frequently felt more like a glorious opportunity for adventure and self-expression than mere work. It had always felt profoundly meaningful. But in recent years this love had started to fade. I attributed this to the way in which working as a doctor felt increasingly like being an unimportant employee in a huge corporation. The feeling that there was something special about being a doctor had disappeared – it was just another job, I was just a member of a team, many of whose members I did not even know. I had less and less authority. I felt less and less trusted. I had to spend more and more time at meetings stipulated by the latest government edicts that I felt were often of little benefit to patients. We spent more time talking about work rather than actually working. We would often look at brain scans and decide whether the patient should be treated or not without any of us having ever seen the patient. Like almost all the doctors I knew, I was becoming deeply frustrated and alienated.

And yet despite this, I was still burdened with an overwhelming sense of personal responsibility for my poor patients. But perhaps my discontent was because I had less and less operating to do – although I was lucky compared to many other surgeons in that I still had two days of operating a week. Many of my colleagues are now reduced to a single day each week; you may well wonder what they are supposed to do for the rest of the week. Recent increases in the number of surgeons have not been matched by any increase in the facilities we need in order to operate. Or then again, perhaps it was simply because I was getting old and tired and it was time to go. Part of me longed to leave, to be free from anxiety, to be master of my own time, but another part of me saw retirement as a frightening void, little different from the death, preceded by the disability of old age and possibly dementia, with which it would conclude.

There had been fewer emergency admissions than usual over the course of the weekend and there were empty beds on the ITU, so I was told that my list could start on time. The anaesthetist, Heidi, had been away on prolonged leave to look after her young son and was now back at work part-time. We were old friends and I was relieved to see her. The relationship between anaesthetist and surgeon is critical, especially if there is going to be trouble, and having colleagues who are friends is all-important. I walked into the anaesthetic room where Heidi and her assistants had Peter already asleep. The ODA – the operating department assistant, whose job is to help the anaesthetist – was stretching a wide band of Elastoplast across his face to keep the endotracheal tube – the tube which Heidi had inserted through his mouth, down his throat and into his lungs – in place. His face now disappeared beneath the Elastoplast, and the process of depersonalization that starts as the intravenous anaesthetic takes effect and the patient becomes unconscious was now complete.

I have watched that process thousands of times – it is, of course, one of the miracles of modern medicine. One moment the patient is talking, wide awake and anxious – although a good anaesthetist like Heidi will be soothing and reassuring – and the next instant, as the intravenously injected drug travels up the veins of the arm via the heart to the brain, the patient sighs, the head falls back a little, and he or she is suddenly and deeply unconscious. As I watch, it still looks to me as though the patient’s soul is leaving the body to go I know not where and all I now see is an empty body.

‘It might bleed a bit,’ I said to Heidi, ‘and the brainstem might be a problem.’ Sudden and alarming changes in the patient’s heart rate and blood pressure, even cardiac arrest, can occur if you get into trouble with the lower part of the brainstem, known as the medulla oblongata.

‘Not to worry,’ said Heidi. ‘We’re prepared. Big IV and plenty of blood cross-matched, ready in the fridge.’

Peter was wheeled into the operating theatre and, having assembled the theatre staff, we rolled him off the trolley face-down onto the operating table with Samih holding his head.

‘Prone, neutral position, head well flexed,’ I told him. ‘Get him in the pins. Midline incision with the craniectomy more to the left and take out the back of CI. Give me a shout when you’ve done that and you’re down to the dura and I’ll come and join you.’

I left the operating theatre and went round to the surgeons’ sitting room for the regular Monday morning meeting with my consultant colleagues. The meeting had already started, with our two line managers in attendance – both of whom, I might add, I liked and got on well with. The meetings were to discuss the day-to-day business of the neurosurgical department and the managers would sometimes tell us about the department’s ‘financial position’. Much of the meeting was spent letting off steam about all the petty frustrations and inefficiencies of working in a large hospital. There was a sky-blue cushion in the shape of a brain that had been given to me by the sister of one of my American trainees and sometimes we would throw it around the room as we talked, rather like holding the conch shell in Golding’s Lord of the Flies. Sean, the senior of the two managers, was talking. He declined to hold the cushion when I threw it at him.

‘I’m afraid that this last year we made only one million pounds’ profit for the Trust whereas the year before we made four million, even though we did not do any more work. We used to be one of the most profitable departments in the Trust but that is no longer the case.’

‘But where on earth did the three million go?’ somebody asked.

‘It’s not very clear,’ Sean replied. ‘We spent a lot on agency nurses. And you’re spending a lot more on putting metalwork into people’s spines and you’re doing too many emergencies – we get only thirty per cent payment if you exceed the target for emergency work.’

‘It’s so bloody ridiculous,’ I snorted. ‘What would the public say if they knew we got penalized for saving too many lives?’

‘You know the reason,’ Sean said. ‘It’s to stop hospitals making cases into emergencies when they’re not emergencies and over-claiming.’

‘Well, we never did that,’ I replied.

I should explain that ‘profit’ in an NHS department is not profit in the usual sense – instead it is whether we have exceeded our ‘financial target’ or not, which is based on previous performance and is an arcane process that I find entirely incomprehensible. Any ‘profit’ that we make goes to prop up less profitable parts of the Trust, so, despite the introduction into the NHS of the incentives and penalties so loved by economists, there is little real motive at a clinical level, on the shop floor, to work more efficiently. Besides, whenever there does seem to be any extra money, it all appears to be spent on employing more and more members of staff, as though to encourage the existing members of staff to do less work.

The conversation meandered on for a while, discussing the problem of spinal implants. There is no easy answer to this question. As intracranial neurosurgery has declined, replaced by non-surgical methods such as the radiological treatment of aneurysms and highly focused radiation for tumours, neurosurgeons (and there are ever-increasing numbers of them, all keen to operate) have moved into spinal surgery. This is largely about inserting all manner of very expensive titanium nuts and bolts and bars into people’s backs, for cancer or for backache, although the evidence base and justification for such surgery, at least for back pain, are very weak. Even with the cancer patients – metastatic cancer often spreads to the spine – it can be a moot point as to whether to operate or not as the poor patient is going to die anyway, sooner or later, from the underlying cancer. Spinal implant surgery is major surgery and is a six-billion-dollar-a-year business in the US. It is a prime example of the ‘over-treatment’ that is a growing problem in modern health care, and especially in commercial, marketized health-care systems such as in America.

I stopped doing such surgery myself some years ago in order to concentrate on brain surgery, so I was happy to abandon the conversation when I was summoned back to the operating theatre, where Samih had started the operation.

‘Let’s have a look,’ I said, and I leant forward, taking care not to touch the sterile drapes, to peer into the large hole in the back of Peter’s head. ‘Very good,’ I commented. ‘Open the dura and I’ll go and put some gloves on. Jinja,’ I said to the circulating nurse (the nurse who is not scrubbed up and does the fetching and carrying while the operation proceeds), ‘can you get the scope in please?’

While Jinja shoved the heavy scope up to the operating table I scrubbed up at the large sink in the corner of the room – a soothing and deeply familiar act, although always accompanied by a feeling of tension in the pit of my stomach. I must have done this many thousands of times over the years and yet now I knew that it was soon to end – at least in my home country.

Jinja came and tied up the laces at the back of my blue gown and I marched up to the table where Peter lay hidden under the sterile blue drapes, with only the gaping and bloody hole in the back of his head to be seen, brilliantly lit by the operating lights. Samih opened the dura – the leathery, outer layer of the meninges – with a small pair of scissors while I watched. I then took over. I sat down on the operating chair with its arm rests. The first rule of microscopic surgery, I tell my trainees, is to be comfortable, and I usually sit when operating, although in some departments this is not considered to be very manly, and the surgeons stand throughout the procedure, often for very many hours on end.

It was easy enough to find the tumour – a bright-red ball shining in the microscope’s light – a few millimetres beneath the back part of the brain, the cerebellum. To the left would be the all-important brainstem, and to the right and deep down the lower cranial nerves, scarcely thicker than thread; but all this was hidden by the tumour. I would not be able to see them until the very end of the operation, when I had removed most of the tumour. As soon as I touched the tumour with the sucker, blood spurted up out of it.

‘Heidi,’ I said, ‘it’s going to bleed.’

‘No problem,’ came the encouraging reply, and I settled down to attack the tumour.

‘If the blood loss gets too much,’ I said to Samih, ‘your anaesthetist might ask you to stop and pack the wound, but then you worry you might damage the brain with the packing. If it looks as though the patient is going to bleed to death – to exsanguinate – sometimes you just have to operate as quickly as possible, get the tumour out before the patient dies and just hope you haven’t damaged anything. The bleeding usually stops once the tumour is all out.’

‘I saw you do a case like that when you came to Khartoum,’ Samih commented.

‘Ah yes. I’d forgotten that. He did OK though…’

It took four hours of intense concentration to get the tumour out. Down the three-centimetre-wide hole in Peter’s head, all I could see was bright-red arterial blood, welling endlessly upwards. There was no way I could see the brain and no way I could delicately dissect the tumour off it. To my disappointment I did not enjoy the operation, which I think I would have done in the past. I should have arranged to do the operation jointly, I told myself, with a colleague. This greatly reduces the stress of operating, but I had not expected the tumour to bleed quite so much, and it is always difficult as a surgeon to ask for help, as bravery and self-reliance are seen as such an important part of the job. I would hate my colleagues to think that I was getting old and losing my nerve.

‘Look, Samih,’ I said, ‘the damn thing did separate away.’ With the tumour finally removed and the bleeding stopped, we could see the brainstem, and the lower cranial nerves and the vertebral artery all perfectly preserved. It made me think of the moon, appearing from behind clouds and transforming the night. It was a good sight.

‘We were lucky,’ I said.

‘No, no,’ said Samih, obeying the first rule for all surgical trainees, flattering me. ‘That was fantastic.’

‘Well, it didn’t feel it,’ I replied, and then shouted across to the far end of the table, ‘Heidi, what was the blood loss?’

‘Only a litre,’ she said happily ‘No need to transfuse him. His haemoglobin is still one hundred and twenty.’

‘Really? It felt like a lot more,’ I said, thinking that maybe I had been unnecessarily nervous during the operation. I consoled myself with the thought that perhaps all the years of experience counted for something after all. But Peter was going to be all right and that was all that mattered, and his young children would be happy that I had cured their Daddy’s headaches.

‘Come on, Samih,’ I said, ‘let’s close.’

Peter awoke well from the operation. His voice was hoarse but I checked that he could cough, so I was not worried that he was at risk of aspiration.

I went back to the hospital late in the evening to see the post-op cases. I went in most evenings: I live nearby so it was easy for me and I knew that my patients liked seeing me on the evenings both before and after their surgery. It was also a private protest against the way in which doctors now are expected to work shifts with fixed hours, and medicine is no longer perceived as a vocation, a true profession. Many doctors now seem to have the same expectation.

I walked onto the ITU and found Peter among the two long lines of beds on either side of the warehouse-like room, each with its own nurse at the foot end, and a little forest of high-tech monitoring equipment at the head end.

‘How is he?’ I asked the nurse.

‘He’s OK,’ came the reply. There are so many ITU nurses that I know only a few of them and I did not recognize this one. ‘We had to put a nasogastric down in case he aspirated…’

To my surprise, when I looked at Peter, who was sitting upright in his bed, wide awake, I saw that somebody had indeed put a nasogastric tube up his nose and then taped it to his face. I was angry that he had been subjected to the unpleasant procedure of having the tube inserted; it should not have been done, as he did not need it. The tube is pushed up the nose and then down the back of the throat into the stomach – a very unpleasant experience, I am reliably informed by my wife Kate, who has personal experience of it. Nor is it an entirely harmless procedure, and cases have been recorded of the end of the tube getting into the lungs and causing aspiration pneumonia and death, or even getting into the brain. These are, admittedly, rare complications, but after such a difficult but successful operation I was furious that it had been done. The decision to insert it had been made by one of the ITU doctors, clearly less experienced than I was, and the doctor on duty on the ITU for the night denied all knowledge of it. There seemed little point in blaming the nurse. I asked Peter how he felt.

‘Better than I expected,’ he said in a slightly hoarse voice, and then proceeded to thank me again and again for the operation. I bid him goodnight and told him that we’d remove the wretched nasogastric tube in the morning.

I went into work next morning, and immediately went with Samih to the ITU. There was a different nurse at the end of Peter’s bed whom, once again, I did not recognize. Peter was awake and told me that he’d managed to sleep a little – quite an achievement in all the inhuman noise and bright lights of the ITU. I turned to the nurse.

‘I know you didn’t insert the nasogastric tube, but please take it out,’ I said.

‘I’m sorry, Mr Marsh, but he will have to be checked by SALT.’

SALT are the speech and language therapists who some years ago started to assume responsibility for patients with swallowing problems as well as speech difficulties. I had had several disagreements with speech therapists in the past when they had refused to sanction removal of nasogastric tubes which in my opinion the patients did not need. As a result several patients had been kept in hospital being unnecessarily tube-fed, despite my protests. I was not the speech therapists’ favourite neurosurgeon.

‘Take the tube out,’ I said, between gritted teeth. ‘It should never have been inserted in the first place.’

‘I’m sorry Mr Marsh,’ the nurse replied politely, ‘but I won’t.’

I was seized by a furious wave of anger.

‘He doesn’t need the tube!’ I shouted. ‘I will take responsibility. It is perfectly safe. I did the operation – the brainstem and cranial nerves were perfectly intact at the end, he’s got a good cough… take the bloody tube out.’

‘I’m sorry Mr Marsh,’ the hapless nurse began again. Overcome with rage and almost completely out of control, I pushed my face in front of his, took his nose between my thumb and index finger and tweaked it angrily.

‘I hate your guts,’ I shouted, turning away, impotent, furious and defeated, to wash my hands at the nearest sink. We are supposed to clean our hands after touching patients, so I suppose the same applies to assaulting members of staff. Years of frustration and dismay at my steady loss of authority, at the erosion of trust and the sad decline of the medical profession, had suddenly exploded – I suppose because I knew I was to retire in two weeks’ time and suddenly could no longer restrain my rage and feeling of intense humiliation. I stormed off the ward followed by Samih, leaving a little group of amazed nurses standing at the end of Peter’s bed. I do not often lose my temper at work and have certainly never laid a hand on a colleague before.

I slowly calmed down and returned later in the day to the ITU to apologize to the nurse.

‘I’m very sorry,’ I said. ‘I shouldn’t have done that.’

‘Well, what’s done is done,’ he replied, though I did not know what he meant and wondered whether he would be making an official complaint – to which I felt he was fully entitled. Towards the end of the day I received an email from the matron for the ITU saying that she had learnt that there had been an ‘incident’ on the ITU and asking me to come and talk to her the next day.

I went home in a state of craven and abject panic, the like of which I had scarcely ever known before. It took me a long time to calm down – I was so pathetically frightened by the prospect of some kind of official disciplinary action being launched against me. Where’s the brave surgeon now? I asked myself as I lay on my bed, shaking with fear and anger. It’s time to go, it really is.

Next morning I duly reported to the ITU matron – a colleague I knew well and had been working with for many years. It brought back memories of being summoned to the headmaster’s office at school for some misdemeanour in the past, and of my intense anxiety as I waited outside the door. Sarah, the ITU matron, and I had been together at the old hospital which had been closed twelve years earlier. It had become something of an anomaly: a single-specialty hospital, with a staff of about 180, dealing only with neurosurgery and neurology in a garden suburb surrounded by trees and gardens. There were some good clinical reasons for integrating us into the major hospital where we now work, with a staff of many thousands; and the site of the old hospital, Atkinson Morley’s in Wimbledon (AMH), was of course far too beautiful to be a mere hospital. It was sold for commercial development and the hospital turned into apartments that now cost millions of pounds.

But we lost a lot as well – above all the friendly working relationships that can come when you work in a small organization where everybody knows each other on a personal level and work together on the basis of personal obligation and friendship. The efficiency of the hospital was a perfect illustration of Dunbar’s number – that magic number of 150. The size of our brain, Robin Dunbar, an eminent evolutionary anthropologist at Oxford University, has argued (and the brain size of other primates), is determined by the size of our ‘natural’ social group, when humans and their brains evolved in small hunting and gathering groups. We have the largest brains among primates, and the largest social group. We can relate to about 150 people on an informal, personal basis, but beyond that leadership, impersonal rules and job descriptions become necessary.

So Sarah knew me quite well. Some of the comradely atmosphere of the old hospital had been preserved, despite the best efforts of the management to merge our department into the anonymous collective of the huge hospital where we now worked. I think anybody else in the nursing hierarchy of the hospital would have initiated some kind of formal disciplinary procedure against me.

‘I’m ashamed of myself,’ I told her. ‘I suppose it happened partly because I know I’m leaving…’

‘Well, he wasn’t to know that SALT for you is like a red rag to a bull. He doesn’t want to make a formal complaint but he said you were very frightening and it brought back memories of an assault he suffered some months ago.’

I hung my head in shame and remembered how my first wife had told me how terrifying I could look, as our marriage fell apart with furious arguments.

‘He handled me very well and kept admirably calm,’ I said. ‘Please thank him when you next see him. It won’t happen again,’ I added with a slight smile. Sarah knew well enough that I was about to retire. I left her office and went round to the men’s ward where Peter had been sent the previous evening. At least the senior nurse there had been happy to remove the wretched nasogastric tube at my request and it was nice to find Peter drinking a cup of tea without any problems, although he certainly had a very hoarse voice.

‘I’m not supposed to attack the nurses in front of the patients,’ I said. ‘I’m really sorry.’

‘No, no, not at all,’ he replied with a croaking laugh. ‘I told them I didn’t need the tube and could swallow perfectly well but they wouldn’t listen to me and just shoved it in. I was on your side.’

My last operation here, I thought, as I cycled home in the evening.

I finally left my hospital two weeks later, having cleared my office. I disposed of the accumulated clutter that a consultant surgeon acquires over the course of his career. There were letters and photographs from grateful patients, presents and plaques, and outdated textbooks, some of which had belonged to the surgeon whom I had replaced almost thirty years earlier. There were even some books, and an ophthalmoscope, that had belonged to his predecessor, the famous knighted surgeon who seventy years ago had created the neurosurgical department in which we worked. I spent days emptying eight filing cabinets, occasionally stopping to read with amusement some of the pronouncements and plans and protocols, reports and reviews, generated by a labyrinth of government offices and organizations, mostly now defunct, renamed, reorganized or restructured. And there were files dealing with cases where I had been sued, or bitter letters of complaint, from which I quickly averted my eyes – the memory was so painful. Having done all this I left my office, empty, for my successor. I had no regrets whatsoever.