Admissions: A Life in Brain Surgery

4

AMERICA

One year before I went to Nepal, and before I had retired, I attended a cerebrovascular workshop in Houston, intended to help trainee surgeons learn how to operate on the brain’s blood vessels. I was to be one of the instructors. I arrived from London after a ten-hour flight. The workshop started next morning at eight, after I had delivered a lecture at seven to my colleagues in the neurosurgical department which I was visiting. American hospitals start early – the interns, the most junior doctors, often begin their ward rounds before five in the morning. I once asked a group of them about the physiological effects of sleep deprivation on their patients and they seemed quite startled by the suggestion that their immensely hard work might actually be harming the patients.

My lecture was about how to avoid mistakes in neurosurgery, but only a handful of people had turned up to listen to me, presumably because they felt that they had little to learn from the mistakes made by an obscure English surgeon such as myself. The large breakfast laid out in the room outside the lecture theatre remained uneaten. There was a short briefing at the beginning of the workshop. We sat on tiered seats in a small room with three enormous LED screens in front of us. Everything looked new and immaculately clean. A businesslike woman dressed in scrubs told us that under no circumstances was photography permitted and that everything we would be doing was regulated by federal law. She cited various specific statutes which were flashed up on the screens, each one with a long reference number. She also told us that we must respect the subjects of the workshop. Different-coloured hats were then handed out – mine was blue as I was a member of the faculty. The medical students’ were yellow and the neurosurgical residents’ were green. We were then ushered through a pair of large security doors into the research facility.

This looked like a cross between an operating theatre and an open-plan office, with several bays. Floor-to-ceiling windows looked out onto the many glittering skyscrapers that form the Texas Medical Center, the largest concentration of hospitals anywhere on the planet. There are 8,000 hospital beds here – fifty-one clinical institutions in total, I was told – practising some of the most advanced medical care anywhere in the world. There were half a dozen shapes lying on operating tables; I suppose each one was about the size of a ten-year-old child. They lay entirely hidden under blue surgical drapes, with anaesthetic tubing and cables coming out of one end, connected to the same ventilators and monitors with colourful digital displays that I see every day at work. I walked up to one of them and put a hesitant hand out – it was strange to feel the hoofed trotters under the drapes at the end of the operating table.

‘Isn’t this just fantastic!’ said my colleague, a trainee of mine from many years ago, who had recently become the chairman of the neurosurgical department which was staging the workshop, which he had organized. ‘Nobody anywhere else is doing anything like this! Come on, guys!’ he said to the residents in their green hats. ‘Enjoy!’

One of the faculty pulled back the blue drapes off the head of one of the pigs and started to operate. The pig was lying on its back with its broad, pink neck stretched out. It had probably been shaved, and although it was clearly not a human neck – it was far too flat and wide – the skin looked disconcertingly similar. He used cutting diathermy to dissect down to the carotid artery, one of the main arteries for the brain – a smaller vessel than in a human. The plan was to dissect out a vein and graft it to the artery, creating an aneurysm, a model for the life-threatening aneurysms that occur in people and cause fatal haemorrhages. The artificial aneurysm can then be treated – with an ‘endovascular’ or ‘coiling’ technique where a microscopic wire is inserted into the aneurysm via the artery, involving only a simple puncture in the skin, and the aneurysm is blocked off from the inside. Alternatively the aneurysm can be treated with the more old-fashioned method of open surgery, where it is clipped off from the outside. Most aneurysms in people in the modern era are treated with coils, but a few still need clipping. The purpose of the workshop was to give trainee surgeons some practice in the techniques without putting a human life at risk. I am sentimental about animals, and felt sorry for the pigs, but reminded myself that they were doing more for humanity by being used for surgical practice than by being turned into bacon – and there were all those federal statutes protecting them, after all.

My fellow instructor started to stitch the vein graft to the artery. It was a rather slow business and I wandered off towards a group of doctors gathered in a corner of the room. A blue-capped faculty member was talking with great enthusiasm.

‘This is awesome! This is so much better than specimens preserved in formaldehyde!’

I looked over his shoulder. Two trainees were operating on a severed human head. It was held in the steel head clamp most neurosurgeons use when operating and the skin of the neck had been formed into two flaps; these had been stitched together with a few broad sutures to form a stump, although some slightly obscure fluid was dripping out between the sutures. If I had not done my year of cadaveric dissection as a medical student forty years ago I think the sight would have given me nightmares for many days afterwards. It was bizarre and disturbing to see a head in a standard head clamp – something I must have experienced thousands of times with living patients when I operate – and yet with no body attached to it.

So I joined the small group standing around the two trainees who were carrying out a craniotomy under the guidance of a fellow instructor – sawing open the severed head with surgical tools, looking down an expensive operating microscope. I was staggered by all the equipment which surrounded the various stations, six with anaesthetized pigs and now one with a dead person’s head. All of it had been provided by the manufacturers – hundreds of thousands of dollars’ worth, all to be used for practice. As I watched the two trainees uncertainly drilling into the severed head, a young man behind me – dressed, to my surprise, entirely in black scrubs like a ninja – accosted me.

‘Professor!’ he said, with the passionate conviction of an equipment rep. ‘Have a look at this.’ He pointed to the beautiful array of miniature titanium plates and screws and tools, each in its own perfect moulded cavity on a black plastic tray in front of him. These plates are screwed in place to reassemble the skull after sawing it open – although in this case only for practice.

‘Have you tried our latest electric screwdrivers?’ he asked, handing me a neat little battery-powered screwdriver which I suppose would save about five seconds, and needed only marginally less effort than the manual screwdriver I normally use when putting patients’ skulls back together again with titanium plates. I switched the electric screwdriver off and on, marvelling at the extravagance of the American medical system.

‘How d’ya like it?’ asked the rep.

‘Outstanding,’ I replied, thinking of how, on my flight the previous day, the pilot had told us over the intercom when the plane was about to begin its descent that now would be an outstanding time to visit the restrooms.

‘Guys! We have a master here!’ the instructor called out when he saw me. ‘Professor, can you give us some surgical pearls?’ I thought a little apologetically of the swine in the nearby bay undergoing surgery.

Happy to have something useful to do, I pulled on a pair of gloves and went up to the microscope to reposition it and look down into the dead brain.

‘Have you got any brain retractors?’ I asked. ‘“Ribbons” you call them here in the US.’ It seemed they did not, so I used a small chisel to gently lift up the frontal lobe. There was, of course, no bleeding, but the consistency of the dead tissue was not unlike that of the living thing.

‘Formaldehyde makes it all stiff and solid, and it smells awful,’ I said. ‘But where do they get these freshly dead heads?’ I asked of nobody in particular.

‘Maybe a John Doe scraped off the sidewalk,’ somebody offered.

Using the small chisel I dissected out the anterior cerebral arteries, explaining how you approach an anterior communicating artery aneurysm by resecting – that is, removing – part of the brain called the gyrus rectus to find the aneurysm.

‘The gyrus rectus serves olfaction,’ I told my small audience. ‘The patients are better off with perhaps some impairment of smell than dying from another haemorrhage if they don’t have the aneurysm treated.’

I handed over the operation to the two residents and walked round to look at the dead face: head shaved, eyes closed, stubble on his cheeks, blackened stumps of a few remaining teeth. He clearly had never seen a dentist. As far as I could tell he was not – or rather had not been – that old before he died. It was impossible not to wonder for a moment who he had been and what sort of life he had led, and to think that once he had been a child, with all his future in front of him.

Workshops like this are not unusual, but I had never been at one before and I found it rather distressing. I would consider this to be a weakness on my part – it is clearly much better that trainee surgeons should practise in workshops like this than on living patients. When I was back in England two weeks later I mentioned this to a colleague who had recently organized a similar workshop in the UK.

‘Ah!’ he said with a laugh. ‘Only one? I had fifteen heads, freeze-dried, flown in from the US for my skull base workshop last year. I needed to put them all through the MRI scanner before the meeting and drove to the hospital with the heads in the boot of my car. I wasn’t quite sure what I would say if I was stopped by the police. The other problem was that they were starting to thaw. I don’t know where they get them from,’ he added.

I left the room with its severed head and anaesthetized pigs and found another huge breakfast laid out next to the lecture theatre where we had started. After breakfast I was taken on a whirlwind tour of the hospital.

The hospital consisted of a series of multi-storey towers, and we went through what seemed to be an almost endless series of huge lobbies and halls. The hospital had its own twelve-floor hotel; patients came from all over the world for treatment, not just from America. There were twenty – twenty! – other hospitals next to my colleague’s, as well as many other medical and clinical research institutions. The Medical Center occupies more than a square mile, and when I looked out of my twelfth-floor hotel window all I could see was hospital after hospital, all built of glittering glass, receding into the distance like a mountain range. Medicine in the USA is notoriously extravagant. I saw one hospital in Chicago which had a luxurious restaurant, bar and garden on its roof. The hospitals are locked in fierce competition for business and many are designed to look as little like hospitals as possible. They resemble instead luxury hotels or shopping malls or first-class airport lounges. They are the peacocks’ tails of health care.

That evening my colleague took me to his country club. We drove there through the city’s suburbs, past large mansions with pillared porticoes and extensive lawns. The club too was built on a grand scale and the clubhouse – icy-cold with air-conditioning – had a massive baronial fireplace in the Scottish style decked out with mounted stags’ heads on either side, and a large reproduction of the famous Victorian painting by Landseer of a stag, known as The Monarch of the Glen, hung above the grand staircase. We had an excellent dinner there. The waiters were elderly Mexican men with solemn and expressionless Aztec faces. They were dressed in black suits with white aprons and they moved with slow dignity as they served the clientele, nearly all of whom were dressed in baggy shorts and long T-shirts. Over dinner there was the usual surgical gossip – mainly about a colleague who had been sacked for having an affair with a rep, and whether the rep was enhanced with silicone or not. Opinions differed as to this latter question. After his dismissal she had apparently sued him successfully for sexual harassment but now, my colleague told me, they were back together again. I also learnt that the operation on the pig to create an aneurysm had not been a success: one of the technicians had forgotten to give the animal an anti-coagulant injection and the pig had suffered a major stroke as a result of the surgery to its carotid artery. It would, however, have presumably been sacrificed – as it is called – in any case, even if the mistake had not occurred.

After dinner we went out into the sweltering, humid heat to inspect a car show outside the clubhouse. Thirty or so classic cars were drawn up in the car park, shiny and polished, many with their bonnets up so that you could see the spotless, chromed engines inside. A red Ferrari inched its way past us to find a parking place.

My colleague nudged me and said with awe: ‘That’s a seven-million-dollar car. And the guy driving it is a billionaire.’

It transpired later that the car was only a reproduction, but was still worth a million dollars. The billionaire apparently was a real billionaire but looked a fairly ordinary sort of guy. A group of people gathered admiringly around the car once the billionaire had parked it, and they took photographs of each other in front of it.

I went out for a run next morning as the sun was rising. I was streaming with sweat within a matter of minutes as I ran along the street beneath the tall hospital towers, past neatly tended flowerbeds. At the edge of the great block of hospitals there was a large park, with a miniature railway line running round it. Several dozen homeless people were dossing out on the benches and sidewalks in one corner of the park. I was told later that there was a church nearby which gave out free meals. As I ran back to the hotel the sun rose behind me, over the dozens of buildings of the Medical Center, and I was almost blinded by its dazzling reflection in the thousands of hospital windows facing me.