Admissions: A Life in Brain Surgery

9

MAKING THINGS

A long time ago I had promised my daughter Sarah that I would make her a table. I am rather good at saying I’ll make things, and then finding I haven’t got the time, let alone getting round to make the many things I want to make or mend myself.

A retired colleague, a patient of mine as well, whose back I had once operated upon, had come to see me a year before I retired with pain down his arm. Another colleague had frightened him by saying it might be angina from heart disease – the pain of angina can occasionally radiate down the left arm. I rediagnosed it as simply pain from a trapped nerve in his neck that didn’t need treating. It turned out that in retirement he was running his own oak mill, near Godalming, and we quickly fell into an enthusiastic conversation about wood. He suggested I visit, which I did, once I had retired. To my amazement I found that he had a fully equipped industrial sawmill behind his home. There was a stack of dozens of great oak trunks, twenty foot high, beside the mill. Eighty thousand pounds’ worth, he told me when I asked. The mill itself had a fifteen-foot-long sawbed on which to put the trunks, with hydraulic jacks to align them, and a great motorized bandsaw that travelled along the bed. The tree trunks – each weighing many tons – were jostled into place using a specialized tractor. All this he did by himself, although in his seventies, and with recurrent back trouble. I was impressed.

I spent a happy day with him, helping him to trim a massive oak trunk so that it ended up with a neatly square cross-section, and then rip-sawing it into a series of thick two-inch boards. The machinery was deafening (we wore ear defenders), but the smell of freshly cut oak was intoxicating. I drove home that evening like a hunter returning from the chase, with the planks lashed to the roof rack of my ancient Saab – a wonderful car, the marque now, alas, extinct – that has travelled over 200,000 miles and only broken down twice. The roof rack was sagging under the weight of the oak and I drove rather slowly up the A3 back to London.

The next morning I went to collect my bicycle from the bicycle shop in Wimbledon Village, as it likes to be called, at the top of Wimbledon Hill. Brian, the mechanic there, has been looking after my bicycles for almost thirty years.

‘I’m afraid the business is closing down,’ Brian told me, after I had paid him.

‘I suppose you can’t afford the rates?’

‘Yes, it’s just impossible.’

‘How long have you been here?’

‘Forty years.’

He asked me for a reference, which I said I would gladly give. He is by far the best and most knowledgeable bike mechanic I have ever met.

‘Have you got another job?’ I asked.

‘Delivery van driver,’ he replied with a grimace. ‘I’m gutted, completely gutted.’

‘I remember the village when it still had real shops. Yours is the last one to go,’ I said. ‘Now it’s all just wine bars and fashion boutiques. Have you seen the old hospital just down the road where I worked? Nothing but rich-trash apartments. Gardens all built over, the place was just too nice to be a hospital.’

We shook hands and I found myself hugging him, not something I am prone to do. Two old men consoling each other, I thought, as I bicycled down the hill to my home. Twenty years ago I lived with my family in a house halfway up the hill. I assume that the only people who can afford to live in the huge Victorian and Edwardian villas at the top of the hill are bankers and perhaps a few lawyers. After divorce, of course, surgeons move to the bottom of the hill, where I now live when not in Oxford or abroad.

The oak boards needed to be dried at room temperature for six months before I could start working on them, so I clamped them together with straps to stop them twisting and left them in the garage at the side of my house (yet another of my handmade constructions with a leaking roof), and later brought them into the house for further drying.

Now that I was retired and back from Nepal, the wood was sufficiently dry for me to start work.

When my first marriage had fallen horribly apart almost twenty years earlier and I left the family home, I took out a large mortgage and bought a small and typical nineteenth-century semidetached house, two up and two down, with a back extension, at the bottom of Wimbledon Hill.

The house had been owned by an Irish builder, and his widow sold the house to me after his death. I had got to hear that the house was for sale from the widow’s neighbours, who were very good friends of mine. So the house came with the best neighbours you could wish for, a wide and unkempt garden and a large garage in the garden itself, approached by a passage at the side of the house. Over the next eighteen years I subjected the property to an intensive programme of home improvements, turning the garage into a guest house (of sorts) with a subterranean bathroom, and building a workshop at the end of the garden and a loft conversion. I did much, but not all, of the work myself. The subterranean bathroom seemed a good idea at the time, but it floods to a foot deep from an underground stream if the groundwater pump I had to have installed beneath it fails.

The loft conversion involved putting in two large steel beams to support the roof and replacing the existing braced purlins (I had taken some informal advice from a structural engineer as to the size of steel beam required). With my son William’s help I dragged the heavy beams up through the house and, using car jacks and sash cramps, manoeuvred them into position between the brick gables at either end of the loft. There was then an exciting moment when, with a sledgehammer, I knocked out the diagonal braces that supported the original purlins. I could hear the whole roof shift a few millimetres as it settled onto the steel beams. I was rather pleased a few years later to see a loft conversion being done in a neighbouring house – a huge crane, parked in the street, was lowering the steel beams into the roof from above. I suppose it was a little crazy of me to do all this myself, and I am slightly amazed that I managed to do it, although I had carefully studied many books in advance. The attic room, I might add, is much admired and I have preserved the chimney and the sloping roof, so it feels like a proper attic room. Most loft conversions I have seen in the neighbourhood just take the form of an ugly, pillbox dormer.

I have always been impatient of rules and regulations and sought neither planning nor building regulation permission for the conversion, something I should have done. This was to cause problems for me when I fell in love with the lock-keeper’s cottage. I could only afford to buy it if I raised a mortgage on my house in London (I had been able to pay off the initial mortgage a few years earlier). The London house was surveyed and the report deemed it fit for a mortgage, ‘subject to the necessary permits’ for the loft extension from the local council, which, of course, I did not have.

With deep reluctance I arranged for the local building inspectors to visit. I expected a couple of fascist bureaucrats in jackboots, but they couldn’t have been nicer. They were most helpful. They advised me how to change the loft conversion so as to make it compliant with the building regulations. The only problem was that the property developers who were selling the lock-keeper’s cottage were getting impatient. So, over the course of three weeks, working mainly at night as I had not yet retired, I removed a wall and built a new one with the required fire-proof door, and installed banisters and handrails on the oak stairs – the stairs on which I had once slipped and broken my leg. I also installed a wirelessly linked mains-wired fire alarm system throughout the house. This last job was especially difficult as over the years I had laid oak floorboards over most of the original ones. Running new cables above the ceilings for the smoke alarms involved cutting many holes in the ceilings and then replastering them. But after three weeks of furious activity it was all done, and I am now the proud possessor of a ‘Regularisation Certificate’ for the loft conversion of my London home, and I also own the lock-keeper’s cottage.

As soon as I had moved into my new home in London seventeen years ago, after the end of my first marriage, I had set about building myself a workshop at the bottom of the garden, which backs onto a small park and is unusually quiet for a London home. I was over-ambitious and made the roof with slates and, despite many efforts on my part, I have never been able to stop the roof leaking. I cannot face rebuilding the whole roof, so two plastic trays collect the water when it rains, and serve as a reminder of my incompetence. Here I store all my many tools, and it was here that I started work on Sarah’s table. In the garden, which I have allowed to become a little wild, I keep my three beehives. London honey is exceptionally fine – there are so many gardens and such a variety of flowers in them. In the countryside, industrial agriculture and the use of chemical fertilizers, pesticides and herbicides have decimated the population of bees, as well as the wild flowers on which they once flourished.

It took many weeks to finish the table, sanded a little obsessionally to 400-grit, not quite a mirror finish, using only tung oil and beeswax to seal it. The critical skill in making tabletops is that the edges of the boards should be planed so flat – I do it all by hand – and the grain of the wood so carefully matched that the joints are invisible. You rest the planed edges of the boards on top of each other with a bright light behind them so that a gap of even fractions of a millimetre will show up. This requires a well-sharpened plane. A well-sharpened and adjusted plane – ‘fettled’ is the woodworker’s traditional word for this – will almost sing as it works and minimal effort is required to push it along the wood.

It took me a long time to learn how to sharpen a plane properly. It now seems obvious and easy and I cannot understand why I found it difficult in the past. It is the same when I watch the most junior doctors struggling to do the simplest operating, such as stitching a wound closed. I cannot understand why they seem to find it so difficult – I become impatient. I start to think they are incompetent. But it is very easy to underestimate the importance of endless practice with practical skills. You learn them by doing, much more than by knowing. It becomes what psychologists call implicit memory. When we learn a new skill the brain has to work hard – it is a consciously directed process requiring frequent repetition and the expenditure of energy. But once it is learnt, the skill – the motor and sensory coordination of muscles by the brain – becomes unconscious, fast and efficient. Only a small area of the brain is activated when the skill is exercised, although at the same time it has been shown, for instance, that professional pianists’ brains develop larger hand areas than the brains of amateur pianists. To learn is to restructure your brain. It is a simple truth that has been lost sight of with the short working hours that trainee surgeons now put in, at least in Europe.

The boards are glued together using what is called a rubbed joint – the edges rubbed against each other to spread the glue – and then clamped together for twenty-four hours with sash cramps. The frame and legs are held fast with pegs, and being oak, the table is very solid and heavy. I had taken great care, when sawing the wood with my friend, that it was ‘sawn on the quarter’, so that the grain would show the beautiful white flecks typical of the best oak furniture. Sarah was very happy with the result after I delivered it, and subsequently sent me a photograph of her eighteen-month-old daughter Iris sitting up to it, smiling happily at the camera as she painted pictures with paintbrush and paper. But, just like surgery, there can be complications, and to my deep chagrin a crack has recently developed between two of the jointed planks of the tabletop. I cannot have dried the wood sufficiently, I was impatient yet again. I will, however, be able to repair this with an ‘eke’ – a strip of wood filling the crack. It should be possible to make it invisible, but I will probably have to refinish the whole surface.

*

I’m not sure how my love of and obsession with making things arose. I hated woodwork at school: you had no choice as to what you made and you would come home at the end of term with some poorly fashioned identikit present for your parents – a wobbly little bookcase, a ridiculous egg-rack or a pair of bookends. I found these embarrassing; my father was a great collector of pictures, antiques and books and there were many fine things in the family home, so I knew how pathetic were my school woodwork efforts. He was also an enthusiastic bodger who loved to repair things, usually involving large quantities of glue, messily applied. The family made ruthless fun of his attempts, but there was a certain nobility to his enthusiasm, to his frequent failures and occasional successes.

He was a pioneer of DIY before the DIY superstores came into existence. I once found him repairing the rusted bodywork of his Ford Zephyr by filling the holes with Polyfilla, gluing kitchen foil over the filler, and then painting it with gloss paint from Woolworth’s. It all fell off as soon he drove the car out of the garage. My first attempts at woodwork away from school were made using driftwood from the beach at Scheveningen in Holland, where we lived when I was between the ages of six and eight. I sawed the wood, bleached white by the sea, into the shapes of boats. I made railings from small nails bought at the local hardware store. The only Dutch words I ever learnt were ‘kleine spijkes, alsjeblieft’ – small nails, please. I would take these boats sailing with me in the bath, but they invariably capsized.

When I married my first wife, we had no furniture and little money. I made a coffee table from an old packing case with a hammer and nails. It was a wooden one from Germany, with some rather attractive stencilled stamps on it, a little reminiscent of some of Kurt Schwitters’ Merz work. It had been sitting in my parents’ garage for years and had contained some of the last possessions of my uncle, the wartime Luftwaffe fighter pilot and wonderful uncle who eventually died from alcoholism many years after the war.

My brother admired the coffee table and asked me to make one for him, and I said I would, for the price of a plane, which I could then buy and use to smooth the wood. I have not looked back since. My workshop is now stacked with tools of every description – for woodwork, for metalwork, for stone-carving, for plumbing and building. There are three lathes, a radial arm saw, a bandsaw, a spindle moulder and several other machine tools in addition to all the hand tools and power tools. I have specialist German bow saws and immensely expensive Japanese chisels, which are diabolically difficult to sharpen properly. One of my disappointments in life is that I have now run out of tools to buy – I have acquired so many over the years. Reading tool catalogues, looking for new tools to buy – ‘tool porn’, as my anthropologist wife Kate calls it – has become one of the lost pleasures of youth. Now all I can do is polish and sharpen the tools I already have, but I would hate to be young again and have to suffer all the anxieties and awkwardness that came with it. I have rarely made anything with which I was afterwards satisfied – all I can see are the many faults – but this means, of course, that I can hope to do better in future.

I once made an oak chest with which I was quite pleased. I cut the through dovetail joints at the corners by hand, where they could be seen as proof of my craftsmanship. The best and most difficult dovetail joints, on the other hand – known as secret mitre dovetail joints – cannot be seen. True craftsmanship, like surgery, does not need to advertise itself. A good surgeon, a senior anaesthetist once told me, makes operating look easy.

*

When I see the tidy simplicity of the lives of the people living in the boats moored along the canal by the lock-keeper’s cottage, or the sparse homes of the Nepalese peasants William and I walked past on our trek, I cannot help but think about the vast amount of clutter and possessions in my life. It is not just all the tools and books, rugs and pictures, but the computers, cameras, mobile phones, clothes, CDs and hi-fi equipment, and many other things for which I have little use.

I think of the schizophrenic men in the mental hospital where I worked many years ago. I was first sent to the so-called Rehabilitation Ward, where attempts were being made to prepare chronic schizophrenics who had been in the hospital for decades for life in community care outside the hospital. Some of them had become so institutionalized that they had to be taught how to use a knife and fork. My first sight of the ward was of a large room with about forty men, dressed in shabby old suits, restlessly walking in complete and eerie silence, in circles, without stopping, for hours on end. It was like a march of the dead. The only sound was of shuffling feet, although occasionally there might be a shout when somebody argued with the voices in his head. Many of them displayed the strange writhing movements called ‘tardive dyskinesias’ – a side effect of the antipsychotic drugs that almost all of them were on. Those who had been treated with high doses of a drug called haloperidol – there had once been a fashion for high-dose treatment until the side effects became clear – suffered from constant and grotesque movements of the face and tongue. Over the next few weeks, before I was sent to work on the psychogeriatric ward, I slowly got to know some of them as individuals. I noticed how they would collect and treasure pebbles and twigs from the bleak hospital garden and keep them in their pockets. They had no other possessions. Psychologists talk of the ‘endowment effect’ – that we are more concerned about losing things than gaining them. Once we own something, we are averse to losing it, even if we are offered something of greater value in exchange. The pebbles in the madmen’s pockets became more valuable than all the other pebbles in the hospital gardens simply by virtue of being owned.

It reminds me of the way that I have surrounded myself with books and pictures in my home, rarely look at them, but would certainly notice their absence. These poor madmen had lost everything – their families, their homes, their possessions, any kind of social life, perhaps their very sense of self. It often seems to me that happiness and possessions are like vitamins and health. Severe lack of vitamins makes us ill, but extra vitamins do not make us healthier. Most of us – I certainly am, as was my father – are driven to collect things, but more possessions do not make us happier. It is a human urge that is rapidly degrading the planet: as the forests are felled, the landfill sites grow bigger and bigger and the atmosphere is filled with greenhouse gases. Progress, the novelist Ivan Klima once gloomily observed, is simply more movement and more rubbish. I think of the streets of Kathmandu.

My father may have been absent-minded and disorganized in some aspects of his life but he was remarkably shrewd when it came to property, even though as an academic lawyer he was never especially wealthy. When my family left Oxford for London in 1960 we moved to a huge Queen Anne terrace house, built in 1713, in the then run-down and unfashionable suburb of Clapham in south London. It was a very fine house with perfectly proportioned rooms, all wood-panelled and painted a faded and gentle green, with cast-iron basket fire grates (each one now worth a small fortune) in every room, and tall, shuttered sash windows looking out over the trees of Clapham Common. There was a beautiful oak staircase, with barley twist banisters. He had an eye for collecting antiques before it became a national pastime and impossibly expensive. So the new family home, with six bedrooms and almost forty windows – I painted them all once and then had a furious row with my father about how much he should pay me for the work – was filled with books, pictures and various objets d’art. I was immensely proud of all this when I was young. My father was also proud of his house and many possessions and liked to show them to visitors, but in an innocent and almost childlike way, wanting to share his pleasure with others. The family used to tease him that he was a wegotist, as opposed to an egotist – the word does exist in the Oxford English Dictionary.

My pride was of a more competitive and aggressive kind, albeit vicarious. When he eventually died at the age of ninety-six, my two sisters, brother and I were faced by a mountain of possessions. I discovered to my surprise that few, if any, of the many thousands of his books were worth keeping. It made me think about what would happen to all my books when I die. We divided everything else up on an amicable basis, but looking back I fear that I took more than my fair share, with my siblings acquiescing to their demanding younger brother so as to avoid disharmony. As for the house, with its forty windows and panelled rooms, I heard that it was recently sold for an astronomical sum, having been renovated. The estate agent’s website showed the interior. It has been transformed: painted all in white, even the oak staircase, it now resembles an ostentatious five-star hotel.

When I am working in Nepal I live out of a suitcase, and have no belongings other than my clothes and my laptop. I have discovered that I do not miss my many possessions back in England at all – indeed I see them as something of a burden to which I must return, even though they mean so much to me. Besides, when I witness the poverty in Nepal, and the wretched effects of rapid, unplanned urbanization, I view my possessions in a different light. I regret that I did not recognize the virtues of trying to travel with hand luggage only at an earlier stage of my life. There are no pockets in the shroud.

‘The first case is Mr Sunil Shrethra,’ said the MO presenting the admission at the morning meeting. ‘He was admitted to Norvik Hospital and then came here. Right-handed gentleman, sixty-six years old. Loss of consciousness five days go. On examination…’

‘Hang on,’ I cried out. ‘What happened after he collapsed? Has he been unconscious since then? Did he have any neurological signs?’

‘He was on ventilator, sir.’

‘So what were his pupils doing?’

‘Four millimetres and not reacting, sir. No motor response.’

‘So he was brain-dead?’

The MO was unable to answer and looked nervously at me. Brain death is not recognized in Nepali law.

‘Yes, sir,’ said Bivec, the ever-enthusiastic registrar, helping the MO.

‘So why was he transferred here from the first hospital if he was brain-dead?’

‘No, sir. He came from home.’

I paused for a moment, unable to understand what this was all about.

‘He went home from the hospital on a ventilator?’ I asked, incredulous.

‘No, sir. Family hand-bagged him, sir.’ In other words, the family took their brain-dead relative home, squeezing a respiratory bag all the time, connected to the endotracheal tube in his lungs to keep him oxygenated (after a fashion).

‘And then they brought him here?’

‘Yes.’

‘Well, let’s look at the scan.’

The scan appeared, shakily and a little dim, on the wall in front of us. It showed a huge and undoubtedly fatal haemorrhage.

‘So what happened next?’

‘We said there was no treatment so they took him home, hand-bagging him again.’

‘Let’s have the next case,’ I said.

I had noticed that the sickest patients on the ITU, the ones expected to die or become brain-dead, had often disappeared by the next morning. I was reluctant to ask what had happened, and it was some time before I learnt that usually the families would take the patients home, hand-bagging them if necessary, so that they could die with some dignity within the family home, with their loved ones around them, rather than in the cruel impersonality of the hospital. It struck me as a very humane solution to the problem, although sadly unimaginable back home.