Do No Harm: Stories of Life, Death and Brain Surgery (15 page)

The chief executive’s office was a suite of rooms, with a secretary in the outer room and a large room beyond with a desk at one end and a table with chairs around it at the other. Just like the offices, I thought a little sourly, of all the ex-communist
apparatchiki
and professors I have dealt with in the former Soviet Union. The chief executive, however, was not going to use the bullying and bluster of some of his post-Soviet counterparts and instead welcomed me enthusiastically and offered me coffee. (On the other hand, some of the nicer post-Soviet professors would welcome me in the morning with vodka.) We were joined shortly afterwards by the director of surgery, who said little throughout the meeting, his expression one of irritation and exasperation with me, and of deference to the chief executive. After the usual niceties, the question of the infection control poster came up.

‘Just for once,’ I said, ‘I followed the proper channels. I sent an email to the director of infection control.’

‘It caused great offence. You compared the hospital to a concentration camp.’

‘Well, I wasn’t the one who copied it to everybody in the Trust,’ I retorted.

‘Did I say that you did?’ the chief executive replied in a stern and headmasterly tone.

‘I regret saying “concentration camp”,’ I said with some embarrassment. ‘It was silly and a bit over the top. I should have said “prison”.’

‘But didn’t you remove the poster?’ asked the chief executive.

‘No, I didn’t,’ I said.

He looked surprised and the room was quiet for a while. I had no intention of sneaking on my colleague.

‘And there was a problem with a Complaints meeting last year.’

‘Yes, your Trust’s Complaints office managed to arrange the meeting on the anniversary of the patient’s death.’

‘Not “your Trust” Henry,’ said the chief executive. ‘
Our
Trust.’

‘The anniversary of a death is the worst possible date for such a meeting. Have you ever come across so-called “Anniversary Reactions”? Grieving relatives are particularly difficult to handle on these occasions.’

‘Well, yes. We did have one of those recently, didn’t we?’ he said, turning to the director of surgery.

‘Nor was there any meeting with me beforehand – with your Trust’s staff about the basis of the complaint,’ I added.

‘
Our
Trust,’ he corrected me again. ‘But it’s true that the procedure is that there should have been a meeting beforehand . . .’

‘Well the procedure wasn’t followed but I’m sorry if I handled the meeting badly,’ I said. ‘But you try sitting opposite the parents of a patient who has died and who are convinced you killed their child. It’s even more difficult when the accusation is absurd, even though I did get the diagnosis wrong and he was subjected to an unnecessary operation.’

The chief executive was silent. ‘I couldn’t do your job,’ he said at last.

‘Well, I couldn’t do yours,’ I replied, filled with sudden gratitude for his understanding. I thought of all the government targets, self-serving politicians, tabloid headlines, scandals, deadlines, civil servants, clinical cock-ups, financial crises, patient pressure-groups, trades unions, litigation, complaints and self-important doctors with which an
NHS
chief executive must deal. The average time for which they serve, not surprisingly, is only four years.

We looked at each other for a few moments.

‘But your Communications Office is crap,’ I said.

‘All I’m asking is that you use your undoubted abilities for Our Trust,’ he said.

‘We want you to follow established procedures . . .’ the director of surgical services added, feeling obliged to contribute to the meeting.

After the meeting I made my way back out of the labyrinth and returned to my office. Later that day I emailed the Communications Department my suggestions for a better poster. ‘We need your
HELP
. . .’ it began, but I never received a reply.

The chief executive left the Trust a few weeks later. He had been re-directed to another Trust with financial difficulties, where no doubt he was to wield the axe again on behalf of the government and the civil servants in the Treasury and Department of Health. I heard a rumour a few months later that he was on sick leave from his new Trust because of stress and, slightly to my surprise, I felt sorry for him.

14

NEUROTMESIS

n.
the complete severance of a peripheral nerve. Complete recovery of function is impossible.

On the first day of June, the weather suddenly hot and humid, I cycled to work for the morning meeting. Before setting off I had gone into my small back garden to inspect my three bee hives. The bees were already hard at work, shooting up into the air, probably heading for the flowering lime trees that grow along one side of the local park. As I pedalled to work I thought happily of the honey I would be harvesting later in the summer. I arrived a few minutes late. One of the senior house officers was presenting the cases.

‘The first case,’ she said ‘is a sixty-two-year-old man who works at one of the local hospitals as a security man. He lives on his own and has no next of kin. He was found confused at home. His colleagues had gone round to look for him because he hadn’t turned up for work. There were many bruises on his right side and his colleagues said that he had had increasing difficulties with talking over the previous three weeks.’

‘Did you see him when he was admitted?’ I asked her, knowing that the house officers presenting the cases at the morning meeting will rarely have seen the patients they present because of their short working shifts.

‘Well, actually I did,’ she said. ‘He was dysphasic and had a slight weakness on the right side.’

‘So what’s the diagnosis going to be?’ I asked.

‘It’s a short history of a progressive neurological deficit. It involves speech,’ she replied. ‘The bruises on the right side of his body suggest he’s falling to the right so he’s probably got a progressive problem on the left side of his brain, probably in the frontal lobe.’

‘Yes, very good. What sort of problem?’

‘Maybe a
GBM
, or maybe a subdural.’

‘Quite right. Let’s have a look at the scan.’

As she worked at the computer keyboard the slices of the poor man’s brain scan slowly appeared. It showed what was obviously a malignant tumour in the left cerebral hemisphere.

‘Looks like a
GBM
,’ somebody said.

There were two medical students that morning in the audience. The
SHO
turned to them, probably enjoying the fact that there was somebody even lower in the strict medical hierarchy than herself.

‘A
GBM
,’ she said in a knowledgeable tone of voice, ‘is a glioblastoma multiforme. A very malignant primary brain tumour.’

‘These are fatal tumours,’ I added for the benefit of the students. ‘A man his age with a tumour like this has only a few months – maybe only weeks – to live. If he’s treated, which means partial surgical removal and then radiotherapy and chemotherapy afterwards, he’ll only live a few months longer at best and he probably won’t regain his speech anyway.’

‘Well, James,’ I said, turning to one of the registrars, ‘the
SHO
has been spot on with the diagnosis. What is the management of this case? And what are the really important points here?’

‘He’s got a malignant tumour we can’t cure,’ James replied. ‘He’s disabled despite steroids. All we can do is a simple biopsy and refer him for radiotherapy.’

‘Yes, but what’s really important about the history?’

James hesitated but before he could reply I said that what was important was that he had no next of kin. He’d never get home. He’d never be able to look after himself. He had only a few months of life left whatever we did – and since he had no family he was likely to spend what little time he had left miserably on a geriatric ward somewhere. But I told James he was probably right – it would be easier to get him back to his local hospital if we established the diagnosis formally, so I said that we had better get a biopsy and bounce him off to the oncologists. We could only hope that they’d be sensible and not prolong his suffering by treating him. The fact of the matter was that we already knew the diagnosis from the scan and any operation would be something of a charade.

I pulled out a
USB
stick from my pocket and walked up to the computer at the front of the viewing room.

‘I’ll show you all some amazing brain scans from my last trip to Ukraine!’ I said but I was interrupted by one of my junior colleagues.

‘Excuse me,’ he said, ‘but the manager responsible for the junior doctors’ working hours has very kindly agreed to come and talk to us about the new rota for the registrars and she can’t stay beyond nine o’clock since she has another meeting to go to afterwards. She’ll be here in a minute.’

I was annoyed that I was not going to be able to show some enormous Ukrainian brain tumours but clearly I had no choice in the matter.

The manager was late, so while we waited for her to arrive I walked round to the operating theatres, to see the only patient for the day’s operating. He was waiting in the anaesthetic room, lying on a trolley, a young man with severe sciatica from a simple disc prolapse. I had seen him six months earlier. He was a computer programmer but also a competitive mountain biker and had been training for some kind of national championship when he developed excruciating sciatic pain down his left leg. An
MRI
scan had shown the cause to be a slipped disc – ‘a herniated intervertebral disc causing S1 nerve root compression’ in medical terms. His disc prolapse had prevented him from training and he had had to drop out of the mountain biking championships, to his bitter disappointment. He had been very frightened by the prospect of surgery and decided to see if he would get better on his own which, I had told him, often happened if one waited long enough. This had not happened, however, and he had now reluctantly decided to undergo surgery.

‘Good morning!’ I said, my voice full of surgical reassurance – genuine reassurance since the planned operation was a simple one. Most patients are pleased to see me before their operation, but he looked terrified.

I leant forward and lightly patted his hand. I told him that the operation really was a very simple one. I explained that we always had to warn people of the risks of surgery but promised him that it really was most unlikely that things would go wrong. If I’d had sciatica for six months I would have the op, I said. I wouldn’t be happy about it, but I’d have it although, like most doctors, I am a coward.

Whether I managed to reassure him or not, I do not know. It really was a simple operation, with a very low risk, but my registrar would have consented him earlier that morning and the registrars – especially the American ones – tend to go over the top with informed consent, and terrorize the poor patients with a long list of highly unlikely complications, including death. I mention the main risks as well but stress the fact that serious complications with simple disc prolapse surgery, such as nerve damage and paralysis, are really very rare.

I left the anaesthetic room to go to the meeting with the
EWTD
compliance manager.

‘I’ll come back and join you,’ I said to my registrar over my shoulder as I left the theatre, though I thought that would scarcely be necessary as he had done such operations before on his own. I went back to the meeting room where my colleagues were waiting with the manager.

She was a large and officious young woman with hennaed hair in tight curls. She spoke imperiously.

‘We need your agreement to the new rota,’ she was saying.

‘Well, what are the options?’ one of my colleagues said.

‘If they are to be compliant with the European Working Time Directive your registrars can no longer be resident on-call. The on-call room will be taken away. We have examined their diary cards – they are working far too much at the moment. They must have eight hours sleep every night, six of it guaranteed uninterrupted. This can only be achieved if they work in shifts like the
SHO
s.’

My colleagues stirred uncomfortably in their seats and grumbled.

‘Shifts have been tried elsewhere and are universally unpopular,’ one of them said. ‘It destroys any continuity of care. The doctors will be changing over two or three times every day. The juniors on at night will rarely know any of the patients, nor will the patients know them. Everybody says it’s dangerous. The shorter hours will also mean that they will have much less clinical experience and that’s dangerous also. Even the President of the Royal College of Surgeons has come out against shifts.’

‘We have to comply with the law,’ she said.

‘Is there any choice?’ I asked. ‘Why can’t we derogate? Our juniors want to opt out of the
EWTD
and work longer hours than forty-eight hours a week and can do this by derogating. Everybody in the City opts out of the
EWTD
. My medical colleagues in France and Germany say that they take no notice of the
EWTD
. Ireland has derogated for doctors.’

‘We have no choice,’ she replied. ‘Anyway, the deadline for derogation was last week.’

‘But we were only told last week about the possibility of derogation!’ I said.

‘Well it’s irrelevant anyway,’ came the reply. ‘The Trust has decided nobody will derogate.’

‘But that was never discussed with us. Does our opinion about what is best for patients count for nothing?’ I asked.

Her utter lack of interest in what I said was very obvious and she did not bother to reply. I started to deliver an impassioned denunciation of the dangers of having trainee surgeons working only forty-eight hours a week.

‘You can send me an email setting out your views,’ she said, interrupting me, and the meeting came to an end.

I went round to the theatres where my registrar was starting the spinal case. He had done a fair number of these cases on his own before, and although not the best of my trainees in terms of operating ability, he was certainly one of the most conscientious and kindest juniors I had had for a long time. The nurses all adored him. It seemed safe enough to let him start and probably do all the operation himself. The patient’s extreme anxiety had, however, made me anxious in turn, so I changed and went into the theatre, when usually I would have stayed outside in the red leather sofa room, readily available but not overlooking everything he did.

As it was a spinal procedure the patient, rendered anonymous by light blue sterile drapes, was lying anaesthetized face down on the table, a small area of skin over the lower spine exposed as a rectangle, coloured yellow by the iodine antiseptic and brilliantly illuminated by the big, dish-shaped operating lights suspended on hinged arms from the ceiling. In the middle of this rectangle was a three inch incision through the skin and into the dark red spinal muscles, which were held open by steel retractors.

‘Why such a large incision?’ I asked irritably, still enraged by the manager and her complete indifference to what I had said. ‘Haven’t you seen how I do these? And why are you using the big bone rongeurs? That shouldn’t be necessary at L5/S1.’ I was annoyed but not alarmed – the operation had scarcely begun, the scan had showed a simple disc prolapse and he would not yet have reached the more difficult part of the operation, which is to expose the trapped nerve root within the spine.

I scrubbed up and came over to the operating table.

‘I’ll have a look,’ I said. I picked up a pair of forceps and looked into the wound. A long shiny white thread, the thickness of a piece of string – four or five inches long – came up out of the wound in my forceps.

‘Oh Jesus fucking Christ!’ I burst out. ‘You’ve severed the nerve root!’ I threw the forceps onto the floor and flung myself away from the operating table to stand against the far wall of the theatre. I tried to calm myself down. I felt like bursting into tears. It is, in fact, highly unusual for gross technical mistakes like this to occur in surgery. Most mistakes during operations are subtle and complex and scarcely count as mistakes. Indeed, in thirty years of neurosurgery I’d never witnessed this particular disaster, although I have heard of it happening.

I forced myself to return to the operating table and looked into the bloody wound, cautiously exploring it, dreading what I might find. It became apparent that my registrar had completely misunderstood the anatomy and opened the spine at the outer rather than the inner edge of the spinal canal and hence had immediately encountered a nerve root, which, even more incomprehensibly, he had then severed. It was an utterly bizarre thing to have done, especially as he had seen dozens of these operations done before, and done many unsupervised on his own.

‘I think you’ve cut straight through the nerve – a complete neurotmesis,’ I said sadly to my dumb-struck assistant. ‘He’ll almost certainly be left with a permanently paralysed ankle and a life-long limp. That’s not a minor disability – he’ll never be able to run again, or to walk on uneven ground. So much for the mountain bike championships.’

We completed the rest of the operation in silence.

I redirected the opening into the spine and quickly removed the disc prolapse without any difficulty – the simple and quick operation I had more or less promised him as he lay looking so frightened in the anaesthetic room earlier that morning.

I went out of the theatre where Judith, my anaesthetist for many years, joined me in the corridor.

‘Oh it’s so terrible,’ she said. ‘And he’s so young. What will you tell him?’

‘The truth. It’s just possible that the nerve is not completely cut through and I suppose he might just recover, though if he does it will take months. To be honest, I doubt if he will, but I suppose there’s some hope . . .’

One of my consultant colleagues passed by and I told him what had happened.

‘Bloody hell,’ he said. ‘That’s bad luck. Do you think he’ll sue?’

‘I think it was reasonable enough for me to let my registrar start – he’s done these operations before. But I got it wrong. He was less experienced than I realized. It really was staggeringly incompetent . . . but then I am responsible for his operating.’

‘Well, it’s the Trust that gets sued anyway – it doesn’t really matter whose fault it was.’

‘But I misjudged his abilities. I’m responsible. And the patient will blame me anyway. He’d put his trust in
me
, not in the bloody Trust. In fact, assuming he doesn’t recover, I’ll tell him to sue.’