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Complications

Seamus O’Mahony

Do No Harm: Stories of Life, Death and Brain Surgery, by Henry Marsh, Weidenfeld & Nicolson, 298 pp, £16.9,  ISBN 978-0297869870

Doctors’ memoirs are generally dull, self-serving affairs, commonly self-published, something to do to fill the long days of retirement. A few rare exceptions have been bestsellers, notably The Story of San Michele (1929) by Axel Munthe, and Adventures in Two Worlds (1952) by AJ Cronin. Munthe’s memoir is largely fiction – an “impressionistic” account of his eventful life in Paris, Rome and Capri: a recent biography shows just how flimsy was the factual basis of the events described in it. Cronin’s book describes, among other things, his years as a young assistant GP in the Scottish village of Tannochbrae, working for a Dr Cameron. Tannochbrae and Cameron were entirely fictitious, and went on to starring roles in Dr Finlay’s Casebook, which established the enduringly successful template for cosy Sunday evening British television. Adventures was branded as “autobiography” mainly on the insistence of Cronin’s publisher, Victor Gollancz.

Do No Harm by Henry Marsh is that rare thing: a memoir written by a still-practising doctor which is actually worth reading. Marsh is a neurosurgeon – a senior consultant, as he frequently reminds us – at St George’s Hospital in London. Why has he written this book now? He is sixty-four, not far off retirement, which he clearly is not looking forward to: “… soon I will be old and retired and then I will no longer count for much in the world.” Do No Harm contains numerous unflattering portraits of hospital managers, relatives and colleagues, and could only be written by a doctor who has no further interest in career progression and who is too near retirement for the managers to bother with disciplinary action. “Although the stories I have told are all true,”, he writes in the Acknowledgements at the end of the book, “I have changed many of the details to preserve confidentiality when necessary.” Marsh may have changed the details, but the medical facts and conversations recounted here seem so individual that one suspects that many patients (and their families and friends) could easily recognise themselves. Some his colleagues must have felt very uncomfortable reading this. Good for him.

Marsh’s parents were accomplished and cosmopolitan, his father a distinguished QC and human rights lawyer, his mother a refugee from Nazi Germany. He came to medicine relatively late, having read Politics, Philosophy and Economics at Oxford. He interrupted his degree after an unhappy and unrequited love affair, left Oxford and went to work – inspired by the character played by Jack Nicholson in Five Easy Pieces ‑ as a hospital porter in the northeast. Here he decided to make medicine, in particular surgery, his career, returned to finish his degree (taking a first) and then enrolled as a mature student at the Royal Free Hospital (the only medical school willing to take students with no science background). He is refreshingly honest about his motives for becoming a doctor: “It seemed to involve excitement and job security, a combination of manual and mental skills, and power and social status as well.” He is suspicious of doctors who claim altruism as their primary motivation; his experience working, when he was a student, as a nursing assistant in a large psychogeriatric hospital in London showed him the grim realities of hospital life: “To go to work at seven in the morning to be faced by a room of twenty-six doubly incontinent old men in beds is an education of sorts, as it was to wash them and shave them and feed them, and pot them, and strap them into geriatric chairs … It was miserable work, with little reward, and I learned much about the limitations of human kindness, and in particular my own.” I too did such a job as a student, and learned far more on the psychogeriatric wards of the now demolished Chadwell Heath Hospital in Essex than I did in the lecture halls of the medical school.

Having qualified, Marsh wondered if it had all been a dreadful mistake, finding the reality of clinical medicine dull and stressful. One momentous experience as a senior house officer, however, sets him on his future course.  He describes the euphoria he experienced when he decided, having watched a brain aneurysm operation, to become a neurosurgeon: “It was unlike any other operation I had ever seen … This operation was done with the operating microscope, through a small opening in the side of the woman’s head using only fine microscopic instruments with which to manipulate her brain’s blood vessels … The operation was elegant, delicate, dangerous and full of profound meaning. What could be finer, I thought, than to be a neurosurgeon? I had the strange feeling that this was what I wanted to do all my life, even though it was only now that I realized it. It was love at first sight.”

Do No Harm is, in part, a meditation on failure: “A brain surgeon’s life is never boring and can be profoundly rewarding but it comes at a price. You will inevitably make mistakes and you must learn to live with the occasional awful consequences.” Marsh describes how, as a young consultant, he embarked on a marathon operation to remove a huge brain tumour from a middle-aged teacher. The patient had gone to a more senior neurosurgeon for a second opinion; this wily old professor advised the patient to go ahead and have the surgery done by Marsh. The operation took many hours, but a slip-up towards the end of the operation led to disaster: “As I started to remove the last part of the tumour I tore a small perforating branch of the basilar artery, a vessel the width of a thick pin. I knew at once that this was a catastrophe. The blood loss was trivial, and easy enough to stop, but the damage to the brainstem was terrible … the patient never woke up and that was why seven years later, I saw him curled into a sad ball, on a bed in the nursing home.” He is horrified when visiting this nursing home: “To my dismay, I recognized at least five of the names as former patients of mine.” Marsh eventually regained his equanimity after this disaster: “I used what I had learned from the tragic consequences of my hubris to achieve much better results with tumours of this kind.” He also ruefully admits that another lesson learned from this tragedy was “not to do an operation that a more experienced surgeon than me did not want to do”.

But shit happens without any help from hubris, vanity or incompetence. Marsh describes an operation performed on an Italian man for a pituitary tumour which is technically successful, but is complicated by a fatal post-operative stroke: “the empty hospital corridors were ringing with the family’s cries, including the three-year-old grand-daughter’s. So I gathered them all together and sat in a chair facing them and explained things and told them how sorry I was. The patient’s wife was on her knees in front of me, clasping her hands, begging me to save her husband.” Another operation – for a malignant brain tumour – is also technically successful, but the patient doesn’t wake up from the anaesthetic, having bled within the brain: “it was clearly both inoperable and fatal – a post-operative intracerebral haemorrhage, a ‘rare but recognized’ complication of such surgery. I picked up the phone in the control room and rang her husband.” Having sat down face to face with the woman’s shocked spouse and told him what had happened, he can take no more: “Eventually I turned to the door saying that I had to leave or I would start crying myself.”An operation on a young woman with a spinal cord tumour leaves the patient with permanent paralysis: “She would be added to the list of my disasters – another headstone in that cemetery which the French surgeon Leriche once said all surgeons carry within themselves.”

Atul Gawande, the celebrated American surgeon and writer, made his name with Complications: a Surgeon’s Notes on an Imperfect Science (2002), written when he was still completing his surgical training. “There is a central truth about medicine,” wrote Gawande, “that complicates this tidy vision of misdeeds and misdoers: all doctors make terrible mistakes.” He is, of course, quite right, but his observations, based on his experience as a surgical trainee, do not quite carry the same authority as those of Marsh, who writes from the perspective of his long (and nearly completed) career. Marsh is a visiting professor at an American medical school, and once delivered a lecture there called “All My Worst Mistakes”: “When I delivered my lecture to my American colleagues, it was met by a stunned silence.”

“I am less frightened by failure,” writes Marsh, “I have come to accept it and feel less threatened by it and hopefully have learned from the mistakes I made in the past. I can dare to be a little less detached. Besides, with advancing age I can no longer deny that I am made of the same flesh and blood as my patients and that I am equally vulnerable.” He astutely observes however, that we are a long way from the much vaunted “blame-free culture”. We may work in “teams”, but we are still blamed as individuals. He describes a meeting with a QC acting on behalf of the Medical Defence Union (a doctors’ indemnity organisation), who are settling a malpractice case brought against him, a case which they feel is indefensible. He accepts this assessment, but afterwards, clearly distraught, he confides in the external neurosurgical expert brought in by the Defence Union: “’I know one has to accept these things,’ I went on lamely, ‘But nobody, nobody other than a neurosurgeon understands what it is like to have to drag yourself up to the ward and see, every day – sometimes for months on end – somebody one has destroyed and face the anxious and angry family at the bedside who have lost all confidence in you.’”

Although Marsh argues forcefully that complications are inevitable, that they are sometimes the fault of the surgeon and sometimes not, he accepts the need for accountability, “since power corrupts. There must be complaints procedures and litigation, commissions of enquiry, punishment and compensation.” He is brave enough, however, to dismiss “informed consent” for the legalistic fantasy which it is: “’Informed consent’ sounds so easy in principle … The reality is very different. Patients are both terrified and ignorant.”

Clinical judgement is difficult to quantify, and can be acquired only with experience: “Knowing when not to operate is just as important as knowing how to operate, and is a more difficult skill to acquire … Often it is better to leave the patient’s disease to run its natural course and not to operate at all.” When Marsh decided to embark on the arduous course of training as a neurosurgeon, he went to visit a famous brain surgeon for advice: “‘The operating is the easy part, you know,’ he said. ‘By my age you realize that the difficulties are all to do with the decision-making.’” But clinical decision-making will always be a flawed process, regardless of protocols, guidelines and multi-disciplinary teams. Marsh advises honesty when error occurs “…if you do not hide or deny any mistakes when things go wrong, and if your patients and their families know that you are distressed by whatever happened, you might, if you are lucky, receive the precious gift of forgiveness.”

One of the reasons Marsh cites for opening his personal cemetery of complications is “the hope that my trainees will learn how not to make the same mistakes themselves.” He describes the camaraderie and the frustrations of training junior doctors who will themselves be consultant neurosurgeons in a few short years: “… it can be a very close relationship – a little, perhaps, like that between soldiers in battle – and it is what I will miss most when I retire.” He describes how every working day begins at 8.00 am with a meeting of all the doctors in the team: “a practice I began twenty years ago. I had been inspired by the TV police soap Hill Street Blues, where every morning the charismatic sergeant would deliver pithy homilies..” (Does Marsh, I wonder, finish each morning meeting with Sgt Esterhaus’s admonition: “let’s be careful out there”?)  Medical teams are not as cohesive as they once were, largely due to the imposition of shift-work for the junior doctors, to comply with the European Working Time Directive (EWTD), which limits doctors’ working hours to 48 a week. The junior doctor who admits the patient overnight is unlikely to be present next morning to present the case to the team. Although junior doctors no longer work the brutal hours which were once the norm, training has been adversely affected, and the young doctors no longer enjoy the camaraderie and protection of being part of the team. As I write this, my own hospital is in the process of introducing shift rotas to comply with the working time directive.

Marsh admits to experiencing “intense anxiety” when supervising his juniors when they operate: “... so much greater than when I operate myself”. The politicians and managers who hatched the idea of the directive didn’t think through the consequences for training, particularly for junior surgeons; their “hands-on” experience has been severely curtailed, and the fear of sanctions or punishment after complications has made their bosses understandably nervous: “ When you are a trainee the ultimate responsibility for any mistakes that you might make are ultimately borne by your consultant and not yourself.” He describes a surgical catastrophe after delegating a relatively uncomplicated lumbar disc operation to his registrar. Marsh returns to the operating theatre (ironically, from a meeting about implementation of the EWTD) to check on his trainee’s progress: “‘Oh Jesus fucking Christ!’ I burst out. ‘You’ve severed the nerve root!’ I threw the forceps on to 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.”

Marsh has to go the patient when the anaesthetic has worn off, and has the Difficult Conversation. The patient, a young man who, before the operation, was a competitive mountain biker, was left with a permanent limp. Marsh vents his spleen as he cycles home: “Why don’t I stop training juniors? Why don’t I just do all the operating myself? Why should I have to carry the burden of deciding when they can operate or not when the fucking management and politicians dictate their training? ... The country’s massively in debt financially, why not have a massive debt of medical experience as well? Let’s have a whole new generation of ignorant doctors in the future. Fuck the future, let it look after itself, it’s not my responsibility. Fuck the management, and fuck the government and fuck the pathetic politicians and their fiddled expenses and fuck the fucking civil servants in the fucking Department of Health. Fuck everybody.”

Most NHS consultants regard their managers with visceral contempt, and Marsh is no exception: “As with all NHS chief executives in my experience (I have now got through eight) they do the rounds of the hospital departments when they are appointed and then one never sees them again, unless one is in trouble, that is. This is called Management, I believe.” Marsh has views on NHS senior managers which most of his colleagues share, but very few would dare to express publicly. His waspish descriptions of the apparatchiks who occupy the higher echelons of management provide some light relief after the heart-rending accounts of cases that didn’t go so well: “… my colleagues and I had recently been threatened with disciplinary action for wearing ties and wristwatches. There is no evidence that consultants wearing ties and wristwatches contributes to hospital infections, but the chief executive viewed the matter so seriously that he had taken to dressing as a nurse and following us on our ward rounds, refusing to talk to us and instead taking copious notes …” While his registrar is in theatre, accidentally severing the lumbar nerve roots of the mountain-biker, Marsh is being lectured on the forthcoming implementation of the EWTD by “a large and officious young woman with hennaed hair in tight curls. She spoke imperiously.” When Marsh attempts to explain to her of the dangers to patient care and safety, as well as the deleterious effects on training, she dismisses him: ‘You can send me an email setting out your views.’

 “I may appear to others to be brave and outspoken,” Marsh admits, “but I have a deep fear of authority, even of NHS managers, despite the fact that I have no respect for them.” A junior manager (“Chris”) leads a session in “Mandatory and Statutory Training” for a diverse group of staff, including nurses, porters and doctors (including Marsh): “How strange it is, I thought as I listened to him talking that after thirty years of struggling with death, disaster and countless crises and catastrophes, having watched patients bleed to death in my hands, having had furious arguments with colleagues, terrible meetings with relatives, moments of utter despair and of profound exhilaration – in short, a typical neurosurgical career – how strange it is that I should now be listening to a young man with a background in catering telling me that I should develop empathy, keep focused and stay calm.” He is relieved to be called out of the meeting to speak with the family of a dying patient.

Those working within the NHS sometimes call the organisation “Stalinist”, a reference, I think, to the fact that it is a nationalised, centralised behemoth, the largest employer in the country. But if you want to know what a truly Stalinist health service is like, there is Ukraine. Marsh first visited the country in the early 1990s, at the invitation of a businessman who was trying to sell medical equipment there. He was horrified by the squalor and barbaric surgical methods when he went to visit a specialist neurosurgical hospital in Kiev: “A surgeon was ‘operating’ on a paralysed man, paralysed from the neck down in an accident some years previously, I was told…The surgeon had inserted several large needles into his spine and was injecting cold saline through them into the spinal canal. This was, apparently, supposed to stimulate the spinal cord to recover.” The former Soviet bloc, isolated from the West and its medical advances for decades, left behind a medieval, chaotic health system, which remains broken to this day: wealthy Russians and Ukrainians go to London, Paris and Vienna for medical care. Marsh befriended a local young neurosurgeon called Igor Kurilets, who seemed to be the only Ukrainian doctor interested in improving the service. Marsh took Kurilets to London for training, and returned to Kiev for several visits. The hospital is as corrupt and chaotic as the country at large, and Kurilets, lacking a powerful patron (“a roof over your head”, as the Ukrainians say), is viewed with suspicion by the hospital hierarchy for his friendship with Marsh. He describes a visit to Kiev in 1998: “On this particular visit, in the summer of 1998 … I learnt that I had been ‘banned’ from the operating theatres by the director.” Undaunted, Kurilets arranges for Marsh to see a succession of patients: “There was no appointment system – patients would turn up at any time, and seemed to accept that this might involve waiting all day to be seen.” One of these patients, a young woman called Ludmilla, suffering from a brain tumour, had been referred to one of the professors in Kiev, but was advised thus by the local Ukrainian junior doctors: “If you want to live, leave before the professor returns. Go and see Kurilets. He has contacts with the West and may be able to help. If you let the professor operate, you will die.” Marsh arranged for Ludmilla to travel to London: “the operation on Ludmilla took eight hours and was a great success.”

He agrees also to take Tanya, an eleven-year-old girl from a remote rural part of Ukraine, who had an enormous brain tumour: “It was the largest tumour of its kind that I have ever seen”. Things don’t go as well for Tanya: “the first operation on Tanya took ten hours, and then there was a second operation that took twelve hours. Both operations were complicated by terrible blood loss. With the first operation she lost four times her entire circulating blood volume but she emerged unscathed, although with half of the tumour still in place. The second operation – to remove the rest of the tumour – was not a success. She suffered a severe stroke ... Tanya died eighteen months after her return home. She would have been just twelve years old.” He is filled with regret: “I should have left Tanya in Ukraine. I should have told her mother to take her back to Horodok, but instead I brought her to London.” Some years later, Marsh was the subject of an acclaimed documentary, The English Surgeon (2007). He is filmed visiting Tanya’s grave (you can view this on YouTube), a scene of heartbreaking sadness: “Tanya’s grave had a six-foot high headstone from which her carved face appeared – odd, perhaps, to western eyes, but beautiful.”

Working in the NHS has different, but no less frustrating, difficulties for Marsh. A grand, elderly lady with a brain tumour, the widow of a professor of gynaecology, has her operation cancelled at short notice, because the (locum) anaesthetist refuses to work beyond 5.00pm, citing lack of child care. “I envy the way in which the generation who trained me,” reflects Marsh, “could relieve the intense stress of their work by losing their temper, at times quite outrageously, without fear of being had up for bullying or harassment.” Instead of throwing his instruments around the theatre or slapping the anaesthetist, Marsh has to apologise to the patient and her angry family: “I resent having to say sorry for something which is not my fault.” He recalls, however, his own anxiety and anger, many years before, when his son was gravely ill, and is philosophical about stroppy families: “Anxious and angry relatives are a burden all doctors must bear, but having been one myself was an important part of my medical education. Doctors, I tell my trainees with a laugh, can’t suffer enough.”

Then there are difficult colleagues. After an angry altercation with a group of rival surgeons who attempted to invade the neurosurgeons’ theatre lounge (the sacrosanct territory where Marsh and his colleagues retreat to between cases), Marsh – still fuming – joins his registrar in theatre and took over the operation: “It was an unusually difficult case and I damaged the nerve for the left side of the patient’s face as I removed the tumour. Perhaps this was going to happen anyway – it is called a ‘recognized’ complication of that particular operation – but I know that I was not in the right state of mind to carry out such dangerous and delicate surgery, and when I saw the patient on the ward round in the day afterwards, and saw his paralysed face, paralysed and disfigured, I felt a deep sense of shame.” A manager rebukes him for trying to transfer a patient from a peripheral hospital, when no beds were available: “In the past, this would never have happened – an extra bed would always have been found, nor would anybody have questioned my instructions ... My hands were starting to shake with anger and I had to make a conscious effort to calm down and get on with the operation.” At the outpatients, a department with “all the charm of an unemployment office”, Marsh struggles to log on to the X-ray computer system to view a patient’s brain scan. A secretary advises him to use another consultant’s password to log on to the system:

“Well, try Mr Johnston’s. That usually works. Fuck Off 45. He hates computers.”
“Why forty-five?”
“It’s the forty-fifth month since we signed on to that hospital’s system and one has to change the password every month.”

But Marsh’s professional life is not all complications and frustration. He loved, and still loves, the actual business of operating: “At the end of a successful day’s operating, when I was younger, I felt an intense exhilaration …” He describes an aneurysm operation which came to the brink of disaster, when the applicator deployed to clip the aneurysm failed to open. His skill and experience, however, carry him through: “I had avoided disaster and the patient was well. It was a deep and profound feeling which I suspect few people other than surgeons ever get to experience. Psychological research has shown that the most reliable route to personal happiness is to make others happy. I have made many patients very happy with successful operations but there have been many terrible failures and most neurosurgeons’ lives are punctuated by periods of deep despair.” Marsh admits that his choice of career cost him his first marriage.

Marsh is a lyrical, elegant prose stylist. He writes tenderly, and unsentimentally, about his mother’s death. He and his sister, a trained nurse, cared for the dying woman at home:

My sister was wonderful to watch, kindly and gently discussing and explaining everything as she carried out the simple, necessary nursing. We had both seen many people die, after all, and I had worked as a geriatric nurse many years ago too. It felt easy and natural for us both, I think, despite our intense emotions. It’s not that we felt anxious – the three of us knew she was dying – I suppose what we felt was simply intense love, a love quite without ulterior motive, quite without the vanity and self-interest of which love is so often an expression. ‘It’s a quite extraordinary feeling to be surrounded by so much love,’ she said two days before she died. ‘I count my blessings.’ … Dying is rarely easy, whatever we might wish to think. Our bodies will not let us off the hook of life without a struggle … I must hope that I live my life now in such a way that, like my mother, I will be able to die without regret. As my mother lay on her death-bed, drifting in and out of consciousness, sometimes lapsing into her German mother-tongue she said: ‘It’s been a wonderful life. We have said everything there is to say.’

He describes a visit to a peripheral hospital – a detour on his drive to a weekend break ‑ to see an old patient of his – “David” – who had undergone surgery for a brain tumour several years previously, but who now had recurrent tumour, tumour which was not operable. He has to tell David the bad news, and is overcome with emotion: “I stood up – his wife came towards me, her eyes full of tears. I buried my face in her shoulder, holding her fiercely for a few seconds and then left the room …Will I be so brave and dignified when my time comes? I asked myself as I walked out into the grim asphalt car park. The snow was falling and I thought yet again of how I hate hospitals ... And I felt shame, not at my failure to save his life – his treatment had been as good as it could be – but at the loss of professional detachment and what felt like the vulgarity of my distress compared to his composure and his family’s suffering, to which I could only bear impotent witness.”

Do No Harm is suffused with an unphony, practical humanity. A dying alcoholic man with an inoperable brain tumour tells Marsh: “I used to work in a hospital, you know. I’m going to die there aren’t I? All the piss and shit … All I want is a cigarette.” Although smoking is now completely banned in all hospitals, Marsh asks a staff nurse if she can help, and the dying man is accommodated: “there must be some secret place in the hospital where they can wheel the paralysed patients for a smoke. I was happy to know that common sense and kindness had not yet been completely beaten out of the nurses.”

The only other book which captures the intense pressure of modern medical practice is Raymond Tallis’s Hippocratic Oaths (2004), a passionate, learned defence of medicine’s core values. Tallis is an academic geriatrician and philosopher who coined the phrase “the unbearable heaviness of responsibility” – a sly nod to Milan Kundera. He has a special regard for the quotidian courage of surgeons: “To face the challenges of surgery day in and day out, to know that at any time a routine operation can go badly wrong and you will find yourself at the end of a harrowing and exhausting day trying to explain to shocked, uncomprehending and grieving relatives what has gone wrong, takes a very special kind of person.” Tallis observed how few prospective medical students identify the burden of responsibility as the greatest stress of a life in medicine, most citing the long hours ‑ soon to be consigned to history by the European Working Time Directive.

When I was a teenager contemplating my future, I read specious rubbish like AJ Cronin’s Adventures in Two Worlds. Should any school-leaver (or, as is more likely, parent) happen to be reading this and considering the merits of a career in medicine, can I suggest that you read, and then read again, Do No Harm? I don’t think I have ever read a better book on what it means to be a doctor.
16/06/2014

Seamus O’Mahony is a consultant physician and a regular contributor to the Dublin Review of Books.

 

 

 

 

 

 

 

 

 

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