I’m sure I’ve read Henry Marsh’s book before. Almost a quarter of our blood supply is dedicated to providing energy for the brain. When things go wrong, brain surgery is the last resort. What makes Marsh different is not that he’s a brain surgeon, but that he’s also a great writer.
Marsh tells us he’s grown more conservative over the years. Not conservative in terms of treating health care as something that should be floated on the market with trust competing with each other for business. He gives that nonsense short shrift. But conservative in terms of intervention.
‘First, do no harm…’Commonly attributed to Hippokrates at Kos, C.460 BC. ‘
The Hippocratic oath is conservative. And for good reason. He quotes Rene Leriche, La philosophie de la chirugie, 1951.
‘Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation for his failures.’
This brings to mind a story about ‘Bomber Brown’ being stopped by a traffic cop and warned about his erratic driving by a policeman. A surgeon does not like Bomber Brown admit to killing hundreds every night, but his or her mistakes last a lifetime and it’s not their lifetime.
What is striking about Marsh is his humility. He doesn’t work for a Trust. He works for every single patient he sees. But a part of his job is letting go and training the next generation of surgeons. Something, he admits he’s not particularly good at. Their mistakes are his mistakes, but written on the patient’s body. He tells stories of medical cover-ups. And his own mistakes. One of them was to do with infection control and streptococcal virus. But another is hand’s on, but the hands aren’t his. And I felt sorry, not for the patient, or the trainee surgeon, but for Marsh, which seems contradictory.
‘Neurotemesis n. the complete severance of a peripheral nerve. Complete recovery of function is impossible.’
The case seemed quite straightforward to Marsh. A slipped disc ‘a herniated intervertebral disc causing S1nerve-root compression’.
The patient was fit, a computer programmer that competed in mountain bike championships before his prolapse.
Marsh complained that we had a tendency to go over the top, with the American model listing all of the possible complications and terrorising the patients before getting their informed consent. Later, he even questions whether such a thing as informed consent is possible. We sign the form (as I’ve done) and we take our chances.
Marsh had a good relationship with his registrar. I imagine he’d a good relationship with most of his colleagues. He recognised he was fortunate in being born middle-class at a time when it was possible to do a degree in political science and economics (PPE at Cambridge) and retrain to be a doctor. Eventually, choosing to become a brain surgeon when there were fewer than 200 brain surgeons in England. Like the idea of informed consent. It wasn’t possible to know what that meant until he was mature enough to have made mistakes. Mistakes that other people, his patients paid for. Recognition that he and his colleagues were the instruments of last resort. Even then, like the cemetery, in Stephen King, Pet Cemetery some bodies should not be brought back from certain death. Not at any price. Not all. Not at all. Marsh’s breadth of experience wasn’t just of the conventional medic but also having lived other lives, outside the STEM system, this government advocates, having for example, worked on a ward as a porter and in a geriatric ward, wiping old men’s bums. If I were to have brain surgery, and I had a choice, I’d choose Marsh.
Marsh rallied against junior doctors working shorter hours of 120 hours per week (3 weeks in a week for normal people). This seemed at odds with the person I imagined him to be. People like me, who imagine only Tory scaremongers would demand that kind of thing). But that’s what we do, he said, invest surgeons with superpowers, imagine them to be godlike, until like Icarus they burn.
He argues for the greater good, ‘it destroys continuity of care, and the shorter hours will mean that they will have much less clinical experience and that’s dangerous.’
Marsh let his registrar start the spinal case. The trainee had done so before (see one, do one, teach one) and although Marsh didn’t think him the best in terms of operating ability, he found him to be very conscientious and kind. Marsh thinks (like me) kindness trumps many other qualities. This was reinforced by the nurses liking him.
Marsh had talked over the operation, scrubbed up and came into the theatre. ‘Why such a large incision? he asked.
On closer inspection.
‘Jesus, fucking Christ. You’ve severed the nerve root.’
In thirty years of neurosurgery I’d never witnessed this disaster, although I have heard of it happening,’ he admitted.
Marsh had to tell the computer programmer and cyclist he would now walk, after rehabilitation, with a permanent drooped foot and limp. The responsibility was Marsh’s not the trainee, who’d opened the spine at the outer rather that inner edge.
‘Hubris, n. arrogant pride, or presumption; (in Greek tragedy) excessive pride towards, or defiance of the gods, leading to nemesis.’
Marsh is able to meet his mistakes and face them down. It humbles him. Imagine a world in which politicians had to live with the choices they made for others. Architects had to live in the buildings they designed for the poor. And the rich, like the Pharaoh of Egypt were left with a mass exodus of the poor that served them. Imagine a better world. Marsh can and does. Not because he’s a surgeon, but because he’s a reader or flawed humanity. Read on.