Do No Harm: Stories of Life, Death and Brain Surgery by Henry Marsh Read Free Book Online Page B

simply enough, the sitting position. The unconscious patient’s head is attached to the pin headrest which in turn is connected to a shiny metal scaffold, attached to the operating table. The table is then split and the top half hinged upwards, so that the patient is sitting bolt upright. This helps reduce blood loss during surgery and also improves access to the tumour, but involves a small risk of anaesthetic disaster as the venous blood pressure in the patient’s head in the sitting position is below atmospheric room pressure. If the surgeon tears a major vein air can be sucked into the heart, with potentially terrible consequences. As with all operating, it is a question of balancing risks, sophisticated technology, experience and skill, and of luck. With the anaesthetists, the theatre porters and U-Nok, Fiona and I positioned the patient. It took half an hour to make sure his unconscious form was upright with his head bent forward, that there were no ‘pressure points’ on his arms or legs where pressure sores might develop, and that all the cables and wires and tubes connected to his body were free and not under tension.
    ‘Well, let’s get on with it,’ I said.
    The operation went perfectly with scarcely any blood loss at all. This type of tumour is the only time in brain tumour surgery that you have to remove the tumour ‘en bloc’ – in a single piece – since if you enter the tumour you will be instantly faced by torrential bleeding. With all other tumours in brain surgery you gradually ‘debulk’ it, sucking or cutting out the inside of it, collapsing it in on itself, away from the brain, and thus minimizing damage to the brain. With solid haemangioblastomas, however, you ‘develop the plane’ between the tumour and the brain, creating a narrow crevice a few millimetres wide by gently holding the brain away from the surface of the tumour. You coagulate and divide the many blood vessels that cross from the brain to the tumour’s surface, trying not to damage the brain in the process. All this is done with a microscope under relatively high magnification – although the blood vessels are tiny, they can bleed prodigiously. One quarter of the blood pumped every minute by the heart, after all, goes to the brain. Thought is an energy-intensive process.
    If all goes well the tumour is eventually freed from the brain and the surgeon will lift the tumour out of the patient’s head.
    ‘All out!’ I shout triumphantly to the anaesthetist at the other end of the table, and wave the scruffy and bloody little tumour, no bigger than the end of my thumb, in the air at the end of a pair of dissecting forceps. It hardly looked worth all the effort and anxiety.
     
    With the day’s operating finished I went to see the patient on the Recovery Ward. He looked remarkably well and wide awake. His wife was beside him and they expressed their heartfelt gratitude.
    ‘Well, we were lucky,’ I said to them, though they probably thought this was false modesty on my part, which I suppose to an extent it was.
    As I left, dutifully splashing alcoholic hand gel on my hands on my way out, James the registrar on-call for emergencies came looking for me.
    ‘I think you’re the consultant on call today,’ he said.
    ‘Am I? Well, what have you got?’
    ‘Forty-six-year-old man with a right temporal clot with intraventricular extension in one of the local hospitals – looks like an underlying AVM. GCS five. He was talking when he was admitted.’
    An AVM is an arterio-venous malformation, a congenital abnormality which consists of a mass of blood vessels that can, and often do, cause catastrophic haemorrhages. The GCS is the Glasgow Coma Scale and a way of assessing a patient’s conscious level. A score of five meant that the man was in coma, and close to death.
    I asked him if he had seen the scan and if the patient was already on a ventilator.
    ‘Yes,’ James replied, so I asked him what he wanted to do. He was one of