Aneurysm

ANEURYSM

1. a morbid dilation of the wall of a blood vessel, usu. an artery.

 

Neurosurgery involves the surgical treatment of patients with diseases of the brain and spine. These are rare problems so there are only a small number of neurosurgeons and neurosurgical departments in comparison to other medical specialties. I never saw any neurosurgery as a medical student. We were not allowed into the neurosurgical theatre in the hospital where I trained – it was considered too specialized and arcane for mere students. Once, when walking down the main theatre corridor, I had a brief view through the small port-hole window of the neurosurgical theatre’s door of a naked woman, anaesthetized, her head completely shaven, sitting bolt upright on a special operating table. An elderly and immensely tall neurosurgeon, his face hidden by a surgical facemask and a complicated headlight fixed to his head, was standing behind her. With enormous hands he was painting her bare scalp with dark brown iodine antiseptic. It looks like a scene from a horror film.

Three years later I found myself in that same neurosurgical operating theatre, watching the younger of the two consultant neurosurgeons who worked in the hospital, operating on a woman with a ruptured cerebral aneurysm. I had been qualified as a doctor for one and a half years by then and was already disappointed and disillusioned with the thought of a career in medicine. I was working at the time as a senior house officer, or SHO for short, in my teacher hospital’s intensive care unit. One of the anaesthetists who worked on the ITU, seeing that I looked a little bored, had suggested that I come down to the operating theatre to help her prepare a patient for a neurosurgical operation.

It was unlike any other operation I had seen, which had usually seemed to involve long, bloody incisions and the handling of large and slippery body parts. This operation was done with an 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.

Aneurysms are small, balloon-like blow-outs on the cerebrial arteries that can–and often do–cause catastrophic haemorrhages in the brain. The aim of the operation is to place a minute spring-loaded metal clip across the neck of the aneurysm–just a few millimetres across–to prevent the aneurysm bursting. There is very real danger that the surgeon, working at several inches’ depth in the centre of the patient’s head, in a narrow space beneath the brain, will inadvertently burst the aneurysm while he dissects it free from the surrounding brain and blood vessels and tries to clip it. Aneurysms have thin, fragile walls, yet they have high pressure, arterial blood within them. Sometimes the wall is so thin that you can see the swirling dark vortices of blood within the aneurysm, made enormous and sinister by the magnification of the operating microscope. If the surgeon ruptures the aneurysm before he can clip it the patient will usually die, or at least suffer a catastrophic stroke–a fate that can easily be worse than death.

The staff in the theatre were silent. There was none of the usual chatter and talk. Neurosurgeons sometimes describe aneurysm surgery as akin to bomb disposal work, though the bravery required is of a different kind as it is the patient’s life that is at risk and not the surgeon’s. The operation I was watching was more like a blood sport than a calm and dispassionate technical exercise, with the quarry a dangerous aneurysm. There was the chase – the surgeon cautiously stalking his way beneath the patient’s brain towards the aneurysm, trying not to disturb it, to where it lay deep within the brain. And then there was the climax, as he caught the aneurysm, trapped it, and obliterated it with a glittering, spring­loaded titanium clip, saving the patient’s life. More than that, the operation involved the brain, the mysterious substrate of all thought and feeling, of all that was important in human life–a mystery, it seemed to me, as great as the stars at night and the universe around us. 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 had wanted to do all my life, even though it was only now that I had realized it. It was love at first sight.

The operation went well. The aneurysm was successfully clipped without causing a catastrophic stroke or haemorrhage and the atmosphere in the operating theatre was suddenly happy and relaxed. I went home that night and announced to my wife that I was going to be a brain surgeon. She looked a little surprised, given that I had been so undecided about what sort of doctor I should be, but she seemed to think the idea made sense. Neither of us could have known then that my obsession with neurosurgery and the long working hours and the self­importance it produced in me would lead to the end of our marriage twenty­five years later. Thirty years and several hundred aneurysm operations later, re­married and only a few years away from retirement, I cycled in to work on a Monday morning with an aneurysm to clip. A heat wave had just ended and heavy grey rain clouds hung over south London. It had poured with rain during the night. There was little traffic–almost everybody seemed to be away on holiday. The gutters at the entrance to the hospital were flooded so that the passing red buses sent cascades of water over the pavement and the small number of staff walking to work had to jump to one side as the buses swept past.

I rarely clip aneurysms now. All the skills that I slowly and painfully acquired to become an aneurysm surgeon have been rendered obsolete by technological change. Instead of open surgery, a catheter and wire is passed through a needle in the patient’s groin into the femoral artery and fed upwards into the aneurysm by a radiology doctor–not a neurosurgeon–and the aneurysm is blocked off from the inside rather than clipped off from the outside. It is, without a doubt, a much less unpleasant experience for patients than being subjected to an operation. Although neurosurgery is no longer what it once was, the neurosurgeon’s loss has been the patient’s gain. Most of my work is now concerned with tumours of the brain–tumours with names like glioma or meningioma or neurinoma–the suffix ‘­oma’ coming from the ancient Greek word for tumour and the first part of the word being the name of the type of cell from which the tumour is thought to have grown. Occasionally an aneurysm cannot be coiled, so every so often I find myself going to work in the morning in that state of controlled anxiety and excitement that I knew so well in the past.

The morning always starts with a meeting–a practice I began twenty years ago. I had been inspired by the TV police soap Hill Street Blues, where every morning the charismatic station police sergeant would deliver pithy homilies and instructions to his officers before they set off onto the city streets in their police cars with their sirens wailing. It was at the time when the government was starting to reduce the long working hours of junior hospital doctors. The doctors were tired and overworked, it was said, and patients’ lives were being put at risk. The junior doctors, however, rather than becoming ever more safe and efficient now that they slept longer at night, had instead become increasingly disgruntled and unreliable. It seemed to me that this had happened because they were now working in shifts and had lost the sense of importance and belonging that came with working the long hours of the past. I hoped that by meeting every morning to discuss the latest admissions, to train the juniors with constant teaching as well as to plan the patients’ treatment, we might manage to recreate some of the lost regimental spirit.

The meetings are very popular. They are not like the dull and humourless hospital management meetings where there is talk of keeping in the loop about the latest targets or of feeling comfortable about the new Care Pathways. Our neurosurgical morning meeting is a different sort of affair. Every day at eight o’clock sharp, in the dark and windowless X­ray viewing room, we shout and argue and laugh while looking at the brain scans of our poor patients and crack black jokes at their expense. We sit in a semi­circle, a small group of a dozen or so consultants and junior doctors, looking as though we were on the deck of the Starship Enterprise.

Facing us is a battery of computer monitors and a white wall onto which brain scans are projected, many times larger than life­size, in black and white. The scans are of patients admitted as emergencies over the preceding twenty­four hours. Many of the patients will have suffered fatal haemorrhages or severe head injuries, or have newly diagnosed brain tumours. We sit there, alive and well and happy in our work, and with sardonic amusement and Olympian detachment we examine these abstract images of human suffering and disaster, hoping to find interesting cases on which to operate. The junior doctors present the cases, giving us the ‘history’ as it is called–the stories of sudden catastrophe or of terrible tragedy that are repeated each day, year in, year out, as though human suffering would never end.

I sat down in my usual place at the back, in the corner. The SHOs are in the front row and the surgical trainees, the specialist registrars, sit in the row behind them. I asked which of the junior doctors had been on call for the emergency admissions.

‘A locum,’ one of the registrars replied, ‘and he’s buggered off.’

‘There were five doctors holding the on­call bleep over twenty­four hours on Friday,’ one of my colleagues said. ‘Five doctors! Handing over emergency referrals to each other every four point two hours! It’s utter chaos . . .’

‘Is there anything to present?’ I asked. One of the juniors got up from his chair and walked to the computer keyboard on the desk at the front of the room.

‘A thirty­-two-­year-­old woman,’ he said tersely. ‘For surgery today. Had some headaches and had a brain scan.’ As he talked a brain scan flashed up on the wall.

I looked at the young SHOs and to my embarrassment could not remember any of their names. When I became a consultant twenty­five years ago the department had just two SHOs, now there are eight. In the past I used to get to know them all as individuals and take a personal interest in their careers, but now they come and go as quickly as the patients. I asked one of them to describe the scan on the wall in front of us, apologizing for not knowing who she was.

‘Alzheimer’s!’ one of the less deferential registrars shouted from the darkness at the back of the room.

The SHO told me that she was called Emily. ‘This is a CTA of the brain,’ she said.

‘Yes, we can all see that. But what does it show?’

There was an awkward silence.

After a while I took pity on her. I walked up to the wall and pointed to the scan. I explained how the arteries to the brain were like the branches of a tree, narrowing as they spread outwards. I pointed to a little swelling, a deadly berry, coming off one of the cerebral arteries and looked enquiringly at Emily.

‘Is it an aneurysm?’ Emily asked.

‘A right middle cerebral artery aneurysm,’ I replied. I explained how the woman’s headaches had in fact been quite mild and the aneurysm was coincidental and had been discovered by chance. It had nothing to do with her headaches.

‘Who’s doing the exam next?’ I asked, turning to look at the row of specialist registrars who all have to take a nationally organized exam in neurosurgery as they reach the end of their training. I try to grill them regularly in preparation for it.

‘It’s an unruptured aneurysm, seven millimetres in size,’ Fiona – the most experienced of the registrars – said. ‘So there’s a point zero five per cent risk of rupture per year according to the international study published in 1998.’

‘And if it ruptures?’

‘Fifteen per cent of people die immediately and another thirty per cent die within the next few weeks, usually from a further bleed and then there’s a compound interest rate of four per cent per year.’

‘Very good, you know the figures. But what should we do?’

‘Ask the radiologists if they can coil it.’

‘I’ve done that. They say they can’t.’

The interventional radiologists – the specialist X­ray doc­tors who now usually treat aneurysms – had told me that the aneurysm was the wrong shape and would have to be surgically clipped if it was to be treated.

‘You could operate . . .’

‘But should I?’

‘I don’t know.’

She was right. I didn’t know either. If we did nothing the patient might eventually suffer a haemorrhage which would probably cause a catastrophic stroke or kill her. But then she might die years away from something else without the aneurysm ever having burst. She was perfectly well at the moment, the headaches for which she had had the scan were irrelevant and had got better. The aneurysm had been discovered by chance. If I operated I could cause a stroke and wreck her – the risk of that would probably be about four or five per cent. So the acute risk of operating was roughly similar to the life­time risk of doing nothing. Yet if we did nothing she would have to live with the knowledge that the aneurysm was sitting there in her brain and might kill her any moment.

‘So what should we do?’ I asked.

‘Discuss it with her?’

I had first met the woman a few weeks earlier in my outpatient clinic. She had been referred by the GP who had organized the brain scan but his referral note told me nothing about her other than that she was thirty­two years old and had an unruptured aneurysm. She came on her own, smartly dressed, with a pair of sunglasses pushed back over her long dark hair. She sat down on the chair beside my desk in the dull outpa­tient room and put her elaborate designer bag down on the floor beside her chair. She looked anxiously at me.

I apologized for keeping her waiting and hesitated before continuing. I did not want to start the interview by immediately asking her about her family circumstances or about herself – it would sound as though I was expecting her to die. I asked her about the headaches.

So she told me about them, and also the fact that they were already better. They certainly sounded harmless in retrospect. If headaches have a serious cause it is usually obvious from the nature of the headaches. The investigation organized by her GP – hoping, perhaps, that a normal brain scan would reassure her – had created an entirely new problem and the woman, although no longer suffering with headaches, was now desperate with anxiety. She had been on the Internet, inevitably, and now believed that she had a time bomb in her head which was about to explode any minute. She had been waiting several weeks to see me.

I showed her the angiogram on the computer on the desk in front of us. I explained that the aneurysm was very small and might very well never burst. It was the large ones which were dangerous and definitely needed treating, I said. I told her that the risks of the operation were probably very much the same as the risk of her having a stroke from the aneurysm bursting.

‘Does it have to be an operation?’ she asked.

I told her that if she was to be treated it would indeed have to be surgery. The problem was knowing whether to do it or not.

‘What are the risks of the operation?’ She started to cry as I told her that there was a four to five per cent chance she would die or be left disabled by the operation.

‘And if I don’t have the operation?’ she asked through her tears.

‘Well, you might manage to die from old age without the aneurysm having ever burst.’

‘They say you’re one of the best neurosurgeons in the country,’ she said with the naive faith that anxious patients use to try to lessen their fears.

‘Well, I’m not. But I’m certainly very experienced. All I can do is promise to do my best. I’m not denying that I’m completely responsible for what happens to you but I’m afraid it’s your decision as to whether to have the op or not. If I knew what to do I promise I would tell you.’

‘What would you do if it was you?’

I hesitated, but the fact of the matter was that by the age of sixty­one I was well past my best­by date and I knew that I had already lived most of my life. Besides, the difference in our ages meant that I had fewer years of life ahead of me so the life­time risk of the aneurysm rupturing, if it was not operated on, would be much lower for me and the relative risk of the operation correspondingly higher.

‘I would not have the aneurysm treated,’ I said, ‘although I would find it quite hard to forget about it.’

‘I want the op,’ she said. ‘I don’t want to live with this thing in my head,’ emphatically pointing at her head.

‘You don’t have to decide now. Go home and talk things over with your family.’

‘No, I’ve decided.’

I said nothing for a while. I was not at all sure she had really listened to what I had told her about the risks of surgery. I doubted if going over it all over again would achieve much so we set off on the long trek along the hospital corridors to find my secretary’s office and arrange a date for the operation.

* * * *

On a Sunday evening three weeks later I trudged in to the hospital, as usual, to see her and the other patients due to have surgery the next day. I went to the hospital reluctantly, irritable and anxious, much of the day having been overhung with the thought of having to see the woman and face her anxiety.

Every Sunday evening I cycle to the hospital full of foreboding. It is a feeling that seems to be generated merely by the transition from being at home to being at work irrespective of the difficulty of the cases awaiting me. This evening visit is a ritual I have performed for many years and yet, try as I might, I cannot get used to it and escape the dread and pre­occupation of Sunday afternoons–almost a feeling of doom–as I cycle along the quiet backstreets. Once I have seen the patients, however, and spoken to them, and discussed with them what will happen to them next day, the fear leaves me and I return home happily enough, ready for the next day’s operating.

I found her in one of the crowded bays on the women’s ward. I had hoped her husband might be with her so that I could talk to them together but she told me that he had already left as their children were at home. We talked about the operation for a few minutes. The decision was now made, so I did not feel the need to stress the risks as I had done in the outpatient clinic, although I still had to refer to them when I got her to sign the complicated consent form.

‘I hope you get some sleep,’ I said. ‘I promise you I will, which is more important in the circumstances.’ She smiled at the joke–a joke I make with all my patients when I see them the night before surgery. She probably knew already that the last thing you get in hospital is peace, rest or quiet, especially if you are to undergo brain surgery next morning.

I saw the other two patients who were also on the list for surgery and went over the details of their operations with them. They signed the consent forms and as they did so both of them had told me how they trusted me. Anxiety might be contagious, but confidence is also contagious, and as I walked to the hospital car park I felt buoyed up by my patients’ trust. I felt like the captain of a ship–everything was in order, everything was ship­shape and the decks were cleared for action, ready for the operating list tomorrow. Playing with these happy nautical metaphors as I left the hospital, I went home.

* * * *

After the morning meeting I went to the anaesthetic room where the patient was lying on a trolley, waiting to be anaesthetized.

‘Good morning,’ I said, attempting to sound cheerful. ‘Did you sleep well?’

‘Yes,’ she replied calmly. ‘I had a good night’s sleep.’

‘Everything’s going to be fine,’ I said.

I could only wonder once again whether she really appreciated the risks to which she was about to be exposed. Perhaps she was very brave, perhaps naive, perhaps she had not really taken in what I had told her.

In the changing room I stripped off and climbed into theatre pyjamas. One of my consultant colleagues was getting changed as well and I asked him what was on his list for the day.

‘Oh, just a few backs,’ he said ‘You’ve got the aneurysm?’

‘The trouble with unruptured aneurysms,’ I said, ‘is that if they wake up wrecked you have only yourself to blame. They’re in perfect nick before the op. At least with the rup­tured ones they’re often already damaged by the first bleed.’

‘True. But the unruptured ones are usually much easier to clip.’

I went in to the theatre where Jeff, my registrar, was positioning the woman on the operating table. My department is unusual in having American surgeons from the neurosurgical training programme in Seattle who train with us for a year at a time. Jeff was one of these and, as with most of the American trainees, he was outstanding. He was clamping her head to the table–three pins attached to a hinged frame are driven through the scalp into the skull to hold the patient’s head immobile.

I had promised her a minimal head shave and Jeff started to shave the hair from her forehead. There is no evidence that the complete head shaves we did in the past, which made the patients look like convicts, had any effect on infection rates, which had been the ostensible reason for doing them. I suspect the real – albeit unconscious – reason was that dehumanizing the patients made it easier for the surgeons to operate.

With the minimal head shave completed we go to the scrub­up sink and wash our hands and then, gloved and masked and gowned, return to the table and start the operation. The first ten minutes or so are spent painting the patient’s head with antiseptic, covering her with sterile towels so that I can only see the area to be operated upon, and setting up the surgical equipment and instruments with the scrub nurse.

‘Knife,’ I say to Irwin, the scrub nurse. ‘I’m starting,’ I shout to the anaesthetist at the other end of the table, and off we go.

After thirty minutes of working with drills and cutters powered by compressed air the woman’s skull is open and the uneven ridges of bone on the inside of her skull have been smoothed down with a cutting burr.

‘Lights away, microscope in and the operating chair!’ I shout, as much from excitement as from the need to make myself heard above the rattle and hum and hissing of all the equipment and machinery in the theatre.

Modern binocular operating microscopes are wonderful things and I am deeply in love with the one I use, just as any good craftsman is with his tools. It cost over one hundred thousand pounds and although it weighs a quarter of a ton it is perfectly counter­balanced. Once in place, it leans over the patient’s head like an inquisitive, thoughtful crane. The binocular head, through which I look down into the patient’s brain, floats as light as a feather on its counter­balanced arm in front of me, and the merest flick of my finger on the controls will move it. Not only does it magnify, but it illuminates as well, with a brilliant xenon light source, as bright as sunlight.

Two of the theatre nurses, bent over with the effort, slowly push the heavy microscope up to the table and I climb into the operating chair behind it–a specially adjustable chair with armrests. This moment still fills me with awe. I have not yet lost the naive enthusiasm with which I watched that first aneurysm operation thirty years ago. I feel like a medieval knight mounting his horse and setting off in pursuit of a mythical beast. And the view down the microscope into the patient’s brain is indeed a little magical – clearer, sharper and more brilliant than the world outside, the world of dull hospital corridors and committees and management and paper work and protocols. There is an extraordinary sense of depth and clarity produced by the microscope’s hugely expensive optics, made all the more intense and mysterious by my anxiety. It is a very private view, and although the surgical team is around me, watching me operate on a video monitor connected to the microscope, and although my assistant is beside me, looking down a side­arm, and despite all the posters in the hospital corridors about something called clinical governance proclaiming the importance of team­working and communication, for me this is still single combat.

‘Well, Jeff, let’s get on with it. And let’s have a brain retractor,’ I add to Irwin.

I choose one of the retractors–a thin strip of flexible steel with a rounded end like an ice­cream stick–and place it under the frontal lobe of the woman’s brain. I start to pull the brain upwards away from the floor of the skull–elevation is the proper surgical word–cautious millimetre by cautious millimetre, creating a narrow space beneath the brain along which I now crawl towards the aneurysm. After so many years of operating with the microscope it has become an extension of my own body. When I use it it feels as though I am actually climbing down the microscope into the patient’s head, and the tips of my microscopic instruments feel like the tips of my own fingers.

I point out the carotid artery to Jeff and ask Irwin for the microscopic scissors. I carefully cut the gossamer veil of the arachnoid around the great artery that keeps half the brain alive. The arachnoid, a fine layer of the meninges, is named after the Greek word for a spider, as it looks as though it was made from the strands of the finest spider’s web.

‘What a fantastic view!’ says Jeff. And it is, because we are operating on an aneurysm before a catastrophic rupture and the cerebral anatomy is clean and perfect.

‘Let’s have another retractor,’ I say.

Armed now with two retractors I start to prise apart the frontal and temporal lobes, held together by the arachnoid. Cerebro­spinal fluid, known to doctors as CSF, as clear as liquid crystal, circulating through the strands of the arachnoid, flashes and glistens like silver in the microscope’s light. Through this I can see the smooth yellow surface of the brain itself, etched with minute red blood vessels–arterioles–which form beautiful branches like a river’s tributaries seen from space. Glistening, dark purple veins run between the two lobes leading down towards the middle cerebral artery and, ultimately, to where I will find the aneurysm.

‘Awesome!’ Jeff says again.

‘CSF used to be called “gin­clear” when there was no blood or infection it,’ I say to Jeff. ‘But probably we’re now supposed to use alcohol­free terminology.’

I soon find the right middle cerebral artery. In reality only a few millimetres in diameter, it is made huge and menacing by the microscope–a great pink­red trunk of an artery which ominously pulses in time with the heart­beat. I need to follow it deep into the cleft–known as the Sylvian fissure–between the two lobes of the brain–to find the aneurysm in its lair, where it grows off the arterial trunk. With ruptured aneurysms this dissection of the middle cerebral artery can be a slow and tortuous business, since recent haemorrhage often causes the sides of the two lobes to stick together. Dissecting them is difficult and messy, and there is always the fear that the aneurysm will rupture again while I am doing this.

I separate the two lobes of the brain by gently stretching them apart, cutting the minute strands of arachnoid that bind them together with a pair of microscope scissors in one hand while I keep the view clear of spinal fluid and blood with a small sucker. The brain is a mass of blood vessels and I must try to avoid tearing the many veins and minute arteries both to prevent bleeding from obscuring the view and also for fear of damaging the blood supply to the brain. Sometimes, if the dissection is particularly difficult and intense, or dangerous, I will pause for a while, rest my hands on the arm­rests, and look at the brain I am operating on. Are the thoughts that I am thinking as I look at this solid lump of fatty protein covered in blood vessels really made out of the same stuff? And the answer always comes back–they are–and the thought itself is too crazy, too incomprehensible, and I get on with the operation.

Today, the dissection is easy. It is as though the brain unzips itself, and only the most minimal manipulation is required on my part for the frontal and temporal lobes to part rapidly, so that within a matter of minutes we are looking at the aneurysm, entirely free from the surrounding brain and the dark purple veins, glittering in the brilliant light of the microscope.

‘Well. It’s just asking to be clipped, isn’t it?’ I say to Jeff, suddenly happy and relaxed. The greatest risk is now past. With this kind of surgery, if the aneurysm ruptures before you reach it, it can be very difficult to control the bleeding. The brain suddenly swells and arterial blood shoots upwards, turning the operative site into a rapidly rising whirlpool of angry, swirling red blood, through which you struggle desperately to get down to the aneurysm. Seeing this hugely magnified down the microscope you feel as though you are drowning in blood. One quarter of the blood from the heart goes to the brain–a patient will lose several litres of blood within a matter of minutes if you cannot control the bleeding quickly. Few patients survive the disaster of premature rupture.

‘Let’s have a look at the clips,’ I say.

Irwin hands me the metal tray containing the gleaming titanium aneurysm clips. They come in all shapes and sizes, corresponding to the many shapes and sizes of aneurysms. I look at the aneurysm down the microscope and at the clips and then back at the aneurysm.

‘Six millimetre, short right­angled’ I tell him.

He picks out the clip and loads it onto the applicator. The applicator consists of a simple instrument with a handle formed by two curved leaf springs, joined at either end. Once the clip is loaded at the instrument’s tip, all you have to do is press the springs of the handle together to open the blades of the clip, position the opened blades carefully across the neck of the aneurysm and then allow the springs to separate gently apart within your hand so that the clip blades close across the aneurysm, sealing it off from the artery from which it has grown, so that blood can no longer get into it. By finally letting the springs of the handle separate even more fully the clip is released from the applicator which you can then with­draw, leaving the clip clamped across the aneurysm for the rest of the patient’s life.

That, at least, is what is supposed to happen and had always happened with the hundreds of similar operations I had carried out in the past.

Since this looks a straightforward aneurysm to clip I let Jeff take over, and I clamber out of the operating chair so that he can replace me. My assistants are all as susceptible to the siren call of aneurysms as I am. They long to operate on them, but the fact that most aneurysms are now coiled rather than clipped means that it is no longer possible to train them properly and I can only give them the simplest and easiest parts of the occasional operation to do, under very close supervision.

Once Jeff is settled in, the nurse hands him the loaded clip applicator, and he cautiously moves it towards the aneurysm. Nothing much seems to happen, and down the assistant’s arm of the microscope I nervously watch the clip wobble uncertainly around the aneurysm. It is a hundred times more difficult and nerve­wracking to train a junior surgeon than it is to operate oneself.

After a while–probably only a few seconds though it feels much longer–I can stand it no longer.

‘You’re fumbling. I’m sorry but I’ll have to take over.’

Jeff says nothing and climbs out of the chair–it would be a rash surgical trainee who ever complained to his boss, especially at a moment like this–and we change places again.

I take the applicator and place it against the aneurysm, pressing the springs of the handle together. Nothing happens.

‘Bloody hell, the clip won’t open!’

‘That was the problem I was having,’ Jeff says, sounding a little aggrieved.

‘Bloody hell! Well, give me another applicator.’

This time I easily open the clip and slip the blades over the aneurysm. I open my hand and the blades close, neatly clipping the aneurysm. The aneurysm, defeated, shrivels since it is now no longer filling with high pressure arterial blood. I sigh deeply–I always do when the aneurysm is finally dealt with. But to my horror I find that this second applicator has an even more deadly fault than the first: having closed the clip over the aneurysm the applicator refuses to release the clip. I cannot move my hand for fear of tearing the minute, fragile aneurysm off the middle cerebral artery and causing a catastrophic haemorrhage. I sit there motionless, with my hand frozen in space. If an aneurysm is torn off its parent artery you can usually only stop the bleeding by sacrifiing the artery, which will result in a major stroke.

I swear violently while trying to keep my hand steady.

‘What the fuck do I do now?’ I shout to no one in particular. After a few seconds–it feels like minutes–I realize that I have no choice other than to remove the clip, despite the risk that this might cause the aneurysm to burst. I re­close the applicator handle and to my relief the blades of the clip open easily. The aneurysm suddenly swells and springs back into life, filling instantly with arterial blood. I feel it is laughing at me and about to burst but it doesn’t. I throw myself back in my chair, cursing even more violently, and then hurl the offending instrument across the room.

‘That’s never happened before!’ I shout but then, quickly calming down, laugh to Irwin, ‘And that’s only the third time in my career I’ve thrown an instrument onto the floor.’

I have to wait a few minutes while yet another applicator was found. The faulty ones, for some strange reason, turned out to have stiff hinges. Only later did I remember that the surgeon I had watched thirty years ago, and whose trainee I became, had told me that he had once encountered the same problem, although his patient had been less fortunate than mine. He was the only surgeon I knew who always checked the applicator before using it.

Doctors like to talk of the ‘art and science’ of medicine. I have always found this rather pretentious, and prefer to see what I do as a practical craft. Clipping aneurysms is a skill, and one that takes years to learn. Even when the aneurysm is exposed and ready to take a clip, after the thrill of the chase, there is still the critical question of how I place the clip across the aneurysm, and the all­important question of whether I have clipped the aneurysm’s neck completely with­out damaging the vital artery from which the aneurysm has grown.

This aneurysm looks relatively easy but my nerves are too frayed to let my assistant take over again and so, with yet another applicator, I clip the aneurysm. The shape of this aneurysm, however, is such that the clip does not pass completely over the neck – I can just see a little part of the aneurysm neck sticking out beyond the tips of the clip.

‘Not quite across,’ Jeff says helpfully.

‘I know!’ I snap.

This is a difficult part of the operation. I can partly open the clip and re­position it to get a more perfect position but I might tear the aneurysm in the process and be left looking at a fountain of arterial blood rushing up the microscope towards me. On the other hand if the aneurysm neck is not completely occluded there is some danger–though it is difficult to say how great–that the patient will eventually suffer a further haemorrhage in the future.

A famous English surgeon once remarked that a surgeon has to have nerves of steel, the heart of a lion and the hands of a woman. I have none of these and instead, at this point of an aneurysm operation, I have to struggle against an over­whelming wish to get the operation over and done with, and to leave the clip in place, even if it is not quite perfectly placed.

‘The best is the enemy of the good,’ I will growl at my assistants, for whom the operation is a wonderful spectator sport. They take a certain pleasure in pointing out that I have not clipped the aneurysm as well as I might have done, since they will not have to cope with the consequences of the aneurysm tearing. And if that happens, it is always exciting to watch their boss struggling with torrential haemorrhage–I certainly enjoyed it when I was a trainee. Besides they will not have to experience the hell of seeing the wrecked patient afterwards on the ward round and feel responsible for the catastrophe.

‘Oh, very well,’ I will say, shamed by my assistant, but also thinking of the hundreds of aneurysms I have clipped in the past and how, like most surgeons, I have become bolder with experience. Inexperienced surgeons are too cautious–only with endless practice do you learn that you can often get away with things that at first seemed far too frightening and difficult.

I cautiously open the clip a little and gently push it further along the aneurysm.

‘There’s still a little bit out,’ says Jeff.’

Sometimes at these moments my past disasters with aneurysm surgery parade before me like ghosts. Faces, names, wretched relatives I forgot years ago suddenly reappear. As I struggle against my urge to finish the operation and escape the fear of causing a catastrophic haemorrhage, I decide at some unconscious place within myself, where all the ghosts have assembled to watch me, whether to re­position the clip yet again or not. Compassion and horror are balanced against cold, technical precision.

I re­position the clip a third time. It finally looks well placed.

‘That will do,’ I say.

‘Awesome!’ says Jeff happily, but sad not have put the clip on himself.

* * * *

I left Jeff to close, retired to the surgical sitting room next to the theatre and lay down on the large red leather sofa which I had bought for the room some years ago and thought, once again, of how so much of what happens to us in life is determined by random chance. After brain surgery all patients are woken up quickly by the anaesthetist so that we can see if they have suffered any harm or not. With difficult operations all neurosurgeons will wait anxiously for the anaesthetic to be reversed, even if–as with this operation–one is fairly certain that no harm has been done. She awoke perfectly, and once I had seen her I left the hospital to go home.

As I cycled away from the hospital under dull, grey clouds, perhaps I felt only a little of the joy that I used to feel in the past after successful aneurysm operations. At the end of a successful day’s operating, when I was younger, I felt an intense exhilaration. As I walked round the wards after an operating list with my assistants beside me and received my patients’ heart­felt gratitude and that of their families, I felt like a conquering general after a great battle. There have been too many disasters and unexpected tragedies over the years, and I have made too many mistakes for me to experience such feelings now, but I still felt pleased with the way the operation had gone. 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.

I went back into the hospital that evening to see the woman. She was sitting up in bed, with the large black eye and swollen forehead that many patients have for a few days after an operation like hers. She told me that she felt sick and had a headache. Her husband was sitting beside her and looked angrily at me as I quickly dismissed her bruises and post­operative pain. Perhaps I should have expressed more sympathy but after the near disaster of the operation I found it difficult to take her minor post­operative problems seriously. I told her that the operation had been a complete success and that she would soon feel better. I had not had the opportunity to talk to her husband before the operation–something I usually take great care to do with relatives–and he had probably appreciated the risks of the operation even less than his wife had done.

We have achieved most as surgeons when our patients recover completely and forget us completely. All patients are immensely grateful at first after a successful operation but if the gratitude persists it usually means that they have not been cured of the underlying problem and that they fear that they may need us in the future. They feel that they must placate us, as though we were angry gods or at least the agents of an unpredictable fate. They bring presents and send us cards. They call us heroes, and sometimes gods. We have been most successful, however, when our patients return to their homes and get on with their lives and never need to see us again. They are grateful, no doubt, but happy to put us and the horror of their illness behind them. Perhaps they never quite realized just how dangerous the operation had been and how lucky they were to have recovered so well. Whereas the surgeon, for a while, has known heaven, having come very close to hell.

 

 

From DO NO HARM: STORIES OF LIFE, DEATH, AND BRAIN SURGERY. Used with permission from St. Martin’s Press. Copyright © 2014 by Henry Marsh.