Do No Harm
Stories of Life, Death,
And Brain Surgery
(Thomas Dunne / St. Martin's)
Henry Marsh has been a neurosurgeon for twenty-seven years. The title of his book comes from the Greek, Hippokrates of Koa. If you presume to treat the human body, he said, and if you bleed and slash and break and cut, at least leave it better or (at worst) as good as it was when it came through your door.
This, according to Marsh, is difficult, if not impossible. Rather, he seems to say, if talent and experience and most of all, luck, are on your side, then you might just fill the bill. But don't plan on it. Better, plan on all hell breaking loose. Thus the magic of modern medicine
We have here a man who just happened to drift into neurosurgery. He was sent off to Oxford - - - a lucky break, since his family was neither rich nor of the upper class. He, tormented by an overdose of unrequited love, decided to become a poet, and ran off to work as a porter in a hospital in a coal-mining town in northern England.
As he watched the surgeons at work, he says, "I decided that this was what I should do."
I found its controlled and altruistic violence deeply appealing. It seemed to involve excitement and job security, a combination of manual and mental skills, and power and social status as well. Nevertheless, it was not until eight years later when as a junior doctor I saw that first aneurysm operation that I discovered my vocation.
It turned out, we learn, that he could do brains . . . as well if not better than many of his peers. Marsh never comes out and says this (he's rather humble), but from the dozens of case studies he offers to us here, we are left with this distinct and overriding thought that if any of us some day plan to be coming down with a brain tumor, we should look up this Marsh, turn our head (or heads) over to him.
§ § §
We suspect that March is a perfectionist. At least, the way he reacts to his occasional mistakes implies such. But operations on the brain are measured in millimeters, so every one of the tumors that he will work on, many of them will manage to fool him.
For instance, take his operation on Melanie. The brain scan had shown a "superastellar" meningioma growing from the meninges, the membrane that encases the brain and the spinal cord. One of the problems of going in to exorcise a growth such as hers is that there is little room in the skull to navigate, so the doctors and their assistants have to create more space. One way is to drain the fluid that lies in the spinal cord, which, along with the hole poked in her head, makes enough room for Marsh to get in there and start slashing.
Her tissue appears "slack" once they start, which is good. But since the right frontal lobe is involved - - - the tumor lies below that - - - if any problems turn up while they are just getting in there, these could result in "a whole range of behavioural problems that are grouped under the phrase personality change . . . If we damage the surface of the brain as we lift up the right frontal lobe - - - a few millimetres at most to reach the tumour - - - it was quite likely that we would leave her with life-long epilepsy."
One of my thoughts here is that if you ever do come down with a tumor that needs to be operated on, it might be best for you to wait until the whole procedure is over and done with before you start to read this book. For instance, during my first night with Do No Harm, I had a bit of a headache when I began, and soon enough, unwilling to blame it all on my now empty bottle of San Lorenzo Castello di Ama. I began instead to be sure that I might have a Glioblastoma, or Pituitary adenoma or at best, Medulloblastoma.
This led me to believe that I had best get on the horn to Marsh at once, get a second opinion, maybe an appointment for this weekend. And after getting to know him thorough this . . . what should we call it? The Autobiography of a Brain I knew I should think of bringing along a few bottles of Castello di Ama if I did indeed hook up with him.
Marsh does this to people. He writes so winningly and so cleanly - - - despite all those med-speak words - - - that we find ourselves trapped in his world. Most of the doctors I've known in my live are rather chilly, quick freeze-dried in the heart-bone. But Marsh, unlike others, can't seem to stop getting bogged down by his urgent sense of humanity . . . to the point that he trips into that no-no of his profession.
He starts to care, sometime too much, for his patients.
I became hardened in the way that doctors have to become hardened and came to see patients as an entirely separate race from all-important, invulnerable young doctors like myself. Now that I am reaching the end of my career this detachment has started to fade. I am less frightened by failure - - - 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. So I now feel a deeper pity for them that in the past - - - I know that I too, sooner or later, will be stuck like them in a bed in a crowded hospital bay, fearing for my life.
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There are some terrific insights strewn about in Do No Harm. For instance, one of the questions before operating, is not will the patient live or die on the table; but rather, the question is deciding on what to do, even if we should operate at all.
Take all the factors in, decide whether or not; and once you have decided, stick with it. In the process, he (and the reader) learn a few hard lessons.
- Do as well as you can for your patient, but don't overdo it;
- Never take on a case that an older and wiser doctor wants to pass on to you;
- Never operate on kids - - - it can be too heartbreaking;
- Learn how to deliver bad news to the patients and their families without resorting to fudging doc-talk;
- Realize that neurosurgery is one of the few career choices that can lead your beneficiary to PVS - - - the persistent vegetative state.
And remember, he repeats, that the hardest choice of the doctor is whether to let some of them die.
We have here a case of a man after a fall from his bicycle. He has a frontal skull fracture, contusions in the brain, part of the brain destroyed with a "not good" prognosis - - - a good chance of "delayed intraparenchymal bleeding like this and the scan now shows catastrophic brain damage."
No matter what the surgeons do, "He will be left profoundly disabled. Would he want to survive like that?" Marsh then opines,
In cases like this we often end up operating because it's easier than being honest and in means that we can avoid a painful conversation. You might think that the operation has been a success because the patient leaves the hospital alive but if you saw him years later - - - I often do - - - you would realize that the result of the operation was a human disaster.
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This is one of those books that just won't let you alone. Just when I think it's time for me to turn off the bed-lamp, I start in on chapters marked "Ependymoma," or "Tyrosine kinase" or "Choroid plexus papilloma" and I know I can kiss my beauty sleep goodbye.
This guy is great, and if nothing else, he lets the lovely words of his chosen field float you away. We find ourselves in a garden of poetry, the one that he damn near got trapped in before, had he not run away from college, and his family . . . and his love.
And chanced into his first heavenly vision: that of some guy in a white coat sawing his way willy-nilly into the back-side of some poor sucker's cranium.