Trauma | Do No Harm

I was early and had to wait for the junior doctors to arrive. The days of white coats are long gone and instead the juniors turn up in Lycra bicycling gear or, if they have been on duty overnight, in the surgical scrubs made popular by TV medical dramas.

"There was only one admission last night," the on-call registrar said, sitting at the front of the room beside the computer keyboard. She was quite unlike the other trainees, who are usually full of youthful enthusiasm. She talked in an irritated and disapproving tone of voice. This invariably had a dampening effect on the meetings when it was her turn to present the cases. I had never understood why she wanted to train as a neurosurgeon.

"He's a forty-year-old man," she said. "Seems he came off his bike last night. He was found by the police."

"Push-bike?" I asked. "Yes. And like you he wasn't wearing a crash helmet," she said, with a look of disapproval. As she talked she typed on the keyboard and the slices of a huge black-and-white brain scan started to appear, like a death sentence, out of the dark onto the white wall in front of us.

"You won't believe this," one of the other registrars broke in. "I was on yesterday evening and took the call. They sent the scan on a CD but because of that crap from the government about confidentiality they sent two taxis. Two taxis! One for the fucking CD and one for the little piece of paper with the fucking encryption password! For an emergency! How stupid can you get?"

We all laughed, apart from the registrar presenting the case who waited for us to calm down.

"The police said he was talking when they found him," she went on, "but when he was admitted to the local hospital he started fitting so he was tubed and ventilated and then scanned."

"He's stuffed," somebody called out from the back of the room as we looked at the scan.

"I hope he doesn't survive," the on-call registrar suddenly said. I was very surprised since I knew from past experience that she believed in treating patients even with a hopeless prognosis.

I looked at the junior doctors in the front row.

"Well," I said to one of them, a dark-haired girl who had only just started in the department, and who would only be with us for two months. "There are many abnormalities on the scan. See how many you can identify."

"There's a frontal skull fracture, and it's depressed - - - the bone's been pushed into the brain."

"What's happened to the brain?"

"There is blood in it - - - contusions."

"Yes. The contusions on the left are so big that it's called a burst frontal lobe. All that area of brain has been destroyed. And what about the other side?"

"There are contusions there as well, but not as big."

"I know he was talking at first and in theory might make a good recovery but sometimes you get delayed intraparenchymal bleeding like this and the scan now shows catastrophic brain damage."

"What's his prognosis?" I asked the registrar.

"Not good," she said.

"But how much not good?" I asked. "Fifty per cent? Ninety per cent?"

"He might recover."

"Oh come off it! With both his frontal lobes smashed up like that? He hasn't got a hope in hell. If we operate to deal with the bleeding he might just survive but he'll be left hopelessly disabled, without language and probably with horrible personality change as well. If we don't operate he'll die quickly and peacefully."

"Well, the family will want something done. It's their choice," she replied.

I told her that what the family wanted would be entirely determined by what she said to them. If she said "we can operate and remove the damaged brain and he may just survive" they were bound to say that we should operate. If, instead, she said "If we operate there is no realistic chance of his getting back to an independent life. He will be left profoundly disabled. Would he want to survive like that?" the family would probably give an entirely different answer. What she was really asking them with the first question was "Do you love him enough to look after him when he is disabled?" and by saying this she was not giving them any choice. In cases like this we often end up operating because it's easier than being honest and it means that we can avoid a painful conversation. You might think the operation has been a success because the patient leaves the hospital alive but if you saw them years later - - - as I often do - - - you would realize that the result of the operation was a human disaster."

The room was silent for a while."The decision has been made to operate," the registrar said stiffly. Apparently the patient was under the care of one of my colleagues and one of the unwritten rules of English medicine is that one never openly criticizes or overrules a colleague of equal seniority, so I remained silent. Most neurosurgeons become increasingly conservative as they get older - - - meaning that they advise surgery in fewer patients than when they were younger. I certainly have - - - but not just because I am more experienced than in the past and more realistic about the limitations of surgery. It is also because I have become more willing to accept that it can be better to let somebody die rather than to operate when there is only a very small chance of the person returning to an independent life. I have not become better at predicting the future but I have become less anxious about how I might be judged by others. The problem, of course, is that so often I do not know just how small the chance of a good recovery might be because the future is always uncertain. It is much easier just to operate on every case and turn one's face away from the fact that such unquestioning treatment will result in many people surviving with terrible brain damage.

We all filed out of the room and scattered over the hospital for the day's work - - - to the theatres, to the wards, to the outpatient clinic, to the offices. I walked down the X-ray corridor with my neuroradiological colleague. Neuroradiologists spend their day analysing brain and spinal scans but do not usually deal directly with patients. I think he had started his career in neurosurgery but was too gentle a soul to be a neurosurgeon and so had become a neuroradiologist.

"My wife's a psychiatrist, you know," he said. "When she was training she worked in a brain damage unit for a while. I'm with you on this one - - - so many of the head injuries have terrible lives. If neurosurgeons followed up the severe head injuries they treated I'm sure they'd be more discriminating in whom they operated upon."