CompletlyBeautifullChaos

Television, these days, seldom succeeds in activating other brain areas than the insula and amygdala, apart from the obligatory assault on the primary visual and auditory cortex. But fortunately there are exceptions, and sometimes very interesting ones. On Wednesday 8 June 2011 Canvas broadcasted “The English surgeon”, an award winning BBC Four documentary movie by Geoffrey Smith about the London neurosurgeon Henry Marsh. It is a story about a brilliant, mildly eccentric neurosurgeon, a pioneer in awake craniotomy, and his friend the Ukrainian neurosurgeon Igor Kurilets. Ever since 1992 Henry has been helping his friend to improve the quality of neurosurgical care in the Ukraine. It is a story about personal friendship, the tragic and glory of medicine, and the courage to accept ones mistakes.

The documentary follows Marsh on one of his visits to the Ukraine, where he will operate on Marian, a young patient with a brain tumor and epilepsy. The process leading up to surgery is followed, and the surgery itself, performed with only local anesthesia (the money and the means to do the first part under general anesthesia are lacking), is shown in detail. Fortunately, this part of story has a happy ending: in the end, after some complications (Marian has a seizure during the operation), the tumor is removed, and the patient survives, apparently in good neurological condition. This is part of the glory. But modern medicine in general, and neurosurgery in particular, have a grim side as well. This is nicely illustrated by many fragments mixed with the main story line.

For instance, bureaucrats do not generally like doctors or what they do (except, of course, when they have a medical problem themselves). This is nicely illustrated in a scene where Marsh is sitting behind his computer in his London office, struggling with some NHS software that requires he enters all his daily activities, from minute to minute. At one point – realizing he often does two or three things at the same time – Marsh wants to enter more than two “activities” in one time slot. This, according to NHS standards, is of course intolerable; the program crashes. Marsh gets furious and leaves the room slamming the door. For any doctor still attempting to treat patients in these modern times there must be a shock of recognition.

But there are more shocks. Craniotomy drills, that cost over 100 pound a piece, are used only once in London; Henry takes used ones with him to the Ukraine. Igor then uses them for the next ten years. Ho said that there are no opportunities for budget cuts in healthcare? Another interesting spectacle is the outpatient consultations Marsh and Igor do in a hospital rented from the former KGB. Dozens of patients are lining up in the dark corridors, waiting (and sometimes fighting) till it is there turn. If the fighting gets too bad, Igor steps into the corridor, and hands out a box of pralines to be passed around; that will keep them quiet for a few minutes. In the meantime Henry and Igor speak to patients with the most advanced stages of neurological and neurosurgical disease. Often, it is simply too late to do anything. By the time patients have the money and the urge to visit a doctor, their condition – even if potentially treatable – has advanced too far.

In some cases the tragedy of the cases is almost too much too bear. A grandmother presents the MRI of her grandchild; Marsh diagnoses a brainstem tumor; Igor explains the grandmother that her grandchild will die, and nothing can be done. Then, a beautiful 23 year old women shows her MRI. She was told by her doctors that she suffered from a kind of “infectious disease”. Marsh studies the MRI and explains to Igor this is a diffuse glioma, a malignant brain tumor that cannot be treated. The woman will get blind due to papillary edema within a few years, and probably die soon afterwards. Marsh and Igor discuss the diagnosis in English while the women, who obviously does not understand a word of what the doctors are saying, looks full of hope to the final verdict. You can see how Igor and Henry struggle with the decision whether or not to inform the woman about her fate; then Henry says you cannot give a young women of 23 a death verdict without any family present. She will have to come back with her mother, who lives in Moskow.

If anything, Henry Marsh is acutely aware of the limitations of what he is doing. He explains: “We are playing Russian roulette with two guns pointed at the head of the patient. One gun is called treatment; the other wait and see. Which gun should you fire?” Marsh also says: “The actual surgery is not what is the most difficult. What is really difficult is to decide when to operate, and when not to operate.” Marsh can know. During one of his early visits to the Ukraine Igor presented a young girl called Tanya to Marsh with a benign, but extremely advanced tumor affecting her beautiful face. Overwhelmed by passion, Marsh simply felt he had to do something. He operated on Tanya in London, twice; it was a miserable failure. Tanya lived for a terrible two years, and then died.

Perhaps it would be only too human to attempt to forget these terrible failures. Such failures are fatal to the narcistic self-image of doctors; we cure patients, don’t we? If I wouldn’t have acted, things might have been even worse. The point is of course, that sometimes intervention makes things worse, much worse. To be able to confront your mistakes and learn from them is the difference between a skilled surgeon and a truly brilliant doctor. At the end of the documentary, Igor and Henry go to visit the mother of Tanya; it is an obsession of Marsh to do this every time he visits the Ukraine. The mother and her family have prepared a feast meal for the two neurosurgeons; it is obvious they do not blame them, but are instead deeply grateful for the fact that they tried to help them. In an emotional speech, translated by Igor, Henry addresses the mother and her family. At the end, Henry Marsh visits Tanya’s grave. It sounds almost like the plot of a Dickens novel, with a failed neurosurgical case featuring as Tiny Tim, but it isn’t. There is not a glimpse of false sentiment in the whole documentary. If it is emotional, it is because life is. We all die; the point is what we do before. If you have ambition and courage you can do something for others, but only if you are brave enough to face the consequences of the terrible mistakes you are bound to make.