All the ghosts have assembled

The surgery began at nine in the morning and continued late into the night. Brain surgery is slow and dangerous, and removing a tumor can be like defusing a bomb. Often, surgeons look through a microscope and use long-handled, fine-tipped instruments to pull the tumor away from the brain before removing it with a sucker. A quarter of the body’s blood courses through the veins and arteries of the brain; if one of them is torn, bleeding and stroke can result. It’s also possible to remove important parts of the brain by accident, because brain tissue and tumor tissue look pretty much the same. Unlike the rest of the body, the brain and the spinal cord rarely heal. If a neurosurgeon makes a mistake, the damage is often permanent.
By midnight, Henry Marsh and his team had removed almost all of the tumor. The atmosphere in the operating theatre was relaxed and celebratory; the surgical team paused for cigarette breaks and listened to Abba and Bach. “I should have stopped at that point, and left the last piece of tumor behind,” Marsh writes in his memoir, “Do No Harm” (Thomas Dunne). Instead, he ventured further—he wanted to be able to say that he had taken it all out. “As I started to remove the last part of the tumor,” Marsh writes, “I tore a small perforating branch off the basilar artery, a vessel the width of a thick pin. A narrow jet of bright red arterial blood started to pump upwards.” The basilar artery carries blood to the brain stem, which regulates the rest of the brain. Marsh quickly stopped the bleeding, but the oxygen deprivation was enough to irreparably damage the man’s brain stem, and he never regained consciousness.



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Brain surgery itself, Marsh writes, is “something I hate doing.” Beforehand, patients are depersonalized—their heads are shaved, and they are covered in sterile drapes—although you can’t entirely depersonalize the brain. Often, there’s a question about how far to go: if an aneurysm clip is not quite perfectly positioned, should Marsh take the risk of repositioning it? To do so, he must struggle against the “urge to finish the operation and escape the fear of causing a catastrophic haemorrhage.” Eventually, he writes, “I decide at some unconscious place within myself, where all the ghosts have assembled to watch me.”
Neurosurgical disasters can be cruel. A patient can wake up and appear healthy only to die, a few days later, of a stroke or a hemorrhage that’s related, in “some unknowable way,” to the operation. And patients can live on despite severe brain damage—an outcome that’s a particular source of fear for Marsh. He tells a colleague, “Nobody, nobody other than a neurosurgeon, understands what it is like to have to drag yourself up to the ward and see, every day—sometimes for months on end—somebody one has destroyed and face the anxious and angry family at the bedside.” The schoolteacher lived on in just this way. Seven years after that failed surgery, Marsh was visiting a home for vegetative patients when he looked into a room and “saw his grey curled-up body in its bed.” Of the feelings such experiences produce in him, Marsh writes, “I will not describe the pain.”

Joshua Rothman, Anatomy of error.