The 2017 National Book Critics Circle (NBCC) Finalist, International Bestseller, and a Kirkus Best Nonfiction Book of 2017!
“Marsh has retired, which means he’s taking a thorough inventory of his life. His reflections and recollections make Admissions an even more introspective memoir than his first, if such a thing is possible.” —The New York Times
"Consistently entertaining...Honesty is abundantly apparent here--a quality as rare and commendable in elite surgeons as one suspects it is in memoirists." —The Guardian
"Disarmingly frank storytelling...his reflections on death and dying equal those in Atul Gawande's excellent Being Mortal." —The Economist
Henry Marsh has spent a lifetime operating on the surgical frontline. There have been exhilarating highs and devastating lows, but his love for the practice of neurosurgery has never wavered.
Following the publication of his celebrated New York Times bestseller Do No Harm, Marsh retired from his full-time job in England to work pro bono in Ukraine and Nepal. In Admissions he describes the difficulties of working in these troubled, impoverished countries and the further insights it has given him into the practice of medicine.
Marsh also faces up to the burden of responsibility that can come with trying to reduce human suffering. Unearthing memories of his early days as a medical student, and the experiences that shaped him as a young surgeon, he explores the difficulties of a profession that deals in probabilities rather than certainties, and where the overwhelming urge to prolong life can come at a tragic cost for patients and those who love them.
Reflecting on what forty years of handling the human brain has taught him, Marsh finds a different purpose in life as he approaches the end of his professional career and a fresh understanding of what matters to us all in the end.
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THE LOCK-KEEPER'S COTTAGE
The cottage stands on its own by the canal, derelict and empty, the window frames rotten and hanging off their hinges and the garden a wilderness. The weeds were as high as my chest and hid, I was to discover, fifty years of accumulated rubbish. It faces the canal and the lock, and behind it is a lake, and beyond that a railway line. The property company that owned it must have paid somebody to clear out the inside of the cottage, and whoever had done the work had simply thrown everything over the old fence between the garden and the lake, so the lake side was littered with rubbish – a mattress, a disembowelled vacuum cleaner, a cooker, legless chairs and rusty tins and broken bottles. Beyond the junk, however, lay the lake, lined by reeds, with two white swans in the distance.
I first saw the cottage on a Saturday morning. A friend had told me about it. She had seen that it was for sale and knew that I was looking for a place where I could establish a woodworking workshop in Oxford to help me cope with retirement. I parked my car beside the bypass and walked along the flyover, deafening cars and trucks rushing past me, to find a small opening in the hedge, almost invisible, at the side of the road. There was a long line of steps covered in leaves and beechmast, under a dark archway formed by the low, bending branches of beech trees, leading down to the canal. It was as though I was suddenly dropping out of the present and returning to the past. The roar of the traffic became abruptly muted as I descended to the quiet and still canal. The cottage was a few hundred yards away along the towpath, over an old, brick-built humpback canal bridge.
There were several plum trees in the garden, one of them growing up through an obsolete and rusty old machine with reciprocating blades like a hedge-trimmer, for cutting heavy undergrowth. It had two big wheels with Allens and Oxford stamped on the rims in large letters. My father had had exactly the same model of machine, which he used in the two-acre garden and orchard where I had grown up less than one mile away in the 1950s. He once accidentally ran over a little shrew in the grass of the orchard as I stood watching him, and I remember my distress at seeing its bleeding body and hearing its piercing screams as it died.
The cottage looks out over the still and silent canal and the heavy black gates of the narrow lock. There is no road access – it can only be reached along the towpath on foot or by barge. There is a brick wall with drinking troughs for horses along one side of the garden, facing the canal – I found later the metal rings to which the horses which towed the barges along the canal would have been tethered. A long time ago the lock-keeper would have been responsible for the gates, but the lock-keepers' cottages along the canal have all been sold off and the gates are now left to be operated by whoever is on the passing barges. I am told that a kingfisher lives here and can be seen flashing across the water, and that there are otters as well, even though only a few hundred yards away there is the roar of the bypass traffic crossing the canal on the high flyover on its concrete stilts. But if I turn away from the road, all I can see are fields and trees, and the reed-lined lake behind the house. I can imagine that I am in ancient, deep countryside, as it was when I was growing up nearby, before the bypass was built sixty years ago.
The young woman from the estate agents was sitting on the grass bank in the sunshine beside the entrance to the cottage, waiting for me. She opened the bolted and padlocked front door. I stepped over a few letters on the floor inside, covered in muddy footprints. The estate agent saw me looking down at them and told me that an old man had lived here by himself for almost fifty years – the deeds for the property described him as a canal labourer. When he died the property developers, who had bought the house some years ago, put it up for sale. She did not know whether he had died here or in hospital or in a nursing home.
The place smelt damp and neglected. The cracked and broken windows were covered by torn, dirty lace curtains and the window sills were black with dead flies. The rooms had been stripped out and had the sad and despondent air of all abandoned homes. Although there was water and electricity, the facilities were primitive, and there was only an outside toilet, smashed into pieces, with the door off its hinges. The dustbin by the front door contained plastic bags full of faeces.
The ancient farmouse nearby where I had spent my childhood was said to have been haunted – at least, according to the Whites, the elderly couple who lived across the road and whom I liked to visit. An improbable tale of a sinister coach and horses in the yard at night and also of a 'grey lady' in the house itself. It was easy to imagine the old man's ghost haunting the cottage.
'I'll take it,' I said.
The girl from the estate agents looked at me sceptically.
'But don't you want to get a survey?'
'No, I do all my own building work and it looks OK to me,' I replied confidently, but wondering whether I was still capable of the physical work that would be required and how I would manage without any road access. Perhaps I should stop being so ambitious and abandon my obsessive conviction that I must do everything myself. Perhaps it no longer mattered. I ought to employ a builder. Besides, although I wanted a workshop, I wasn't sure that I wanted to live in this small and lonely cottage, with a possible ghost.
'Well, you'd better make an offer to Peter, the manager in our local office,' she replied.
I drove back to London the next day – with the uneasy thought that perhaps this little cottage would be where I myself would eventually end my days and die, and where my story would end. Now that I am retiring, I am starting all over again, I thought, but now I am running out of time.
I was back in the operating theatre on Monday – I was in my blue theatre scrubs, but expected to be only an observer. In three weeks' time I was to retire – after almost forty years of medicine and neurosurgery. My successor, Tim, who had started off as a trainee in our department, had already been appointed. He is an exceptionally able and nice man, but not without that slightly fanatical determination and attention to detail that neurosurgery requires. I was more than happy to be replaced by him and it seemed appropriate to leave most of the operating to him, in preparation for the time when – and it would probably be something of a shock for him – he suddenly carried sole responsibility for what happened to the patients under his care.
The first case was an eighteen-year-old woman who had been admitted for surgery the previous evening. She was five months pregnant but had started to suffer from severe headaches, and a scan showed a very large tumour – almost certainly benign – at the base of her brain. I had seen her as an emergency in my outpatient clinic a few days earlier; she came from Romania and her English was limited, but she smiled bravely as I tried to explain things to her via her husband, who spoke a little English. He told me that they came from Maramures, the area of northern Romania on the border with Ukraine. I had been there myself two years ago on a journey from Kiev to Bucharest with my Ukrainian colleague Igor. The landscape was exceptionally beautiful, with ancient wooden farms and monasteries – it seemed that the modern world had scarcely caught up with the place at all. There were haystacks in the fields and hay wagons drawn by horses on the roads, with the drivers wearing traditional peasant costumes. Igor was outraged that Romania had been allowed to join the European Union whereas Ukraine had been kept out. My Romanian colleague, who had come to collect us from the border with Ukraine, wore a tweed cloth cap and leather driving gloves, and drove us at high speed on the terrible roads in his son's souped-up BMW all the way to Bucharest, almost without stopping. We did, however, spend a night on the way at Sighisoara, where the house still stood where Vlad the Impaler – the prototype for Dracula – had been born. It was now a fast-food joint.
The operation on the woman was not an emergency in the sense that it did not need to be done at once, but it certainly had to be done within a matter of days. Such cases do not fit easily into the culture of targets which now defines how the National Health Service in England is supposed to function. She was not a routine case but nor was she an emergency.
My own wife Kate, a few years ago, had fallen into the same trap when awaiting major surgery after many weeks of intensive care at a famous hospital. She had been admitted as an emergency and underwent emergency surgery without any difficulty, but then needed further surgery after several weeks of intravenous feeding. I became accustomed to the sight of a large foil-wrapped bag of glutinous fluid hanging above her bed, dripping into her central line – a catheter inserted into the great veins leading to her heart. Kate was now no longer an emergency but nor was she a routine admission, so there was no provision for her to undergo surgery. For five days in a row she was prepared for surgery – very major surgery, with all manner of frightening potential complications – and each day by midday the operation was cancelled. Eventually, in despair, I rang her surgeon's secretary. 'Well, it's not really up to Prof as to who goes on the routine operating lists,' she explained apologetically. 'It's a manager – the List Broker. Here's the number to ring ...'
So I rang the number only to receive a message that the voice mailbox was full and I could not leave a message. At the end of the week the decision was made to make Kate into a routine case by sending her home with a large bottle of morphine. She was readmitted a week later, presumably now with the List Broker's permission. The operation was a great success, but I mentioned the problem we had encountered to one of my neurosurgical colleagues at the same hospital when we met at a meeting shortly afterwards.
'I find it very difficult being a medical relative,' I said. 'I don't want people to think my wife should get better treatment just because I'm a surgeon myself, but it really was getting pretty unbearable. Having your operation cancelled is bad enough – but five days in a row!'
My colleague nodded. 'And if we can't look after our own, what about Joe Bloggs?'
So I had gone to work on Monday morning worried that there would be the usual shambles of trying to find a bed for the young girl into which she could go after surgery. If her condition was life-threatening I would be able to start the operation without having to seek the permission of the many hospital staff involved in trying to allocate an insufficient number of beds to too many patients, but her condition was not life-threatening – at least not yet – and I knew that I was going to have a difficult start to the day.
At the theatre reception area there was an animated group of doctors and nurses and managers looking at the day's operating lists sellotaped to the top of the desk, discussing the impossibility of getting all the work done. I saw that several of the cases were routine spinal operations.
'There are no ITU beds,' the anaesthetist said with a grimace.
'Well why not just send for the patient anyway?' I asked. 'A bed always turns up later.' I always say this, and always get the same reply.
'No,' she said. 'If there's no ITU bed I will end up having to recover the patient in theatre after the op and it could take hours.'
'I'll try to go and sort it out after the morning meeting,' I replied.
There was the usual collection of disasters and tragedies at the morning meeting.
'We admitted this eighty-two-year-old man with known prostate cancer yesterday. He had gone first to his local hospital because he was going off his legs and was in retention of urine. They wouldn't admit him and sent him home,' Fay, the on-call registrar, told us as she put up a scan. This was met with sardonic laughter in the darkened room.
'No, no, it's true,' Fay said. 'They catheterized him and wrote in the notes that he was now much better. I have seen the notes.'
'But he couldn't fucking walk!' somebody shouted.
'Well, that didn't seem to trouble them. At least they must have achieved their four-hour target by sending him home. He spent forty-eight hours at home and the family got the GP in, who sent him here.'
'Must have been a very uncomplaining and longsuffering patient,' I observed to my colleague sitting next to me.
'Samih,' I said to one of the other registrars, 'what do you see on the scan?' I had first met Samih some years earlier on one of my medical visits to Khartoum. I had been very impressed by him and did what I could to help him to come to England to continue his training. In the past it had been relatively easy to bring trainees over to my department from other countries, but the combination of European Union restrictions on doctors from outside Europe and increasing bureaucratic regulations in recent years has made it very difficult, even though the UK has fewer doctors per capita than any country in Europe other than Poland and Romania. Samih passed all the required examinations and hurdles with flying colours. He was a joy to work with, a large and very gentle man, utterly dedicated to our craft, who was loved by the patients and nurses. He was now to be my last registrar.
'The scan shows metastatic posterior compression of the cord at T3. The rest of the scan looks OK.'
'What's to be done?' I asked.
'Well, it depends on how he is.'
'He was sawn off when I saw him at ten o'clock last night.'
This is the brutal but accurate phrase to describe a patient who has a spinal cord so badly damaged that they have no feeling or movement of any kind below the level of the damage and when there is no possibility of recovery. T3 means the third thoracic vertebra, so the poor old man would have no movement of his legs or trunk muscles. He would even have difficulties just trying to sit upright.
'If he's sawn off he's unlikely to get better,' Samih said. 'It's too late to operate now. It would have been a simple operation,' he added.
'What's this man's future?' I asked the room at large. Nobody replied so I answered the question myself.
'It's very unlikely he'll be able to get home as he'll need full twenty-four-hour nursing, with being turned every few hours to prevent bed sores. It takes several nurses to turn a patient, doesn't it? So he will be stuck in some geriatric ward somewhere until he dies. If he's lucky the cancer elsewhere in his body will carry him off soon, and he may make it into a hospice first, nicer than a geriatric ward, but the hospices won't take people if their prognosis is that they might live for more than a few weeks. If he's unlucky, he may hang on for months.'
I wondered if that was how the old man in the cottage had died, alone in some impersonal hospital ward. Would he have missed his home, the little cottage by the canal, even though it was in such a sorry state? My trainees are all much younger than I am; they still have the health and self-confidence of youth, which I too had at their age. As a junior doctor you are pretty detached from the reality that faces so many of the older patients. But now I am losing my detachment from patients as I prepare to retire. I will become a member of the underclass of patients – as I was before I became a doctor, no longer one of the elect.
The room remained silent for a while.
'So what happened?' I asked Fay.
'He came in at ten in the evening and Mr C. planned to operate but the anaesthetists refused – they said there was no prospect of his getting better and they weren't willing to do it at night.'
'Well, there's not much to be lost by operating – we can't make him any worse,' somebody said from the back of the room.
'But is there any realistic prospect of making him better?' I asked, but I went on to say: 'Although, to be honest, if it was me I'd probably say go and operate ... just in case ... The thought of ending my days paraplegic on a geriatric ward is so awful ... indeed, if the operation killed me, I wouldn't complain.'
'We decided to do nothing,' Fay said. 'We're sending him back to his local hospital today – if there's a bed there, that is.'
'Well, I hope they take him back – we don't want another Rosie Dent.' Rosie had been an eighty-year-old woman earlier in the year with a cerebral haemorrhage whom I had been forced to admit by a physician at my own hospital – at least, so many complaints and threats were made if I didn't admit her to an acute neurosurgical bed that I gave in – even though she did not need neurosurgical treatment. It proved impossible to get her home and she sat on the ward for seven months, before we eventually managed to persuade a nursing home to accept her. She was a charming, uncomplaining old lady and we all became quite fond of her, even though she was 'blocking' one of our precious acute neurosurgical beds.
Excerpted from "Admissions"
Copyright © 2017 Henry Marsh.
Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
1. The Lock-Keeper's Cottage,
5. Awake Craniotomy,
6. The Mind–Brain Problem,
7. An Elephant Ride,
9. Making Things,
10. Broken Windows,
14. The Red Squirrel,
15. Neither the Sun Nor Death,
Also by Henry Marsh,
About the Author,