Summary: Do No Harm: Stories of Life, Death, and Brain Surgery by Henry Marsh

Key Takeaways

• Neurosurgery is one of the most demanding and dangerous specialties in medicine, but also one of the most rewarding and fascinating. How can we understand the work and life of a neurosurgeon, and what can we learn from their experiences? In this article, we will review the book Summary: Do No Harm: Stories of Life, Death, and Brain Surgery by Henry Marsh, which is a condensed version of the original memoir by a renowned British neurosurgeon, who shares his personal and professional stories of performing brain surgery.
• If you want to learn more about the book and how it can help you or someone you know who is interested in neurosurgery, read on. You will discover some of the joys and sorrows, the successes and failures, and the risks and rewards of operating on the most complex and delicate organ in the human body. You will also find out how you can get a copy of the book and access more resources from the author.

Brain surgeons don’t just hold their patients’ lives in their hands; they quite literally hold all of their patients’ thoughts, memories, and feelings. “Do No Harm” examines the challenges of becoming, practicing, and defining oneself as a brain surgeon over the course of 40 years of experience in the operating theater.

The brain holds all of a person’s life — what happens when you operate on it?

READ THIS BOOK SUMMARY IF YOU:

• Aspire to a career in medicine
• Want to know what your doctors are thinking about you
• Find medical bureaucracies maddeningly frustrating

Introduction

Dr. Henry Marsh has been operating on brains for four decades, and although much has changed in that time, some things never will, like patients’ vulnerability, fear of death, and need for kindness and honesty from their doctors. By examining his mistakes and successes, Marsh hopes to illuminate these four themes from a life in brain surgery:

1. Finding your purpose: Marsh was an unlikely brain surgeon; he studied philosophy and had little scientific training before entering medical school, but found deep inspiration watching a brain surgeon performing a simple operation on an aneurysm.
2. Admit your mistakes: One of Marsh’s guiding principles is taking responsibility for mistakes — and he’s made many. It’s easy to gloss over them, but impossible to learn if you do so.
3. Hope and realism: Doctors have to strike a fragile balance between giving their patients hope and being realistic about their outlook. Marsh hopes that patients would do more to both get the truth out of their doctors and to be receptive to it.
4. End of life: Hospitals and medical bureaucracies have the unfortunate tendency to make patient care, especially for end-of-life care, inhumane.

Pineocytoma

Marsh’s patient was a company director, a man with a demanding job who thought that his recent headaches had been caused by work stress. Scans showed, instead, that the patient had a pineocytoma, a tumor of the pineal gland. Marsh suggested a biopsy on the tumor to find out if it was benign or malignant, and the patient’s anxiety prior to the surgery made Marsh anxious as well.

Compounding his anxiety was a surgery he’d performed the week prior. His patient wound up paralyzed on one side of her body. He felt he’d been insufficiently fearful during that operation, and had a nagging feeling that because the woman’s surgery went poorly, the man’s pineal operation would, too.

Pineal biopsy involves finding a crevice that separates the cerebral hemispheres from the brainstem and cerebellum, entering the crevice at a depth of three inches, and scraping away part of the tumor. The surgeon is aided by Computer Navigation, a sort of GPS for brain surgery. After an hour and a half, Marsh reached the pineal gland and removed a chunk of the tumor to biopsy. It took another nerveracking 45 minutes to get the result back from the pathology lab, but Marsh found out that the tumor was benign and was able to easily remove it.

While he was waiting for the man to wake up, he visited the patient who was half-paralyzed. He told her he believed that she would regain feeling and improve. Despite everything, she told him she believed him. It was to his enormous relief, which was compounded by being able to tell the male patient’s wife, with absolute certainty, that everything was going to be OK.

Aneurysm

Aneurysms were Marsh’s inspiration for becoming a brain surgeon. As a resident, unsure of his future in the medical field, he was invited to watch a surgeon clipping a ruptured aneurysm, and the precision of the procedure appealed to him.

An aneurysm is the dilation of the walls of a blood vessel, and they’re dangerous because the walls are thin and easy to rupture. If they burst, it can cause death or a catastrophic stroke. They are rarely clipped today. Now, they’re more often treated by radiologists, who put a catheter into the femoral artery and block off the aneurysm from the inside. However, some aneurysms can’t be coiled, so they have to be clipped — manually blocked with an instrument that squeezes the blood vessel.

The present patient’s aneurysm couldn’t be coiled, and Marsh had to explain that the immediate risk of operating was about the same as the lifetime risk of doing nothing. The woman elected for the operation without giving it too much thought: If she did nothing, she’d know that the aneurysm was there.

Marsh was assisted by Jeff, an American doctor participating in a neurosurgical training program. Since the procedure was simple, Marsh let Jeff take over. He stretched the lobes of the patient’s brain slightly apart and cut through her arachnoid tissue to find the aneurysm, loaded a clip onto an applicator, and attempted to place it — but it was taking too long.

Marsh took over and found the source of the delay: the applicator wouldn’t release the clip. On Marsh’s second try, the clip’s hinges wouldn’t work. Finally, the third applicator and clip both worked, but it needed to be repositioned twice in order to clip the entire aneurysm.

Everything turned out OK for the patient, who was ignorant of the complications of the procedure and indifferent toward Marsh. But he didn’t mind; he’s happiest when patients forget him entirely after their surgeries.

Hemangioblastoma

Informed consent is easier in principle than in practice. Most patients tune out as they’re being informed, and hardly anyone actually reads the consent forms. Marsh recommends that patients ask more questions; many feel they’re not in a position to have doubts, need more information, or be skeptical of their doctors without understanding that their doctors are as nervous and flawed as they are.

A hemangioblastoma is a rare tumor formed from a mass of blood vessels. They’re benign but fatal if untreated, and the surgery carries a 1% to 2% chance of death or stroke. While the surgery went easily enough in the case Marsh describes, she, like most patients, barely registered the risk. All Marsh, or any surgeon, can do is to be as sure as he can that the decision to operate is right and that no other surgeon could do it better than he could.

Melodrama

One of Marsh’s most exciting surgeries was on a woman who was 28 weeks pregnant. She had started going blind and had to walk through the hospital corridors with one hand in front of her and the other resting on her belly, as if to protect the baby from all sorts of unseen threats.

She had a meningioma, a tumor on the meninges, a membrane around the brain and spinal cord. Meningiomas are sensitive to estrogen, which is why she developed one while she was pregnant. Now it was pressing on her optic nerve. The surgery can leave the patient completely blind; Melanie looked like she’d be fine after the surgery, based on Marsh’s evaluation of her optic nerve, as seen through her retinas.

The plan was to operate on Melanie’s meningioma, then to perform a Caesarean section. Marsh opened her meninges with scissors, being careful to not damage the right frontal lobe, which can cause personality changes. He was able to suck the tumor out, clearing space for the optic nerves.

The patients’ pupils were slow to recover after waking up, but as her eyes adjusted her eyesight returned completely — just in time to see her beautiful new baby.

Reforming the Ukranian Medical System

Marsh first started visiting Kiev in 1992 on an invitation from another surgeon to give lectures while visiting part of the newly dissolved former Soviet Union. The country was in shambles and the hospitals were a wreck, but everyone working in the hospitals claimed they were using state-of-the-art technology and techniques. When Marsh pressed them for answers to complex questions, he received vague answers. A mixture of national pride and fear of reprisal kept the Ukrainian doctors from being honest about the state of their medical system.

Marsh met Igor Kurilets at Kiev’s Emergency Hospital, which at the time was partially without power. Kurilets immediately remarked that the hospital was a mess, and appreciating his forthrightness, Marsh took to him right away. He invited Kurilets to visit London to learn modern surgical techniques. After three months of working with Marsh, Kurilets’ patron died. Rather than finding another one, Kurilets started speaking out openly against the medical system. By so doing, he jeopardized his own life. To help, Marsh began traveling to Ukraine in return, performing videotaped surgeries and lecturing in endorsement of Kurilets’ push for reform.

Angor Animi

Prior to going to medical school, Marsh had practically no scientific education. He was accepted to Oxford to study philosophy and politics, but quit for a year to pursue a love affair that wound up not working out anyway. In that year, he started working in a hospital and realized in the process that he wanted to be a neurosurgeon. Oxford allowed him to return, and he was later accepted into the Royal Free Medical School.

After he graduated, Marsh started working in a surgical firm in his teaching hospital. Having little responsibility other than administrative work, he became bored and uncertain about his career. He left to work in an NHS hospital as a houseman, where he was exposed to the responsibility of a medical career when he misdiagnosed a heart attack patient’s symptoms. Marsh dismissed the patient’s breathlessness as anxiety, when in fact the man was going into cardiac arrest. The expression of angor animi — knowledge of his own death — haunted Marsh throughout the rest of his career.

Choroid Plexus Papilloma

One night, early in his career as a surgeon, Marsh’s wife, Hillary, called him while he was at a bar frequented by junior doctors. There was something wrong with their son William’s brain.

William had acute hydrocephalus, a condition in which cerebrospinal fluid fills the brain cavity, as well as a tumor in the middle of his brain. While he and his family waited for hours for the surgeon to appear, Marsh got himself so worked up that he had to leave. He went to his parents’ to vent and terrified them by smashing a chair out of helplessness.

In Marsh’s absence, the surgeon arrived and immediately drained William’s brain. He operated on the tumor five days later. Although patients can be difficult and testy toward their doctors, in comparison to the patient’s pain and anxiety, doctors can’t suffer enough.

Ependymoma and Glioblastoma

One of Marsh’s favorite patients was a woman named Helen. He had operated on her to remove a recurring tumor called an ependymoma. Another doctor had referred her for photo-dynamic therapy, but Marsh knew it probably wouldn’t be effective. Regardless, the family wanted to proceed. It’s hard to know when to stop with slowly progressive cancers.

Marsh operated on Helen later that morning. The family appreciated his continuing to operate, even if her condition was hopeless.

Another of Marsh’s repeat patients, David, was a favorite because he always realistic about his condition. Marsh had originally operated on a low-grade astrocytoma in David’s right temporal lobe. It came back years later as a cancerous tumor. He requested that Marsh look at his brain scans and give him his most honest and forthright opinion. Marsh saw that the cancer was deep in the brain, but that David’s intellect and understanding were intact, which surgery could jeopardize. He recommended against surgery, which David took well, saying that he’d already made arrangements for his death.

While surgeons are ethically bound to telling their patients the truth, hope is too powerful to deny it to patients and their families when it’s available.

Mistakes: Infarct, Neurotmesis, and Empyema

One of Marsh’s guiding principles is that surgeons should embrace their mistakes. Hospitals encourage this at Morbidity and Mortality meetings, but it’s easy for doctors to gloss over their missteps in these meetings.

One mistake, for example, was a misdiagnosis on a 21-year-old man. Marsh misdiagnosed an abnormality as an inoperable tumor and performed a biopsy. It turned out that it was an infarct, not a tumor; the man had had a stroke. The patient ultimately died because of the stroke, but his father was convinced that the operation had caused his son’s death. The Trust that manages NHS hospitals, for their part, made another mistake: They scheduled a meeting with Marsh and the father on the anniversary of the patient’s death, which caused more heartache than was compassionate for the man.

Another mistake was misjudging a junior doctor’s readiness for a surgery. A patient who was a competitive cyclist came in with a slipped disc and sciatica. His informed consent meeting took place with a young American registrar who overemphasized the risks of the surgery, making the patient nervous. Since the surgery was simple, Marsh let the registrar perform it. When it turned out taking too long for Marsh’s comfort, he intervened, but found that the registrar had severed the nerve root, which would leave the patient with a paralyzed ankle for the rest of his life, leaving him unable to compete. It would be easy, in a situation like this, for a doctor to lie in his operating notes and chalk the neurotmesis up to chance, but Marsh decided to take responsibility for his negligence.

Finally, there are mistakes that are costly in terms of both human life and dollar amount. One of Marsh’s patients had a catastrophic streptococcus infection after an operation called a subdural empyema. Marsh had never had this particular surgery go wrong, so when a colleague phoned him about the infection, he diagnosed the patient with inflammation over the phone. This was a fatal misstep. His misdiagnosis — without even seeing the patient — caused a delay in treatment that caused the infection to spread and kill the patient. Three years later, the patient’s family sued. Marsh and the Trust both knew and admitted that the case couldn’t be defended, and the Trust settled with the family for $6 million.

End of Life: Carcinoma, Akinetic Mutism, and Hubris

Marsh’s mother developed carcinoma late in her life, and was able to live out her last days in her home, under the care of her children, a doctor, and a nurse. When friends and family happened to be in town, they were able to hold an impromptu living wake, and when she died the whole family was able to come to grips with it easily, because the death had been so slow and relatively painless.

Not all patients have this luxury. One was referred to Marsh in a persistent vegetative state. She had been a bright young woman, a journalist, and her doctor hoped that a shunt operation to relieve the pressure on her brain would help her to regain consciousness. Marsh wasn’t so optimistic, and the shunt ultimately didn’t make a difference. Marsh agreed to visit her in her nursing home, a Catholic organization where nuns took care of terminally ill patients until the end of their lives. The nuns claimed that the patient was able to communicate in morse code, but it was unclear whether it was real or a figment of the nuns’ hope.

Marsh was troubled to see many patients in the nursing home who were former patients of his. One had been a schoolteacher in his late 50s with a huge petroclival meningioma. The tumor was benign but very large, and left untreated it would be fatal because of its size. Surgery was risky, also because of its size — damage to the area around the tumor could cause deafness, facial paralysis, death, or stroke.

Marsh was hesitant to operate. The family reported that an American professor said he could operate on it, but the patient didn’t have the $100,000 the surgery would cost. They proceeded to get a second opinion from a more experienced surgeon in England, who referred them back to Marsh.

While he was operating, Marsh liked to play music in the operating theater. During this surgery, he removed a large portion of the tumor, but couldn’t resist trying to get all of it out. In the process of removing the last part of the tumor, he tore part of the patient’s basal artery, causing terrible damage to his brainstem.

Marsh later found out that the American surgeon who said he could operate was called “The Butcher” because of all the patients he had left either dead or horrifically injured in the process of practicing surgery. This patient also wound up in the Catholic nursing home, curled up and wasting away on his bed, barely recognizable. Marsh learned not to do a surgery a more experienced surgeon didn’t want to — and not to trust a surgeon’s reputation based on their publicity.

Photopsia

When doctors first go through medical school, there’s a period in which they believe that they have every disease and disorder they read about. Once they get over it, it’s hard for doctors to believe they ever need to be a patient.

Late in his career, Marsh started seeing flashing lights. He initially attributed them to anxiety, but as they worsened, he finally decided to see a doctor. It turned out he had a detached retina in his left eye, and needed to see a vitreo-retinal surgeon to get a gas-bubble vitrectomy, in which needles are inserted into the eyeball, the vitreous jelly is sucked out, the retina is plastered back in place, and the eyeball is filled with nitrous oxide.

The surgery went well, but it left Marsh blind in his left eye for a few weeks. Nonetheless, he refused to rest and ended up falling down a flight of stairs at home, breaking his leg and dislocating his foot.

A few weeks later he had another vitreous hemorrhage in his right eye, but it was easier to fix. He got a taste of the seemingly irrational gratitude patients feel for their doctors when their care goes well.

Bureaucracy: Tyrosine Kinase and Anesthesia Dolorosa

The bureaucracy attached to England’s National Health Service has its advantages, but from a doctor’s perspective, it has several disadvantages as well.

One such disadvantage is that it necessitates putting a dollar value on human life. Marsh volunteered his services to the National Institute of Clinical Excellence on their Technology Appraisal Committee, thinking that he’d be evaluating surgical tools. Instead, he was evaluating pharmaceuticals. In these evaluations, the extra time patients get to live is weighed against the quality of that time, but it’s hard to pin down that quality because it requires asking terminally ill patients about their impending death. Sometimes, a drug is denied without even having information about patients’ quality of life.

Other disadvantages are merely frustrating. One patient who came to see Marsh had started having inexplicable epileptic fits. It had taken two weeks to get an appointment to see Marsh after getting brain scans, during which the patient had to just wonder and worry about whether he had a brain tumor. Once he was in the office, Marsh couldn’t get the digital imaging system to accept his password; they have to be changed every month. It turned out that the patient had a benign tumor, and the risks of operating were smaller than the risks of doing nothing, making the decision to operate easier than getting the patient’s X-ray to show up on a computer screen.

Conclusion

Patients tend to see their surgeons as godlike, but in reality, both patients and surgeons would benefit by acknowledging each other’s vulnerability and fallibility. Surgeons have to tread fine lines with their patients not only in the operating theater, but in informed consent meetings and the recovery room as well. Recall the four themes Marsh would have you remember as you approach your own healthcare:

1. Finding your purpose: Marsh was an unlikely brain surgeon; he studied philosophy and had little scientific training before entering medical school, but found deep inspiration watching a brain surgeon performing a simple operation on an aneurysm.
2. Admit your mistakes: One of Marsh’s guiding principles is taking responsibility for mistakes — and he’s made many. It’s easy to gloss over them, but impossible to learn if you do so.
3. Hope and realism: Doctors have to strike a fragile balance between giving their patients hope and being realistic about their outlook. Marsh hopes that patients would do more to both get the truth out of their doctors and to be receptive to it.
4. End of life: Hospitals and medical bureaucracies have the unfortunate tendency to make patient care, especially for end-of-life care, inhumane.

About the author

Henry Marsh is a prominent English neurosurgeon, a pioneer of Ukrainian neurosurgical advances, and the author of Admissions: A Life in Brain Surgery.

Genres

Nonfiction, Memoir, Medicine, Neurosurgery, Biography, Science, Health, Psychology, Ethics, Personal Development

Review

The book is a condensed version of the original memoir by Henry Marsh, a renowned British neurosurgeon, who shares his personal and professional experiences of performing brain surgery. The book highlights the joys and sorrows, the successes and failures, and the risks and rewards of operating on the most complex and delicate organ in the human body. The book also reveals the challenges and pressures that neurosurgeons face, such as dealing with stress, uncertainty, and bureaucracy, as well as the ethical and emotional dilemmas that arise from their work. The book is divided into three parts: the first part covers the basics of neurosurgery, such as the anatomy of the brain, the tools and techniques of the trade, and the common neurological conditions and diseases. The second part covers the stories of some of the patients that Marsh has operated on, such as a young woman who became paralyzed after a spinal cord tumor removal, a man who suffered a stroke during a routine operation, and a child who had a brain tumor that was too dangerous to operate on. The third part covers the reflections and lessons that Marsh has learned from his career, such as how to cope with failure, how to communicate with patients and colleagues, and how to balance work and life.

The book is a captivating and informative read that offers a glimpse into the fascinating and challenging world of neurosurgery. The book is well-written and well-organized, using clear and concise language, as well as diagrams and illustrations, to explain the complex and technical aspects of neurosurgery. The book is also honest and candid, showing the human side of neurosurgery, as well as the scientific one. The book does not shy away from the harsh and tragic realities of neurosurgery, but also does not lose sight of the hopeful and rewarding ones. The book is not only informative, but also inspiring and empowering, as it shows the reader how neurosurgeons use their skills and knowledge to save and improve lives, as well as how they cope with the inevitable mistakes and complications that can occur.