We joined the green-gowned brain surgery team soon after daybreak. The chill of the operating theatre was filled with the inevitable frisson of nerves before a big op. Inside the Orlika Street children’s hospital in the suburbs of Lviv, on the western edge of Ukraine, the patient was waiting for us, under halogen lights, anaesthetised upon the table.
She was corpse-like in unconsciousness. Her chilled cerise fingernails offered a poignant reminder she is a young girl. Viktoria, who is just 11, has a malignant brain tumour. The day before, in the ICU, she had been weepy, fretful and disoriented with brain sickness. She had come with her mother to this 10- storey late-Soviet paediatric facility for a high-risk, potentially life-saving operation.
Approached through the echoing shadows of twilit corridors, the ICU had been virtually empty. With so few patients, the hospital seemed over-staffed. At Viktoria’s bedside was one of the world’s best-known neurosurgeons, Henry Marsh, the author of Do No Harm, and a celebrity in Ukraine. Here, as much as in Britain, Marsh commands attention for his instinctive candour, a lifetime of experience and his bracing clarity. The author Karl Ove Knausgaard once wrote of Marsh: “His job is to slice into the brain, the most complex structure we know of in the universe, where everything that makes us human is contained.”
Viktoria’s mother was frightened at the prospect of her daughter’s surgery, but “Professor Marsh” presented a cool and impressively frank assessment of the risks and likely outcomes. Although Marsh operates around the world, Lviv is an apt destination for a surgeon who is a junkie for jeopardy. This former Austro-Hungarian provincial capital, once called Lemberg, has been described as the “soul city” of Ukraine. Blink, and you could be in pre-Anschluss Vienna. Barely 50 miles from the Polish border, Lemberg’s cobblestones have the melancholy of streets steeped in atrocities. Long before the current civil war, fought out at the eastern, pro-Russian end of the country, European Ukraine saw Nazi war crimes, and murderous Polish blood feuds, mixed with the horrors of endemic antisemitism.
Marsh, who has been coming here since 1992, just after the collapse of the USSR, admits to “a slight obsession” with the transgressive, marginal side of Ukraine, a country that appeals to his maverick instincts.
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In the nationalist half of Ukraine, visiting Europeans such as Marsh – an English surgeon of half-German descent conducting a neurosurgical consultancy – offer a parable of an evolving Europe, in which a society at war with Russia struggles to find a place in the new European order through the assistance of philanthropic outsiders.
Today’s operation says a lot about post-Soviet Ukraine, and possibly even more about Marsh. Ask him about his German mother, her guilt about fleeing the Nazis and his own need to atone for the past; at once you are plunged into the abyss of mitteleuropean history.
Marsh has watched the country torn apart by the Euromaidan conflict of 2013, seen pitched battles between demonstrators and the Berkut riot police, and devoted a lot of time to help improve an antiquated medical system. He identifies strongly with Ukraine’s drive for independence. “My work,” he says, “was part of the same struggle against corrupt autocracy as the Euromaidan protests.”
In those days, when local medicine was decades behind the west, Marsh worked pro bono, to share a lifetime of experience. He still donates his time and remembers how, on his first visit to Kiev, one of two centres for neurosurgery in the USSR, operating theatres contained buckets with the brains of patients who had died after treatment for acoustic tumors.
Marsh, who made two films (Your Life in Their Hands and The English Surgeon) about his experiences, became something of a local hero, and then published Do No Harm, the surprise hit of 2014, adding to his celebrity status. Today, he can’t walk down the street in Lviv without getting stopped for selfies or autographs.
On this visit, literature and medicine have intersected. He’s here to launch his new book, Admissions, and to operate in the Orlika Street hospital, having moved from his former base in Kiev to help his friend, the neurosurgeon Andriy Myzak, and colleague Taras Mykytyn establish good surgical routines.
The hospital is a microcosm of a society in painful transition, fully equipped with up-to-date technology but lacking both the staff and the management disciplines appropriate to 21st century medicine. Marsh’s philanthropic endeavours will soon run into the same problems. Nevertheless, in anticipation of a long day’s work, Marsh remains optimistic. He prefers Ukraine’s operating theatres: “They have windows,” he said. Such attractions are a rare bonus. At 67, he’s reaching most surgeons’ sell-by date. In his new book, indeed, he confesses to moments of deep anxiety before embarking on another investigation of the cortex. In the theatre, he betrays none of these qualms, projecting bonhomie and confidence.
When I joined Marsh and his team of 12 (three surgeons and nine nursing assistants), the world of wellness remained tantalisingly close; beyond the Winnie-the-Pooh stencils on the windows it’s a lovely late-autumn day with sunshine gilding the birch trees.
Marsh chatted to the anaesthetist while the team prepared.
The tumour was on Viktoria’s brainstem. It was going to be a tricky operation, but unavoidable. “Without treatment,” said Marsh, “she would be dead in a few weeks.”
First, they positioned the patient’s head for surgery, a delicate manoeuvre. Once the incision had been made, and the skull opened, Marsh and his surgeons navigated their way to the tumour with a microscope.
Thanks to a Canadian-Ukrainian benefactor, this rundown former Soviet hospital boasts state-of-the-art surgical equipment. The problem, said Marsh, is the lack of training. “My analogy for Ukraine is that it’s a like a Trabant wanting to become a Ferrari.”
Marsh’s role that morning was to supervise. “I’m keen not to do too much,” he said. “My job is to teach. The point is to help the next generation.” We looked across the theatre to Mykytyn, who was preparing to open the patient’s skull. “I don’t want to be a white wizard, flying in as a kind of hit-and-run consultant,” confided Marsh. He broke off to ask about the Ukrainian word for “happy”. It’s important to conduct dangerous brain surgery in a stress-free atmosphere, he instructed.
The Orlika team, fully scrubbed up, moved round the operating table like actors in costume. Marsh stood apart: watchful, focused and poised for action. At about 10am, the gruesome “bone-work” began – the application of drills and retractors to expose the patient’s brain. It’s a slow and delicate operation. The smell of burned flesh mingled with the faint chemical tang of ketamine. The only sign of life on the operating table was the barely perceptible rise and fall of Viktoria’s chest.
By 11.10, most of the bone-work was completed. At 12.15pm, the microscope was wheeled into position and Marsh began to extract the tumour. “Lovely,” he said, as the procedure proceeded. His biggest worry (has the tumour attached itself to the brain-stem?) seemed to have been resolved. At 1.10pm, Marsh looked up from the microscope: “It’s not bleeding heavily, which is nice.”
Surgeons hate bleeding. He instructed Mykytyn about what they could see on the monitor: “That’s not tumour, that’s brain-stem.” It was an awesome moment: in this procedure, Marsh was operating at the crossroads of Viktoria’s consciousness.
Finally, at 1.35pm, with a tricky manoeuvre complete, everyone could relax. Marsh was cock-a-hoop. He advised Mykytyn to have “a 10-minute wait” before closing the wound, to ensure no further bleeding: “Let’s have an English cup of tea.” He was plainly relieved at the immediate outcome of a hard morning’s work.
But there was no let-up for the celebrity visitor. While Mykytyn and the team wheeled Viktoria back to the ICU, Marsh took the creaky lift downstairs to conduct an out-patients’ clinic, surrounded by more trainees.
A mother and her teenage son came in, nervous in the presence of the famous English surgeon, clutching an MRI scan. Marsh affected no interest in the scan. Through an interpreter, he questioned mother and son.
“How dizzy? Since when? Where?” When, finally, he looked at the negative, it was as a veteran of neurosurgery who had spent a lifetime studying more than 50,000 brain scans.
“I’m not sure what this is,” he said, frankly. “It could be cortical dysplasia. I’d do another scan in a year’s time. The advantage is that it’s completely safe. The disadvantage of waiting is the anxiety. But, if it’s cortical dysplasia, there’ll be no need to operate.” He smiled encouragement at the boy. “You’ll just have to think about something else. Have a busy life. Get on with things. We call it ‘distraction.’” At home in England, Marsh fills his spare time with bee-keeping, DIY and woodworking.
Andriy Myzak hurried in, looking worried. There were post-operative complications with Viktoria. The outpatients’ session went into temporary recess while Marsh consulted. “Let’s wake her up and see,” he concluded.
The afternoon wore on, Marsh handing out verdicts. To reassure one patient, he introduced himself as “the strange Englishman”; to another he complimented their “nice brain”. Despite the off-stage drama of Viktoria’s fate, his mood was decisive and upbeat. Eventually, he rose from his chair, stretching: “Welcome to the terrible world of brain surgery.”
The next day there was an air of despondency; the day’s schedule was cancelled. Viktoria had suffered overnight bleeding, and needed urgent treatment. While Marsh waited to go back into theatre, he conducted further outpatient consultations. A local TV crew turned up to capture “Professor Marsh” in action. Had he achieved his goals here? “Not yet,” he replied. He insisted there was still “a way to go”, that neurosurgery is “dangerous”, and that “we should learn from our mistakes.”
It was very late before Marsh reappeared, visibly exhausted. Viktoria was back in the ICU, in a coma. He spoke, with dismay, about his experience of Ukraine medicine, and the crippling shortage of trained staff. Does he ever get frustrated ? “Oh yes, but I am resigned to achieving very little. We’re talking about ripples in a pond. Lecturing to medical students is probably more important than operating.” He reflected on the long arc of history. “Maybe in future they will try to change things. The Ukrainians must sort out their problems for themselves; the poverty and corruption of the country will not be solved quickly.”
Two days later, we got the news we had all feared. Viktoria was dead.
Marsh seemed resigned. In Do No Harm, he quoted the French physician René Leriche, saying: “Every surgeon carries within himself a small cemetery.” Marsh had been here before, a successful procedure followed by post-operative complications. He blamed himself for not properly checking out the post-op care, but added that this is part of the systemic failure of Ukraine medicine.
“She almost certainly died from hopeless post-op care on the ICU,” he said. “The chances of her recovering from the bleed were pretty slim. The tumour was malignant; it may well have killed her eventually despite radiotherapy. So perhaps it’s better she died quickly, but who’s to know?”
How were his spirits, I asked. “It is obviously horrible (he later confessed to being “utterly depressed for several days”), but I have been through worse over the years. Poor Taras [Mykytyn] is devastated.”
The pioneering medical reformer in Marsh quickly reasserted itself: “The important thing now is trying to improve post-op care. I have come to understand better the feeling of hopelessness that affects many Ukrainians. How can one change anything when the whole system is corrupt and broken?”
Later, back in Britain, he reflected on his recent experience: “I go up and down like a yo-yo when I am in Ukraine, and return home exhausted. What keeps me going is the fact that my colleagues want me to continue to visit and work with them. I cannot really stop.”