The English Surgeon Storyville

GREETINGS IN UKRAINIAN

It's very difficult to cross to the other side of a street.

It's very difficult to know whether one's being brave or reckless,

and when one is being wise or being a coward.

HE STARTS MACHINERY

I like the smell and the feel of wood. It's nice stuff to handle.

Um...and it's wonderful starting off, particularly if you have rough wood and you plane it all.

You start off with rough planks and end up with something very beautiful at the end of it.

I mean, this is knockabout woodwork, just making a packing case.

I've always loved, um, using tools. I love using my hands.

This particular shipment is five defibrillators...

..an operating stool, which I've sat on during thousands of operations over the years,

and now Igor will be able to sit on it and it will do active service

in the Ukraine for many years to come, which is a nice thought.

Nothing goes to waste.

It is 15 years when Henry came to Kiev,

and each time with the new ideas, with the new medical things -

I mean, medical presents -

some instruments, and screws,

things like that. But after we became

closer with each other,

I understood that it is not a medical co-operation.

It is much deeper,

and we are much closer,

his role in my life, so he is elder brother.

Is elder brother.

A BELL PEALS

TRANSLATION:

A DOG YAPS

I first went out to Kiev in 1992,

as I'd been asked to give some lectures on brain surgery there.

When I was there,

I visited one of the state hospitals and I was appalled

to see a completely broken-down, bankrupt medical system.

I was seeing medical problems, the like of which

have not really been seen in the West for,

at that time, maybe for 50 or 60 years.

It was like going back in a time machine.

And I remember talking to a Ukrainian doctor.

I said I'd like to help, and he said, "It's a waste of time.

"Anything you do is a drop in the ocean. The system will never change. Go away. You can't help."

And I remember feeling, "Well, actually, no, I'm not going to accept that.

"I can't really respect myself if, having seen so much suffering...

"Surely I can do something to help."

And then by chance, the next day, I met Igor.

OK, it's my favourite painting.

It's Ukrainian heroes, Cossacks, and we can compare

Cossacks with neurosurgeons!

There are many similarities between us,

because they are happy because they won the battle,

and the same happened with us

after the successful surgery.

Sometimes I suggest that I am in this place,

and my colleagues sitting on the table.

And, by the way, table means in surgery quite something,

so it's Cossacks' table,

but it can be surgical table also.

So they are happy around the table,

and we are also happy, and unhappy,

around the neurosurgical table.

So I like it very, very much.

Because Igor was so extraordinary and so determined,

he was basically questioning the official ideology of how medicine should be practised.

-She is disabled...

-Yes.

-..from the age of three years.

-Yes.

WOMAN SPEAKS IN UKRAINIAN

-Because there is a tumour.

-Yes.

-There is no indications for neurosurgical treatment.

-Yes.

'As he tried to make things better, not surprisingly,

'he had endless problems. He had death threats at one point.

'He was sleeping in a different room every night. His department was closed.

'God knows how many times he was sacked, his staff were sacked.

'There were endless official committees of inquiry,

'and I couldn't very well abandon him. I'd sort of set him up -

'I'd brought him to the West and said, "Look! Brave new world,

' "full of wonderful things and modern equipment."

'So the more his professional rivals and enemies tried to destroy him,

'the more I felt obliged to support him.

'So I wrote articles in Ukrainian newspapers.

'I went out to Ukraine and did unprecedented operations.

'I provided him with secondhand medical equipment,

'in a funny sort of way, all because of people trying to squash him.'

This is the loose bits...

CONGREGATION SINGS

Is it out the front? Right.

You get started, Patrick, with the head position we discussed.

That's fine.

Where's...? Oh, perforators.

Have you got some perforators?

-They are kind of...

-They're what?

-£100?

-100...

-Come on! That's what they said!

Three, four, five. Thank you very much.

-You're welcome.

-Thank you. I'll put those in my bag.

-How many of these have you done before?

-I've done three.

-Three? On your own or with one of the attendants?

-No, I did it.

Well, because she's old, there should be loads of space.

I have a very specific approach.

So I'd have her...

-See, like that.

-Yeah.

-Maybe a bit more...

You'll find you're coming down almost vertically.

-Presumably you used disposable perforators back then?

-Almost exclusively.

I'm trying to reuse them in Ukraine for my friend Igor.

Well, it needn't replace the plastic clip.

DRILLING

Yes, I'm not sure I'll be doing the operating myself.

That's it, that's fine.

I think you'll find that cracks now.

The really difficult thing about neurosurgery is knowing when to operate.

The actual operating isn't so difficult.

But the really difficult thing is balancing the risks of the operation

against the risks of not operating.

It's a bit like Russian roulette with two revolvers -

you've got one revolver called treatment or surgery,

and the other revolver, which is no treatment.

And you have... It's like that with the patient.

And you have to decide which to go for.

Marian's epilepsy is caused by a brain tumour,

which ultimately will kill him if it's not removed.

He's being told in Ukraine it's inoperable.

I think I can save him,

but there's a very real risk I could wreck him in the process.

Would you want to lose your personality or your intellect

or your ability to think?

Cos that's the sort of risks we're talking about.

I'm trying to fill up my job plan, but every time

I'm given a different password.

I'm supposed to specify every few minutes of the day where I am and what I'm doing,

as I was at school.

Let's try that. Wednesday, ward round...

It can't do more than one activity.

All right, another activity, maybe...

I do many things a day, but for some reason you can only put one thing in.

..administrative meetings.

I feel I shouldn't have to justify my existence like this, either.

Tried to change that... Oh, bloody hell!

Just...

"The appropriate operation was started..."

Now, will that save?

Oh-h, bloody hell!

I really just can't stand it any longer.

I'll just go away...

Igor, it's Henry. Hello.

Hi.

Look, I'm looking at the scans on the boy from Zolochiv again.

The possible craniotomy, yeah?

It's a question of when I meet him,

trying to assess whether he could cope with this -

whether he'd find it very stressful or not.

Having holes drilled in your head while you're awake,

and then the sound of the saw - it's extremely noisy

and actually quite violent as you have to hold the patient's head quite strongly.

Is everything else all right otherwise?

And the plans for a doctor to see Tanya's mother, is that OK?

..Minus 13 degrees in the daytime on Friday?

So it may feel a bit more like winter when I'm there.

And I'm told it's going to be hell at Heathrow

because of all the skiers going to Austria.

-Which wouldn't have happened if...?

-No, if I flew straight to Kiev it wouldn't be a problem.

Does anyone ski in Ukraine?

STATION ANNOUNCEMENT

I'm taking out some instruments again for Igor, old surplus ones,

and I'm going to show him some very difficult operations he hasn't really done before.

But what I'm thinking most about is going to see Tanya's mother.

You might say why do I want to go and see the mother of a child who died several years ago?

And I've had many patients who've died, many of them children.

And I don't quite know the answer,

but I just know I want to go and see Katya. I think about her and Tanya very often.

Um...

I suppose cos it was so much about hope,

and failed hope, really.

Um...

..I can remember so clearly when I first met Tanya.

She was very shy, and I remember she burst into tears when she was first brought into the room.

She was very beautiful, but she had this lopsided face,

cos half her face was paralysed because of the tumour.

How could you see a young girl

who was slowly dying from a brain tumour...

..which in theory is curable, because it's not cancerous -

how can you do nothing? How can you say, "Go away and die"?

You'd say whatever the risks, whatever the costs, we've got to do something.

Hope is more important than anything else in life.

And as Katya said to me, "You gave us hope."

And that's a very precious thing to give.

Tanya's tumour was said to be inoperable in Ukraine,

so I brought her to London.

But things went horribly wrong.

During the first operation, Tanya lost her circulating blood volume

four times over. It was an appalling operation.

There was a second operation,

and I tried to remove the rest of the tumour,

but everything went catastrophically wrong.

Cos of my operations,

she had a terrible last two years to her life - paralysed, disabled.

It couldn't really have been much worse.

So today Henry is coming,

and our favourite topic, it's what is the meaning of the life?

What to do?

Is it means to... to become professor?

Or what it means to become a minister of the public health service.

Or is it better to be a good doctor?

Just to be a good doctor.

To see patients every day,

to listen them and try to help them.

Surgery is a risky business,

but neurosurgery...it is 100 times more risky business.

Marian came to our office.

He is more or less...OK.

But he can...can be...

disabled, totally disabled, tomorrow or the day after tomorrow.

And it...will be our wrong decision...

It's a responsibility. It's a moral responsibility.

-Ah, tired.

-Tired?

-Yeah, a bit tired.

-Quite tired.

-I got up at 2.30 in London.

-And I came via Vienna.

-Why you chose Vienna?

-Because there was a strike.

-I've got some amazing things for you in there.

-Really?

Quite amazing! Oh, totally legal! I mean, it's fine!

It's staggering what gets thrown away.

You will not believe what I've got.

-And how are you?

-Actually, I'm very well. It's always good to be here!

Nice to escape the NHS,

I can tell you!

Oh, fantastic.

The ambulance! How's your poor old car?

At least two months to repair it.

You said there was another investigation against you recently,

in the hospital. What was the result of that?

It is more or less normal to be investigated

-in this country.

-Yeah.

-If you are successful,

-it means that your life will be...

-Difficult.

-..difficult.

-Yep.

We say in English, if you stick your head up above the parapet,

above the wall, you are likely to have it cut off.

Actually, although I've been to Ukraine so many times,

-this is the first time I've seen the Dnieper frozen.

-Oh?

It's exciting. I like that.

It's very good. And it's going to be much colder this week, isn't it?

Mm-hm.

I suppose one of the most bizarre and ironic aspects

of my work with Igor is that when I first met him,

he was really a victim of the dictatorial Soviet medical system.

But now, 15 years later,

he's running a very humane clinic in rooms rented in the hospital run by the KGB.

BELL RINGS

And the explanation is that many things have changed in the Ukraine.

The country is now a democracy.

And the KGB are keen to support doctors

who will carry Ukrainian medicine hopefully forwards to a new future.

They even have a lunchtime karaoke concert for the staff.

MUSICAL INTRO PLAYS

I'll get my coat off. Well, it's still...

I've been doing this for 15 years,

but being faced by this whole corridor of people,

most of whom are going to have quite horrendous neurosurgery -

still I find it very frightening, in a way. Quite daunting.

Hope - and a lot of it is going to be hope disappointed.

I'm a last port of call.

I sometimes feel I raise false hope by coming here.

One thing, there are various things you asked me for. I think you'll be quite interested.

Here are just a few...

throwaway perforators.

Do you know, they cost £80 each, and they're thrown away after one use.

I'll take these all out,

and you can leave them there.

This is the Ojemann stimulator we'll need - I have to take that back to London.

That's the cortical stimulator.

-Special drills?

-Yep, they're all here. That's the drill bits.

-There's even a craniotome.

-It's a nice toy.

-Oh, it's superb.

And then you connect that there.

Thank you, Henry.

Right, well, look, if I could have some coffee, Igor Petrovich...

HE SHOUTS IN UKRAINIAN

Then maybe we should start seeing some patients.

Otherwise Igor will be here all day, playing with the tools.

Um... Oh!

Thank you.

You see, a chordoma destroys bone. This cannot be a chordoma, if you mean chordoma.

HE SPEAKS UKRAINIAN

-People...they stay outside...

-MOBILE RINGS

-..in the queue...

-Oh, they're ringing you?

-Yeah!

It's a child

in their family.

She is a grandma.

I would judge that tumour to be inoperable, basically.

I mean, it's in the brainstem.

I'm afraid the child has less than a year to live.

IGOR TRANSLATES

Obviously, as parents and as grandparents,

we find it very, very difficult to do nothing.

It's very hard.

IGOR TRANSLATES

SHE ASKS A QUESTION

So what to do? Something to do?

My opinion is

there is nothing to do but wait for the child to die.

IGOR TRANSLATES

Life can be very cruel.

Oh, I'm sorry.

MOBILE PHONES RING

Without surgery, she probably...

she probably will die within the next five years or so.

Surgery is safer than no surgery.

And she will continue to... she will continue to get worse

as time goes by.

All these cases I'm seeing,

I would operate on them all in London, without any hesitation.

Sure, there are risks, but I would be reasonably confident.

I'd be quite certain that the risks of treatment,

the risks of surgery, were less than the risks of no surgery.

But when you translate that into the circumstances here,

it's different, and it's much more difficult to know.

So in that sense, it's...it's very frustrating.

There are all these salvageable people.

Ah!

So you're looking for a... In English, it's called a jubilee clip.

-Yeah. Many things I bought in this place.

-Yes.

-For the clinic.

-Oh, really? For the hospital. Yes.

There we are.

That was slightly better quality than the other one, I think.

-It's better made. It's better metal...

-Very nice.

They've got bearings here as well, which I need.

I wish I knew the size. Did you buy your Bosch drill in a place like this?

Er, yes.

Do they do a 24-volt...?

No, no.

It's not really strong enough, that cordless drill, is it?

Now, the problem with trying to remove all of the tumour

is there is some risk, there is some danger,

that the operation could leave you paralysed down the right.

The tumour is on the left - the left side of the brain is responsible for the right side of the body.

And there is a risk, if we try to remove all of the tumour,

of producing paralysis of the right arm and the right leg.

Usually, we have the patient under a general anaesthetic to begin with

when we make the opening, the incision in the head and the bone.

And then we wake the patient up and remove the tumour.

So I think it would be simpler, and we have a better chance of success,

if you are awake throughout the whole time of the operation.

It makes the operation safer,

because it makes the surgeon braver!

Because I know I can see what I am doing. I can see you,

I can talk to you,

I can ask you to move your arm and leg, and that gives us

a much, much better chance of removing all of the tumour.

There will then be about ten minutes, which is not painful, but is unpleasant.

That is when Dr Kurilets is sawing, cutting through the bone

of your skull. That is very noisy, and you'll feel the pressure of the drill pushing on your head.

Um, and that is unpleasant, but it's OK.

The only part of the head which feels pain is the skin.

That is all.

The brain itself does not feel pain.

So in a strange...in a strange way,

to remove a brain tumour under local anaesthetic

is no different from going to the dentist.

And I really, really think we can do this,

and I mean that from my heart.

-OK?

-OK.

-Harasho?

-Harasho.

Right. We have a plan.

-The most important, to put the plan into action.

-Yes.

Making plans, it's a Soviet...

-Yeah, all right.

-Soviet...

-Soviet National Health Service.

The National Health Service has nothing but plans now.

But making plans, it is nothing.

I've yet to have a...

a catastrophic result here in Ukraine but...

you know, I think the law...

Sooner or later, things are going to go badly.

But nothing ventured, nothing gained, I suppose.

However much you tell patients there is risk...

they never really take it in.

If you're very nice and charming with them, they will trust you

and think, "I'll be all right." That's human nature.

We all think, "It's never going to happen to me."

Are you ready to eat?

Uh...let us play for ten minutes first, if that's all right.

Look at this perforator. I'm sure we could use it dozens of times.

It may be you can just make a metal sleeve to go over it.

-You said your toolmaker has died, alas.

-Yes. From brain tumour.

-Yeah.

He did a lot of good work for you. He made the operating table as well.

And the bar for sitting position.

-He made that?

-Yes.

-That's very sad. He made it very nicely.

Need a pair of circlet pliers.

My department, I calculated - it's unbelievable -

-it spends £40,000 a year...

-A year?

-..just on those.

We use ten a week. They cost £80 each.

We must use at least ten a week.

Which is...

800 quid a week, times 50.

I mean, it's...

..extraordinary.

I use one for...

-ten years.

-Yeah, I know.

-So it is a plastic...

-There's a plastic thing there, yeah.

There's millions of pounds a year being thrown away.

If you had tungsten carbide tipped ones

like you have for a router in woodworking, it would last for ever.

-Now you've got the compressed air hose for the ventilator.

-Yes.

It fits.

I...

..made fixing here.

-So we will try.

-Bye-bye.

See you tonight.

Good luck.

Thank you.

You like my idea?

Yep, fine.

In England, I don't have to...

plumb in the ventilators myself. We have somebody else to do that.

You're just a one-man hospital.

My job is to do the operation.

-You're privileged.

-Yes.

-Very privileged.

I must be responsible for everything.

LIFT RUMBLES

It's a long journey.

Well, um...

50 seconds.

HENRY LAUGHS

So...hundred seconds...each day.

I saw some of those new apartment blocks they're building.

They're 40 storeys high.

Right, here we go.

A difficult day.

And can she see any light?

And is the light in her eye now?

Yes.

So she's not seeing light.

-I think...

-How much time we have?

-No, it's too late.

Totally blind. It's too late.

You have to operate for raised intracranial pressure

before they completely lose their eyesight.

Typical problem here, cos diagnosis is so often delayed,

and by the time a brain scan is done...

the damage is done.

Even with benign tumours, people have gone blind and suffered irreversible damage.

You get earlier diagnosis if you have more scanners,

but even though a brain scan in the Ukraine costs 50 to 100,

even 50 to 100 to many people here is a huge sum of money

and they can't afford it,

and so things get left. Left too late.

We cannot run good treatment of the patients

in...in our...hospitals.

How far away do you think you are from actually starting building your own hospital?

It depends on...on finance.

Yeah.

-And you had to borrow the money, presumably, from...?

-We can,

but it is very difficult to run clinic if you have...

-A large mortgage?

-Yes.

-Yeah.

From bank, so...

This will be a first in Ukraine.

So, here we are.

-Yep.

-That's the place.

Oh. What a dream, heh?

-Is it your dream?

-Yeah.

-Must be.

Your own hospital, Igor.

No, no! It's...

-That's a field.

-Yeah, I know, but...

-Now it's a field.

But it's a field of dreams.

Yes.

So...

This is where it'll be?

Isn't it fantastic?

So exciting.

Igor, this can be the ornamental lake...

-Yeah?

-..for the hospital.

HENRY LAUGHS

I like it.

-So the building will be there.

-Here?

-Will be here.

It's a water pipe.

Deep water pipe here.

And the patients' rooms will look onto the courtyard?

-Yes.

-And there'll be a garden in the courtyard?

-Yes.

-That's wonderful.

-The lake there...

-Yes.

-..so we can go there.

-And the lake is over here.

And concerning grass, I would prefer natural grass

-and not changing it.

-Yes.

It's filled with fish.

Be careful!

I'm not sure that it is strong enough.

It looks pretty thick to me.

-Are you happy?

-Yes, yes.

-Henry...

-It's all very, very exciting.

CAMERA CLICKS

Igor, it's so important to have good design in hospitals

cos hospitals are like prisons.

They are places where a small number of people are doing nasty things

to a large number of people.

Nice weather(!)

You do realise this is a very big, serious case, don't you?

The one we're going to do now.

Yes, Henry.

-A risky surgery.

-And the patient realises?

The problem is that if you run a successful clinic,

so nobody realises how risky surgery CAN be.

-Can be.

-I know. But you gotta tell them.

Yes, I told them.

-Told them. But they reply that...

-They go like that?

..that you...you...you had... good results.

We asked many patients, so we suggest that...

Yeah, but with simpler, smaller tumours. This is a terrible big tumour.

You become less enthusiastic with years.

What a load of crap! It's not that! It's just you're giving me more and more difficult...

You're showing me more and more difficult operations. That's the problem.

That's what it's about.

Every time I come, you show me a bloody more dangerous operation.

But you told that we should, step by step, make progress.

Yeah, but one day we're going to make a step too far.

Bloody Cossacks!

HENRY MUMBLES

Now that the die is cast, we're actually going to start the operation,

I cheer up a bit.

A certain amount of...

Whether it's blood lust or training, I'm not quite sure.

Surgery isn't just about rational altruism.

I mean, it's a blood sport, in a way.

Surgeons become surgeons for the excitement of it,

and the sort of fierce joy of operating.

So, in that sense, I suppose it is a slightly Cossack activity.

You know, a sort of brave Ukrainian heroism, things like that.

Right, well, off to battle.

Everything is possible.

Tell him it'll hurt a little bit, like being stung by a bee,

when he puts the local anaesthetic in there.

-Bomkee?

-Bomkee?

Bomkee is the word for bigger mosquitos.

A bigger bomkee is a bigger mosquito? Yes.

It's a Western Ukrainian word.

Dr Kurilets is a bomkee. He is a big mosquito. Many people think he is a mosquito.

He is a mosquito for the medical establishment. Aren't you, Igor?

MACHINE BEEPS

-That's fine. That's fine from this side, Igor. Is that all right for you?

-Yes.

Because this cage is rigidly fixed, he can do anything he likes.

No, no, no, not at all.

Dr Kurilets is quite happy up there.

I can hear something scratching.

It'll get very noisy when Dr Kurilets starts drilling,

cos the whole skull will act like the sound board of a piano.

So it'll be very, very loud.

DRILLING

A colleague of mine, a neurosurgeon, once did an experiment

where he had a colleague of his drill a hole in his head.

It was some scientific experiment

with putting an electric wire into the inside of his head

to measure the pressure.

I mean, crazy.

But he said it was very noisy,

having the hole drilled in his head.

-He can't hear anything.

-He can't?

Ah! That's interesting.

He can't hear our voice cos of the noise. Yes, yes.

Yeah.

I think the 24-volt version might be better, Igor.

DRILL SLOWS

The battery's a bit flat.

DRILL SLOWS FURTHER

DRILLING STOPS

-All the holes done.

-Good.

All right. Yeah.

Yeah, OK.

Igor's operating theatre is a little bit on the small side

for all the equipment in it.

Now...

SUCKING NOISE

What's he saying now?

-He's already used to these sensations.

-He's getting used to it? He's bored, yes!

He'll probably fall asleep. We'll have to abandon the operation!

-He'll fall asleep?

-No!

-He won't fall asleep?

-No.

HISS OF AIR

We're now...we're now...

Igor is now cutting through the skull.

LOUD DRILLING

To have a pulse rate of 70 while you're lying there

having your head sawn off is, um...

quite something!

We'll start removing the tumour in five, ten minutes.

That's the most important thing.

Igor, I'll go and get scrubbed up.

I'm feeling extremely tense at the moment.

Admittedly, I always do before serious operations.

I suppose it's like stage fright with experienced actors.

The worst of all surgical sins is complacency,

so a certain anxiety, I suspect, is necessary.

And yet it's always a critical moment -

will we be able to see the tumour clearly

and is it going to be straightforward or not?

Right.

Igor, hang on a moment. Let's have a look.

Where is the tumour?

-Maybe here.

-What do you mean, maybe here?

Thank you.

All right. Now, um... Yes, Igor, come and have a look.

I think we can tell the difference.

That's a little bit discoloured, but that's certainly abnormal.

We know from the scan there's a big vein. We'll try to preserve it,

but I think that'll be very difficult.

I think, probably, the edges of the tumour are like that.

So let's have the cortical stimulator now.

The leads plug in the front.

The two contacts... Put it there, facing up.

-Put it here?

-It doesn't matter. OK.

I'm going to touch an electrode on his brain.

He might feel his arm or his leg move, all right?

CRACKLING

All right?

Ah, got him! That's motor here, do you see?

OK, Marian, I'll make your hand jump.

It's like a doll with strings. Here we go. Ready? Watch.

There. See?

So we're in front of the motor strip.

No more, because I don't want to start a fit.

Marian, OK?

-OK. OK.

-Well done.

Right, we can turn that off now.

So what we need to do now is open it, which we know is safe here,

because the motor mapping, which was very easy,

has shown us where the motor is.

That's tumour.

Normal brain has the consistency of very smooth cream cheese,

fairly thick cream cheese,

and tumours make it rubbery.

It's slightly more rubbery and stickier and thicker.

-SUCKING NOISE

-This is all tumour, Igor.

Tumour?

-Karena?

-Yes?

You can tell Marian that the beastly tumour that has been ruining his life

for so many years, I'm now starting to remove it.

SUCKING NOISE

You can feel, with the sucker, that that is too firm.

That's possibly the edge. All this is tumour.

It's actually very nice.

This is very clear.

LOUD SUCKING NOISE

QUIETER SUCKING NOISE

See what his movements are like.

Marian is the reassuring check.

By seeing he can move his right side

as we continue, I know that I'm not producing any serious weakness

in his arm as I take the tumour out. Which makes me braver.

-Are you all right?

-Yeah.

-OK.

He's having a fit.

He's having a fit?

A big fit? Is Obsidenenko there?

Is he having a fit?

What's he saying?

He's... I don't know. He's strange to me.

Can somebody sort him out, please? I can't sort him out. Is he having a fit at the moment?

Could he talk to him and see if he thinks he's all right?

Dry throat. Can we give him a drink?

Yes. Can we give him some water, please, to wet his throat?

-So, Marian, OK?

-OK.

Everything all right? Is he in pain? Or is he fairly comfortable?

-No more? Is he all right?

-Yeah.

Everything is going fine. I'm happy.

Everything is fine.

When we're thinking or talking,

that is billions of electrical impulses

travelling along all these nerve fibres,

but I always find it virtually impossible, even when the patient's awake,

to look at the physical substance of the brain we're operating on,

and I can't really comprehend that this is thought itself.

Feeling itself.

It's just too crazy and extraordinary.

But that's what it is.

And that is the absolutely incontrovertible evidence of modern neuroscience.

Thought is a physical process.

We are our brain.

-All right, Igor?

-Yeah.

-Igor?

-He just moved.

-His hand...

-He's moving all right, is he?

-Yeah.

-Good.

Tell Marian I've removed the tumour.

The tumour is gone. Hurrah!

Let us hope a new life can begin, hey?

We hope. We say in English, "Fingers crossed."

Fingers crossed!

Oh... Yeah, yeah.

OK.

Thank you.

OK.

OK?

..Full stop.

-Are you tired?

-No, not particularly.

-Hello.

-Irena, good evening.

Mr Marsh.

Hello.

He's very tired.

I'm not very tired!

I've just got a stiff back, that's all.

So am I.

Oh...

The beer will be here.

Domestic goddess, full-time cardiologist

and domestic goddess... Oh...

What?

It went all right today. It was a big, big tumour.

-And how is the patient?

-He's all right.

Is there a bottle-opener in there, Igor?

-Here you are.

-Thank you very much.

I have now taught you everything I know about brain surgery.

You're a wonderful teacher.

You've now picked my brain clean.

The only problem... The only problem...

that we can kill patients.

-Yes.

-With it.

And probably will. That's the problem.

In Ukrainian conditions, a few deaths, medically, are acceptable.

The tumours are so big and the conditions so difficult,

but politically, only you can decide whether...

Thank you ever so much, Irena.

And they will advertise the bad case...

-Well, your very good health.

-Thank you.

Well, if it's not too cold next week,

I would like to go down to Kamjanetsk-Podolski if possible.

It would be important for me because Tanya was quite an important part of my life in many ways,

and I still think about her and her mother a lot.

-Yes, indeed. It was a lesson for us.

-Yes. Yes, it was.

It was a very important lesson.

-Intensive care here?

-Yeah.

-There Marian is.

-Mr Marsh.

Marian.

THEY SPEAK IN UKRAINIAN

Hello.

OK?

Any fits at all?

No fits.

Arms up in the air.

Turn the palms around.

Right round. Close your eyes.

That's very good.

There's no significant... That's fine.

So he's fine. He's going to be all right.

The only question now is if we've abolished the epilepsy.

I think we almost certainly have, but we have to wait.

We can sit him right now?

Yes, yes, of course. He can get up and about.

-Can he walk?

-He can do anything he likes now.

Get him up and about.

He'll feel a bit... He'll feel a bit dizzy,

because he's been lying flat for the last day. But that's fine.

What is...what is his treatment?

Intravenous...?

-Nothing.

-Nothing?

-Nothing.

So...it was a last chance for him.

Yes.

It looks better in the scan.

Although it's probably a low-grade glioma.

Has she developed epilepsy?

Why was the scan done?

This, to me, looks like liomatosis.

It's a widely infiltrating, diffuse low-grade glioma.

Is it possible in her age...?

-What, to get...?

-23.

-Oh, yes. Yeah.

What is her future?

Um...not good.

You cannot remove the tumour by surgery because it is too extensive.

What can we advise her?

Well, I... Nothing, I think, is the honest answer.

I think, what would I do in London?

Well, we'd do a biopsy operation and then refer her to my oncological colleagues.

But, no, the prognosis is... is not a good one.

How many years it will take...?

I would have thought less than five.

But she'll probably go blind first.

But I don't know if it's appropriate to tell her that or not.

She said that maybe it is a viral infection

-because she was biting...

-Bitten by an insect. Hmm.

-Encephalitis.

-Hmm.

Is it possible?

It's unlikely, but if that belief gives her some hope and happiness

maybe it's better to stick with that possibility.

-I do not know what to say.

-I don't know...

When I break really bad news to patients,

I don't talk to them on their own.

It's a complicated business. You have to find out what they know,

what they fear, what they understand.

It's not an easy... You can't just say, "This is a bad tumour. Goodbye."

It takes time, and I think you need other members of the family present, as well.

-We must give some hope.

-Yes, I know. Exactly, exactly. It's all we can do.

The reality is, although she's young and beautiful

and looks very well,

the reality is, she's going to go blind

and die probably within the next two or three years.

None of us, all human beings, we cannot look our own...

Particularly at that age. You can't look your own death in the face

and shrug it away. You can't.

So a lot of dealing with people with inoperable brain tumours

is giving hope when there isn't really any hope.

So there's a lot of...not exactly dishonesty involved,

but a lot of...

You know...

..avoiding the truth but trying not to lie, but it's terrible.

INAUDIBLE

I made what I felt, in retrospect, was a big mistake many years ago

when I saw a young child, Tanya,

with about the biggest brain tumour I'd ever seen.

It was a benign tumour, so in theory it was curable.

But again, the diagnosis had been missed and delayed.

In a sense, I was being sentimental.

I had been swayed by emotion.

But it's so very difficult to cross to the other side of a street.

It's so very difficult to say no.

And I remember the time when Katya first started visiting us....

-Yeah.

-..in emergency hospital.

And, um, you was frightened... what to do,

-and what will happen with the child.

-Yes.

I think about the whole story quite a lot,

because, in a sense, I think it was a mistake to have operated.

If it happened again, I would say no...

I think, probably, it's too...

Well, I THINK I'd say that.

But one always hopes, doesn't one?

Mr Marsh!

Katya.

Right, we brought some flowers.

Translate a bit, Igor.

It's like a dream.

You can tell, can't you, I was quite worried!

I was quite nervous. I've been feeling quite nervous as well.

-Where shall we all sit?

-The table is ready.

Looks wonderful.

Some photographs of Tanya on the wall there, I see.

Yes.

And the hydrotherapy in the bottom one.

One of her physios.

It's wonderful. I love it.

They are afraid the... There's something wrong!

The food is wonderful. I'm just overcome by emotion.

That's why I'm not eating very much at the moment.

-He is too young.

-Too young!

-Too young.

Too upset - understood.

She will drink for us and er, maybe we should drink for her family.

-Yes.

-Tanya. Misha.

Well, I'll make a toast - would you like to translate, Igor?

I've been coming to Ukraine now for 15 years...

IGOR TRANSLATES

And in many ways I've come to love this country as much as my own.

And Igor and I have been working together for all that time

trying to make progress, treating patients with neurosurgical problems.

And sometimes we succeed, and sometimes we fail.

IGOR SPEAKS IN UKRAINIAN

Well, I'd like to drink to all your future successes.

And we'll never stop trying to make things better.

IGOR SPEAKS

WOMAN:

THEY MAKE TOASTS

I don't know whether I'll be thinking about anything when I die,

but the way I see things at the moment, I'll know that what I will think mattered most

was how I tried to help Igor and his patients and I'll think about Tanya and I'll think about Katya.

What are we if we don't try to help others? We're nothing.

Nothing at all.

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