There are two ways to open a person’s head. Usually, I shave the hair, nick the skin with a scalpel, then apply an electrocautery device to burn down the tissue to bone level. It’s slow, precise and leaves almost no scarring. But it takes time.
However, that day years ago in Oxford, London, Dr Jay Jayamohan, consultant paediatric surgeon at John Radcliffe Hospital, did not have the luxury of time.
A four-year-old girl had just been wheeled into the hospital and scans revealed that she’d had a massive haemorrhage in the brain resulting in a blood clot that was now blocking the brain fluid’s path. The clot, Dr Jay knew, wasn’t the immediate risk; it was the pressure spike from the blocked fluid. If a drainage tube was not inserted quickly into her brain, the little girl could end up with severe brain damage. If she lived.
The case of the four-year-old girl is but one of several that figure in Dr Jay Jayamohan’s fascinating book, Everything That Makes Us Human: Case Notes of a Children’s Brain Surgeon.
Published last year, it offers an over-the-shoulder view – and a peek into the mind – of the distinguished surgeon at work, including how he is often forced to make split-second life and death decisions on babies and children. Told in first person, it is gripping and revelatory, lucidly showcasing the nerve-racking pressures surgeons like him face almost every day.
The doctor will be addressing bibliophiles at the forthcoming Emirates Airline Festival of Literature on his book – written with Jeff Hudson – that highlights not just successes but the failures too that happened while he was beside the operating table. "I’m looking forward to the session with the readers in the UAE," he says.
For Dr Jay, medicine is a passion – and his career has completely consumed him. He grins when I remind him that his wife once told him "you are completely your job… everything fits around your job".
Surgeons in general and neuro surgeons in particular rarely get time to switch off, he tells me in a Zoom call from his home in London. "Once I started doing neuro surgery, it was increasingly obvious that it’d become a priority and my patients are my priority quite a lot of the time."
But then medicine is something he grew up around. "My dad was a doctor and we lived in the hospital accommodation in London," he says. Growing up, little Jay would accompany his father to the hospital and occasionally on some rounds as well.
"I think when you [grow up] in that kind of surroundings, it ends up becoming part of your life," says the father-of-three.
Initially, though, his father felt he was better suited to be a lawyer "because I had a big mouth and was always arguing with him". For a while Jay considered careers in physics, astronomy and astrophysics before finally deciding on medicine and then neurosurgery, fascinated by the brain and its functioning.
"If you are a GP or are looking after people with more chronic diseases, you have to treat them for a long time before you see them get better, and that’s very important. But I really preferred the immediate feedback you get after performing an operation – seeing the patient get better either at the operation or immediately afterwards; that’s what really drew me towards surgery," says the doctor, who has been part of Brain Doctors, the acclaimed BBC fly-on-the-wall series that showcases the work of surgeons treating brain and spinal conditions.
Having dealt with the brains and spines of thousands of children – the John Radcliffe Hospital where he practices performs around 5,000 operations related to the brain annually – Dr Jay has been improving children’s life chances on a daily basis.
"Have we got the scans?" I ask.
"On their way. But there’s another thing. One pupil dilating."
Oh God. A single pupil enlarging is a really bad sign. When a doctor shines a light into your pupil, they’re monitoring brain function. Pupils are meant to shrink with light. If they don’t, there’s a real risk of death.
A doctor is really an ordinary person doing extraordinary things, Dr Jay says, quickly adding, the danger is when you believe you are extraordinary.
Have there been moments when you believed you were extraordinary? I ask the good doctor.
"Of course," he says, leaning forward into the camera. "There have been moments." He, however, believes what is important is maintaining a balance. "You need to have a certain level of self-confidence to go in and do what needs to be done to a patient; [and] to those parents with whom you have made an unwritten contract saying "we will look after your children with everything we have".
"You’ve got to genuinely believe that you can do that better than anyone else; if not, you should give the patient to someone else to do the work." Dr Jay admits that it is a fine line before that self-confidence "jumps into arrogance and taking a risk with patients. So yes, you’ve got to be at the top level of normal confidence and not become self-aggrandising".
"Heart rate?" I ask. "Thirty-five and dropping." [The paramedic] checks again. "Thirty-four."...
"We don’t have time for theatre," I tell my registrar. "Get everyone here."
There are two parts when preparing for an elective surgery – preparing the patient and the family, and preparing yourself, says Dr Jay.
Often, preparing the family takes the most time. But since in many instances the cases he gets are of an emergency nature, conversation with family members needs to be done really fast.
The next step is preparing for the surgery.
"We examine the scans, talk to colleagues… bounce ideas… make sure equipment required for the surgery and for any complications that may arise is available and at hand."
For the doctor, part of the preparation also includes going through all the steps in his mind – considering everything that could go wrong during the op and how he plans to fix each of the things that could happen. "I have a plan A, a plan B and a plan C for each of these problems."
Next, the paediatric surgeon ensures he has the right music playlist for the surgery he is about to perform. "Music has always been a part of my life and I find it hard to work without music," he says. "It helps block out everything else around me allowing me to concentrate on whatever I’m doing."
And his choice of music?
"When operating, I prefer dance, heavy metal or indie music. I don’t like pop music. If I’m doing something extremely intricate, it has to be electronic or dance music without lyrics."
Although the brain surgeon is also fond of ambient/white sounds, he avoids playing this in the op theatre. "Not everyone likes sounds of an engine or an aeroplane. So it’s dance music in the theatre."
The second I get the all-clear... I make a drill hole through the skull and pass a rubber tube into the brain. We don’t have scans in front of us. I’m doing it by memory. Mess this up and it’s game over.
For a person who is able to make a difference between life and death, Dr Jay is a self-admitted grump. But shouldn’t you be a happy person because you are able to make a difference in the lives of so many people? I ask him.
The father-of-three chuckles. "I’m actually inordinately happy with how my patients do mostly, and even for the ones who don’t do well I think I’ve at least done a good thing," he says, admitting that his natural setting is ‘slightly grumpy because I’m always suspicious about what can happen to my patients. But of course, you have to be an optimist to do this job."
Optimism is surely what keeps him on his toes – on one occasion performing a 28-hour non-stop brain surgery on a woman.
"That was early in my career," he recollects. The patient had an abnormal concentration of blood vessels in the brain that had bled and Dr Jay and his boss were working to fix it. That day, beginning early on Christmas eve they finished the operation at around 5am on Christmas.
"It was amazing but extraordinarily exhausting. I just wanted to crash into bed, but my boss insisted that I go to his house for Christmas lunch. And it was a lovely day."
As a consultant though, the longest surgery he performed was on a child with a serious tumour case. "It went on for around 18 hours."
How has having children impacted your work, I ask the doctor.
Dr Jay allows the question to sink in for a moment before answering: "It’s good and bad. Having children is, of course, good; [like] the emotional support I get from them when I return home after a day’s surgery; a hug from them when you are feeling low really helps immensely."
And the bad? I ask.
"Sometimes you worry a lot about them. You see your children in your patients sometimes. If I have patients who look or sound like or are about the same age as one of my guys, then I can’t help but think that it’s just by fluke that this child is sitting here with a brain tumour and my child is at home having fun. [I wonder] why and how that happens – how that decision to give one to one and the other to the other happens. It does make you feel sad… the relative randomness of life…"
Dr Jay leans back in his chair before admitting that those moments make him a "bit grumpy and cynical. So yes, they can be a downer as well as an upper. But mostly it’s an upper."
When not in the op theatre, Dr Jay relaxes by watching movies, playing video games and the Playstation or going for a long run. "I listen to history podcasts or music while running – nothing to do with medicine," he says. "I really like history – trying to learn from the mistakes of the past… and see if you can do better in the future."
Another pastime is reading and watching TV or movies. "I binge-watch or binge read," he says with a laugh. "I recently read Hilary Mantel’s three-part Wolf Hall series in about two weeks."
"We’re in," I say, feeling the tell-tale change in resistance as the tube goes in from the ‘school blancmange’ bit of the brain into the water of the ventricle (the central cavity).
"Heart rate rising," the anaesthetist confirms, "blood pressure dropping." His face is as elated as mine.
Then smiles fade. Our crash-bang-wallop-style procedure has saved her life — for now.
Once she became stronger, we would have to look at the ongoing cause behind this crisis.
But that was for another day. "Now," I say, "it’s time to meet the parents."
How the book came together
Since the time he was a junior trainee, Dr Jay Jayamohan would keep a diary of unusual patients and interesting things that occurred in the operation theatre. "It was mainly so I could look back and learn from the last one – a memory jog, if you like," he says.
That came in handy when he sat down with the writer, Jeff Hudson, and narrated cases. Four to six hours every day for over six days, he would pour out incidents and cases to Jeff sharing what went on in his mind before, during and after surgeries while the writer recorded it all before putting it together as text.
Is there another book on the table?
"I don’t think so," he says. "I like to try everything… we did a TV series, then a book. Maybe I’ll try something else. There’s really plenty to do."
The 2021 Emirates Airline Festival of Literature is spread over three venues and three weekends from January 29 to February 13.
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