The Knife’s Edge
The Knife’s Edge
Stephen Westaby
An intimate and compelling exploration into the unique psyche of the heart surgeon, by one of the profession’s most eminent figures.Although Professor Stephen Westaby was born with the necessary coordination and manual dexterity, it was a head trauma sustained during university that gifted him the qualities of an exceptional heart surgeon: qualities that are frequently associated with psychopathy. His thirty-five-year career has been characterised by fearlessness and ruthless ambition; leaving empathy at the hospital door as thousands of patients put their lives in his hands.For heart surgeons, the inevitable cost of failure is death and in The Knife’s Edge, Westaby reflects on the unique mindset of those who are drawn to this exhilarating and often tragic profession. We discover the pioneers who grasped opportunities and took chances to drive innovation and save lives. Often difficult, uninhibited and fearless, theirs is a field constantly threatened by the risk of public failure.Like those before him, Westaby refuses to draw the line in his search of a lifetime solution to problems of the heart. His determination is unerring – a steadfastness underpinned by his unusual mind. But as we glimpse into the future of cardiac surgery, for all its remarkable scientific advancement, one question remains: within the confines of socialised medical healthcare systems, how can heart surgeons – individuals often hardwired with avoidance of self-doubt, a penchant for glory and a flagrant disregard for authority – truly flourish?
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copyright (#u02de273e-a631-5f22-b6be-1ce6612625a5)
Certain details, including names, places and dates, have been changed to protect privacy.
Mudlark
An imprint of HarperCollinsPublishers
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First published by Mudlark 2019
FIRST EDITION
© Stephen Westaby 2019
Cover layout design Claire Ward © HarperCollinsPublishers 2019
Cover images © Granger/Bridgeman Images (heart engraving), Shutterstock.com (scalpel)
Stephen Westaby asserts the moral right to be identified as the author of this work
A catalogue record of this book is available from the British Library
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Source ISBN: 9780008285777
Ebook Edition: April 2019 ISBN: 9780008285807
Version: 2019-04-17
dedication (#u02de273e-a631-5f22-b6be-1ce6612625a5)
For Sarah, who saved me from myself, together with Gemma and Mark, then Alice and Chloe, the children and grandchildren who give me so much pleasure.
contents
1 Cover (#u9a74612b-e8d6-5914-a31a-938f2131c790)
2 Title Page
3 Copyright
4 Dedication
5 Contents (#u02de273e-a631-5f22-b6be-1ce6612625a5)
6 Preface
7 Introduction
8 1 Family
9 2 Sadness
10 3 Risk
11 4 Hubris
12 5 Perfectionism
13 6 Joy
14 7 Danger
15 8 Pressure
16 9 Hope
17 10 Resilience
18 11 Misery
19 12 Fear
20 Acknowledgements
21 Glossary
22 By the Same Author
23 About the Publisher
LandmarksCover (#u9a74612b-e8d6-5914-a31a-938f2131c790)FrontmatterStart of ContentBackmatter
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preface (#u02de273e-a631-5f22-b6be-1ce6612625a5)
Every single heart operation risks a life. This tension between kill or cure is unique to my specialty, with no professional equivalent, and few people can live with it on a daily basis. During my formative years, to operate within the heart was seen as the last surgical frontier. Direct vision repair was considered as difficult as landing on the moon or splitting the atom. Then the heart–lung machine and the swinging sixties changed everything. Heart transplants and artificial hearts both emerged during my impressionable medical school years. When I embarked on training in the 1970s, heart surgery remained an exclusive and remote club that was exceptionally difficult to join. Yet I was eventually granted the profound privilege of being able to improve thousands of lives.
Each heart is unique in its own way. Although most operations prove straightforward and uneventful, some evolve into an extraordinary battle for survival and a few are quite literally a bloody disaster. As my experience and knowledge increased, I became a last port of call for the cardiologically destitute, a depository for cases that no one else wanted, at home and abroad. Ultimately I lost patients whom I knew could be saved with equipment we were denied in the NHS. The recriminations that accompany death soon followed. An agonising interview with the bereaved, dismal discussions at the ‘Morbidity and Mortality Meeting,’ then a joyless visit to the coroner’s court. I was vehemently outspoken about the system’s deficiencies, and suffered as a result. The NHS doesn’t care for those who do not conform.
In this book I have set out to describe how it felt to be a heart surgeon as the specialty emerged and what it is like in the current hostile environment. I have depicted the physical and the psychological endeavour, the emotional highs and lows, the triumphs and the disappointments, and how being a surgeon affected me and my loved ones. When I was a young man, as we shall see, a peculiar quirk of fate helped me by dispelling my inhibitions and rendering me immune to fear. It’s not something I would freely recommend and it was a curious launchpad for a career at the sharp end, one that enabled me to embrace challenges that others would wish to avoid.
For someone who is not a professional writer, it takes an inordinate amount of time and effort to write a book for public consumption. You will undoubtedly conclude that I was more the surgeon than the literary genius, yet to my delight my first book, Fragile Lives, became an award-winning bestseller. As the title suggests, the book largely focused on remarkable cases. The Knife’s Edge is darker. It describes my humble beginnings, my struggle to succeed, and my priceless relationships with some of the pioneers and great leaders of the specialty. Because of the huge risks involved and the pile of bodies that ensued, the pioneers all manifested a particular personality type – bold, determined, often flamboyant, with resilience and immunity to grief. Sadly, so taxing is the lifestyle that by the end of my career few UK graduates were prepared to make it their calling and career. The ‘end of an era’, or the ‘end of the beginning’ as some would put it.
The whole riveting story of modern heart surgery evolved during my lifetime, and I was proud to be part of it.
introduction (#u02de273e-a631-5f22-b6be-1ce6612625a5)
Just weeks after my surgical career came to an end I was invited to present the prizes at a local school speech day. The headmistress urged me to treat the teenagers as adults, and suggested that I convey to them what personal qualities I possessed that enabled me to become a cardiac surgeon. By this stage I had a stock response: ‘To study medicine,’ I said to the assembled schoolchildren, ‘demands an unstinting work ethic and great determination. Then it requires more than a modicum of manual dexterity, together with supreme confidence to train as a surgeon. To aspire to become a heart surgeon and risk a patient’s life every time you operate is a step beyond. For that you need the courage to fail.’
This last phrase wasn’t original – it was regularly used to describe the heart surgery pioneers in the era when more patients died than survived – but the kids didn’t know that. I decided to omit the claim that gender, social class, colour and creed played no part, because I really didn’t believe it myself. Nor did I regard myself as possessing all the qualities I talked about. I was more of an artist. My fingertips and brain were connected.
After rewarding the school swats, I started nonchalantly answering questions about my achievements in Oxford. With considerable insight, one biology boffin asked how it’s possible to operate inside an organ that pumps five litres of blood every minute and whether the brain dies if the heart stops. Another wanted to know how to get to the heart when it’s surrounded by ribs, breast-bone and spine. Then the art teacher asked what causes blue babies, as if someone paints them blue.
Coming to the end of the session, a bespectacled little girl with pigtails raised her hand. Standing up like a poppy in a cornfield, she boomed out, ‘Sir, how many of your patients died?’
So loud was her earnest approach that there was no way I could pretend not to hear. One set of parents tried to disappear under the floorboards while the flustered headmistress began explaining that it was time for the honoured guest to now leave. But I couldn’t ignore this inquisitive individual in front of her friends. I considered the question for a moment, then had to confess: ‘I really don’t know the answer to that. More than most soldiers but fewer than a bomber pilot, I guess.’ At least fewer than Enola Gay over Hiroshima, I thought to myself cynically.
Quick as a flash, Miss Curiosity probed again. ‘Can you remember them all? Did they make you sad?’
Another brief moment of deliberation. Could I admit to a hall full of parents, teachers and schoolchildren that I had no idea exactly how many patients I had dispatched, let alone recall their names. I could only muster one response: ‘Yes, every death upset me.’ I waited to be struck down with a thunderbolt but mercifully that was the end of our brief dialogue.
It was only after I stopped being an inadvertent serial killer that I began to remember patients as people, rather than simply recalling mortality statistics and the many times I went along to autopsies or coroner’s courts. And there were deaths that haunted me, not least the young people who succumbed needlessly to heart failure. Those who were not accepted for transplantation but who could have been saved with the new circulatory support devices that our NHS declined to pay for.
In the 1970s one in five of my boss’s cases at the Brompton Hospital died after surgery. As a cocky trainee I would greet each patient, record their medical history, then listen to their fears and expectations about the upcoming operation. Most were severely symptomatic, having waited months to come to the famous hospital in London. It didn’t take long for me to predict the ones who wouldn’t make it, usually the ones with rheumatic valve disease who arrived in a wheelchair and could barely speak on account of their breathlessness. Breathlessness is uniquely terrifying, likened by the patient to drowning or suffocation. They didn’t die because of poor needlework. They simply couldn’t tolerate their time on the heart–lung machine or the poor protection afforded to heart muscle during surgery in those days. We all knew that the slower the surgeon, the more likely the patient was to die. We would take bets on it. ‘If X does the valve replacement he stands a chance. But he’s buggered with Y.’
That was the way it used to be in the NHS. Treatment was free, so the punters didn’t question what was on offer. Life or death followed from the toss of the dice. But the finality of death was still devastating. The consultants would shield themselves from all the misery by dispatching us juniors to talk with the family.
I seldom had to speak. The bereaved relatives would recognise the slow walk with dropped shoulders and head down as I approached. They could read my unequivocal ‘bad news’ expression. After the reflex indrawing of breath came shock, my words ‘Sorry’ and ‘Didn’t make it’ triggering emotional disintegration. The sudden relief of suspense and the subsequent crushing grief were often followed by dignified resignation, but sometimes by abject denial or frank meltdown. I’ve had hysterical demands for me to return to theatre and resurrect the corpse, to resume cardiac massage or put the body back on the bypass machine. It was particularly heart-breaking for the parents of young children, little ones who had just developed their own innocent personality. As I saw it, newborn babies just screamed and pooed, but toddlers were well on their way to becoming people. They walked in holding Mummy’s hand and clutching their teddy bears, which all too often were carried off with them to the mortuary fridge. Yet the minute I turned and walked away from these families, my sorrow was filed in the out tray. Eventually, when I started to lose my own patients, I became well used to it.
Only once did it strike me that I had murdered someone, and the grim circumstances came as a shocking and bloody reminder that I was not invincible. It was a third-time operation on the mitral valve of a middle-aged patient who had a huge heart on the chest X-ray and excessively high pressures in the right ventricle situated directly below the breast-bone. I always took precautions when reopening the chest after previous surgery, and had started to request a CT scan to determine the gap between bone and heart. This led to me being admonished for adding to the costs of my many reoperations – only committees were allowed to sanction additional expense. The gentleman’s anxious partner accompanied him to the anaesthetic room and I urged her not to worry. I told her I was very experienced and would take good care of him.
‘That’s why we came to you,’ she replied, her voice quivering with apprehension. She kissed his forehead and slipped out.
I drew the knife along the old scar and used the electrocautery to singe the outer table of the sternum. The wire cutter snipped the steel wires from the second operation, which I then tore out with heavy grasping forceps. It was just like pulling teeth – should they break, it makes life difficult. The oscillating saw screeched against them as if screaming, ‘I’m not designed to cut steel.’ Then came the tricky bit, which involved edging my way through the full thickness of bone with a powerful saw designed not to lacerate the soft tissues beneath. I had safely reopened the sternum for hundreds of reoperations, but this time there was a great ‘whoosh’. Dark blue blood hosed out through the slit in the bone, poured down my gown, splashed onto my clogs and streamed across the floor.
I let out a chain of expletives. While I pressed hard over the incision to slow the bleeding, I instructed my jelly-legged assistant to cannulate the blood vessels in the groin so we could get onto the bypass machine. As the anaesthetist frantically squeezed in bags of donor blood through the drips in the neck, it all went dreadfully wrong. The cannula dissected the layers of the main leg artery so we couldn’t establish any flow. With continued profuse haemorrhage, I had no alternative but to prise open the rigid bone edges and attempt to gain access to the bleeding beneath, forcing a small retractor through the bony incision and cranking it open. But there was no gap between the underside of the bone and heart muscle. The cavernous, thin-walled right ventricle had been plastered by inflammatory adhesions to the bone by a previous wound infection. So I found myself ripping the heart asunder and staring at the underside of the tricuspid valve. Both the hand-held suckers, then the heart itself filled with air as I fought for better access. I then found that this tissue-friendly saw had also transected the right coronary artery. My paralysed registrar simply gaped, as if to say, ‘How the fuck are you going to get out of this mess?’
There was nothing I could do in time to save him. Deprived of oxygen, the heart soon fibrillated, so at best – had I persisted – he would have suffered devastating brain injury. So I called time on the gruesome spectacle. The whole shambles had taken less than ten minutes. Apologising to the nurses who had to lay him out and clean the floor, I tossed away my gloves and mask in disgust. The whole bloody catastrophe was straight out of Saw II or Driller Killer. It felt as if I had driven a bayonet into the man’s heart and twisted the blade. Then, just as had been done to me during my formative years, I dispatched the registrar to talk to the man’s wife while I went off to the pub.
I didn’t see the poor lady again until the inquest, where she sat unaccompanied, listening intently. She bore no malice, nor was the coroner critical in any way. The gruesome fact was that I had unintentionally sawn open that heart and emptied the circulation onto my clogs. In my own mind, I knew that a CT scan would have prompted me to cannulate the man’s leg vessels myself, which could have averted the tragedy and was something that I always did after that. Undeterred, I reopened a sternum for the fifth time in front of television cameras just weeks later.
Most deaths in surgery are wholly impersonal. The patient is either covered in drapes on the operating table or obscured by the grim paraphernalia of the intensive care unit. As a result, my most haunting experiences of death stemmed from trauma cases. The sudden, unexpected process of injury pitches an unsuspecting individual into their own Dante’s Inferno. Knife and bullet injuries were predictable and easy for me. Cut open the chest, find the haemorrhage, sew up the bleeding points, then refill the circulation with blood – such cases always provoked an adrenaline rush, but usually involved young, healthy tissues to repair.
My own worst nightmare wasn’t caused by a gun or a knife. As a young consultant I was once fast-bleeped to the emergency department to help with an incoming road accident. It was still what was called the ‘swoop, scoop and run’ era, so the patient was being brought in directly without transfusion of cold fluid to screw up the blood clotting. With foresight and sensitivity, the police had already warned reception what to expect, but unfortunately I’d not been party to that. I was outside in the ambulance bays enjoying the sunshine when the vehicle came thundering up the drive, siren blaring and blue lights flashing. When the rear doors were thrown open, the crew wanted a doctor to take a look before they risked moving the patient again.
I could hear the whimpering before I could see the girl, but I knew from the paramedic’s grim expression that it was something unpleasant. Unusually awful, in fact. The teenage motorcyclist was lying on her left side, covered by a blood-soaked white sheet. This sheet and what I could see of her face were the same colour. The poor girl had been drained of blood. Normally she would have been shunted quickly through to the resuscitation room, but there was every reason not to rush.
The paramedics quietly and deliberately drew back the sheet so I could see that the girl was transfixed by a fence post. A witness had watched her motorcycle swerve to avoid a deer, then she veered off the road, smashing through a fence into a field. She was left skewered like meat on a kebab stick. The fire brigade eventually released her by sawing through the fence and lifting her free. This left the stake protruding from her blood-soaked blouse. The response of the gathering team was to glare incongruously at the gruesome transfixion and ignore that horrified face behind the oxygen mask.
I took her cold, clammy hand more in clinical assessment than humanity. She was in circulatory shock, not to mention profound mental turmoil. Her pulse rate was around 120 beats per minute, but the fact that I could feel it suggested that her blood pressure was still above 50 mm Hg. Before we moved her I needed to scrutinise the anatomical features of the injury so as to predict what damage we would be confronted with. I had seen several cases of transfixion trauma where the patient survived because the implement narrowly missed or pushed aside all the vital organs. Here the degree of shock indicated otherwise. It was time to get some cannulas in place in a calm and controlled manner, and bring group O negative blood ready to transfuse her. And for pity’s sake, she deserved a slug of morphine to take the edge off the sheer terror of her predicament.
Some things I knew instinctively. Had the stake damaged the heart or aorta she would have bled out at the scene. Traumatised small arteries will go into spasm, clot and stop the bleeding themselves as long as injudicious clear fluid infusion doesn’t raise the blood pressure and blow the clots off. So I surmised that most of the bleeding must be coming from the veins, which do not constrict. I asked the nurses for some scissors to remove her clothing, now stiff with dried blood. It was like cutting through cardboard and opening a window on the grim reality of her situation.
Her pleading brown eyes remained firmly fixated on the stake. I could make out the jagged ends of ribs protruding through macerated fat and pale, bruised skin. The post had entered directly below her right breast, marginally to the right of the midline, and emerged from her body higher up in her back, suggesting that she had slid feet first after tumbling from her motorcycle. My three-dimensional anatomical knowledge left me in no doubt which structures had been damaged. The post must have taken out her diaphragm and liver, the lower lobe of her right lung and probably the largest vein in the body, the inferior vena cava. The lung wasn’t a problem. But if her liver was pulped and the veins torn off the cava, I knew that we couldn’t fix her. Scrutiny of the post protruding from her back confirmed my fears – there were fragments of both liver and lung on the wooden shards. Everyone knows what liver looks like from the butcher’s, while youthful lung is pink and spongy. I recognised both, and it made me sad.
In just seconds on a Saturday morning she had gone from vivacious carefree student to dying swan transfixed like a vampire. With every agonising breath, blood slopped from the wound edges. Whatever the way forward, I had to talk to her. I edged around the trolley and knelt by her head to distract her as the emergency doctors painfully probed with needles to locate an empty vein. With blood and froth dripping from her mouth, she was finding it difficult to breathe, let alone speak. We needed to put her to sleep right there in the ambulance, then get a tube into her windpipe – a seemingly impossible task in that awkward position. By now I was pretty sure that whatever we did she would die. If not soon, it would be in days or weeks as a result of infection and organ failure in the intensive care unit. So whatever else we attempted to do for her, we had to be kind. Do as little as possible to add to her pain.
Staring directly into her eyes I asked her name. I was simply trying to inject a semblance of humanity into the proceedings and relieve the brutality of it all. Stuttering between breaths, she told me she was a law student, like my own daughter Gemma, which added to my discomfort. I took her icy cold fingers in my right hand and rested my left hand on her hair, hoping to obscure that stake from her gaze.
With tears streaming down her cheeks she murmured, ‘I’m going to die, aren’t I?’
At that point I ceased being the surgeon because I knew she was right. For her last agonising moments on earth I could only comfort her. So I would be her substitute dad for that time. I held her head and told her what she wanted to hear. That we would put her to sleep now and when she awoke everything would be back in its place. The stake would be gone. The pain and fear would be gone. Her shoulders dropped and she felt less tense.
The gadget clipped onto her index finger showed very low oxygen saturation, so we had to move her to give the anaesthetist his chance with the endotracheal tube. Only then could we begin a token effort at resuscitation. I extended my hand to feel her belly, which was distended and tense. As we explained the need to move her, I could sense her consciousness fading.
She whispered, ‘Can you tell mum and dad that I love them, and I’m sorry? They never did want me to have that bike.’
Then she coughed up a plug of blood clot. As she rolled backwards the stake shifted, grating audibly against her shattered ribs. Her eyes rolled towards heaven and she slipped away. Whatever blood she had left in her circulation was pouring out over me. But I didn’t mind. It was a privilege to be there with her. The junior doctors from the resuscitation room stirred, intending to begin cardiac massage. Without hesitation I told them to back off. What the fuck did they expect to achieve?
The back of the ambulance fell silent with the horror of it all. I would have loved to have dragged that hideous fence post out of her chest – that had to be left to the pathologists. I couldn’t bring myself to watch her autopsy, but it confirmed that her diaphragm had been torn away and her pulped liver avulsed from the inferior vena cava.
That balmy summer’s evening I went walking through the bluebell woods of Bladon Heath with Monty, my jet black flat-coated retriever. While he chased rabbits, I sat on a fallen tree carpeted in moss and wondered if there was a God. Where was he on those fraught occasions when I needed some divine intervention? Where was he today when that poor girl tried to avoid hurting a deer and was killed by her kindness? I visualised her devastated parents sitting with a cold corpse in the mortuary, holding their daughter as I’d done in the ambulance, beseeching God to turn the clock back.
There was no point trying to be logical about religion. I knew that high-ranking Oxford – and indeed Cambridge – academics scoffed at the deity concept. Both Richard Dawkins and Stephen Hawking had that gold-plated atheistic confidence in their own abilities, spurning outside help. I guess I was the same. But I would still sneak into the back of a college auditorium and listen to debates on the subject. Some disputed God’s existence because of all the evil and misery in the world, and while I could identify with that, I had contrary and privileged insight through the odd patient who actually claimed to have reached the Pearly Gates before we clawed them back.
These vivid out-of-body experiences were rare but occasionally compelling. One spiritual lady described floating calmly on the ceiling as she watched me pumping her heart with my fist through an open chest. Forty minutes into this internal cardiac massage my thumb tore through into her right ventricle – she clearly recalled my words: ‘Oh shit, we’ve had it now.’ Fortunately, the perfusionists arrived with the circulatory support system I needed to keep her alive, and I succeeded in repairing the hole.
She uncannily related her memory of the events a number of weeks later in the clinic. Having been party to her own resuscitation attempts from above, she had floated through the clouds to meet with St Peter. This journey amid peace and tranquillity contrasted sharply with our gruesome efforts back down on the ground. But having arrived in heaven she was told she had to return to earth and wait her turn again – a ridiculously close-run thing between me and Grim Reaper. Perhaps God changed as he got older. Maybe he started out with the best of intentions but became cynical and less caring with time. Just like the NHS.
It was only after retiring from surgery that I began to reflect on my role in dispatching so many to that great hospital in the sky. One tranquil spot on the heath still holds a great deal of significance for me. It is a haunted place, a gap in the woodland that overlooks both Blenheim Palace, where my hero Winston Churchill was born, and St Martin’s Church, Bladon, where he is buried. A few yards from this clearing a jet plane that had just taken off from Oxford Airport crashed and exploded.
My son Mark was working for exams in his bedroom and watched the whole spectacle unfold. Heroically, he was the first to reach the drama in the field but could do nothing amid the conflagration. He watched the cockpit burn and cremate the occupants. Obviously at seventeen he had a different constitution to his lobotomised father, so the dismal spectacle disturbed him as it might any normal person. After dropping a single grade in biology he was dumped by his chosen university. I was very bitter about that. I still am.
One day when we reached this sacred ground, Monty spotted a stag silhouetted against the evening sky a hundred or so yards up the ride. A shaft of evening sunlight shone through the trees to illuminate a clump of fading bluebells, their heads dipping at the end of their season. Was that majestic stag in fact God looking down on me, surrounded by the spirits I had set free during my career, the ghosts of operations past?
In truth, I had always been a loner. I was still a restless insomniac who would wake in the early hours and write, making stupid notes on material I would never use, continuing to invent impossible operations that no one would ever perform. Did I miss surgery? Not at all, surprisingly enough. Forty years had been plenty. But it remained a great mystery to me how I had achieved so much from my humble beginnings in the backstreets of a northern steel town. Perhaps it was that battle to escape obscurity that provided the momentum. I wanted to be different, and I had the ruthless ambition to take on the system and overcome my past.
Although I spent my whole career writing textbooks and scientific papers for the profession, I reflected for many years on whether it was appropriate to discuss my battles in a public forum. Ironically it was my own patients who urged me to do so, even the loved ones of some who died. So many were eager for their stories to be told. From my own perspective, I always found the history of modern heart surgery to be among the most compelling stories ever told. As a trainee in London and the US I actually knew a number of the pioneers personally, and they had shared their own trials and tribulations with me face to face, encouraging me to make a difference, not to sit in the shadows avoiding conflict. And I certainly attracted trouble right from the start.
The government’s policy of releasing named-surgeon death rates to the press was another factor that edged me towards writing a tome for consumption by the general public. What is life really like on the other side of the fence? Is it different from being a statistician, politician or a journalist? The barrister and medical ethicist Daniel Sokol wrote in the British Medical Journal, ‘The public has an appetite for glimpses of the private lives and thoughts of doctors. They demystify a profession that was once deemed blessed with magical powers.’ Perhaps some of us still do have mystical powers. There are few things more intriguing than delivering electricity into a patient’s head through a metal plug screwed into their skull like Dr Frankenstein’s monster or reinventing human circulation with continuous blood flow without a pulse. These innovations may be construed as witchcraft, but they were my own practical solutions to the terrible illness that is heart failure. Sokol went on to say that doctors are in the habit of revealing ‘not the chiselled frame of Apollo … but the wart covered body of Mr Burns, the Simpsons character’. But Burns was the rich factory owner. I’m more of a sensitive intellectual, like Bart Simpson’s father Homer.
As is often the case, the French have a phrase for it: ‘se mettre à nu’, to get naked. So that is what I decided to do, although this was a much more interesting spectacle in my younger years than now. My own insight tells me that the public are happier to learn that their surgeon, even a heart or brain surgeon, is human and subject to the same core emotions as anyone else. But because of a freak sporting accident, some qualities possessed by the vast majority of people were lost to me for a while, which proved an unexpected but substantial boost to a career at the sharp end – life perpetually on the ‘knife’s edge’.
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family (#u02de273e-a631-5f22-b6be-1ce6612625a5)
When I searched the internet for a contemporary description of the surgical personality, I found this:
Testosterone-infused swagger, confident, brash, charismatic, commanding. Arrogant, volatile, even bullying and abusive. Aggressive. Cuts first, asks questions later, because to cut is to cure and the best cure is cold steel. Sometimes wrong but never in doubt. Good with his hands but no time to explain. Compassion and communication are for sissies.
The psychologist author argued that the highly stressful, adrenaline-fuelled environment in which surgeons work attracts a certain personality type. And so it does. Cutting into people, then wallowing in blood, bile, shit, pus or bone dust is such an alien pastime for normal folk that the mere process of operating immediately sets us apart. Those with introspection and self-doubt select themselves out from my specialty.
It is hard to describe how agonisingly difficult it was to gain access to a cardiac surgery training programme in the 1970s, when open heart surgery with the heart–lung machine was only in its second decade. The surgeons of that era were an unashamedly elitist group with the guts, skill and sheer daring to expose a sick heart and attempt to repair it. Methods to protect the muscle when it was starved of blood were frequently inadequate, and prolonged interaction between blood and the foreign surfaces of the bypass machine triggered a damaging inflammatory reaction known as the ‘post-perfusion syndrome’. Heart surgeons therefore needed above all to work against the clock – deaths were a daily occurrence, yet most patients were so sick that this wasn’t considered a catastrophe. While survival and symptomatic relief were gratifying, death put an end to suffering. Consequently, most families were grateful that their loved ones had at least a chance of their condition improving through surgical intervention.
We all had to go through general surgery training first to show that we had what it takes. First, good hands – and you have to be born that way. Most organs just sit there while you cut and sew them, but the heart is a moving target, a bag of blood under pressure that bleeds torrentially if you bugger it up. Just touching it clumsily can provoke disorganised rhythm and sudden cardiac arrest. Second, the right temperament – the ability to explain death to grieving relatives and to bounce back from a bollocking in the operating theatre. Then courage – the bravery to take over from the boss when he’s had enough, the guts to take responsibility for the post-operative care of tiny babies or to address a catastrophe in the trauma room when the nearest consultant is an hour away. Then patience and resilience – being able to stand there as first assistant for six hours without losing concentration, sometimes with a hangover, or to face five days continuously on call in the hospital, day and night without respite. That was surgical training in those days.
A series of infernal exams to become a fellow of the Royal College of Surgeons was an additional burden over and above the clinical work. These covered every aspect of surgery and only a third of the candidates passed each time. It didn’t matter that I wanted to operate in the chest. For the ‘primary’ fellowship we were required to know the anatomy of a human being in minute detail, brain to asshole, teeth to tits – every nerve, artery and vein in the whole body, where they went, what they did, what happened if we damaged them. We had to learn the physiological processes of every organ and the biochemistry of every cell. After some basic operative experience, the ‘final’ fellowship examined us on the pathology of every surgical condition in the book, then the diagnostic and surgical techniques for each specialty. Only after conclusively demonstrating comprehensive knowledge and skills were we allowed to move on and specialise. I failed both the primary and final fellowship on first sitting, an expensive exercise. Most of my associates did too. The whole miserable process was there to sort the wheat from the chaff, and I wasn’t fazed by failure. It was just like rugby, the sport I loved above all others. Some games you won, others you lost.
The surgical world resembles the army. The consultants are the officers and the gentlemen, the trainees line up in tiers through the ranks: senior house officer is equivalent to corporal, registrar acting as sergeant, senior registrar akin to a non-commissioned officer doing all the work and eventually being promoted to the officer’s mess. That final step was the most competitive of all. For the ruthlessly ambitious it had to be a top teaching hospital. Heart surgeons strove for London hospitals like the Royal Brompton, the Hammersmith, Guy’s or St Thomas’. Appointment to one of these, and you had made it big time. In those days Cambridge had a vibrant cardiothoracic centre in Papworth village out of town. Oxford was doing very little.
All this took place during our formative years, our late twenties and early thirties, when normal people cement relationships, settle down in one location and start a family. Trainee surgeons lived like gypsies, moving from city to city – wherever the best posts were advertised. Something about being a surgeon elevated us to a different plane. We were the fighting cocks of the doctors’ mess, the flash Harrys who constantly strove to outdo each other and ruthlessly coveted the top jobs; the guys – and at that time, as now, it was almost exclusively guys – who stayed in the hospital night after night seeking every chance to operate, or, if it was quiet, drifting across to the nurses’ quarters, where other exciting action was easy to find.
I was a backstreet kid from Scunthorpe who had married his childhood sweetheart from the local grammar school. Caught up in this whirlwind of ruthless ambition, things changed and marriage became an unintended casualty. I was ashamed of this, but I knew some surgical teams where every member, from junior houseman to consultant, was having an affair in the hospital. Grim in reality, but the stuff of television soaps that glamorise adultery. So widespread was the problem that the Johns Hopkins Hospital in Baltimore carried out a formal study of divorce as an occupational hazard in medicine. The younger their residents were when they married, the higher their divorce rate. Understandably, divorce was commonplace when the spouse did not work in the medical field. Blame it on the communication gap. They had little to talk about because doctors – and especially surgeons – are engrossed in their hospital life.
The Johns Hopkins study showed that more than half of psychiatrists and one in three surgeons divorced. Cardiac surgery had an impressive divorce rate, which I already knew from my colleagues’ experience. Reasons cited were high testosterone levels, long hours and nights in the hospital, and close working relationships with numerous attractive young women, often in stressful and emotional circumstances. Professional bonds are formed, and these evolve into romance. At one stage the Dean of Duke University Medical School saw fit to warn applicants that the institution was experiencing a greater than 100 per cent divorce rate. Why exceeding the maximum? Because students showed up already married, got divorced, then remarried and divorced a second time. They all lived a life in which work was seen to come first, with everything else a distant second.
Once at a conference in California I picked up a copy of Pacific Standard magazine that contained an article entitled ‘Why are so many surgeons assholes?’. Obviously it was about prevailing personality types. A scrub nurse friend of the journalist described an incident in the operating theatre where she had passed the sharp scalpel to the surgeon and he lacerated his thumb on the blade. Now furious, he shouted at her, ‘What kind of pass was that. What are we, two kids in the playground with Play-Doh? Ridiculous.’ Then to emphasise his point he threw the scalpel back at her. The nurse was horrified, but as she didn’t know how to react she just kept quiet. No one stood up for her, and no one ever reprimanded the surgeon for being aggressive or throwing the sharp instrument. The inference was that this is how a lot of surgeons behaved and they get away with it all the time.
I have known many surgeons who threw instruments around the room, and although I never aimed one at an assistant I did use to toss faulty instruments onto the floor. It meant that I couldn’t be given them a second time. Having said that, most successful surgeons have certain malign traits in common. These have been summarised in the medical literature as the ‘dark triad’ of psychopathy, Machiavellianism – the callous attitude in which the ends are held to justify the means – and narcissism, which manifests as the excessive self-absorption and sense of superiority that goes with egoism and an extreme need for attention from others. This dark triad emanates from placing personal goals and self-interest above the needs of other people.
Just in the last few months psychologists at the University of Copenhagen have shown that if a person manifests just one of these dark personality traits, they probably have them all simmering below the surface, including so-called moral disengagement and entitlement, which enables someone to throw surgical instruments with absolutely no conscience at all. This detailed mapping of the dark triad is comparable to Charles Spearman’s demonstration a hundred years ago that people who score highly in one type of intelligence test are likely to perform equally well in other kinds. Perhaps the daunting road to a surgical career inadvertently selects characters with these negative traits. It certainly appears that way, yet I had a very different side to my personality when it came to my own family. Maritally I fell into the same old traps, but I would go to any lengths to make my children happy or my parents proud.
I was not rostered to be in surgery as it was my daughter Gemma’s birthday and I hoped to be free. The phantom father who had let her down so many times in the past, I planned to drive to Cambridge in the afternoon to surprise her. Then I discovered that three of our five surgeons were out of town. Two were committed to outreach clinics at district hospitals trying to bring in ‘customers’, as the NHS now called them, or better still the odd private patient. The third was away at a conference, one of those academically destitute commercial meetings at a glamorous resort paid for by the sponsor, with business-class flights and all the rest. As a gullible young consultant I had enjoyed these trips, but it eventually wears thin – tedious airports, buckets of alcohol and forced comradery with competitive colleagues who would cheerfully drive their scalpel into your back the minute it was all over.
It was this surgeon’s operating list that lay vacant, and the unit manager had twisted my arm to stand in for him. To let an operating theatre with a full complement of staff lie idle for the day was a criminal waste of resources, so I reluctantly agreed to the request. I had built this unit from nothing to being virtually the largest in the country, not that anyone could give a shit. The management changed so frequently that history was soon forgotten, dispatched to oblivion by the quagmire of financial expediency. So my daughter would have to wait. Again.
When I asked Sue, my secretary, to find two urgent waiting-list patients at short notice, I didn’t mention the birthday. Just two cases should see me on the road by mid-afternoon. I suggested that one should be the infant girl with Down’s syndrome who had been cancelled twice before. She was in danger of becoming inoperable because of excessive blood flow and rising pressure in the artery to the lungs. I bore special affection for these children. When I started out in cardiac surgery, many considered it inappropriate to repair their heart defects. I couldn’t get my head around a policy that discriminated against kids with a particular condition, so ultimately I overcompensated by taking them on as desperately debilitated young adults – trying to turn the clock back, sometimes without success.
The second case needed to be more straightforward. Sue had repeatedly been pestered by a self-styled VIP who held some snooty position in a neighbouring health authority. When I reviewed this lady in the outpatient clinic, she took exception to my suggesting that weight loss would not only improve her breathlessness but reduce the risks during her mitral valve surgery. I was sternly reminded that she had featured in a recent honours list, presumably for services dedicated to getting her onto an honours list, as is frequently the case in healthcare. I wasn’t in the slightest bit impressed – and she could see that. But she kept insisting on an early date and I couldn’t blame Sue for wanting her out of the way. The titled lady wouldn’t make first slot on the list, however. That was for the baby. A third cancellation was not an option.
6 am. As I set out for work from Woodstock, my home in Oxfordshire, shafts of sunlight burst through the turrets of Blenheim Palace like rays of optimism. I would be seeing Gemma on her birthday. When she was born I was nowhere to be found, and I’d spent twenty years trying to make up for that. Sue, who also suffers from traffic phobia, joined me in the office before 7 am, and we soon dispensed with the paperwork that I had to do before the adult intensive care ward round at 7.30. The day’s operating lists were already displayed on a white board at the main nurse’s station. The male charge nurse knew that my only adult patient was unlikely to reach the unit until mid-afternoon, but still felt obliged to warn me that beds were tight. Glancing towards the row of empty beds surrounded by unplugged ventilators and cardiac monitors, I didn’t need to ask. It was more of the same. ‘Tight on beds’ means not enough nurses. In the NHS, every intensive care bed must have a dedicated nurse. In other countries they double up quite safely to get the work done, but here we just cancel operations as if they were appointments with the hairdresser.
On this particular morning I didn’t know many of the nurses’ faces – and they didn’t recognise me. This told me that the night shift had relied heavily on agency staff. Two of my three cases from the previous day could leave the unit, but only when ward beds became available. Until then, they would continue to languish in this intimidating environment that never slept, at a cost exceeding £1,000 per day. Sometimes we’d even discharge patients directly home from intensive care when the ward was chronically blocked with the elderly and the destitute.
This was not how it used to be. >When we fought to build the department, just three heart surgeons would perform 1,500 heart operations each year and we’d cover the chest surgery between us. Now in the same modest facilities we had five heart surgeons performing half that number of cases, alongside another three chest surgeons operating on the lungs. This was the price of progress – twice as many highly trained professionals doing much less work amid a disintegrating infrastructure. But hey. A hospital delegation was trying to recruit nurses in the Philippines that very week, so all would be well one day.
8 am – and my early-morning optimism was already punctured. I left the cacophony of life support, pulsating balloon pumps, hissing ventilators and screeching alarms. I heard weeping relatives, suggesting that a bed might soon be vacated. Knife to skin should be at 8.30, and I expected the baby to be anaesthetised by now. I assiduously avoided watching parents part from their children at the operating theatre doors. It was traumatic enough for me when my son had his tonsils out. Heart operations were a cut above. When I told parents that their child had a 95 per cent chance of survival, all that registered was the 5 per cent possibility of death. Statistics don’t help when it’s your child that doesn’t make it. So I told them what they wanted to hear, then hoped it would be true.
But the anaesthetic room was empty. The anaesthetist was sitting in the coffee room eating breakfast.
‘Have we sent yet?’ I asked with an air of resignation.
She shook her head. We had to wait for the paediatric intensive care ward round to decide whether they could give us a bed. No bed, third cancellation. It couldn’t be allowed to happen, yet the round hadn’t even started. It was an 8.30 start at the other end of the corridor, so I went there directly. With rising blood pressure, I still tried to remain polite. The staff had desperately sick children to care for and my little patient was just another anonymous name in the diary, followed by the words ‘atrioventricular canal’. The whole centre of her heart was missing and her lungs were flooded. With every day that passed, her chances of survival decreased.
The trouble was that I loved the children’s intensive care unit. That little enclave of rooms was my escape from the rest of the hospital, a place that always put life – and my own troubles – in perspective. Only special people could survive the heartache in that place. The nurses liked to work with my heart surgery cases because the vast majority got better, a welcome relief from the ravages of children’s cancer, septicaemia or road-traffic accidents that they also had to deal with. The worst things in the world happened there, but everyone came back the next day to start all over again.
Every one of the cots had a little body in it, with fretful family groups gathered around. My eyes fixed on a pair of gangrenous arms – the meningococcal meningitis child I’d watched for weeks, hanging on to life. The mother knew me well enough by now, seeing my babies come and go with happy parents. I always asked her how things were going, she always smiled. Today they were going to amputate those black, mummified limbs. No more little hands or tiny fingers. They would just drop off, with a little help to tidy things up.
I asked whether there was any chance of a bed by lunchtime, so that we could at least send for the baby. Sister really didn’t want to let me down. One of her day-shift nurses was already in the radiology department with a head-trauma victim who’d been hit by a speeding car on the way to school. Should the injuries prove as severe as feared, ventilatory support would be withdrawn. Then my case could go to theatre. I enquired whether the organ donor phrase had been mentioned.
‘Do you want the bed or don’t you?’ she replied. ‘That route could take us well into tomorrow.’
For comfort I picked up a bacon sandwich, then wandered off in my theatre gear through the hordes who arrived for work at nine o’clock. These were normal people who didn’t have to split breast-bones, stop hearts or give desolate parents bad news, such as ‘Your child’s operation is cancelled again.’ Now the dilemma. Should I give up on the little girl, then send for the VIP and her mitral repair? The lady wouldn’t have been starved long enough or had a pre-med, but at least I could take off to Cambridge to see my daughter afterwards without the worry of leaving a newly operated infant when I wasn’t on call. Or should I hold out for the possibility of a bed for her parents’ sake?
Turning away from blank faces and the tacit acceptance of dysfunctionality, I diverted to radiology. They knew me well enough at the CT scanner and seemed relieved to discover that I was not attempting to take over their next slot. The images of the child’s battered brain emerged slice by slice. The skull had been cracked open like the top of a boiled egg. Where there should have been clear lakes of cerebrospinal fluid, there was nothing. The brain surgeon and intensive care doctors shook their heads in dismay. Nothing would be gained by operating. The cerebral cortex was pulp and the brain stem had herniated through the base of the skull. I was relieved that I couldn’t see that poor broken body concealed within the scanner. She had toddled off happily to the village school; now she hovered between earth and heaven, her brain already gone. So I had my intensive care bed. Relief for one set of parents, complete and utter desolation for another.
Striding purposefully back to the operating theatres, I requested that they send directly for my first case. The agency anaesthetic nurse hadn’t the faintest idea who I was and confronted me with the usual crap, saying that they hadn’t heard if there was a bed yet.
Uncharacteristically, and because I didn’t know the woman, I lost the plot and shouted, ‘I’m telling you there’s a fucking bed. Now send for the child.’
The anaesthetist stood in the doorway and gave me a long, hard stare. The nurse picked up the phone and called the paediatric intensive care unit sister. At that moment, I worried that others had not been informed that the trauma case was not for ventilation. But I got lucky. The response confirmed my outburst. Yes, we could send for the cardiac case.
To put the baby asleep and insert cannulas into her tiny blood vessels would take an hour, so to avoid the transmitted anxiety from the parents’ tearful separation from their baby girl, I slipped into the anaesthetic room of the thoracic theatre, carrying a plastic cup of ghastly grey coffee. This time I was warmly greeted by an old friend, whom I asked to measure my blood pressure. It was 180/100 – far too high, despite the daily blood pressure medication I had been taking for ten years.
As the fearful parents shuffled past the door I heard one of them say, ‘Please tell Professor Westaby we are grateful for this chance.’ I suspected they still didn’t believe that their baby would make it. Perhaps they were worried that we wouldn’t try as hard as we could because of the Down’s syndrome.
Would a concert pianist prepare for an important recital by first enduring three hours of intense frustration? Would a watchmaker have to face a blazing row before assembling a complicated Rolex movement? My job was to reconfigure a deformed heart the size of a walnut, yet I enjoyed zero consideration for my state of mind from those around me. I wouldn’t so much as get on a bus if the driver was subject to that much irritation. The first time I stood as the operating surgeon looking into the void at the centre of an atrioventricular canal defect, I thought, ‘Shit, what the hell do I do with this?’ Yet I always succeeded in separating the left and right sides of the heart with patches, then creating new mitral and tricuspid valves from the rudimentary valve tissue. It’s complex work, but I never lost one on the operating table.
I finally ran the stainless-steel blade through the baby’s skin at 11 am. As the first drops of blood skidded over the plastic drape, I remembered that I had not made contact with my daughter. That thought hit me just as the oscillating saw bisected the baby’s sternum, but there was nothing I could do about it now. I needed complete focus to reconfigure that tiny deformed heart and give the baby a lifetime without breathlessness or pain. So what did I need to consider? The new mitral valve must not leak, although it wouldn’t be too bad if there was a whiff of regurgitation through the tricuspid valve on the low-pressure side of the circulation. And we had to be careful not to damage the invisible electrical conduction system that crucially coordinates the heart’s contraction and relaxation. Otherwise she would need a permanent pacemaker. At that point I felt it would have been much easier to be a watchmaker or concert pianist …
As it turned out, that little heart would be the least of my problems that day. I separated the chambers with obsessively sewn patches of Dacron cloth, then carefully created the new valves upon which the baby’s future depended. It was much the same as operating within an egg cup. When blood was reintroduced into the tiny coronary arteries the little heart took off like an express train. Just as I prepared to separate the baby from the heart–lung machine, a pale and worried face appeared at the theatre door.
‘Sorry, Professor,’ the woman said, ‘but we need you right now in Theatre 2. Mr Maynard is in trouble.’
‘How much trouble?’ I asked, without diverting my eyes from the baby’s heart.
‘The patient is bleeding from a hole in the aorta and he can’t stop it.’ She had a note of desperation in her voice.
Although the baby seemed fine, I would not normally leave a registrar to remove the bypass cannulas and close up. But it needed a snap decision. On the balance of probabilities, I decided that I should try to help. In haste, I forgot that I was tethered by the electric cable of my powerful head lamp. Standing back from the operating table, I avulsed the bloody thing. Several hundred pounds’ worth of damage in two seconds.
Nick Maynard was a first-rate upper gastrointestinal surgeon who specialised in stomach and oesophageal cancer. He dealt with tubes normally filled with food and air, not blood at high pressure. But this unfortunate patient did not have cancer. Just days before, she had been completely well. While happily eating sea bass in a fancy restaurant she swallowed a fish bone. At first the discomfort abated and she could swallow. Then a dull ache emerged deep in the chest, next a swinging fever with night sweats. Soon just swallowing liquids became difficult and made the pain worse. The GP knew she was in trouble. Blood results sent from the surgery showed a very high white blood cell count, which suggested an abscess. Rather than passing through the gut as most bones do, this one had clearly penetrated through the wall of the oesophagus.
Nick’s team was surrounded by medical students and radiologists as the CT scans came through. There was an abscess the size of an orange wedged between oesophagus and aorta in the back of her chest. Worryingly, there were bubbles of gas in the pus. Gas-forming organisms are among the most dangerous, so it was no surprise that she felt dreadful. The pus needed to be drained away urgently before the bugs entered her blood stream and caused septicaemia. Otherwise it could be fit to fatal within days.
The oesophagus and aorta descend side by side in the chest, nestled behind the heart and in front of the spine – oesophagus on the right, aorta to the left. Tiger country. Under high-dose antibiotic cover, Nick planned to open the right side of the chest through the ribs and locate the abscess behind the lung. Then, by opening the abscess cavity, the pus could be washed out and drains left in place for a few days until the antibiotics clobbered the infection. Nick thought that the small perforation through the muscular wall of the oesophagus would seal itself. While awfully simple in theory, it was destined to be simply awful.
Through the glass door of Theatre 2, I could see Nick, sweating profusely with his face covered in blood, and both arms up to the elbows in the woman’s chest. Blood was slopping out of the chest cavity and down his blue gown, while anaesthetists were squeezing in bags of blood. It transpired that all had gone according to plan until he swept an index finger around the abscess cavity to clear the infected debris. First came the noxious odour of anaerobic bacteria and rotting flesh. Then, whoosh! Blood hit the operating lights. The abscess had eroded through the wall of the aorta. Behind the heart lay an infected swamp. All Nick could do was to stick his fist into the fountain and press hard. Big problem. They had already lost more than a litre of blood and if his fist moved she would bleed out in seconds.
Groaning deeply under the burden of the day, I gave Nick a resigned look and thought for a moment. The bleeding was still not under control and there was no prospect of repairing the hole while her heart kept on pumping. She would simply bleed to death. The only potential route out of the predicament – I called it ‘deep shit’ at the time – was to get onto cardiopulmonary bypass, cool her down to 16°C, then stop the circulation altogether. Deep cooling of the brain would give us a safe thirty- to forty-minute window without blood flow to identify and deal with the damage.
Given the morning’s conflict, I very politely asked anyone not immediately engaged in the frantic resuscitation to ask one of my perfusionists to bring in and prepare a heart–lung machine. And for a couple of my own scrub nurses and a specialist cardiac anaesthetist to come across. Nick just had to keep on pressing. His anaesthetists kept on squeezing.
Once I’d scrubbed up and joined the team around the body, I couldn’t even see the heart. I needed a much bigger hole in the chest to work around my colleague’s ‘finger in the dyke’. There was no time for finesse. With the scalpel and cautery I virtually split her in half as she lay there, right side uppermost on the operating table. The metal retractor cranked the chest wide apart with a crack that told me that one of her ribs had just broken. This was not unusual. Chest surgery is a brutal business.
Now I could see the pale, empty heart beating rapidly in its fibrous sac. I needed to cut this open and insert two cannulas to connect to the bypass machine. The first went into the aorta as it left the left ventricle carrying cherry-red oxygenated blood. The second was pushed into the empty right atrium, where blue blood from the veins of the body re-entered the heart to be pumped to the lungs. This venous blood, low in oxygen, would now pass through a heat exchanger and mechanical oxygenator before re-entering the aorta. Then we could cool and protect the brain and other vital organs. The heart is rarely approached through the right chest, but I had done it on a number of occasions for complex reoperations on the mitral valve. With a daunting challenge like this, every ounce of experience counted.
Thinking ahead, I told one of the watching cardiac registrars to go in person to the homograft bank and ask for a tube of antibiotic-treated aorta from the supply of spare parts we obtained from dead donors at autopsy with the relatives’ permission. Human tissue is more resistant to infection than synthetic vascular grafts made from Dacron fabric. I often used donated heart valves, patches of aorta or segments of blood vessels from the dead to repair the living. This is recycling. God’s stuff is still better than man-made.
At 2 pm the registrar from Theatre 5 came in to announce that he had put in pacemaker wires and chest drains, and had closed the baby’s chest. All was well.
It took us around thirty minutes to cool down for the next stage of the operation. While his hands grew colder and colder, I congratulated Nick for saving the woman’s life. I told him not to risk moving and that cold was good as it meant the woman’s brain was cooling too. Then I asked the enthusiastic registrar to scrub up and babysit the bypass circuit so I could duck out for coffee and a piss. What I really wanted to do was to phone Gemma, but when I did there was no answer. She was still in a seminar. Although time was passing relentlessly, I remained hopeful that I would be in Cambridge by the evening.
At 18°C I was too impatient to wait any longer. Gowned and gloved for the third time that day, I told the perfusionist to stop the pump and empty the lady’s circulation into the blood reservoir. Nick could finally withdraw his cold, stiff arms from her chest after having had them in there for more than an hour, while I took the first operator’s position. In turn, Nick moved the registrar out of the way, eager to get a look at the damage for himself.
With no blood flowing around the body, we were working against the clock. The infected tissues had the consistency of wet blotting paper and the stench of rotten cabbage. We could not repair the damaged oesophagus, and Nick agreed it had to go. I chopped through the precious muscular tube above and below the abscess, and dissected it away from the aorta. Nick passed a wide-bore suction tube down into the stomach to prevent it from spewing acid and bile over my aortic repair.
Now we had a clear view of the ragged hole, which really should have been a fatal problem. I reluctantly decided to replace the whole infected segment of aorta with the homograft tube rather than risk just a patch. No time to debate this. I trimmed the donor tube to the correct length, then sewed at top speed using blue polyester thread on a fine stainless-steel needle, held in a long titanium needle holder; deep bites into healthy tissue – aesthetically pleasing, bordering on the erotic. Throwing the final knot left-handed, I told Richard the perfusionist to ‘go back on’ and rewarm. Cold blood from the machine expanded the flaccid graft and air fizzed through the needle holes. It needed a couple of extra stitches to make the whole repair blood tight, but we restored blood flow to the brain after thirty-two minutes. Happy days. Though not so happy in my own case.
I really didn’t have time to loiter and admire my needlework. Between us we agreed that Nick would divert the upper end of the oesophagus out of the left side of the poor lady’s neck to drain saliva and enable her to swallow liquids for comfort. The lower end would then be closed off and an entrance to the stomach fashioned through the abdominal wall through which she would now be fed. We call this a gastrostomy. Months down the line Nick would restore her swallowing with a new gullet made by transposing a length of large bowel between her neck and stomach. But for now she was safe. In life, and for that matter death, timing is everything. Heart surgeon close at hand. Heart–lung machine and perfusionist available between cases. Spare parts on the shelf. Otherwise she was dead, killed by a fish.
Nick’s gastro team were happy to close the chest, put in the drains and finish off. Stepping backwards from the table into a pool of slippery blood clot, I skidded gracelessly onto my backside, hard down on the tiled floor with a crack – retribution perhaps for leaving Nick for so long with his cold hands in the chest. Now with a soggy red patch on my trousers and the suspense of a near-death drama lifted, it gave the nurses something to laugh at. Some proffered concern for the integrity of my coccyx. But, pain apart, I was content to have dispelled the gloom.
The levity was short-lived as no fewer than four messages with my name attached were taped to the door. First, the lady waiting for the mitral repair on the ward was agitated and wanted to see me. Predictable. Second, would I go to the paediatric intensive care unit where the baby was losing a little too much blood into the drains? Shit. Next, a lady doctor in the accident department of the Norfolk and Norwich Hospital was trying to get hold of me. Why on earth would that be? It was many miles away. And last, the medical director would like to see me in his office with the director of nursing at 4 pm.
Bugger that. It was already 4.10, and I was in no doubt what the chat would be about – swearing at the unhelpful agency nurse, quite inappropriate conduct for a consultant surgeon. Another ticking off. Nor was I in the mood for an acrimonious discussion with the cancelled mitral lady. After 5 pm there were only sufficient nurses to staff one emergency theatre. The nurses would never allow me to begin an elective operation at this time of day. So my only concern was for the baby. Was it significant surgical bleeding or just oozing through compromised blood clotting after being on the bypass machine? Still hoping to leave town, I went directly to the unit to find out.
The afternoon ward round was congregated around the cot. On either side crouched an anxious parent holding a cool, sweaty little hand. Suspended from the drip stand was a tell-tale bag of donor blood dripping briskly through the jugular vein cannula in the baby’s neck. Without reading the levels I could see that there was too much blood in the drains. The precious red stuff was dripping in one end and straight out the other. What’s more, they had checked the clotting profile and it was virtually normal.
With that one glance my plans for the evening were dashed. Cambridge might as well have been on a different planet. I had to take the baby back to theatre and stop the bloody bleeding. Abject despair turned to anger. I should have closed the chest myself – but then fishbone lady would be dead now. Acrimoniously I rang my so-called ‘helper’, telling him to lay claim to the emergency operating theatre and that I would push the cot around myself. Five minutes later Mr Putty Fingers called back to say that they couldn’t staff an emergency theatre because the chest surgeons were running late with a lung cancer operation. We would have to wait for them to finish. Until then, no room for emergencies, so keep squeezing in the blood. In the meantime, any remaining chance of seeing my daughter on her birthday had gone. More of the same. Useless absentee father ridden with guilt, and made worse by the fact that I had still not made contact. I was a sorry sight with my bloody trousers and sore bum.
There was no point in trying to rush the chest surgeons. They operate slowly through small holes with telescopes and invariably overestimate what they can squeeze in to an operating list. Yet no access for emergency surgery spells trouble. I was now glued to the cot side, with the fretting parents wanting me to stop the bleeding. I deployed that old chestnut: ‘It was alright when I left. It can’t be bleeding from the heart.’
Sure enough, over the next thirty minutes the bleeding slowed to a trickle. I fantasised that blood clotting had finally sealed the needle holes, which would allow me to escape the hospital without reopening the chest. Except the jugular veins were distending as the blood loss slowed. Perhaps there was too much transfusion. More likely, the chest drains had blocked off and blood was now accumulating under pressure in the closed space within the pericardium so the right atrium couldn’t fill properly – what we call cardiac tamponade. Should the blood pressure begin to fall, we would be in real trouble.
The baby’s blood pressure drifted down. We couldn’t wait any longer for an operating theatre. Now I needed to reopen the chest right there in the cot and scoop out the blood clot. Sister carried the heavy pre-sterilised thoracotomy kit to the cot side and dumped it on a trolley. Still wearing theatre blues, I hastily scrubbed up at the sink while calling for the registrar who had left me in this mess. He had already gone home, so we tried to find the on-call registrar. It was a locum, who was already scrubbed up in the thoracic theatre.
So I got on and did it without help – it was a very small chest, after all – getting the baby prepared, draped and her sternum wide open in less than two minutes. The suction tubing was not connected yet, so I scooped out the clots with my index finger, then packed the pericardial cavity with virginal white swabs. An expanding bright red spot soon showed me the bleeding point, a continuous trickle from the temporary pacing wire site in the muscle of the right ventricle, ostensibly trivial but life-threatening. That’s the way with cardiac surgery. It has to be perfect every time or patients die needlessly.
The cardiac rhythm was normal, so I pulled out the wire and stemmed the dribble with a single mattress stitch. Sure enough the drains were blocked. I changed them for clean ones and closed up. The whole process took ten minutes, but it had been a completely avoidable charade. It transpired that the trainee surgeon lacked the confidence to put a stitch into the baby’s twitching ventricle, simply hoping that the oozing would stop. He would not make it in this specialty.
7 pm. I was intrigued by that message from Norwich A&E. Were they still waiting to talk to me in the hospital? At first bewildered, I now became uneasy, paranoid even. Norwich was not far from Cambridge. Could Gemma have been out with friends and had an accident? Why did that not occur to me earlier? So I fretfully called her mobile. This time birthday girl answered cheerily and asked whether I was well on my way. The ensuing silence spoke volumes. There was no way I would get to see either of my children that night. Both patients survived, but part of me died. Again.
2
sadness (#u02de273e-a631-5f22-b6be-1ce6612625a5)
7.30 pm. I had given a child a new life then pulled off one of surgery’s great saves. I should have been floating on air that evening, but I wasn’t. Far from it. I was guilt ridden and inconsolable, still drawn to Cambridge when every element of logic insisted that going there would be futile. I needed to take off for Woodstock and drink myself into oblivion. That bloody phone message was still unanswered – but I wasn’t on call. Why on earth should I bother now? Because I always did, I guess. There had to be a reason for it. My life was never my own.
‘Good evening. Ipswich Hospital. Which department, please?’
‘Accident department, please.’
‘Sorry, that line is engaged. Can I put you on hold?’
There followed mindless waiting-forever music, tunes that made minutes seem like hours, time more joyfully spent waiting to be castigated by the medical director.
Then the young doctor was found.
‘Thank you, Professor. I know you’ve been in theatre all day. I’m Lucy, the on-call medical SHO. I was hoping that you would accept an emergency that has been with us for some time. An aortic dissection.’ (In medicine, people are frequently referred to by their condition rather than their name.) ‘He’s a GP and had heart surgery a few years ago – an aortic valve replacement at Papworth.’
‘Then why aren’t Papworth operating on his aortic dissection?’
There followed an embarrassed silence.
‘Their surgeon on call said he had another emergency waiting and we should send the doctor somewhere else.’
I was rather nonplussed by this approach as there were several cardiac centres in London that were closer to Ipswich. Aortic dissection is a dire emergency, where the main artery supplying the whole body suffers a sudden tear through the innermost of its three layers. This exposes the middle layer, which usually splits along its entire length under the high pressure, all the way from just above the valve down to the leg arteries. Branches to the vital organs can be sheared off, interrupting their blood supply and causing stroke, dead gut, pulseless legs or failing kidneys. Worse still, the split aorta is likely to rupture at any time, causing sudden death. And the poor chap was a doctor. He deserved better. Anyone deserved better.
I asked his age and current condition. The man was sixty and had complained of sudden severe chest pain, rapidly followed by paralysis of his right side. That meant he had extensive brain injury caused by the carotid artery supplying the left cerebral hemisphere becoming detached. The longer he was left before surgery, the less likely he was to experience any recovery. The patient couldn’t speak but sweet, persistent Lucy remained optimistic, saying that he was still awake and could move his left side.
There was one piece of critical information I didn’t have, besides his name, that is. What was his blood pressure? Before committing any patient with dissection to an ambulance or helicopter journey, it was vital that the blood pressure was carefully controlled with intravenous anti-hypertensive drugs because a surge in pressure can easily rupture the damaged vessel. So many patients die during or soon after transfer for that very reason.
‘180/100. We can’t seem to get it down.’ An element of panic had now entered her voice.
What that meant was that all the senior staff had buggered off home and left her to it, and she had never seen such a case before. After a day of conflict and castigation I chose my words carefully.
‘Oh shit! You must get that down. Get him on nitroprusside.’
I pictured the paper-thin tissue expanding to bursting point while the dissection process extended further throughout the vascular tree. Even with emergency surgery, one in four of these patients died.
Lucy responded that they didn’t want to drop the blood pressure too far because he wasn’t passing much urine and the CT scan showed that the left kidney had no blood flow. Only surgery could help fix that, so the sooner we got him onto an operating table the better. Should the guts lose their blood supply, little could be done. I asked whether he had abdominal pain or tenderness. Apparently not, so that was a positive.
This terrified patient had been lying paralysed on a hard hospital trolley for hours, surrounded by his family. He knew his own diagnosis and was fully aware that urgent surgery was his only chance of survival. Worse still, he’d had heart surgery before for an abnormal aortic valve, which is often associated with a weakened aortic wall. Reoperations are much more taxing than virgin surgery, so I summarised the situation in my mind. Physician with the highest-risk acute emergency needs reoperation but has an established stroke and one kidney down. His blood pressure is uncontrolled and he is at least two hours away by road. Could they arrange a helicopter? No, they had already tried. No wonder Papworth weren’t interested!
Lucy sensed that I was wavering. Hedging my bets, I told her that I had no idea whether we had any intensive care beds available.
So Lucy played her trump card. ‘The family asked that he be sent to you personally. Apparently you were at medical school together. I think he was a friend of yours.’
What was that question I never asked? Something we don’t regard as important – the patient’s name. Surgeons are less interested in people. We want problems to fix, but I had already had enough problems for one day.
Suddenly the penny dropped. A GP in Suffolk. My own age and with previous heart surgery. He was a jovial rugby prop forward, captain of the 2nd XV at Charing Cross Hospital, my old mate Steve Norton. We met on our first day at medical school in 1966. I was a shy, unassuming backstreet kid, frightened by my own shadow, and no one from my family had ever been to university before. Steve was an ebullient extrovert, full of confidence, destined to become a much-loved GP in rural Suffolk while I underwent metamorphosis into a fearless operating machine. Same profession, worlds apart. How did that happen?
I just said, ‘Bugger the beds. Send him across as fast as you can. I appreciate you should be going off duty, Lucy, but someone must come with him to screw that pressure down. And please send the CT scan.’
With no one to delegate to at this time of the evening, I had to make all the arrangements myself. The on-call nursing team had already worked all day and were just finishing a routine lung cancer operation. They were less than delighted by the prospect of a protracted emergency reoperation, one they expected to take all night. With foot down and blue lights flashing, the ambulance ought to be with us by 11 pm. If Steve survived to see Oxford alive, I would wheel him directly to the anaesthetic room.
Now the battle had started. Was there an empty intensive care bed? If not, there would be a bloody row about accepting a patient from outside the region without asking. Who was the on-call anaesthetist? I got lucky with Dave Pigott, a dour South African who helped with my artificial hearts and revelled in a challenge. Then lucky again that Ayrin was the scrub nurse. She was a diminutive, ultra-polite Filipino girl who never complained about anything because she was proud to work for the NHS. Her invariable response to any expression of gratitude was ‘Welcome.’ I used to think that this was the only English word she knew. The perfusionists always moaned and groaned when called at night, but they were all ultra-reliable. I just asked switchboard to call in whoever was on the rota and I looked forward to the surprise.
As the sun went down, we waited. I called home and spoke to my long-suffering wife Sarah, who thought I was in Cambridge and was sad for me that I wasn’t. I explained that I was waiting to operate on Steve Norton from medical school and wouldn’t be home tonight. That concerned her. I wasn’t the duty surgeon, and she remembered the heated discussions when I was faced with the prospect of operating on my own father during his heart attack. In the end, my cardiology colleague Oliver spared me the moral issues by curing him with coronary stents.
Sarah asked tentatively whether I should ask the on-call surgeon to do it. How did I feel about operating on a good friend at such high stakes? Cardiac surgeons are rarely introspective and self-effacing. I answered her question with a question: ‘If you had an aortic dissection, who would you want to do the surgery?’ Response: ‘You.’ Well then, why are you surprised that Steve’s family felt the same?
As she’d sat by the bedside, Steve’s wife Hilary knew the situation was dire. What was the anticipated mortality rate for aortic dissection? An international registry from top cardiac centres in Europe and the United States reported 25 per cent. What is the lowest recorded mortality in any series of cases? Six per cent. Who had operated on those cases? A surgeon in Oxford. So who would give Steve the best chance of coming through this catastrophe? I had no reservations whatever about battling to save my mate. As the phrase goes, ‘That’s what friends are for.’
Sarah’s next question was whether I’d eaten anything that day. This took some time to think about. I recalled a bacon sandwich at the crack of dawn. I told her that I’d find a bag of crisps from a vending machine before we launched into the night’s work. But food was the least of my concerns at that point. I needed an experienced first assistant, someone who had operated with me on dissections before, not an inexperienced locum brought in to cover a few night shifts. When the shit hits the fan, a coherent team makes a massive difference. Bums on seats is not the same. Amir was not on call, so I picked up the phone and asked him if he was doing anything. One thing he certainly wouldn’t be doing was drinking. He was effusive in his willingness to help, honoured to be dragged in at night to help the boss with a complex case. And I knew that he was capable of standing at the table for hours when I needed someone to stem the bleeding then close up. That was a young man’s game.
Steve and Hilary were at my wedding to my first wife Jane. Our pack were all young interns at Charing Cross Hospital after graduating, part of the rugby crowd that never took life too seriously. It was Steve who placed the bet that saw me streak naked the length of Pembridge Gardens to Notting Hill Gate tube station during rush hour. And we had both been fished out of the fountains in Trafalgar Square after a rugby club bash in Fleet Street, only to spend a cold night in Bow Street nick. I failed anatomy that term. Escapades long forgotten, just flashbacks for me as he travelled paralysed and semi-conscious through the night, unexpectedly perched on the edge of life. Once good friends, we were now surgeon and patient, something I never expected nor wanted to happen.
I wandered the silent hospital corridors to pass the time, consciously avoiding a confrontation with cardiac intensive care. I would let Pigott tell them we had an emergency once we were in theatre. Or maybe I’d ask Amir, who joined me in general intensive care, where we visited the fishbone lady. The ‘great save’, whose name I never knew, was beginning to wake up, her bed surrounded by her anxious daughters, arms extended to their mother’s cold hands under the warming blanket. Predictably, she had ‘after-cooled’ down to 34°C following the hypothermic circulatory arrest and was now shivering violently. Shivering, and the vasoconstriction response to cold, had pushed her blood pressure up to astronomical levels and Amir realised that this was likely to burst the repair.
The lady night registrar nonchalantly strolled across, clearly uncertain about whom she was about to address.
‘Can I help you?’ she enquired in an aloof manner, presuming that this scruffy visitor in theatre blues was a porter or something. My response must have come as a surprise.
‘No, but you can help this lady by getting her blood pressure down before she blows her bloody graft off. Paralyse her and keep her asleep until morning.’
The daughters were wide-eyed. The implications of my reply were lost on them, but they sensed an air of tension between the players.
‘Give her a bolus of propranolol right now,’ Amir chipped in assertively.
Registrar lady was now defensive and flustered, verging on shocked. She was not much older than my birthday girl and I immediately regretted being short with her. Maybe we should have done this differently. I could have taken the time to introduce myself and immodestly taken credit for saving the woman’s life, have the relatives fawn around and worship me for the bizarre and heroic rescue. But this was Nick’s case. He had already explained everything to the relatives. I didn’t want to intrude, but I certainly didn’t want to see the repair blown to pieces after all that effort. Having made the point, we wished them all a peaceful night and moved on. Sensitive souls, the intensive care doctors.
10 pm. Amir and I slipped silently into children’s intensive care to check on the morning’s case. Yet I was first drawn to the mother of the meningitis child whose black, gangrenous arms were now gone, replaced with rolls of pristine crepe bandage. Stark contrasts. Was she happy or sad that those mummified little hands had been removed? I wondered whether I would have asked to keep them had it been my child. I set that morbid thought aside and simply asked how the operation had gone. Was she, the mother, OK? Could I help her with anything? Fetch her a coffee? Anything at all to ease her pain? She just looked up at me with tears rolling down her cheeks and said nothing. The nurse knew me well enough and shook her head. It was time to move on to my own little patient.
The chest drains were dry now, with a steady pulse and blood pressure. Nurse told me that Dr Archer had done an echo and was very pleased – no leak on either valve or across the patches. Fixed for life. The parents had drifted down from the ceiling after the shock of the sudden reoperation and had gone to crash out in their hospital room. They understood the difficulties we faced, which was what really mattered. Not the daily battle for the privilege of bringing a patient to the operating theatre, nor the repeated conflict over intensive care beds. As night fell, we hoped for stable patients, cheerful parents, happy husbands or wives, and a brighter future for them all. While they drifted off to bed, I strolled down a long, dark corridor to the doors of the accident department.
Out in the fresh air for the first time in sixteen hours, I stared at the night sky and waited for the ambulance to arrive. The operating theatre lay ready, the heart–lung machine was primed, and the team were watching Newsnight in the coffee room, yawning with boredom and resigned to the fact that we were likely to be there all night. My own thoughts drifted back to Gemma and the disappointment I must have caused her once again. But maybe I was wrong. Maybe she had a much better time without me.
11.50 pm. The ambulance with East Anglia Health Authority painted across the side finally arrived, its blue lights flashing. Paramedics threw open the rear doors and the long-off-duty Lucy stepped down the ramp. I just knew it was her. Like a scene from Casablanca, she walked towards the Emergency entrance carrying a stack of medical notes. I thought at that moment how beautiful she was.
‘You’re the Prof, aren’t you?’ she said. ‘Mrs Norton told me about you. I trained in Cambridge and they still talk about you there.’ Nothing positive, I expected.
The trolley bearing Steve’s broken brain and body was being pushed towards us. The last time we met was barely six months before at a medical school reunion. He had delivered a very amusing speech celebrating the fact that all present were still alive despite his open heart surgery. I responded by jesting that things could have been different had he come to me for surgery. Now he was in Oxford in dire straits, not the next reunion we’d all anticipated, with his family still somewhere on the M25. I took his left hand, which firmly gripped mine. The good side that still moved. Then, along with Lucy, we walked in procession through the accident department down the corridor and straight into the operating theatres. A cursory glance at the CT scan confirmed the lethal diagnosis.
We can’t operate without consent, but he was alone and I didn’t want to be too explicit. I just told him that I would repair the dissection and with luck the stroke might recover. He struggled to tell me that he wanted to see Hilary and his children again before being put to sleep. Lucy had a number for Hilary, so I called. They were forty-five minutes away at best. Every extra minute meant less likelihood of neurological recovery, and too many hours had been wasted already. When I promised not to let him die, Steve used his left hand to mark a cross on the form. I counter-signed beneath, then Dave Pigott dispatched him to oblivion with a brain-protective barbiturate.
We had kept the interpersonal rapport to a minimum. Surgery has to be dispassionate, anonymous even. It was less of a problem because Steve couldn’t speak and I simply couldn’t verbalise the real risks to a friend who faced certain death if no one was prepared to operate. He was a doctor and knew the score. I didn’t need to render him any more anxious in his last conscious moments.
I sat in the coffee room until the lily-white body had been painted brown with iodine and covered with drapes. I didn’t want to see his flabby torso. I preferred to remember him the way he once was, that fine physical specimen striding out onto the pitch on a winter’s afternoon, adrenaline pumping, ready for the scrap. Closely aligned in those days, we were very different characters now. Steve would sit in an office chatting affably to patients and dishing out pills. A proper doctor. There I was at midnight, ready to wield the knife and drive an oscillating saw through his chest, all after an endless day of disappointment, conflict and misery. But adrenaline dissipates the tiredness, wipes out time as the contest begins.
After the previous surgery, Steve had no pericardium or thymus gland between the back of the breast-bone and the front of his heart. So with an expanded, tissue-paper-thin aorta immediately beneath, chest re-entry with an oscillating saw was extremely hazardous. I reduced the risk of catastrophic bleeding by exposing the main artery and vein of the leg, and connecting them to the heart–lung machine. Should the saw lacerate the heart or aorta, I could go rapidly onto cardiopulmonary bypass, take pressure out of the circulation, then suck away blood from the bleeding site. Mostly that works. Sometimes it doesn’t. If heart surgery were easy, everybody would be doing it.
Fixing Steve was like replumbing a Victorian house. All the main pipes were buggered and those coming out of the boiler needed to be replaced as they were rusty and might fall to bits at any moment, so I couldn’t do it with hot water flowing through them. I needed the same conditions as fishbone lady – a cold brain and all the blood drained off into the machine. Dave put electroencephalogram leads onto the scalp to monitor the brain waves, which gradually disappeared as Steve’s temperature fell but were already grossly abnormal after his stroke. Amir began by cutting the skin straight down the line of the scar from the previous operation, then used the electrocautery to sizzle through fat onto bone. He snipped through the old stainless-steel bone sutures with a wire cutter, then ripped them out. I was always going to open the sternum myself. Getting the depth of the oscillating saw just right is a matter of fine judgement. You must gently feel it pass through the back of the sternum, then pull back in case the posterior table of the bone and the muscle of the right ventricle are adherent.
The dissected aorta had the intimidating appearance of a tense aubergine, purple and angry, and I could see blood swirling beneath its perilously thin outer layer. Dave had positioned an echo probe in the oesophagus, directly behind the heart. This showed the original tear in the wall around 1 cm beyond the origin of the coronary arteries, the vital branches that supply the heart muscle itself. My job was to replace the torn part and redirect blood flow back to where nature intended, in the hope that this would restore flow to Steve’s blocked brain and kidney arteries. The compromised kidney would undoubtedly survive, but the injured brain was unlikely to. It had been starved of blood and oxygen for too long, although barbiturates and cooling might help.
I told Brian the perfusionist to go onto bypass and cool to 18°C. Draining the whole living body of blood is a curious thing to do. Only vampires and the few heart surgeons who operate on congenital heart defects and extensive aortic aneurysms ever do it. I specialised in both, so I emptied people out on a regular basis. I once gave a spoof lecture about halal humans at Dracula’s castle in Romania. I felt at home there. The Count and I had much in common.
I was normally relaxed about working against the clock, even when the brain had no blood flow. I didn’t stand there contemplating the nerve cells as they died, nor did I rush the job. At 1.30 in the morning I told Brian to come off bypass and drain, the second time I had done that in twenty-four hours. Steve’s cold, anticoagulated blood emptied into a reservoir and would sit there like a jug of Ribena until we pumped it all back again. I chopped away at the empty disintegrating aorta until I could see the inside of those vital branches coursing up into the head and arms.
The first step was to reapproximate the dissected layers of the filleted vessel with tissue glue. I was one of the first surgeons in the world to use the glue and it undoubtedly contributed to my gratifying survival rate. Then, with care bordering on obsession, I sewed in the vascular tube graft buttressed with strips of Teflon felt to prevent the stitches from cutting through the fragile tissue. Every patient’s survival relied upon the connections between my cerebral cortex and fingertips, but this was especially the case in aortic dissections. Amir’s eyes fixed on my every movement. He wanted to learn all the nuances of technique, which is why he willingly came in. Amir would definitely make it one day.
The repair to the aorta and inserting the graft without blood flow took thirty-four minutes. This lay within the window of safety for a normal brain, but Steve’s brain was not normal. We carefully refilled the vascular tree with blood and evacuated air from the head vessels. Once back on cardiopulmonary bypass, blood oozed through the needle holes. These would continue to bleed until we reversed the anticoagulation that prevented blood from clotting on the foreign surfaces of the circuit. So many detailed steps to recall, but the whole sequence was ingrained in my neural circuits, with everything done on autopilot, even in the early hours of the morning.
It was now time to re-warm to normal body temperature. With warm blood coursing through his coronary arteries, Steve’s heart muscle came to life again, first wriggling in what we call ventricular fibrillation, followed by spontaneous defibrillation and then the slow, lazy contractions that sped up as his temperature rose. Soon brain waves reappeared on the electroencephalogram. Dave thought it looked a bit better already.
The only other time that we watched this process of reanimation was when we tried to save children who had fallen through ice and drowned in a frozen pond, and there are rare cases of survival from Canada. Our Oxford trauma doctors pressed us to rewarm these lifeless bodies, and while we succeeded in salvaging hearts, lungs, livers and kidneys, the children were always fatally brain injured. We gave hope to their parents, then snatched it away again.
At 3 am I left Amir in charge at the operating table. Rewarming takes thirty minutes, and I’d been told that Hilary and several visitors were waiting in the intensive care relatives’ room. On the positive side, their arrival broke the ice with our nursing staff and I at least now knew that there was a bed waiting for him. As I appeared in the doorway they all sprang to their feet. This was reflex not reverence. Here was a medical school reunion, such was Steve’s popularity. Stan was a professor of oncology, John a consultant anaesthetist and Mike a GP. All were here to support Hilary and her children.
Before any type of greeting I told them the news they wanted to hear, that Steve’s OK, I’ve repaired the aorta and fixed the blood supply to his brain. The surgery has gone well. This simple sentence scraped them down from the ceiling and untied the knot in their stomachs. News – either good or bad – always dissolves that agonising fear of the unknown. As they stood there, far from home in the middle of the night, their old pal assumed a different persona. I was no longer the boozy buffoon from Scunthorpe.
There followed hugs, kisses and expressions of relief, then the usual request – ‘Can we see him now?’ I had to explain that Steve was still on the table with his chest wide open being rewarmed on the bypass machine and that while he was not entirely out of the woods, things had gone according to plan. I added that it was likely to be another couple of hours before we controlled the bleeding and closed him up. With that I left, intending to apologise to the sister in charge for springing this upon them. But it transpired that in fact there had been enough nurses – the last heart attack patient brought up from the catheter laboratory had ruptured his left ventricle and could not be resuscitated. The conveyor belt rumbled on.
I wandered wearily back to theatre and sat down with the two anaesthetists beside Steve’s head. Amir was happy enough to remain in charge. Steve’s temperature was back at 37°C and although still empty, his heart looked cheerful enough. I asked Brian to leave some blood in it, so any residual air would be ejected into the graft. I could hear Steve’s artificial aortic valve clicking away reassuringly, and from the echo probe behind the heart we could see tiny bubbles flashing through it like a snow storm. I didn’t have to ask. Amir already had the air needle in place. Bubbles fizzed out intermittently, then stopped. Now we were ready to come off the machine. I asked Dave to start ventilating the lungs and soon afterwards heard Brian say that he was ‘off bypass’. Amir and the locum registrar stood like spectators at a football match, as I dispatched instructions from the stool. I was scrutinising the inside of the heart and aorta on the monitor screen while they watched it from the outside.
‘How does it look?’ I asked Amir. ‘Any bleeding?’
‘Looks great. Just some oozing from around the graft. Nothing serious.’
‘What are you going to do now then?’
No answer. He was tired.
‘Give the protamine,’ I told Dave. Protamine extracted from salmon sperm reverses the anticoagulant effect of heparin, which comes from digested cow’s guts. So my noble profession relied on cows and fish, a sobering thought at this time in the morning.
Amir gently packed gauze swabs around the heart to encourage the oozing blood to clot on them. Next he set about putting in the chest drains and stainless-steel wires to close up. The clock on the wall read 4.30. Dave flicked through a motorcycle magazine and Brian asked whether he could remove his equipment, get it ready for the morning and go home. No stamina, some people. Ayrin and her runner nurse were wilting too. I suggested they took turns to take a break while we transfused blood and clotting factors. For the first time a sense of calm filled the room. Job done.
Behind the operating theatre block was a car park, and beyond this lay Old Headington graveyard, thinly shielded by an unkempt hedge of privet and conifers. I walked out into the night past the Mercedes that never got to Cambridge, with Gemma’s birthday present still concealed in the well of the passenger seat. I drifted on through the ornate metal gate to the brow of a hill overlooking the Oxfordshire countryside. There I lay silently on the grass by the grave of a baby girl and stared up into the night sky. The tombstone read, ‘Taken too soon’. She’d been taken by me twenty years earlier, something I hadn’t forgotten. She would have been Gemma’s age now, had God not given her that twisted, convoluted heart that I failed to fix. So I sat with her from time to time when I was feeling bad, just to remind myself that I wouldn’t always succeed. Difficult day today. Or was it yesterday?
6 am. Daylight broke the horizon and the sparrows chirped. Headlights sprinted around the Oxford ring road below, the early-bird London commuters and shift workers at the Cowley car plant. Sue would already be on her way into the office, so I ambled back to Theatre 5, now empty except for Ayrin. She was scrubbing blood and urine from the floor, ready for the morning’s operating list. Steve was already settled in intensive care, surrounded by his extended family, perfectly stable.
Cheerful Amir said, ‘Great case. So pleased you called me.’
The locum registrar was nowhere to be seen. Gone to collect his pot of gold, I thought.
I looked bad and smelled bad, so I went to the changing rooms, took a shower and stepped into clean theatre blues. The ritual signified the end of yesterday and the beginning of today. First, I made tea for Sue in the office, taking a dose of Ritalin with mine. Oxford students used the stimulant to aid concentration and inflate their exam grades; I used it for a boost when I was buggered or with added melatonin for jet lag. All in the patients’ best interest, of course.
At 7.30 I joined the intensive care ward round. I related Steve’s case story and asked whether his pupils were still small and reacting to light. Had anyone looked? Not yet, but they would. Had he shown any signs of waking up yet? No, but I was happy about that because I wanted him kept sedated and didn’t want the tube in his windpipe to make him cough. Coughing would shoot his intra-cranial pressure through the roof and his brain was already too swollen in there. By explaining that to the juniors in front of Hilary, I assumed that they would get the message. At least I hoped they would.
I celebrated Steve’s recovery with a sausage and egg sandwich, and, with the Ritalin kicking in, I felt better too. I had a floppy mitral valve to fix, and happily for me there was no bed for a second case. But the tone of day soon changed. As I emerged from theatre in the late morning, Steve partially woke from the sedation and started to struggle in his bed. With his brain swelling, he was disorientated, confused and agitated, then he started coughing vigorously against the tracheal tube and strained against the ventilator. He was a big man and not easy to control.
A debate ensued about whether to let him wake up fully and remove the endotracheal tube or re-sedate and paralyse him. In the midst of this, his left pupil dilated widely. Understanding its dire significance, John, our anaesthetist friend who had stayed by Steve’s bedside, hurried off to find me in my office. We returned to check the pupils again. Steve’s nurse thought that his right pupil was larger too. My spirits plummeted. I had hoped that cooling and barbiturates would limit the swelling around the stroke.
Did Hilary know of this sinister development? She had been given a relatives’ room and gone there to rest after the stressful night. Perhaps it was best to leave the family alone until we gained a clear picture of what had happened. That meant an urgent brain CT scan, which was not easy for a post-operative patient connected to all the paraphernalia. Drips, drains, pacing wires and monitors had to be wheeled through the hospital corridors to the radiology department, then his paralysed body moved from his bed into the scanner. But without the pictures, we couldn’t know how to help. So I walked round there myself and grovelled to my friend the chief radiographer to fit him in as a dire emergency.
As the scans emerged it was obvious that the whole brain was swollen. The parts damaged during the original stroke had haemorrhaged, probably as a result of the obligatory anticoagulant given during surgery. The injured brain had expanded like a sponge soaking up water yet confined in a rigid box. The skull has one hole at its base, through which the spinal cord enters its bony canal. When pressure rises, the brain stem can be forced down into the spinal canal with fatal consequences. This is called coning, and a blown pupil heralds that catastrophe. So I needed a brain surgeon to look at the scans with me.
It was not an easy conversation. Richard Kerr was the chief. He had seen it all, done it all, and was destined to be President of the British Association of Neurosurgeons. I asked him to decompress Steve’s brain by removing the top of his skull. A craniectomy is like taking off the top of a boiled egg, except the bone is kept in a fridge and put back again should the patient survive. Richard was a man of few words. Before he even spoke, I knew he believed it to be a lost cause. I pleaded the family’s case for them. Richard said that even if he survived, he would never be a GP again, indeed he might not even wake again. The delay in re-perfusing the stroke with the surgery had already destroyed his chance of survival. But that was now history. We couldn’t turn the clock back.
So I played my last card. Steve was an old friend, I said, and I had spent all night and lots of money trying to save him. Richard groaned and went back through the scans.
‘OK, you win. He has nothing to lose, but it has to be quick. I’ll put off my next case.’
Within thirty minutes Steve was on a neurosurgery operating table at the far end of the hospital. I pushed the bed there myself.
2 pm. Steve’s scalp was peeled back and the bone saw removed the top of his cranium, revealing a tense, swollen brain without pulsation. We were watching a dying brain. Richard inserted an intracranial pressure monitor into the pulp and closed the scalp skin loosely over the top. Then we took him back to cardiac intensive care, whose expertise he needed most.
Hilary and her children were still napping on a single bed and an armchair in their room. Consumed by my own misery and her husband’s impending doom, I tentatively knocked on the door. Hilary read my gaunt expression and realised that this was not a social call.
‘He’s dead, isn’t he?’
I hesitated to say no, since Steve’s chances of survival were negligible. I just told her the truth. That he had a dilated pupil and the brain scan looked bad, that I’d immediately persuaded the finest neurosurgeon in the country to help, but we were both doubtful that Steve could recover now. It was a waiting game. More of our medical school friends arrived, hoping for better news. I heard that old chestnut – ‘If anyone can save him, Westaby can.’ But he couldn’t. Great dissection repair, pity about the outcome. Soon afterwards, the second pupil dilated. Neither reacted to light. Despite the decompression, his brain was not going to recover. Hilary and the children had lost him.
Unbeknown to me, both Hilary and her eldest son had congenital polycystic kidneys, and the lad was teetering on the edge of needing renal dialysis. With remarkable composure, she asked whether he could be given his father’s functioning kidney. An organ from his dad would provide the best possible chance of immune compatibility – same blood group, same genes, no rejection. For a brief moment I thought I could generate something positive out of this disaster. At the same time as the intensive care doctors carried out tests for brain stem death, I called the director of the transplant service.
What I learned was barely believable. While Steve was conscious he could have voluntarily donated a kidney to his son. Now that he was functionally dead, the family could request that he become an organ donor. But now the body blow. Whatever was still transplantable must go to the national donor pool. Those were the rules. The transplant authorities would not allow Steve’s kidney to be used for his son, nor given to Hilary, who was close to needing a transplant herself. That was the law, so the Oxford transplant team couldn’t get involved. I was dumbstruck, then apoplectic about it. Fucking bureaucracy.
Steve’s ventilator was switched off at lunchtime. He died peacefully, surrounded by his family, with many of my medical school year grieving in the hospital corridors. I was alone in my office when his proud heart fibrillated, when the metallic click of his prosthetic valve finally came to a stop. Twelve hours earlier I had watched it beating vigorously and I had been confident that I’d saved him. Now it was forever still. All his organs died with him, except the corneas from his eyes. Despite my protestations, the transplant authorities had their way.
When Sue went home she left a note on my desk – ‘The medical director wants to see you.’
‘One day,’ I said to myself, and drove home with Gemma’s present still tucked away in the passenger seat.
Next day I was back in the car park by 6.10 am, another three cases on the operating list, beginning with a newborn infant whose right ventricle was missing. The car park lies between the graveyard and the mortuary at the back of the hospital. I always attended the autopsies of my own patients, so the morticians knew me well enough. This morning was a social call. I wanted to let Steve know that we had done our best for him. He was cold, pale and peaceful now. It was the only time I’d known him to be speechless. Had he still been able to talk, he would have said, ‘You bastard. You were meant to get me out of this mess!’ My instinct was to remove the drips and drains left in his lifeless body, but I was not allowed to. Those who die soon after surgery are the coroner’s property, and the pathologists must satisfy themselves as to the cause of death. Not difficult in this case, but it was an autopsy I wouldn’t be returning to watch. So I said my goodbyes to a great character.
There were many sad moments in my professional career, but this one stayed with me. Steve had devoted his life to the NHS but was caught up in the pass the parcel lottery that was out-of-hours surgery for aortic dissection. Eventually a decree was issued by the Society for Cardiothoracic Surgery that each regional centre must take responsibility for patients in their area. Special aortic dissection rotas were established in London and specific experienced surgeons designated to operate on the cases. That brought the mortality rate down. After UK Transplant prevented us taking a kidney for Steve’s son, the issue of organ donation was not discussed further. A healthy liver and two lungs could have gone in to the pool, had that single functioning kidney been used in Oxford.
Later that year Steve’s son Tom received a kidney donated by his wife. Steve’s daughter Kate was given one of her husband’s kidneys in 2015. Hilary was fortunate enough to meet a new partner and received one of his kidneys in 2011. They are all well.
3
risk (#u02de273e-a631-5f22-b6be-1ce6612625a5)
As a boy, my stoical and religious parents taught me that I should never take risks – never to gamble with money, never to be deceitful or steal, never to cheat in exams. Not even to climb over the stadium wall to watch Scunthorpe United, because that was a form of stealing too. Consequently, I began life as both boring and introspective.
Eventually I learned that the ability to take risks is an indispensable part of human psychology. Victory in war depends upon risk-takers and recklessness, hence the adage ‘Who dares wins’. The economy depends upon financial risk-takers. Innovation, speculation, even the exploration of the planet and outer space – all depend on putting something you cherish on the line in the hope of greater rewards. Thus risk-taking is the world’s principal driver for progress, but it requires a particular character type, one defined by courage and daring, not reticence and prudence – Winston Churchill rather than Clement Attlee, Boris Johnson not Jeremy Corbyn.
In 1925, when Henry Souttar first stuck a finger into the heart and tried to relieve mitral stenosis, it posed a risk to his reputation and livelihood. When Dwight Harken removed a piece of shrapnel from a soldier’s heart in the Cotswolds, it was a risk that went against all he’d learned from the medical textbooks of the day. By exposing blood to the foreign surfaces of the heart–lung machine, John Gibbon took a huge risk, as did Walton Lillehei with his reckless but brilliant cross-circulation operations, the only medical interventions in history outside the maternity ward that posed the risk of 200 per cent mortality. All progress in medicine and surgery is predicated on risk, yet I was taught to avoid it. Fortunately, things changed.
Character is said to be the product of nature and nurture, the former being the hand genetics deals to us. Then from birth onwards we are moulded by life’s events. I started out well enough. My mother was an intelligent woman who was deprived of an education but read The Times. During the Second World War with the men away, she managed the Trustee Savings Bank on the High Street. One of my earliest recollections was that every birthday she took me, along with a bunch of flowers, to another woman’s home. I thought that strange, but eventually I came to learn the significance of her pilgrimage.
After a long and painful labour my mother brought me safely back from the carnage of the delivery suite. She was exhausted, torn and bleeding, but elated to have a pink, robust son wailing from the depths of his newly expanded lungs. In the next bed, a wide-eyed factory girl was suffering noisily. Spurred on by the bossy midwife, she was preoccupied with pushing and pain. Finally, her perineum split. The straining emptied her uterus, bowels and bladder all at the same time, and the midwife caught the greasy, bloodied newborn like a cricket ball in the slips. The bonny little girl lay on a starched white towel soaked in urine, while the slithering umbilical cord was clamped and cut. Her baby’s only dependable source of oxygen was now gone. Finally, the whole placenta separated and squelched out, to join the party in the outside world. Mother would need a gynaecologist to put things back where they should be – but not yet.
All babies are blue at birth, then they bawl as loudly as I did. It’s cold outside and they no longer hear that soothing maternal heartbeat. Freed from their claustrophobic cocoon, they thrash their little arms and legs around and suck in air for the first time. At that point they should turn pink. This little mite stayed blue and silent. Listless, with eyes wide open but seeing nothing.
The midwife recognised that things were not right. She vigorously rubbed the baby’s greasy back and swept her finger around its throat. Rough stimulation suddenly caused its breathing efforts to begin, but with a whimper not a roar. And the baby remained blue, a darker blue despite the rapid breathing, and still cool and limp. Now beginning to panic, the midwife called for an oxygen cylinder and some help. At first, the tiny oxygen mask helped. Baby’s muscle tone improved but her grim slate blue colour persisted. The doctor arrived and listened to the tiny heaving chest with his stethoscope. There was a heart murmur, not loud but clearly audible when searching for something specific. It transpired that the artery to the lungs hadn’t developed properly – pulmonary atresia, we call it. Dark blue blood returning from the tiny body streamed through a hole in the ventricular septum and back around the body. The chaotic circulation was progressively depleted of oxygen, accumulating more and more acid. The baby was doomed. A ‘blue baby’. The doctor shook his head and walked away. Nothing could be done to help.
All this passed the mother by as she sweated in pain and perineal Armageddon. She was impatient to hold her new daughter. As they handed over the dying infant, the midwife’s grave expression told the story, as did the child’s pathetic face, lifeless and grey, eyes rolling aimlessly. Our factory girl pleaded for an explanation. Why so still and silent? Why not pink and warm like me in the cot next door? Milk started to flow, but there was no suckling. In 1948 blue babies died.
They returned to the maternity bed next to my mother. There was a stark contrast in mood after nine months of excitement and anticipation – one woman radiant, proud and optimistic with her robust, pink son, the other desolate with a grey, motionless little girl left to die in her arms. The curtains were pulled around. Her expectant husband was stuck at work, rolling steel, never to see his daughter alive. The hospital chaplain arrived as a matter of urgency to christen the child as life ebbed away. It was probably too late, but they went through the motions.
This emotional meltdown already greatly saddened my mother, then the contrasts deepened at visiting time when the families arrived. There were repeated emotional breakdowns as the young woman’s parents, then the bereaved husband, arrived too late to see the dead baby before it was spirited away in a shoe box. Feelings of guilt quickly followed. What did she do wrong? Was it the cigarettes? Or was it the sickness pills? Should she have gone to church? My own family’s joy was tinged with compassion for the poor girl. My mother stayed in the maternity bed beside her for five days while she was taken for pelvic surgery, with nothing to bring home but sadness and stitches.
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Stephen Westaby
An intimate and compelling exploration into the unique psyche of the heart surgeon, by one of the profession’s most eminent figures.Although Professor Stephen Westaby was born with the necessary coordination and manual dexterity, it was a head trauma sustained during university that gifted him the qualities of an exceptional heart surgeon: qualities that are frequently associated with psychopathy. His thirty-five-year career has been characterised by fearlessness and ruthless ambition; leaving empathy at the hospital door as thousands of patients put their lives in his hands.For heart surgeons, the inevitable cost of failure is death and in The Knife’s Edge, Westaby reflects on the unique mindset of those who are drawn to this exhilarating and often tragic profession. We discover the pioneers who grasped opportunities and took chances to drive innovation and save lives. Often difficult, uninhibited and fearless, theirs is a field constantly threatened by the risk of public failure.Like those before him, Westaby refuses to draw the line in his search of a lifetime solution to problems of the heart. His determination is unerring – a steadfastness underpinned by his unusual mind. But as we glimpse into the future of cardiac surgery, for all its remarkable scientific advancement, one question remains: within the confines of socialised medical healthcare systems, how can heart surgeons – individuals often hardwired with avoidance of self-doubt, a penchant for glory and a flagrant disregard for authority – truly flourish?
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copyright (#u02de273e-a631-5f22-b6be-1ce6612625a5)
Certain details, including names, places and dates, have been changed to protect privacy.
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First published by Mudlark 2019
FIRST EDITION
© Stephen Westaby 2019
Cover layout design Claire Ward © HarperCollinsPublishers 2019
Cover images © Granger/Bridgeman Images (heart engraving), Shutterstock.com (scalpel)
Stephen Westaby asserts the moral right to be identified as the author of this work
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Source ISBN: 9780008285777
Ebook Edition: April 2019 ISBN: 9780008285807
Version: 2019-04-17
dedication (#u02de273e-a631-5f22-b6be-1ce6612625a5)
For Sarah, who saved me from myself, together with Gemma and Mark, then Alice and Chloe, the children and grandchildren who give me so much pleasure.
contents
1 Cover (#u9a74612b-e8d6-5914-a31a-938f2131c790)
2 Title Page
3 Copyright
4 Dedication
5 Contents (#u02de273e-a631-5f22-b6be-1ce6612625a5)
6 Preface
7 Introduction
8 1 Family
9 2 Sadness
10 3 Risk
11 4 Hubris
12 5 Perfectionism
13 6 Joy
14 7 Danger
15 8 Pressure
16 9 Hope
17 10 Resilience
18 11 Misery
19 12 Fear
20 Acknowledgements
21 Glossary
22 By the Same Author
23 About the Publisher
LandmarksCover (#u9a74612b-e8d6-5914-a31a-938f2131c790)FrontmatterStart of ContentBackmatter
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preface (#u02de273e-a631-5f22-b6be-1ce6612625a5)
Every single heart operation risks a life. This tension between kill or cure is unique to my specialty, with no professional equivalent, and few people can live with it on a daily basis. During my formative years, to operate within the heart was seen as the last surgical frontier. Direct vision repair was considered as difficult as landing on the moon or splitting the atom. Then the heart–lung machine and the swinging sixties changed everything. Heart transplants and artificial hearts both emerged during my impressionable medical school years. When I embarked on training in the 1970s, heart surgery remained an exclusive and remote club that was exceptionally difficult to join. Yet I was eventually granted the profound privilege of being able to improve thousands of lives.
Each heart is unique in its own way. Although most operations prove straightforward and uneventful, some evolve into an extraordinary battle for survival and a few are quite literally a bloody disaster. As my experience and knowledge increased, I became a last port of call for the cardiologically destitute, a depository for cases that no one else wanted, at home and abroad. Ultimately I lost patients whom I knew could be saved with equipment we were denied in the NHS. The recriminations that accompany death soon followed. An agonising interview with the bereaved, dismal discussions at the ‘Morbidity and Mortality Meeting,’ then a joyless visit to the coroner’s court. I was vehemently outspoken about the system’s deficiencies, and suffered as a result. The NHS doesn’t care for those who do not conform.
In this book I have set out to describe how it felt to be a heart surgeon as the specialty emerged and what it is like in the current hostile environment. I have depicted the physical and the psychological endeavour, the emotional highs and lows, the triumphs and the disappointments, and how being a surgeon affected me and my loved ones. When I was a young man, as we shall see, a peculiar quirk of fate helped me by dispelling my inhibitions and rendering me immune to fear. It’s not something I would freely recommend and it was a curious launchpad for a career at the sharp end, one that enabled me to embrace challenges that others would wish to avoid.
For someone who is not a professional writer, it takes an inordinate amount of time and effort to write a book for public consumption. You will undoubtedly conclude that I was more the surgeon than the literary genius, yet to my delight my first book, Fragile Lives, became an award-winning bestseller. As the title suggests, the book largely focused on remarkable cases. The Knife’s Edge is darker. It describes my humble beginnings, my struggle to succeed, and my priceless relationships with some of the pioneers and great leaders of the specialty. Because of the huge risks involved and the pile of bodies that ensued, the pioneers all manifested a particular personality type – bold, determined, often flamboyant, with resilience and immunity to grief. Sadly, so taxing is the lifestyle that by the end of my career few UK graduates were prepared to make it their calling and career. The ‘end of an era’, or the ‘end of the beginning’ as some would put it.
The whole riveting story of modern heart surgery evolved during my lifetime, and I was proud to be part of it.
introduction (#u02de273e-a631-5f22-b6be-1ce6612625a5)
Just weeks after my surgical career came to an end I was invited to present the prizes at a local school speech day. The headmistress urged me to treat the teenagers as adults, and suggested that I convey to them what personal qualities I possessed that enabled me to become a cardiac surgeon. By this stage I had a stock response: ‘To study medicine,’ I said to the assembled schoolchildren, ‘demands an unstinting work ethic and great determination. Then it requires more than a modicum of manual dexterity, together with supreme confidence to train as a surgeon. To aspire to become a heart surgeon and risk a patient’s life every time you operate is a step beyond. For that you need the courage to fail.’
This last phrase wasn’t original – it was regularly used to describe the heart surgery pioneers in the era when more patients died than survived – but the kids didn’t know that. I decided to omit the claim that gender, social class, colour and creed played no part, because I really didn’t believe it myself. Nor did I regard myself as possessing all the qualities I talked about. I was more of an artist. My fingertips and brain were connected.
After rewarding the school swats, I started nonchalantly answering questions about my achievements in Oxford. With considerable insight, one biology boffin asked how it’s possible to operate inside an organ that pumps five litres of blood every minute and whether the brain dies if the heart stops. Another wanted to know how to get to the heart when it’s surrounded by ribs, breast-bone and spine. Then the art teacher asked what causes blue babies, as if someone paints them blue.
Coming to the end of the session, a bespectacled little girl with pigtails raised her hand. Standing up like a poppy in a cornfield, she boomed out, ‘Sir, how many of your patients died?’
So loud was her earnest approach that there was no way I could pretend not to hear. One set of parents tried to disappear under the floorboards while the flustered headmistress began explaining that it was time for the honoured guest to now leave. But I couldn’t ignore this inquisitive individual in front of her friends. I considered the question for a moment, then had to confess: ‘I really don’t know the answer to that. More than most soldiers but fewer than a bomber pilot, I guess.’ At least fewer than Enola Gay over Hiroshima, I thought to myself cynically.
Quick as a flash, Miss Curiosity probed again. ‘Can you remember them all? Did they make you sad?’
Another brief moment of deliberation. Could I admit to a hall full of parents, teachers and schoolchildren that I had no idea exactly how many patients I had dispatched, let alone recall their names. I could only muster one response: ‘Yes, every death upset me.’ I waited to be struck down with a thunderbolt but mercifully that was the end of our brief dialogue.
It was only after I stopped being an inadvertent serial killer that I began to remember patients as people, rather than simply recalling mortality statistics and the many times I went along to autopsies or coroner’s courts. And there were deaths that haunted me, not least the young people who succumbed needlessly to heart failure. Those who were not accepted for transplantation but who could have been saved with the new circulatory support devices that our NHS declined to pay for.
In the 1970s one in five of my boss’s cases at the Brompton Hospital died after surgery. As a cocky trainee I would greet each patient, record their medical history, then listen to their fears and expectations about the upcoming operation. Most were severely symptomatic, having waited months to come to the famous hospital in London. It didn’t take long for me to predict the ones who wouldn’t make it, usually the ones with rheumatic valve disease who arrived in a wheelchair and could barely speak on account of their breathlessness. Breathlessness is uniquely terrifying, likened by the patient to drowning or suffocation. They didn’t die because of poor needlework. They simply couldn’t tolerate their time on the heart–lung machine or the poor protection afforded to heart muscle during surgery in those days. We all knew that the slower the surgeon, the more likely the patient was to die. We would take bets on it. ‘If X does the valve replacement he stands a chance. But he’s buggered with Y.’
That was the way it used to be in the NHS. Treatment was free, so the punters didn’t question what was on offer. Life or death followed from the toss of the dice. But the finality of death was still devastating. The consultants would shield themselves from all the misery by dispatching us juniors to talk with the family.
I seldom had to speak. The bereaved relatives would recognise the slow walk with dropped shoulders and head down as I approached. They could read my unequivocal ‘bad news’ expression. After the reflex indrawing of breath came shock, my words ‘Sorry’ and ‘Didn’t make it’ triggering emotional disintegration. The sudden relief of suspense and the subsequent crushing grief were often followed by dignified resignation, but sometimes by abject denial or frank meltdown. I’ve had hysterical demands for me to return to theatre and resurrect the corpse, to resume cardiac massage or put the body back on the bypass machine. It was particularly heart-breaking for the parents of young children, little ones who had just developed their own innocent personality. As I saw it, newborn babies just screamed and pooed, but toddlers were well on their way to becoming people. They walked in holding Mummy’s hand and clutching their teddy bears, which all too often were carried off with them to the mortuary fridge. Yet the minute I turned and walked away from these families, my sorrow was filed in the out tray. Eventually, when I started to lose my own patients, I became well used to it.
Only once did it strike me that I had murdered someone, and the grim circumstances came as a shocking and bloody reminder that I was not invincible. It was a third-time operation on the mitral valve of a middle-aged patient who had a huge heart on the chest X-ray and excessively high pressures in the right ventricle situated directly below the breast-bone. I always took precautions when reopening the chest after previous surgery, and had started to request a CT scan to determine the gap between bone and heart. This led to me being admonished for adding to the costs of my many reoperations – only committees were allowed to sanction additional expense. The gentleman’s anxious partner accompanied him to the anaesthetic room and I urged her not to worry. I told her I was very experienced and would take good care of him.
‘That’s why we came to you,’ she replied, her voice quivering with apprehension. She kissed his forehead and slipped out.
I drew the knife along the old scar and used the electrocautery to singe the outer table of the sternum. The wire cutter snipped the steel wires from the second operation, which I then tore out with heavy grasping forceps. It was just like pulling teeth – should they break, it makes life difficult. The oscillating saw screeched against them as if screaming, ‘I’m not designed to cut steel.’ Then came the tricky bit, which involved edging my way through the full thickness of bone with a powerful saw designed not to lacerate the soft tissues beneath. I had safely reopened the sternum for hundreds of reoperations, but this time there was a great ‘whoosh’. Dark blue blood hosed out through the slit in the bone, poured down my gown, splashed onto my clogs and streamed across the floor.
I let out a chain of expletives. While I pressed hard over the incision to slow the bleeding, I instructed my jelly-legged assistant to cannulate the blood vessels in the groin so we could get onto the bypass machine. As the anaesthetist frantically squeezed in bags of donor blood through the drips in the neck, it all went dreadfully wrong. The cannula dissected the layers of the main leg artery so we couldn’t establish any flow. With continued profuse haemorrhage, I had no alternative but to prise open the rigid bone edges and attempt to gain access to the bleeding beneath, forcing a small retractor through the bony incision and cranking it open. But there was no gap between the underside of the bone and heart muscle. The cavernous, thin-walled right ventricle had been plastered by inflammatory adhesions to the bone by a previous wound infection. So I found myself ripping the heart asunder and staring at the underside of the tricuspid valve. Both the hand-held suckers, then the heart itself filled with air as I fought for better access. I then found that this tissue-friendly saw had also transected the right coronary artery. My paralysed registrar simply gaped, as if to say, ‘How the fuck are you going to get out of this mess?’
There was nothing I could do in time to save him. Deprived of oxygen, the heart soon fibrillated, so at best – had I persisted – he would have suffered devastating brain injury. So I called time on the gruesome spectacle. The whole shambles had taken less than ten minutes. Apologising to the nurses who had to lay him out and clean the floor, I tossed away my gloves and mask in disgust. The whole bloody catastrophe was straight out of Saw II or Driller Killer. It felt as if I had driven a bayonet into the man’s heart and twisted the blade. Then, just as had been done to me during my formative years, I dispatched the registrar to talk to the man’s wife while I went off to the pub.
I didn’t see the poor lady again until the inquest, where she sat unaccompanied, listening intently. She bore no malice, nor was the coroner critical in any way. The gruesome fact was that I had unintentionally sawn open that heart and emptied the circulation onto my clogs. In my own mind, I knew that a CT scan would have prompted me to cannulate the man’s leg vessels myself, which could have averted the tragedy and was something that I always did after that. Undeterred, I reopened a sternum for the fifth time in front of television cameras just weeks later.
Most deaths in surgery are wholly impersonal. The patient is either covered in drapes on the operating table or obscured by the grim paraphernalia of the intensive care unit. As a result, my most haunting experiences of death stemmed from trauma cases. The sudden, unexpected process of injury pitches an unsuspecting individual into their own Dante’s Inferno. Knife and bullet injuries were predictable and easy for me. Cut open the chest, find the haemorrhage, sew up the bleeding points, then refill the circulation with blood – such cases always provoked an adrenaline rush, but usually involved young, healthy tissues to repair.
My own worst nightmare wasn’t caused by a gun or a knife. As a young consultant I was once fast-bleeped to the emergency department to help with an incoming road accident. It was still what was called the ‘swoop, scoop and run’ era, so the patient was being brought in directly without transfusion of cold fluid to screw up the blood clotting. With foresight and sensitivity, the police had already warned reception what to expect, but unfortunately I’d not been party to that. I was outside in the ambulance bays enjoying the sunshine when the vehicle came thundering up the drive, siren blaring and blue lights flashing. When the rear doors were thrown open, the crew wanted a doctor to take a look before they risked moving the patient again.
I could hear the whimpering before I could see the girl, but I knew from the paramedic’s grim expression that it was something unpleasant. Unusually awful, in fact. The teenage motorcyclist was lying on her left side, covered by a blood-soaked white sheet. This sheet and what I could see of her face were the same colour. The poor girl had been drained of blood. Normally she would have been shunted quickly through to the resuscitation room, but there was every reason not to rush.
The paramedics quietly and deliberately drew back the sheet so I could see that the girl was transfixed by a fence post. A witness had watched her motorcycle swerve to avoid a deer, then she veered off the road, smashing through a fence into a field. She was left skewered like meat on a kebab stick. The fire brigade eventually released her by sawing through the fence and lifting her free. This left the stake protruding from her blood-soaked blouse. The response of the gathering team was to glare incongruously at the gruesome transfixion and ignore that horrified face behind the oxygen mask.
I took her cold, clammy hand more in clinical assessment than humanity. She was in circulatory shock, not to mention profound mental turmoil. Her pulse rate was around 120 beats per minute, but the fact that I could feel it suggested that her blood pressure was still above 50 mm Hg. Before we moved her I needed to scrutinise the anatomical features of the injury so as to predict what damage we would be confronted with. I had seen several cases of transfixion trauma where the patient survived because the implement narrowly missed or pushed aside all the vital organs. Here the degree of shock indicated otherwise. It was time to get some cannulas in place in a calm and controlled manner, and bring group O negative blood ready to transfuse her. And for pity’s sake, she deserved a slug of morphine to take the edge off the sheer terror of her predicament.
Some things I knew instinctively. Had the stake damaged the heart or aorta she would have bled out at the scene. Traumatised small arteries will go into spasm, clot and stop the bleeding themselves as long as injudicious clear fluid infusion doesn’t raise the blood pressure and blow the clots off. So I surmised that most of the bleeding must be coming from the veins, which do not constrict. I asked the nurses for some scissors to remove her clothing, now stiff with dried blood. It was like cutting through cardboard and opening a window on the grim reality of her situation.
Her pleading brown eyes remained firmly fixated on the stake. I could make out the jagged ends of ribs protruding through macerated fat and pale, bruised skin. The post had entered directly below her right breast, marginally to the right of the midline, and emerged from her body higher up in her back, suggesting that she had slid feet first after tumbling from her motorcycle. My three-dimensional anatomical knowledge left me in no doubt which structures had been damaged. The post must have taken out her diaphragm and liver, the lower lobe of her right lung and probably the largest vein in the body, the inferior vena cava. The lung wasn’t a problem. But if her liver was pulped and the veins torn off the cava, I knew that we couldn’t fix her. Scrutiny of the post protruding from her back confirmed my fears – there were fragments of both liver and lung on the wooden shards. Everyone knows what liver looks like from the butcher’s, while youthful lung is pink and spongy. I recognised both, and it made me sad.
In just seconds on a Saturday morning she had gone from vivacious carefree student to dying swan transfixed like a vampire. With every agonising breath, blood slopped from the wound edges. Whatever the way forward, I had to talk to her. I edged around the trolley and knelt by her head to distract her as the emergency doctors painfully probed with needles to locate an empty vein. With blood and froth dripping from her mouth, she was finding it difficult to breathe, let alone speak. We needed to put her to sleep right there in the ambulance, then get a tube into her windpipe – a seemingly impossible task in that awkward position. By now I was pretty sure that whatever we did she would die. If not soon, it would be in days or weeks as a result of infection and organ failure in the intensive care unit. So whatever else we attempted to do for her, we had to be kind. Do as little as possible to add to her pain.
Staring directly into her eyes I asked her name. I was simply trying to inject a semblance of humanity into the proceedings and relieve the brutality of it all. Stuttering between breaths, she told me she was a law student, like my own daughter Gemma, which added to my discomfort. I took her icy cold fingers in my right hand and rested my left hand on her hair, hoping to obscure that stake from her gaze.
With tears streaming down her cheeks she murmured, ‘I’m going to die, aren’t I?’
At that point I ceased being the surgeon because I knew she was right. For her last agonising moments on earth I could only comfort her. So I would be her substitute dad for that time. I held her head and told her what she wanted to hear. That we would put her to sleep now and when she awoke everything would be back in its place. The stake would be gone. The pain and fear would be gone. Her shoulders dropped and she felt less tense.
The gadget clipped onto her index finger showed very low oxygen saturation, so we had to move her to give the anaesthetist his chance with the endotracheal tube. Only then could we begin a token effort at resuscitation. I extended my hand to feel her belly, which was distended and tense. As we explained the need to move her, I could sense her consciousness fading.
She whispered, ‘Can you tell mum and dad that I love them, and I’m sorry? They never did want me to have that bike.’
Then she coughed up a plug of blood clot. As she rolled backwards the stake shifted, grating audibly against her shattered ribs. Her eyes rolled towards heaven and she slipped away. Whatever blood she had left in her circulation was pouring out over me. But I didn’t mind. It was a privilege to be there with her. The junior doctors from the resuscitation room stirred, intending to begin cardiac massage. Without hesitation I told them to back off. What the fuck did they expect to achieve?
The back of the ambulance fell silent with the horror of it all. I would have loved to have dragged that hideous fence post out of her chest – that had to be left to the pathologists. I couldn’t bring myself to watch her autopsy, but it confirmed that her diaphragm had been torn away and her pulped liver avulsed from the inferior vena cava.
That balmy summer’s evening I went walking through the bluebell woods of Bladon Heath with Monty, my jet black flat-coated retriever. While he chased rabbits, I sat on a fallen tree carpeted in moss and wondered if there was a God. Where was he on those fraught occasions when I needed some divine intervention? Where was he today when that poor girl tried to avoid hurting a deer and was killed by her kindness? I visualised her devastated parents sitting with a cold corpse in the mortuary, holding their daughter as I’d done in the ambulance, beseeching God to turn the clock back.
There was no point trying to be logical about religion. I knew that high-ranking Oxford – and indeed Cambridge – academics scoffed at the deity concept. Both Richard Dawkins and Stephen Hawking had that gold-plated atheistic confidence in their own abilities, spurning outside help. I guess I was the same. But I would still sneak into the back of a college auditorium and listen to debates on the subject. Some disputed God’s existence because of all the evil and misery in the world, and while I could identify with that, I had contrary and privileged insight through the odd patient who actually claimed to have reached the Pearly Gates before we clawed them back.
These vivid out-of-body experiences were rare but occasionally compelling. One spiritual lady described floating calmly on the ceiling as she watched me pumping her heart with my fist through an open chest. Forty minutes into this internal cardiac massage my thumb tore through into her right ventricle – she clearly recalled my words: ‘Oh shit, we’ve had it now.’ Fortunately, the perfusionists arrived with the circulatory support system I needed to keep her alive, and I succeeded in repairing the hole.
She uncannily related her memory of the events a number of weeks later in the clinic. Having been party to her own resuscitation attempts from above, she had floated through the clouds to meet with St Peter. This journey amid peace and tranquillity contrasted sharply with our gruesome efforts back down on the ground. But having arrived in heaven she was told she had to return to earth and wait her turn again – a ridiculously close-run thing between me and Grim Reaper. Perhaps God changed as he got older. Maybe he started out with the best of intentions but became cynical and less caring with time. Just like the NHS.
It was only after retiring from surgery that I began to reflect on my role in dispatching so many to that great hospital in the sky. One tranquil spot on the heath still holds a great deal of significance for me. It is a haunted place, a gap in the woodland that overlooks both Blenheim Palace, where my hero Winston Churchill was born, and St Martin’s Church, Bladon, where he is buried. A few yards from this clearing a jet plane that had just taken off from Oxford Airport crashed and exploded.
My son Mark was working for exams in his bedroom and watched the whole spectacle unfold. Heroically, he was the first to reach the drama in the field but could do nothing amid the conflagration. He watched the cockpit burn and cremate the occupants. Obviously at seventeen he had a different constitution to his lobotomised father, so the dismal spectacle disturbed him as it might any normal person. After dropping a single grade in biology he was dumped by his chosen university. I was very bitter about that. I still am.
One day when we reached this sacred ground, Monty spotted a stag silhouetted against the evening sky a hundred or so yards up the ride. A shaft of evening sunlight shone through the trees to illuminate a clump of fading bluebells, their heads dipping at the end of their season. Was that majestic stag in fact God looking down on me, surrounded by the spirits I had set free during my career, the ghosts of operations past?
In truth, I had always been a loner. I was still a restless insomniac who would wake in the early hours and write, making stupid notes on material I would never use, continuing to invent impossible operations that no one would ever perform. Did I miss surgery? Not at all, surprisingly enough. Forty years had been plenty. But it remained a great mystery to me how I had achieved so much from my humble beginnings in the backstreets of a northern steel town. Perhaps it was that battle to escape obscurity that provided the momentum. I wanted to be different, and I had the ruthless ambition to take on the system and overcome my past.
Although I spent my whole career writing textbooks and scientific papers for the profession, I reflected for many years on whether it was appropriate to discuss my battles in a public forum. Ironically it was my own patients who urged me to do so, even the loved ones of some who died. So many were eager for their stories to be told. From my own perspective, I always found the history of modern heart surgery to be among the most compelling stories ever told. As a trainee in London and the US I actually knew a number of the pioneers personally, and they had shared their own trials and tribulations with me face to face, encouraging me to make a difference, not to sit in the shadows avoiding conflict. And I certainly attracted trouble right from the start.
The government’s policy of releasing named-surgeon death rates to the press was another factor that edged me towards writing a tome for consumption by the general public. What is life really like on the other side of the fence? Is it different from being a statistician, politician or a journalist? The barrister and medical ethicist Daniel Sokol wrote in the British Medical Journal, ‘The public has an appetite for glimpses of the private lives and thoughts of doctors. They demystify a profession that was once deemed blessed with magical powers.’ Perhaps some of us still do have mystical powers. There are few things more intriguing than delivering electricity into a patient’s head through a metal plug screwed into their skull like Dr Frankenstein’s monster or reinventing human circulation with continuous blood flow without a pulse. These innovations may be construed as witchcraft, but they were my own practical solutions to the terrible illness that is heart failure. Sokol went on to say that doctors are in the habit of revealing ‘not the chiselled frame of Apollo … but the wart covered body of Mr Burns, the Simpsons character’. But Burns was the rich factory owner. I’m more of a sensitive intellectual, like Bart Simpson’s father Homer.
As is often the case, the French have a phrase for it: ‘se mettre à nu’, to get naked. So that is what I decided to do, although this was a much more interesting spectacle in my younger years than now. My own insight tells me that the public are happier to learn that their surgeon, even a heart or brain surgeon, is human and subject to the same core emotions as anyone else. But because of a freak sporting accident, some qualities possessed by the vast majority of people were lost to me for a while, which proved an unexpected but substantial boost to a career at the sharp end – life perpetually on the ‘knife’s edge’.
1
family (#u02de273e-a631-5f22-b6be-1ce6612625a5)
When I searched the internet for a contemporary description of the surgical personality, I found this:
Testosterone-infused swagger, confident, brash, charismatic, commanding. Arrogant, volatile, even bullying and abusive. Aggressive. Cuts first, asks questions later, because to cut is to cure and the best cure is cold steel. Sometimes wrong but never in doubt. Good with his hands but no time to explain. Compassion and communication are for sissies.
The psychologist author argued that the highly stressful, adrenaline-fuelled environment in which surgeons work attracts a certain personality type. And so it does. Cutting into people, then wallowing in blood, bile, shit, pus or bone dust is such an alien pastime for normal folk that the mere process of operating immediately sets us apart. Those with introspection and self-doubt select themselves out from my specialty.
It is hard to describe how agonisingly difficult it was to gain access to a cardiac surgery training programme in the 1970s, when open heart surgery with the heart–lung machine was only in its second decade. The surgeons of that era were an unashamedly elitist group with the guts, skill and sheer daring to expose a sick heart and attempt to repair it. Methods to protect the muscle when it was starved of blood were frequently inadequate, and prolonged interaction between blood and the foreign surfaces of the bypass machine triggered a damaging inflammatory reaction known as the ‘post-perfusion syndrome’. Heart surgeons therefore needed above all to work against the clock – deaths were a daily occurrence, yet most patients were so sick that this wasn’t considered a catastrophe. While survival and symptomatic relief were gratifying, death put an end to suffering. Consequently, most families were grateful that their loved ones had at least a chance of their condition improving through surgical intervention.
We all had to go through general surgery training first to show that we had what it takes. First, good hands – and you have to be born that way. Most organs just sit there while you cut and sew them, but the heart is a moving target, a bag of blood under pressure that bleeds torrentially if you bugger it up. Just touching it clumsily can provoke disorganised rhythm and sudden cardiac arrest. Second, the right temperament – the ability to explain death to grieving relatives and to bounce back from a bollocking in the operating theatre. Then courage – the bravery to take over from the boss when he’s had enough, the guts to take responsibility for the post-operative care of tiny babies or to address a catastrophe in the trauma room when the nearest consultant is an hour away. Then patience and resilience – being able to stand there as first assistant for six hours without losing concentration, sometimes with a hangover, or to face five days continuously on call in the hospital, day and night without respite. That was surgical training in those days.
A series of infernal exams to become a fellow of the Royal College of Surgeons was an additional burden over and above the clinical work. These covered every aspect of surgery and only a third of the candidates passed each time. It didn’t matter that I wanted to operate in the chest. For the ‘primary’ fellowship we were required to know the anatomy of a human being in minute detail, brain to asshole, teeth to tits – every nerve, artery and vein in the whole body, where they went, what they did, what happened if we damaged them. We had to learn the physiological processes of every organ and the biochemistry of every cell. After some basic operative experience, the ‘final’ fellowship examined us on the pathology of every surgical condition in the book, then the diagnostic and surgical techniques for each specialty. Only after conclusively demonstrating comprehensive knowledge and skills were we allowed to move on and specialise. I failed both the primary and final fellowship on first sitting, an expensive exercise. Most of my associates did too. The whole miserable process was there to sort the wheat from the chaff, and I wasn’t fazed by failure. It was just like rugby, the sport I loved above all others. Some games you won, others you lost.
The surgical world resembles the army. The consultants are the officers and the gentlemen, the trainees line up in tiers through the ranks: senior house officer is equivalent to corporal, registrar acting as sergeant, senior registrar akin to a non-commissioned officer doing all the work and eventually being promoted to the officer’s mess. That final step was the most competitive of all. For the ruthlessly ambitious it had to be a top teaching hospital. Heart surgeons strove for London hospitals like the Royal Brompton, the Hammersmith, Guy’s or St Thomas’. Appointment to one of these, and you had made it big time. In those days Cambridge had a vibrant cardiothoracic centre in Papworth village out of town. Oxford was doing very little.
All this took place during our formative years, our late twenties and early thirties, when normal people cement relationships, settle down in one location and start a family. Trainee surgeons lived like gypsies, moving from city to city – wherever the best posts were advertised. Something about being a surgeon elevated us to a different plane. We were the fighting cocks of the doctors’ mess, the flash Harrys who constantly strove to outdo each other and ruthlessly coveted the top jobs; the guys – and at that time, as now, it was almost exclusively guys – who stayed in the hospital night after night seeking every chance to operate, or, if it was quiet, drifting across to the nurses’ quarters, where other exciting action was easy to find.
I was a backstreet kid from Scunthorpe who had married his childhood sweetheart from the local grammar school. Caught up in this whirlwind of ruthless ambition, things changed and marriage became an unintended casualty. I was ashamed of this, but I knew some surgical teams where every member, from junior houseman to consultant, was having an affair in the hospital. Grim in reality, but the stuff of television soaps that glamorise adultery. So widespread was the problem that the Johns Hopkins Hospital in Baltimore carried out a formal study of divorce as an occupational hazard in medicine. The younger their residents were when they married, the higher their divorce rate. Understandably, divorce was commonplace when the spouse did not work in the medical field. Blame it on the communication gap. They had little to talk about because doctors – and especially surgeons – are engrossed in their hospital life.
The Johns Hopkins study showed that more than half of psychiatrists and one in three surgeons divorced. Cardiac surgery had an impressive divorce rate, which I already knew from my colleagues’ experience. Reasons cited were high testosterone levels, long hours and nights in the hospital, and close working relationships with numerous attractive young women, often in stressful and emotional circumstances. Professional bonds are formed, and these evolve into romance. At one stage the Dean of Duke University Medical School saw fit to warn applicants that the institution was experiencing a greater than 100 per cent divorce rate. Why exceeding the maximum? Because students showed up already married, got divorced, then remarried and divorced a second time. They all lived a life in which work was seen to come first, with everything else a distant second.
Once at a conference in California I picked up a copy of Pacific Standard magazine that contained an article entitled ‘Why are so many surgeons assholes?’. Obviously it was about prevailing personality types. A scrub nurse friend of the journalist described an incident in the operating theatre where she had passed the sharp scalpel to the surgeon and he lacerated his thumb on the blade. Now furious, he shouted at her, ‘What kind of pass was that. What are we, two kids in the playground with Play-Doh? Ridiculous.’ Then to emphasise his point he threw the scalpel back at her. The nurse was horrified, but as she didn’t know how to react she just kept quiet. No one stood up for her, and no one ever reprimanded the surgeon for being aggressive or throwing the sharp instrument. The inference was that this is how a lot of surgeons behaved and they get away with it all the time.
I have known many surgeons who threw instruments around the room, and although I never aimed one at an assistant I did use to toss faulty instruments onto the floor. It meant that I couldn’t be given them a second time. Having said that, most successful surgeons have certain malign traits in common. These have been summarised in the medical literature as the ‘dark triad’ of psychopathy, Machiavellianism – the callous attitude in which the ends are held to justify the means – and narcissism, which manifests as the excessive self-absorption and sense of superiority that goes with egoism and an extreme need for attention from others. This dark triad emanates from placing personal goals and self-interest above the needs of other people.
Just in the last few months psychologists at the University of Copenhagen have shown that if a person manifests just one of these dark personality traits, they probably have them all simmering below the surface, including so-called moral disengagement and entitlement, which enables someone to throw surgical instruments with absolutely no conscience at all. This detailed mapping of the dark triad is comparable to Charles Spearman’s demonstration a hundred years ago that people who score highly in one type of intelligence test are likely to perform equally well in other kinds. Perhaps the daunting road to a surgical career inadvertently selects characters with these negative traits. It certainly appears that way, yet I had a very different side to my personality when it came to my own family. Maritally I fell into the same old traps, but I would go to any lengths to make my children happy or my parents proud.
I was not rostered to be in surgery as it was my daughter Gemma’s birthday and I hoped to be free. The phantom father who had let her down so many times in the past, I planned to drive to Cambridge in the afternoon to surprise her. Then I discovered that three of our five surgeons were out of town. Two were committed to outreach clinics at district hospitals trying to bring in ‘customers’, as the NHS now called them, or better still the odd private patient. The third was away at a conference, one of those academically destitute commercial meetings at a glamorous resort paid for by the sponsor, with business-class flights and all the rest. As a gullible young consultant I had enjoyed these trips, but it eventually wears thin – tedious airports, buckets of alcohol and forced comradery with competitive colleagues who would cheerfully drive their scalpel into your back the minute it was all over.
It was this surgeon’s operating list that lay vacant, and the unit manager had twisted my arm to stand in for him. To let an operating theatre with a full complement of staff lie idle for the day was a criminal waste of resources, so I reluctantly agreed to the request. I had built this unit from nothing to being virtually the largest in the country, not that anyone could give a shit. The management changed so frequently that history was soon forgotten, dispatched to oblivion by the quagmire of financial expediency. So my daughter would have to wait. Again.
When I asked Sue, my secretary, to find two urgent waiting-list patients at short notice, I didn’t mention the birthday. Just two cases should see me on the road by mid-afternoon. I suggested that one should be the infant girl with Down’s syndrome who had been cancelled twice before. She was in danger of becoming inoperable because of excessive blood flow and rising pressure in the artery to the lungs. I bore special affection for these children. When I started out in cardiac surgery, many considered it inappropriate to repair their heart defects. I couldn’t get my head around a policy that discriminated against kids with a particular condition, so ultimately I overcompensated by taking them on as desperately debilitated young adults – trying to turn the clock back, sometimes without success.
The second case needed to be more straightforward. Sue had repeatedly been pestered by a self-styled VIP who held some snooty position in a neighbouring health authority. When I reviewed this lady in the outpatient clinic, she took exception to my suggesting that weight loss would not only improve her breathlessness but reduce the risks during her mitral valve surgery. I was sternly reminded that she had featured in a recent honours list, presumably for services dedicated to getting her onto an honours list, as is frequently the case in healthcare. I wasn’t in the slightest bit impressed – and she could see that. But she kept insisting on an early date and I couldn’t blame Sue for wanting her out of the way. The titled lady wouldn’t make first slot on the list, however. That was for the baby. A third cancellation was not an option.
6 am. As I set out for work from Woodstock, my home in Oxfordshire, shafts of sunlight burst through the turrets of Blenheim Palace like rays of optimism. I would be seeing Gemma on her birthday. When she was born I was nowhere to be found, and I’d spent twenty years trying to make up for that. Sue, who also suffers from traffic phobia, joined me in the office before 7 am, and we soon dispensed with the paperwork that I had to do before the adult intensive care ward round at 7.30. The day’s operating lists were already displayed on a white board at the main nurse’s station. The male charge nurse knew that my only adult patient was unlikely to reach the unit until mid-afternoon, but still felt obliged to warn me that beds were tight. Glancing towards the row of empty beds surrounded by unplugged ventilators and cardiac monitors, I didn’t need to ask. It was more of the same. ‘Tight on beds’ means not enough nurses. In the NHS, every intensive care bed must have a dedicated nurse. In other countries they double up quite safely to get the work done, but here we just cancel operations as if they were appointments with the hairdresser.
On this particular morning I didn’t know many of the nurses’ faces – and they didn’t recognise me. This told me that the night shift had relied heavily on agency staff. Two of my three cases from the previous day could leave the unit, but only when ward beds became available. Until then, they would continue to languish in this intimidating environment that never slept, at a cost exceeding £1,000 per day. Sometimes we’d even discharge patients directly home from intensive care when the ward was chronically blocked with the elderly and the destitute.
This was not how it used to be. >When we fought to build the department, just three heart surgeons would perform 1,500 heart operations each year and we’d cover the chest surgery between us. Now in the same modest facilities we had five heart surgeons performing half that number of cases, alongside another three chest surgeons operating on the lungs. This was the price of progress – twice as many highly trained professionals doing much less work amid a disintegrating infrastructure. But hey. A hospital delegation was trying to recruit nurses in the Philippines that very week, so all would be well one day.
8 am – and my early-morning optimism was already punctured. I left the cacophony of life support, pulsating balloon pumps, hissing ventilators and screeching alarms. I heard weeping relatives, suggesting that a bed might soon be vacated. Knife to skin should be at 8.30, and I expected the baby to be anaesthetised by now. I assiduously avoided watching parents part from their children at the operating theatre doors. It was traumatic enough for me when my son had his tonsils out. Heart operations were a cut above. When I told parents that their child had a 95 per cent chance of survival, all that registered was the 5 per cent possibility of death. Statistics don’t help when it’s your child that doesn’t make it. So I told them what they wanted to hear, then hoped it would be true.
But the anaesthetic room was empty. The anaesthetist was sitting in the coffee room eating breakfast.
‘Have we sent yet?’ I asked with an air of resignation.
She shook her head. We had to wait for the paediatric intensive care ward round to decide whether they could give us a bed. No bed, third cancellation. It couldn’t be allowed to happen, yet the round hadn’t even started. It was an 8.30 start at the other end of the corridor, so I went there directly. With rising blood pressure, I still tried to remain polite. The staff had desperately sick children to care for and my little patient was just another anonymous name in the diary, followed by the words ‘atrioventricular canal’. The whole centre of her heart was missing and her lungs were flooded. With every day that passed, her chances of survival decreased.
The trouble was that I loved the children’s intensive care unit. That little enclave of rooms was my escape from the rest of the hospital, a place that always put life – and my own troubles – in perspective. Only special people could survive the heartache in that place. The nurses liked to work with my heart surgery cases because the vast majority got better, a welcome relief from the ravages of children’s cancer, septicaemia or road-traffic accidents that they also had to deal with. The worst things in the world happened there, but everyone came back the next day to start all over again.
Every one of the cots had a little body in it, with fretful family groups gathered around. My eyes fixed on a pair of gangrenous arms – the meningococcal meningitis child I’d watched for weeks, hanging on to life. The mother knew me well enough by now, seeing my babies come and go with happy parents. I always asked her how things were going, she always smiled. Today they were going to amputate those black, mummified limbs. No more little hands or tiny fingers. They would just drop off, with a little help to tidy things up.
I asked whether there was any chance of a bed by lunchtime, so that we could at least send for the baby. Sister really didn’t want to let me down. One of her day-shift nurses was already in the radiology department with a head-trauma victim who’d been hit by a speeding car on the way to school. Should the injuries prove as severe as feared, ventilatory support would be withdrawn. Then my case could go to theatre. I enquired whether the organ donor phrase had been mentioned.
‘Do you want the bed or don’t you?’ she replied. ‘That route could take us well into tomorrow.’
For comfort I picked up a bacon sandwich, then wandered off in my theatre gear through the hordes who arrived for work at nine o’clock. These were normal people who didn’t have to split breast-bones, stop hearts or give desolate parents bad news, such as ‘Your child’s operation is cancelled again.’ Now the dilemma. Should I give up on the little girl, then send for the VIP and her mitral repair? The lady wouldn’t have been starved long enough or had a pre-med, but at least I could take off to Cambridge to see my daughter afterwards without the worry of leaving a newly operated infant when I wasn’t on call. Or should I hold out for the possibility of a bed for her parents’ sake?
Turning away from blank faces and the tacit acceptance of dysfunctionality, I diverted to radiology. They knew me well enough at the CT scanner and seemed relieved to discover that I was not attempting to take over their next slot. The images of the child’s battered brain emerged slice by slice. The skull had been cracked open like the top of a boiled egg. Where there should have been clear lakes of cerebrospinal fluid, there was nothing. The brain surgeon and intensive care doctors shook their heads in dismay. Nothing would be gained by operating. The cerebral cortex was pulp and the brain stem had herniated through the base of the skull. I was relieved that I couldn’t see that poor broken body concealed within the scanner. She had toddled off happily to the village school; now she hovered between earth and heaven, her brain already gone. So I had my intensive care bed. Relief for one set of parents, complete and utter desolation for another.
Striding purposefully back to the operating theatres, I requested that they send directly for my first case. The agency anaesthetic nurse hadn’t the faintest idea who I was and confronted me with the usual crap, saying that they hadn’t heard if there was a bed yet.
Uncharacteristically, and because I didn’t know the woman, I lost the plot and shouted, ‘I’m telling you there’s a fucking bed. Now send for the child.’
The anaesthetist stood in the doorway and gave me a long, hard stare. The nurse picked up the phone and called the paediatric intensive care unit sister. At that moment, I worried that others had not been informed that the trauma case was not for ventilation. But I got lucky. The response confirmed my outburst. Yes, we could send for the cardiac case.
To put the baby asleep and insert cannulas into her tiny blood vessels would take an hour, so to avoid the transmitted anxiety from the parents’ tearful separation from their baby girl, I slipped into the anaesthetic room of the thoracic theatre, carrying a plastic cup of ghastly grey coffee. This time I was warmly greeted by an old friend, whom I asked to measure my blood pressure. It was 180/100 – far too high, despite the daily blood pressure medication I had been taking for ten years.
As the fearful parents shuffled past the door I heard one of them say, ‘Please tell Professor Westaby we are grateful for this chance.’ I suspected they still didn’t believe that their baby would make it. Perhaps they were worried that we wouldn’t try as hard as we could because of the Down’s syndrome.
Would a concert pianist prepare for an important recital by first enduring three hours of intense frustration? Would a watchmaker have to face a blazing row before assembling a complicated Rolex movement? My job was to reconfigure a deformed heart the size of a walnut, yet I enjoyed zero consideration for my state of mind from those around me. I wouldn’t so much as get on a bus if the driver was subject to that much irritation. The first time I stood as the operating surgeon looking into the void at the centre of an atrioventricular canal defect, I thought, ‘Shit, what the hell do I do with this?’ Yet I always succeeded in separating the left and right sides of the heart with patches, then creating new mitral and tricuspid valves from the rudimentary valve tissue. It’s complex work, but I never lost one on the operating table.
I finally ran the stainless-steel blade through the baby’s skin at 11 am. As the first drops of blood skidded over the plastic drape, I remembered that I had not made contact with my daughter. That thought hit me just as the oscillating saw bisected the baby’s sternum, but there was nothing I could do about it now. I needed complete focus to reconfigure that tiny deformed heart and give the baby a lifetime without breathlessness or pain. So what did I need to consider? The new mitral valve must not leak, although it wouldn’t be too bad if there was a whiff of regurgitation through the tricuspid valve on the low-pressure side of the circulation. And we had to be careful not to damage the invisible electrical conduction system that crucially coordinates the heart’s contraction and relaxation. Otherwise she would need a permanent pacemaker. At that point I felt it would have been much easier to be a watchmaker or concert pianist …
As it turned out, that little heart would be the least of my problems that day. I separated the chambers with obsessively sewn patches of Dacron cloth, then carefully created the new valves upon which the baby’s future depended. It was much the same as operating within an egg cup. When blood was reintroduced into the tiny coronary arteries the little heart took off like an express train. Just as I prepared to separate the baby from the heart–lung machine, a pale and worried face appeared at the theatre door.
‘Sorry, Professor,’ the woman said, ‘but we need you right now in Theatre 2. Mr Maynard is in trouble.’
‘How much trouble?’ I asked, without diverting my eyes from the baby’s heart.
‘The patient is bleeding from a hole in the aorta and he can’t stop it.’ She had a note of desperation in her voice.
Although the baby seemed fine, I would not normally leave a registrar to remove the bypass cannulas and close up. But it needed a snap decision. On the balance of probabilities, I decided that I should try to help. In haste, I forgot that I was tethered by the electric cable of my powerful head lamp. Standing back from the operating table, I avulsed the bloody thing. Several hundred pounds’ worth of damage in two seconds.
Nick Maynard was a first-rate upper gastrointestinal surgeon who specialised in stomach and oesophageal cancer. He dealt with tubes normally filled with food and air, not blood at high pressure. But this unfortunate patient did not have cancer. Just days before, she had been completely well. While happily eating sea bass in a fancy restaurant she swallowed a fish bone. At first the discomfort abated and she could swallow. Then a dull ache emerged deep in the chest, next a swinging fever with night sweats. Soon just swallowing liquids became difficult and made the pain worse. The GP knew she was in trouble. Blood results sent from the surgery showed a very high white blood cell count, which suggested an abscess. Rather than passing through the gut as most bones do, this one had clearly penetrated through the wall of the oesophagus.
Nick’s team was surrounded by medical students and radiologists as the CT scans came through. There was an abscess the size of an orange wedged between oesophagus and aorta in the back of her chest. Worryingly, there were bubbles of gas in the pus. Gas-forming organisms are among the most dangerous, so it was no surprise that she felt dreadful. The pus needed to be drained away urgently before the bugs entered her blood stream and caused septicaemia. Otherwise it could be fit to fatal within days.
The oesophagus and aorta descend side by side in the chest, nestled behind the heart and in front of the spine – oesophagus on the right, aorta to the left. Tiger country. Under high-dose antibiotic cover, Nick planned to open the right side of the chest through the ribs and locate the abscess behind the lung. Then, by opening the abscess cavity, the pus could be washed out and drains left in place for a few days until the antibiotics clobbered the infection. Nick thought that the small perforation through the muscular wall of the oesophagus would seal itself. While awfully simple in theory, it was destined to be simply awful.
Through the glass door of Theatre 2, I could see Nick, sweating profusely with his face covered in blood, and both arms up to the elbows in the woman’s chest. Blood was slopping out of the chest cavity and down his blue gown, while anaesthetists were squeezing in bags of blood. It transpired that all had gone according to plan until he swept an index finger around the abscess cavity to clear the infected debris. First came the noxious odour of anaerobic bacteria and rotting flesh. Then, whoosh! Blood hit the operating lights. The abscess had eroded through the wall of the aorta. Behind the heart lay an infected swamp. All Nick could do was to stick his fist into the fountain and press hard. Big problem. They had already lost more than a litre of blood and if his fist moved she would bleed out in seconds.
Groaning deeply under the burden of the day, I gave Nick a resigned look and thought for a moment. The bleeding was still not under control and there was no prospect of repairing the hole while her heart kept on pumping. She would simply bleed to death. The only potential route out of the predicament – I called it ‘deep shit’ at the time – was to get onto cardiopulmonary bypass, cool her down to 16°C, then stop the circulation altogether. Deep cooling of the brain would give us a safe thirty- to forty-minute window without blood flow to identify and deal with the damage.
Given the morning’s conflict, I very politely asked anyone not immediately engaged in the frantic resuscitation to ask one of my perfusionists to bring in and prepare a heart–lung machine. And for a couple of my own scrub nurses and a specialist cardiac anaesthetist to come across. Nick just had to keep on pressing. His anaesthetists kept on squeezing.
Once I’d scrubbed up and joined the team around the body, I couldn’t even see the heart. I needed a much bigger hole in the chest to work around my colleague’s ‘finger in the dyke’. There was no time for finesse. With the scalpel and cautery I virtually split her in half as she lay there, right side uppermost on the operating table. The metal retractor cranked the chest wide apart with a crack that told me that one of her ribs had just broken. This was not unusual. Chest surgery is a brutal business.
Now I could see the pale, empty heart beating rapidly in its fibrous sac. I needed to cut this open and insert two cannulas to connect to the bypass machine. The first went into the aorta as it left the left ventricle carrying cherry-red oxygenated blood. The second was pushed into the empty right atrium, where blue blood from the veins of the body re-entered the heart to be pumped to the lungs. This venous blood, low in oxygen, would now pass through a heat exchanger and mechanical oxygenator before re-entering the aorta. Then we could cool and protect the brain and other vital organs. The heart is rarely approached through the right chest, but I had done it on a number of occasions for complex reoperations on the mitral valve. With a daunting challenge like this, every ounce of experience counted.
Thinking ahead, I told one of the watching cardiac registrars to go in person to the homograft bank and ask for a tube of antibiotic-treated aorta from the supply of spare parts we obtained from dead donors at autopsy with the relatives’ permission. Human tissue is more resistant to infection than synthetic vascular grafts made from Dacron fabric. I often used donated heart valves, patches of aorta or segments of blood vessels from the dead to repair the living. This is recycling. God’s stuff is still better than man-made.
At 2 pm the registrar from Theatre 5 came in to announce that he had put in pacemaker wires and chest drains, and had closed the baby’s chest. All was well.
It took us around thirty minutes to cool down for the next stage of the operation. While his hands grew colder and colder, I congratulated Nick for saving the woman’s life. I told him not to risk moving and that cold was good as it meant the woman’s brain was cooling too. Then I asked the enthusiastic registrar to scrub up and babysit the bypass circuit so I could duck out for coffee and a piss. What I really wanted to do was to phone Gemma, but when I did there was no answer. She was still in a seminar. Although time was passing relentlessly, I remained hopeful that I would be in Cambridge by the evening.
At 18°C I was too impatient to wait any longer. Gowned and gloved for the third time that day, I told the perfusionist to stop the pump and empty the lady’s circulation into the blood reservoir. Nick could finally withdraw his cold, stiff arms from her chest after having had them in there for more than an hour, while I took the first operator’s position. In turn, Nick moved the registrar out of the way, eager to get a look at the damage for himself.
With no blood flowing around the body, we were working against the clock. The infected tissues had the consistency of wet blotting paper and the stench of rotten cabbage. We could not repair the damaged oesophagus, and Nick agreed it had to go. I chopped through the precious muscular tube above and below the abscess, and dissected it away from the aorta. Nick passed a wide-bore suction tube down into the stomach to prevent it from spewing acid and bile over my aortic repair.
Now we had a clear view of the ragged hole, which really should have been a fatal problem. I reluctantly decided to replace the whole infected segment of aorta with the homograft tube rather than risk just a patch. No time to debate this. I trimmed the donor tube to the correct length, then sewed at top speed using blue polyester thread on a fine stainless-steel needle, held in a long titanium needle holder; deep bites into healthy tissue – aesthetically pleasing, bordering on the erotic. Throwing the final knot left-handed, I told Richard the perfusionist to ‘go back on’ and rewarm. Cold blood from the machine expanded the flaccid graft and air fizzed through the needle holes. It needed a couple of extra stitches to make the whole repair blood tight, but we restored blood flow to the brain after thirty-two minutes. Happy days. Though not so happy in my own case.
I really didn’t have time to loiter and admire my needlework. Between us we agreed that Nick would divert the upper end of the oesophagus out of the left side of the poor lady’s neck to drain saliva and enable her to swallow liquids for comfort. The lower end would then be closed off and an entrance to the stomach fashioned through the abdominal wall through which she would now be fed. We call this a gastrostomy. Months down the line Nick would restore her swallowing with a new gullet made by transposing a length of large bowel between her neck and stomach. But for now she was safe. In life, and for that matter death, timing is everything. Heart surgeon close at hand. Heart–lung machine and perfusionist available between cases. Spare parts on the shelf. Otherwise she was dead, killed by a fish.
Nick’s gastro team were happy to close the chest, put in the drains and finish off. Stepping backwards from the table into a pool of slippery blood clot, I skidded gracelessly onto my backside, hard down on the tiled floor with a crack – retribution perhaps for leaving Nick for so long with his cold hands in the chest. Now with a soggy red patch on my trousers and the suspense of a near-death drama lifted, it gave the nurses something to laugh at. Some proffered concern for the integrity of my coccyx. But, pain apart, I was content to have dispelled the gloom.
The levity was short-lived as no fewer than four messages with my name attached were taped to the door. First, the lady waiting for the mitral repair on the ward was agitated and wanted to see me. Predictable. Second, would I go to the paediatric intensive care unit where the baby was losing a little too much blood into the drains? Shit. Next, a lady doctor in the accident department of the Norfolk and Norwich Hospital was trying to get hold of me. Why on earth would that be? It was many miles away. And last, the medical director would like to see me in his office with the director of nursing at 4 pm.
Bugger that. It was already 4.10, and I was in no doubt what the chat would be about – swearing at the unhelpful agency nurse, quite inappropriate conduct for a consultant surgeon. Another ticking off. Nor was I in the mood for an acrimonious discussion with the cancelled mitral lady. After 5 pm there were only sufficient nurses to staff one emergency theatre. The nurses would never allow me to begin an elective operation at this time of day. So my only concern was for the baby. Was it significant surgical bleeding or just oozing through compromised blood clotting after being on the bypass machine? Still hoping to leave town, I went directly to the unit to find out.
The afternoon ward round was congregated around the cot. On either side crouched an anxious parent holding a cool, sweaty little hand. Suspended from the drip stand was a tell-tale bag of donor blood dripping briskly through the jugular vein cannula in the baby’s neck. Without reading the levels I could see that there was too much blood in the drains. The precious red stuff was dripping in one end and straight out the other. What’s more, they had checked the clotting profile and it was virtually normal.
With that one glance my plans for the evening were dashed. Cambridge might as well have been on a different planet. I had to take the baby back to theatre and stop the bloody bleeding. Abject despair turned to anger. I should have closed the chest myself – but then fishbone lady would be dead now. Acrimoniously I rang my so-called ‘helper’, telling him to lay claim to the emergency operating theatre and that I would push the cot around myself. Five minutes later Mr Putty Fingers called back to say that they couldn’t staff an emergency theatre because the chest surgeons were running late with a lung cancer operation. We would have to wait for them to finish. Until then, no room for emergencies, so keep squeezing in the blood. In the meantime, any remaining chance of seeing my daughter on her birthday had gone. More of the same. Useless absentee father ridden with guilt, and made worse by the fact that I had still not made contact. I was a sorry sight with my bloody trousers and sore bum.
There was no point in trying to rush the chest surgeons. They operate slowly through small holes with telescopes and invariably overestimate what they can squeeze in to an operating list. Yet no access for emergency surgery spells trouble. I was now glued to the cot side, with the fretting parents wanting me to stop the bleeding. I deployed that old chestnut: ‘It was alright when I left. It can’t be bleeding from the heart.’
Sure enough, over the next thirty minutes the bleeding slowed to a trickle. I fantasised that blood clotting had finally sealed the needle holes, which would allow me to escape the hospital without reopening the chest. Except the jugular veins were distending as the blood loss slowed. Perhaps there was too much transfusion. More likely, the chest drains had blocked off and blood was now accumulating under pressure in the closed space within the pericardium so the right atrium couldn’t fill properly – what we call cardiac tamponade. Should the blood pressure begin to fall, we would be in real trouble.
The baby’s blood pressure drifted down. We couldn’t wait any longer for an operating theatre. Now I needed to reopen the chest right there in the cot and scoop out the blood clot. Sister carried the heavy pre-sterilised thoracotomy kit to the cot side and dumped it on a trolley. Still wearing theatre blues, I hastily scrubbed up at the sink while calling for the registrar who had left me in this mess. He had already gone home, so we tried to find the on-call registrar. It was a locum, who was already scrubbed up in the thoracic theatre.
So I got on and did it without help – it was a very small chest, after all – getting the baby prepared, draped and her sternum wide open in less than two minutes. The suction tubing was not connected yet, so I scooped out the clots with my index finger, then packed the pericardial cavity with virginal white swabs. An expanding bright red spot soon showed me the bleeding point, a continuous trickle from the temporary pacing wire site in the muscle of the right ventricle, ostensibly trivial but life-threatening. That’s the way with cardiac surgery. It has to be perfect every time or patients die needlessly.
The cardiac rhythm was normal, so I pulled out the wire and stemmed the dribble with a single mattress stitch. Sure enough the drains were blocked. I changed them for clean ones and closed up. The whole process took ten minutes, but it had been a completely avoidable charade. It transpired that the trainee surgeon lacked the confidence to put a stitch into the baby’s twitching ventricle, simply hoping that the oozing would stop. He would not make it in this specialty.
7 pm. I was intrigued by that message from Norwich A&E. Were they still waiting to talk to me in the hospital? At first bewildered, I now became uneasy, paranoid even. Norwich was not far from Cambridge. Could Gemma have been out with friends and had an accident? Why did that not occur to me earlier? So I fretfully called her mobile. This time birthday girl answered cheerily and asked whether I was well on my way. The ensuing silence spoke volumes. There was no way I would get to see either of my children that night. Both patients survived, but part of me died. Again.
2
sadness (#u02de273e-a631-5f22-b6be-1ce6612625a5)
7.30 pm. I had given a child a new life then pulled off one of surgery’s great saves. I should have been floating on air that evening, but I wasn’t. Far from it. I was guilt ridden and inconsolable, still drawn to Cambridge when every element of logic insisted that going there would be futile. I needed to take off for Woodstock and drink myself into oblivion. That bloody phone message was still unanswered – but I wasn’t on call. Why on earth should I bother now? Because I always did, I guess. There had to be a reason for it. My life was never my own.
‘Good evening. Ipswich Hospital. Which department, please?’
‘Accident department, please.’
‘Sorry, that line is engaged. Can I put you on hold?’
There followed mindless waiting-forever music, tunes that made minutes seem like hours, time more joyfully spent waiting to be castigated by the medical director.
Then the young doctor was found.
‘Thank you, Professor. I know you’ve been in theatre all day. I’m Lucy, the on-call medical SHO. I was hoping that you would accept an emergency that has been with us for some time. An aortic dissection.’ (In medicine, people are frequently referred to by their condition rather than their name.) ‘He’s a GP and had heart surgery a few years ago – an aortic valve replacement at Papworth.’
‘Then why aren’t Papworth operating on his aortic dissection?’
There followed an embarrassed silence.
‘Their surgeon on call said he had another emergency waiting and we should send the doctor somewhere else.’
I was rather nonplussed by this approach as there were several cardiac centres in London that were closer to Ipswich. Aortic dissection is a dire emergency, where the main artery supplying the whole body suffers a sudden tear through the innermost of its three layers. This exposes the middle layer, which usually splits along its entire length under the high pressure, all the way from just above the valve down to the leg arteries. Branches to the vital organs can be sheared off, interrupting their blood supply and causing stroke, dead gut, pulseless legs or failing kidneys. Worse still, the split aorta is likely to rupture at any time, causing sudden death. And the poor chap was a doctor. He deserved better. Anyone deserved better.
I asked his age and current condition. The man was sixty and had complained of sudden severe chest pain, rapidly followed by paralysis of his right side. That meant he had extensive brain injury caused by the carotid artery supplying the left cerebral hemisphere becoming detached. The longer he was left before surgery, the less likely he was to experience any recovery. The patient couldn’t speak but sweet, persistent Lucy remained optimistic, saying that he was still awake and could move his left side.
There was one piece of critical information I didn’t have, besides his name, that is. What was his blood pressure? Before committing any patient with dissection to an ambulance or helicopter journey, it was vital that the blood pressure was carefully controlled with intravenous anti-hypertensive drugs because a surge in pressure can easily rupture the damaged vessel. So many patients die during or soon after transfer for that very reason.
‘180/100. We can’t seem to get it down.’ An element of panic had now entered her voice.
What that meant was that all the senior staff had buggered off home and left her to it, and she had never seen such a case before. After a day of conflict and castigation I chose my words carefully.
‘Oh shit! You must get that down. Get him on nitroprusside.’
I pictured the paper-thin tissue expanding to bursting point while the dissection process extended further throughout the vascular tree. Even with emergency surgery, one in four of these patients died.
Lucy responded that they didn’t want to drop the blood pressure too far because he wasn’t passing much urine and the CT scan showed that the left kidney had no blood flow. Only surgery could help fix that, so the sooner we got him onto an operating table the better. Should the guts lose their blood supply, little could be done. I asked whether he had abdominal pain or tenderness. Apparently not, so that was a positive.
This terrified patient had been lying paralysed on a hard hospital trolley for hours, surrounded by his family. He knew his own diagnosis and was fully aware that urgent surgery was his only chance of survival. Worse still, he’d had heart surgery before for an abnormal aortic valve, which is often associated with a weakened aortic wall. Reoperations are much more taxing than virgin surgery, so I summarised the situation in my mind. Physician with the highest-risk acute emergency needs reoperation but has an established stroke and one kidney down. His blood pressure is uncontrolled and he is at least two hours away by road. Could they arrange a helicopter? No, they had already tried. No wonder Papworth weren’t interested!
Lucy sensed that I was wavering. Hedging my bets, I told her that I had no idea whether we had any intensive care beds available.
So Lucy played her trump card. ‘The family asked that he be sent to you personally. Apparently you were at medical school together. I think he was a friend of yours.’
What was that question I never asked? Something we don’t regard as important – the patient’s name. Surgeons are less interested in people. We want problems to fix, but I had already had enough problems for one day.
Suddenly the penny dropped. A GP in Suffolk. My own age and with previous heart surgery. He was a jovial rugby prop forward, captain of the 2nd XV at Charing Cross Hospital, my old mate Steve Norton. We met on our first day at medical school in 1966. I was a shy, unassuming backstreet kid, frightened by my own shadow, and no one from my family had ever been to university before. Steve was an ebullient extrovert, full of confidence, destined to become a much-loved GP in rural Suffolk while I underwent metamorphosis into a fearless operating machine. Same profession, worlds apart. How did that happen?
I just said, ‘Bugger the beds. Send him across as fast as you can. I appreciate you should be going off duty, Lucy, but someone must come with him to screw that pressure down. And please send the CT scan.’
With no one to delegate to at this time of the evening, I had to make all the arrangements myself. The on-call nursing team had already worked all day and were just finishing a routine lung cancer operation. They were less than delighted by the prospect of a protracted emergency reoperation, one they expected to take all night. With foot down and blue lights flashing, the ambulance ought to be with us by 11 pm. If Steve survived to see Oxford alive, I would wheel him directly to the anaesthetic room.
Now the battle had started. Was there an empty intensive care bed? If not, there would be a bloody row about accepting a patient from outside the region without asking. Who was the on-call anaesthetist? I got lucky with Dave Pigott, a dour South African who helped with my artificial hearts and revelled in a challenge. Then lucky again that Ayrin was the scrub nurse. She was a diminutive, ultra-polite Filipino girl who never complained about anything because she was proud to work for the NHS. Her invariable response to any expression of gratitude was ‘Welcome.’ I used to think that this was the only English word she knew. The perfusionists always moaned and groaned when called at night, but they were all ultra-reliable. I just asked switchboard to call in whoever was on the rota and I looked forward to the surprise.
As the sun went down, we waited. I called home and spoke to my long-suffering wife Sarah, who thought I was in Cambridge and was sad for me that I wasn’t. I explained that I was waiting to operate on Steve Norton from medical school and wouldn’t be home tonight. That concerned her. I wasn’t the duty surgeon, and she remembered the heated discussions when I was faced with the prospect of operating on my own father during his heart attack. In the end, my cardiology colleague Oliver spared me the moral issues by curing him with coronary stents.
Sarah asked tentatively whether I should ask the on-call surgeon to do it. How did I feel about operating on a good friend at such high stakes? Cardiac surgeons are rarely introspective and self-effacing. I answered her question with a question: ‘If you had an aortic dissection, who would you want to do the surgery?’ Response: ‘You.’ Well then, why are you surprised that Steve’s family felt the same?
As she’d sat by the bedside, Steve’s wife Hilary knew the situation was dire. What was the anticipated mortality rate for aortic dissection? An international registry from top cardiac centres in Europe and the United States reported 25 per cent. What is the lowest recorded mortality in any series of cases? Six per cent. Who had operated on those cases? A surgeon in Oxford. So who would give Steve the best chance of coming through this catastrophe? I had no reservations whatever about battling to save my mate. As the phrase goes, ‘That’s what friends are for.’
Sarah’s next question was whether I’d eaten anything that day. This took some time to think about. I recalled a bacon sandwich at the crack of dawn. I told her that I’d find a bag of crisps from a vending machine before we launched into the night’s work. But food was the least of my concerns at that point. I needed an experienced first assistant, someone who had operated with me on dissections before, not an inexperienced locum brought in to cover a few night shifts. When the shit hits the fan, a coherent team makes a massive difference. Bums on seats is not the same. Amir was not on call, so I picked up the phone and asked him if he was doing anything. One thing he certainly wouldn’t be doing was drinking. He was effusive in his willingness to help, honoured to be dragged in at night to help the boss with a complex case. And I knew that he was capable of standing at the table for hours when I needed someone to stem the bleeding then close up. That was a young man’s game.
Steve and Hilary were at my wedding to my first wife Jane. Our pack were all young interns at Charing Cross Hospital after graduating, part of the rugby crowd that never took life too seriously. It was Steve who placed the bet that saw me streak naked the length of Pembridge Gardens to Notting Hill Gate tube station during rush hour. And we had both been fished out of the fountains in Trafalgar Square after a rugby club bash in Fleet Street, only to spend a cold night in Bow Street nick. I failed anatomy that term. Escapades long forgotten, just flashbacks for me as he travelled paralysed and semi-conscious through the night, unexpectedly perched on the edge of life. Once good friends, we were now surgeon and patient, something I never expected nor wanted to happen.
I wandered the silent hospital corridors to pass the time, consciously avoiding a confrontation with cardiac intensive care. I would let Pigott tell them we had an emergency once we were in theatre. Or maybe I’d ask Amir, who joined me in general intensive care, where we visited the fishbone lady. The ‘great save’, whose name I never knew, was beginning to wake up, her bed surrounded by her anxious daughters, arms extended to their mother’s cold hands under the warming blanket. Predictably, she had ‘after-cooled’ down to 34°C following the hypothermic circulatory arrest and was now shivering violently. Shivering, and the vasoconstriction response to cold, had pushed her blood pressure up to astronomical levels and Amir realised that this was likely to burst the repair.
The lady night registrar nonchalantly strolled across, clearly uncertain about whom she was about to address.
‘Can I help you?’ she enquired in an aloof manner, presuming that this scruffy visitor in theatre blues was a porter or something. My response must have come as a surprise.
‘No, but you can help this lady by getting her blood pressure down before she blows her bloody graft off. Paralyse her and keep her asleep until morning.’
The daughters were wide-eyed. The implications of my reply were lost on them, but they sensed an air of tension between the players.
‘Give her a bolus of propranolol right now,’ Amir chipped in assertively.
Registrar lady was now defensive and flustered, verging on shocked. She was not much older than my birthday girl and I immediately regretted being short with her. Maybe we should have done this differently. I could have taken the time to introduce myself and immodestly taken credit for saving the woman’s life, have the relatives fawn around and worship me for the bizarre and heroic rescue. But this was Nick’s case. He had already explained everything to the relatives. I didn’t want to intrude, but I certainly didn’t want to see the repair blown to pieces after all that effort. Having made the point, we wished them all a peaceful night and moved on. Sensitive souls, the intensive care doctors.
10 pm. Amir and I slipped silently into children’s intensive care to check on the morning’s case. Yet I was first drawn to the mother of the meningitis child whose black, gangrenous arms were now gone, replaced with rolls of pristine crepe bandage. Stark contrasts. Was she happy or sad that those mummified little hands had been removed? I wondered whether I would have asked to keep them had it been my child. I set that morbid thought aside and simply asked how the operation had gone. Was she, the mother, OK? Could I help her with anything? Fetch her a coffee? Anything at all to ease her pain? She just looked up at me with tears rolling down her cheeks and said nothing. The nurse knew me well enough and shook her head. It was time to move on to my own little patient.
The chest drains were dry now, with a steady pulse and blood pressure. Nurse told me that Dr Archer had done an echo and was very pleased – no leak on either valve or across the patches. Fixed for life. The parents had drifted down from the ceiling after the shock of the sudden reoperation and had gone to crash out in their hospital room. They understood the difficulties we faced, which was what really mattered. Not the daily battle for the privilege of bringing a patient to the operating theatre, nor the repeated conflict over intensive care beds. As night fell, we hoped for stable patients, cheerful parents, happy husbands or wives, and a brighter future for them all. While they drifted off to bed, I strolled down a long, dark corridor to the doors of the accident department.
Out in the fresh air for the first time in sixteen hours, I stared at the night sky and waited for the ambulance to arrive. The operating theatre lay ready, the heart–lung machine was primed, and the team were watching Newsnight in the coffee room, yawning with boredom and resigned to the fact that we were likely to be there all night. My own thoughts drifted back to Gemma and the disappointment I must have caused her once again. But maybe I was wrong. Maybe she had a much better time without me.
11.50 pm. The ambulance with East Anglia Health Authority painted across the side finally arrived, its blue lights flashing. Paramedics threw open the rear doors and the long-off-duty Lucy stepped down the ramp. I just knew it was her. Like a scene from Casablanca, she walked towards the Emergency entrance carrying a stack of medical notes. I thought at that moment how beautiful she was.
‘You’re the Prof, aren’t you?’ she said. ‘Mrs Norton told me about you. I trained in Cambridge and they still talk about you there.’ Nothing positive, I expected.
The trolley bearing Steve’s broken brain and body was being pushed towards us. The last time we met was barely six months before at a medical school reunion. He had delivered a very amusing speech celebrating the fact that all present were still alive despite his open heart surgery. I responded by jesting that things could have been different had he come to me for surgery. Now he was in Oxford in dire straits, not the next reunion we’d all anticipated, with his family still somewhere on the M25. I took his left hand, which firmly gripped mine. The good side that still moved. Then, along with Lucy, we walked in procession through the accident department down the corridor and straight into the operating theatres. A cursory glance at the CT scan confirmed the lethal diagnosis.
We can’t operate without consent, but he was alone and I didn’t want to be too explicit. I just told him that I would repair the dissection and with luck the stroke might recover. He struggled to tell me that he wanted to see Hilary and his children again before being put to sleep. Lucy had a number for Hilary, so I called. They were forty-five minutes away at best. Every extra minute meant less likelihood of neurological recovery, and too many hours had been wasted already. When I promised not to let him die, Steve used his left hand to mark a cross on the form. I counter-signed beneath, then Dave Pigott dispatched him to oblivion with a brain-protective barbiturate.
We had kept the interpersonal rapport to a minimum. Surgery has to be dispassionate, anonymous even. It was less of a problem because Steve couldn’t speak and I simply couldn’t verbalise the real risks to a friend who faced certain death if no one was prepared to operate. He was a doctor and knew the score. I didn’t need to render him any more anxious in his last conscious moments.
I sat in the coffee room until the lily-white body had been painted brown with iodine and covered with drapes. I didn’t want to see his flabby torso. I preferred to remember him the way he once was, that fine physical specimen striding out onto the pitch on a winter’s afternoon, adrenaline pumping, ready for the scrap. Closely aligned in those days, we were very different characters now. Steve would sit in an office chatting affably to patients and dishing out pills. A proper doctor. There I was at midnight, ready to wield the knife and drive an oscillating saw through his chest, all after an endless day of disappointment, conflict and misery. But adrenaline dissipates the tiredness, wipes out time as the contest begins.
After the previous surgery, Steve had no pericardium or thymus gland between the back of the breast-bone and the front of his heart. So with an expanded, tissue-paper-thin aorta immediately beneath, chest re-entry with an oscillating saw was extremely hazardous. I reduced the risk of catastrophic bleeding by exposing the main artery and vein of the leg, and connecting them to the heart–lung machine. Should the saw lacerate the heart or aorta, I could go rapidly onto cardiopulmonary bypass, take pressure out of the circulation, then suck away blood from the bleeding site. Mostly that works. Sometimes it doesn’t. If heart surgery were easy, everybody would be doing it.
Fixing Steve was like replumbing a Victorian house. All the main pipes were buggered and those coming out of the boiler needed to be replaced as they were rusty and might fall to bits at any moment, so I couldn’t do it with hot water flowing through them. I needed the same conditions as fishbone lady – a cold brain and all the blood drained off into the machine. Dave put electroencephalogram leads onto the scalp to monitor the brain waves, which gradually disappeared as Steve’s temperature fell but were already grossly abnormal after his stroke. Amir began by cutting the skin straight down the line of the scar from the previous operation, then used the electrocautery to sizzle through fat onto bone. He snipped through the old stainless-steel bone sutures with a wire cutter, then ripped them out. I was always going to open the sternum myself. Getting the depth of the oscillating saw just right is a matter of fine judgement. You must gently feel it pass through the back of the sternum, then pull back in case the posterior table of the bone and the muscle of the right ventricle are adherent.
The dissected aorta had the intimidating appearance of a tense aubergine, purple and angry, and I could see blood swirling beneath its perilously thin outer layer. Dave had positioned an echo probe in the oesophagus, directly behind the heart. This showed the original tear in the wall around 1 cm beyond the origin of the coronary arteries, the vital branches that supply the heart muscle itself. My job was to replace the torn part and redirect blood flow back to where nature intended, in the hope that this would restore flow to Steve’s blocked brain and kidney arteries. The compromised kidney would undoubtedly survive, but the injured brain was unlikely to. It had been starved of blood and oxygen for too long, although barbiturates and cooling might help.
I told Brian the perfusionist to go onto bypass and cool to 18°C. Draining the whole living body of blood is a curious thing to do. Only vampires and the few heart surgeons who operate on congenital heart defects and extensive aortic aneurysms ever do it. I specialised in both, so I emptied people out on a regular basis. I once gave a spoof lecture about halal humans at Dracula’s castle in Romania. I felt at home there. The Count and I had much in common.
I was normally relaxed about working against the clock, even when the brain had no blood flow. I didn’t stand there contemplating the nerve cells as they died, nor did I rush the job. At 1.30 in the morning I told Brian to come off bypass and drain, the second time I had done that in twenty-four hours. Steve’s cold, anticoagulated blood emptied into a reservoir and would sit there like a jug of Ribena until we pumped it all back again. I chopped away at the empty disintegrating aorta until I could see the inside of those vital branches coursing up into the head and arms.
The first step was to reapproximate the dissected layers of the filleted vessel with tissue glue. I was one of the first surgeons in the world to use the glue and it undoubtedly contributed to my gratifying survival rate. Then, with care bordering on obsession, I sewed in the vascular tube graft buttressed with strips of Teflon felt to prevent the stitches from cutting through the fragile tissue. Every patient’s survival relied upon the connections between my cerebral cortex and fingertips, but this was especially the case in aortic dissections. Amir’s eyes fixed on my every movement. He wanted to learn all the nuances of technique, which is why he willingly came in. Amir would definitely make it one day.
The repair to the aorta and inserting the graft without blood flow took thirty-four minutes. This lay within the window of safety for a normal brain, but Steve’s brain was not normal. We carefully refilled the vascular tree with blood and evacuated air from the head vessels. Once back on cardiopulmonary bypass, blood oozed through the needle holes. These would continue to bleed until we reversed the anticoagulation that prevented blood from clotting on the foreign surfaces of the circuit. So many detailed steps to recall, but the whole sequence was ingrained in my neural circuits, with everything done on autopilot, even in the early hours of the morning.
It was now time to re-warm to normal body temperature. With warm blood coursing through his coronary arteries, Steve’s heart muscle came to life again, first wriggling in what we call ventricular fibrillation, followed by spontaneous defibrillation and then the slow, lazy contractions that sped up as his temperature rose. Soon brain waves reappeared on the electroencephalogram. Dave thought it looked a bit better already.
The only other time that we watched this process of reanimation was when we tried to save children who had fallen through ice and drowned in a frozen pond, and there are rare cases of survival from Canada. Our Oxford trauma doctors pressed us to rewarm these lifeless bodies, and while we succeeded in salvaging hearts, lungs, livers and kidneys, the children were always fatally brain injured. We gave hope to their parents, then snatched it away again.
At 3 am I left Amir in charge at the operating table. Rewarming takes thirty minutes, and I’d been told that Hilary and several visitors were waiting in the intensive care relatives’ room. On the positive side, their arrival broke the ice with our nursing staff and I at least now knew that there was a bed waiting for him. As I appeared in the doorway they all sprang to their feet. This was reflex not reverence. Here was a medical school reunion, such was Steve’s popularity. Stan was a professor of oncology, John a consultant anaesthetist and Mike a GP. All were here to support Hilary and her children.
Before any type of greeting I told them the news they wanted to hear, that Steve’s OK, I’ve repaired the aorta and fixed the blood supply to his brain. The surgery has gone well. This simple sentence scraped them down from the ceiling and untied the knot in their stomachs. News – either good or bad – always dissolves that agonising fear of the unknown. As they stood there, far from home in the middle of the night, their old pal assumed a different persona. I was no longer the boozy buffoon from Scunthorpe.
There followed hugs, kisses and expressions of relief, then the usual request – ‘Can we see him now?’ I had to explain that Steve was still on the table with his chest wide open being rewarmed on the bypass machine and that while he was not entirely out of the woods, things had gone according to plan. I added that it was likely to be another couple of hours before we controlled the bleeding and closed him up. With that I left, intending to apologise to the sister in charge for springing this upon them. But it transpired that in fact there had been enough nurses – the last heart attack patient brought up from the catheter laboratory had ruptured his left ventricle and could not be resuscitated. The conveyor belt rumbled on.
I wandered wearily back to theatre and sat down with the two anaesthetists beside Steve’s head. Amir was happy enough to remain in charge. Steve’s temperature was back at 37°C and although still empty, his heart looked cheerful enough. I asked Brian to leave some blood in it, so any residual air would be ejected into the graft. I could hear Steve’s artificial aortic valve clicking away reassuringly, and from the echo probe behind the heart we could see tiny bubbles flashing through it like a snow storm. I didn’t have to ask. Amir already had the air needle in place. Bubbles fizzed out intermittently, then stopped. Now we were ready to come off the machine. I asked Dave to start ventilating the lungs and soon afterwards heard Brian say that he was ‘off bypass’. Amir and the locum registrar stood like spectators at a football match, as I dispatched instructions from the stool. I was scrutinising the inside of the heart and aorta on the monitor screen while they watched it from the outside.
‘How does it look?’ I asked Amir. ‘Any bleeding?’
‘Looks great. Just some oozing from around the graft. Nothing serious.’
‘What are you going to do now then?’
No answer. He was tired.
‘Give the protamine,’ I told Dave. Protamine extracted from salmon sperm reverses the anticoagulant effect of heparin, which comes from digested cow’s guts. So my noble profession relied on cows and fish, a sobering thought at this time in the morning.
Amir gently packed gauze swabs around the heart to encourage the oozing blood to clot on them. Next he set about putting in the chest drains and stainless-steel wires to close up. The clock on the wall read 4.30. Dave flicked through a motorcycle magazine and Brian asked whether he could remove his equipment, get it ready for the morning and go home. No stamina, some people. Ayrin and her runner nurse were wilting too. I suggested they took turns to take a break while we transfused blood and clotting factors. For the first time a sense of calm filled the room. Job done.
Behind the operating theatre block was a car park, and beyond this lay Old Headington graveyard, thinly shielded by an unkempt hedge of privet and conifers. I walked out into the night past the Mercedes that never got to Cambridge, with Gemma’s birthday present still concealed in the well of the passenger seat. I drifted on through the ornate metal gate to the brow of a hill overlooking the Oxfordshire countryside. There I lay silently on the grass by the grave of a baby girl and stared up into the night sky. The tombstone read, ‘Taken too soon’. She’d been taken by me twenty years earlier, something I hadn’t forgotten. She would have been Gemma’s age now, had God not given her that twisted, convoluted heart that I failed to fix. So I sat with her from time to time when I was feeling bad, just to remind myself that I wouldn’t always succeed. Difficult day today. Or was it yesterday?
6 am. Daylight broke the horizon and the sparrows chirped. Headlights sprinted around the Oxford ring road below, the early-bird London commuters and shift workers at the Cowley car plant. Sue would already be on her way into the office, so I ambled back to Theatre 5, now empty except for Ayrin. She was scrubbing blood and urine from the floor, ready for the morning’s operating list. Steve was already settled in intensive care, surrounded by his extended family, perfectly stable.
Cheerful Amir said, ‘Great case. So pleased you called me.’
The locum registrar was nowhere to be seen. Gone to collect his pot of gold, I thought.
I looked bad and smelled bad, so I went to the changing rooms, took a shower and stepped into clean theatre blues. The ritual signified the end of yesterday and the beginning of today. First, I made tea for Sue in the office, taking a dose of Ritalin with mine. Oxford students used the stimulant to aid concentration and inflate their exam grades; I used it for a boost when I was buggered or with added melatonin for jet lag. All in the patients’ best interest, of course.
At 7.30 I joined the intensive care ward round. I related Steve’s case story and asked whether his pupils were still small and reacting to light. Had anyone looked? Not yet, but they would. Had he shown any signs of waking up yet? No, but I was happy about that because I wanted him kept sedated and didn’t want the tube in his windpipe to make him cough. Coughing would shoot his intra-cranial pressure through the roof and his brain was already too swollen in there. By explaining that to the juniors in front of Hilary, I assumed that they would get the message. At least I hoped they would.
I celebrated Steve’s recovery with a sausage and egg sandwich, and, with the Ritalin kicking in, I felt better too. I had a floppy mitral valve to fix, and happily for me there was no bed for a second case. But the tone of day soon changed. As I emerged from theatre in the late morning, Steve partially woke from the sedation and started to struggle in his bed. With his brain swelling, he was disorientated, confused and agitated, then he started coughing vigorously against the tracheal tube and strained against the ventilator. He was a big man and not easy to control.
A debate ensued about whether to let him wake up fully and remove the endotracheal tube or re-sedate and paralyse him. In the midst of this, his left pupil dilated widely. Understanding its dire significance, John, our anaesthetist friend who had stayed by Steve’s bedside, hurried off to find me in my office. We returned to check the pupils again. Steve’s nurse thought that his right pupil was larger too. My spirits plummeted. I had hoped that cooling and barbiturates would limit the swelling around the stroke.
Did Hilary know of this sinister development? She had been given a relatives’ room and gone there to rest after the stressful night. Perhaps it was best to leave the family alone until we gained a clear picture of what had happened. That meant an urgent brain CT scan, which was not easy for a post-operative patient connected to all the paraphernalia. Drips, drains, pacing wires and monitors had to be wheeled through the hospital corridors to the radiology department, then his paralysed body moved from his bed into the scanner. But without the pictures, we couldn’t know how to help. So I walked round there myself and grovelled to my friend the chief radiographer to fit him in as a dire emergency.
As the scans emerged it was obvious that the whole brain was swollen. The parts damaged during the original stroke had haemorrhaged, probably as a result of the obligatory anticoagulant given during surgery. The injured brain had expanded like a sponge soaking up water yet confined in a rigid box. The skull has one hole at its base, through which the spinal cord enters its bony canal. When pressure rises, the brain stem can be forced down into the spinal canal with fatal consequences. This is called coning, and a blown pupil heralds that catastrophe. So I needed a brain surgeon to look at the scans with me.
It was not an easy conversation. Richard Kerr was the chief. He had seen it all, done it all, and was destined to be President of the British Association of Neurosurgeons. I asked him to decompress Steve’s brain by removing the top of his skull. A craniectomy is like taking off the top of a boiled egg, except the bone is kept in a fridge and put back again should the patient survive. Richard was a man of few words. Before he even spoke, I knew he believed it to be a lost cause. I pleaded the family’s case for them. Richard said that even if he survived, he would never be a GP again, indeed he might not even wake again. The delay in re-perfusing the stroke with the surgery had already destroyed his chance of survival. But that was now history. We couldn’t turn the clock back.
So I played my last card. Steve was an old friend, I said, and I had spent all night and lots of money trying to save him. Richard groaned and went back through the scans.
‘OK, you win. He has nothing to lose, but it has to be quick. I’ll put off my next case.’
Within thirty minutes Steve was on a neurosurgery operating table at the far end of the hospital. I pushed the bed there myself.
2 pm. Steve’s scalp was peeled back and the bone saw removed the top of his cranium, revealing a tense, swollen brain without pulsation. We were watching a dying brain. Richard inserted an intracranial pressure monitor into the pulp and closed the scalp skin loosely over the top. Then we took him back to cardiac intensive care, whose expertise he needed most.
Hilary and her children were still napping on a single bed and an armchair in their room. Consumed by my own misery and her husband’s impending doom, I tentatively knocked on the door. Hilary read my gaunt expression and realised that this was not a social call.
‘He’s dead, isn’t he?’
I hesitated to say no, since Steve’s chances of survival were negligible. I just told her the truth. That he had a dilated pupil and the brain scan looked bad, that I’d immediately persuaded the finest neurosurgeon in the country to help, but we were both doubtful that Steve could recover now. It was a waiting game. More of our medical school friends arrived, hoping for better news. I heard that old chestnut – ‘If anyone can save him, Westaby can.’ But he couldn’t. Great dissection repair, pity about the outcome. Soon afterwards, the second pupil dilated. Neither reacted to light. Despite the decompression, his brain was not going to recover. Hilary and the children had lost him.
Unbeknown to me, both Hilary and her eldest son had congenital polycystic kidneys, and the lad was teetering on the edge of needing renal dialysis. With remarkable composure, she asked whether he could be given his father’s functioning kidney. An organ from his dad would provide the best possible chance of immune compatibility – same blood group, same genes, no rejection. For a brief moment I thought I could generate something positive out of this disaster. At the same time as the intensive care doctors carried out tests for brain stem death, I called the director of the transplant service.
What I learned was barely believable. While Steve was conscious he could have voluntarily donated a kidney to his son. Now that he was functionally dead, the family could request that he become an organ donor. But now the body blow. Whatever was still transplantable must go to the national donor pool. Those were the rules. The transplant authorities would not allow Steve’s kidney to be used for his son, nor given to Hilary, who was close to needing a transplant herself. That was the law, so the Oxford transplant team couldn’t get involved. I was dumbstruck, then apoplectic about it. Fucking bureaucracy.
Steve’s ventilator was switched off at lunchtime. He died peacefully, surrounded by his family, with many of my medical school year grieving in the hospital corridors. I was alone in my office when his proud heart fibrillated, when the metallic click of his prosthetic valve finally came to a stop. Twelve hours earlier I had watched it beating vigorously and I had been confident that I’d saved him. Now it was forever still. All his organs died with him, except the corneas from his eyes. Despite my protestations, the transplant authorities had their way.
When Sue went home she left a note on my desk – ‘The medical director wants to see you.’
‘One day,’ I said to myself, and drove home with Gemma’s present still tucked away in the passenger seat.
Next day I was back in the car park by 6.10 am, another three cases on the operating list, beginning with a newborn infant whose right ventricle was missing. The car park lies between the graveyard and the mortuary at the back of the hospital. I always attended the autopsies of my own patients, so the morticians knew me well enough. This morning was a social call. I wanted to let Steve know that we had done our best for him. He was cold, pale and peaceful now. It was the only time I’d known him to be speechless. Had he still been able to talk, he would have said, ‘You bastard. You were meant to get me out of this mess!’ My instinct was to remove the drips and drains left in his lifeless body, but I was not allowed to. Those who die soon after surgery are the coroner’s property, and the pathologists must satisfy themselves as to the cause of death. Not difficult in this case, but it was an autopsy I wouldn’t be returning to watch. So I said my goodbyes to a great character.
There were many sad moments in my professional career, but this one stayed with me. Steve had devoted his life to the NHS but was caught up in the pass the parcel lottery that was out-of-hours surgery for aortic dissection. Eventually a decree was issued by the Society for Cardiothoracic Surgery that each regional centre must take responsibility for patients in their area. Special aortic dissection rotas were established in London and specific experienced surgeons designated to operate on the cases. That brought the mortality rate down. After UK Transplant prevented us taking a kidney for Steve’s son, the issue of organ donation was not discussed further. A healthy liver and two lungs could have gone in to the pool, had that single functioning kidney been used in Oxford.
Later that year Steve’s son Tom received a kidney donated by his wife. Steve’s daughter Kate was given one of her husband’s kidneys in 2015. Hilary was fortunate enough to meet a new partner and received one of his kidneys in 2011. They are all well.
3
risk (#u02de273e-a631-5f22-b6be-1ce6612625a5)
As a boy, my stoical and religious parents taught me that I should never take risks – never to gamble with money, never to be deceitful or steal, never to cheat in exams. Not even to climb over the stadium wall to watch Scunthorpe United, because that was a form of stealing too. Consequently, I began life as both boring and introspective.
Eventually I learned that the ability to take risks is an indispensable part of human psychology. Victory in war depends upon risk-takers and recklessness, hence the adage ‘Who dares wins’. The economy depends upon financial risk-takers. Innovation, speculation, even the exploration of the planet and outer space – all depend on putting something you cherish on the line in the hope of greater rewards. Thus risk-taking is the world’s principal driver for progress, but it requires a particular character type, one defined by courage and daring, not reticence and prudence – Winston Churchill rather than Clement Attlee, Boris Johnson not Jeremy Corbyn.
In 1925, when Henry Souttar first stuck a finger into the heart and tried to relieve mitral stenosis, it posed a risk to his reputation and livelihood. When Dwight Harken removed a piece of shrapnel from a soldier’s heart in the Cotswolds, it was a risk that went against all he’d learned from the medical textbooks of the day. By exposing blood to the foreign surfaces of the heart–lung machine, John Gibbon took a huge risk, as did Walton Lillehei with his reckless but brilliant cross-circulation operations, the only medical interventions in history outside the maternity ward that posed the risk of 200 per cent mortality. All progress in medicine and surgery is predicated on risk, yet I was taught to avoid it. Fortunately, things changed.
Character is said to be the product of nature and nurture, the former being the hand genetics deals to us. Then from birth onwards we are moulded by life’s events. I started out well enough. My mother was an intelligent woman who was deprived of an education but read The Times. During the Second World War with the men away, she managed the Trustee Savings Bank on the High Street. One of my earliest recollections was that every birthday she took me, along with a bunch of flowers, to another woman’s home. I thought that strange, but eventually I came to learn the significance of her pilgrimage.
After a long and painful labour my mother brought me safely back from the carnage of the delivery suite. She was exhausted, torn and bleeding, but elated to have a pink, robust son wailing from the depths of his newly expanded lungs. In the next bed, a wide-eyed factory girl was suffering noisily. Spurred on by the bossy midwife, she was preoccupied with pushing and pain. Finally, her perineum split. The straining emptied her uterus, bowels and bladder all at the same time, and the midwife caught the greasy, bloodied newborn like a cricket ball in the slips. The bonny little girl lay on a starched white towel soaked in urine, while the slithering umbilical cord was clamped and cut. Her baby’s only dependable source of oxygen was now gone. Finally, the whole placenta separated and squelched out, to join the party in the outside world. Mother would need a gynaecologist to put things back where they should be – but not yet.
All babies are blue at birth, then they bawl as loudly as I did. It’s cold outside and they no longer hear that soothing maternal heartbeat. Freed from their claustrophobic cocoon, they thrash their little arms and legs around and suck in air for the first time. At that point they should turn pink. This little mite stayed blue and silent. Listless, with eyes wide open but seeing nothing.
The midwife recognised that things were not right. She vigorously rubbed the baby’s greasy back and swept her finger around its throat. Rough stimulation suddenly caused its breathing efforts to begin, but with a whimper not a roar. And the baby remained blue, a darker blue despite the rapid breathing, and still cool and limp. Now beginning to panic, the midwife called for an oxygen cylinder and some help. At first, the tiny oxygen mask helped. Baby’s muscle tone improved but her grim slate blue colour persisted. The doctor arrived and listened to the tiny heaving chest with his stethoscope. There was a heart murmur, not loud but clearly audible when searching for something specific. It transpired that the artery to the lungs hadn’t developed properly – pulmonary atresia, we call it. Dark blue blood returning from the tiny body streamed through a hole in the ventricular septum and back around the body. The chaotic circulation was progressively depleted of oxygen, accumulating more and more acid. The baby was doomed. A ‘blue baby’. The doctor shook his head and walked away. Nothing could be done to help.
All this passed the mother by as she sweated in pain and perineal Armageddon. She was impatient to hold her new daughter. As they handed over the dying infant, the midwife’s grave expression told the story, as did the child’s pathetic face, lifeless and grey, eyes rolling aimlessly. Our factory girl pleaded for an explanation. Why so still and silent? Why not pink and warm like me in the cot next door? Milk started to flow, but there was no suckling. In 1948 blue babies died.
They returned to the maternity bed next to my mother. There was a stark contrast in mood after nine months of excitement and anticipation – one woman radiant, proud and optimistic with her robust, pink son, the other desolate with a grey, motionless little girl left to die in her arms. The curtains were pulled around. Her expectant husband was stuck at work, rolling steel, never to see his daughter alive. The hospital chaplain arrived as a matter of urgency to christen the child as life ebbed away. It was probably too late, but they went through the motions.
This emotional meltdown already greatly saddened my mother, then the contrasts deepened at visiting time when the families arrived. There were repeated emotional breakdowns as the young woman’s parents, then the bereaved husband, arrived too late to see the dead baby before it was spirited away in a shoe box. Feelings of guilt quickly followed. What did she do wrong? Was it the cigarettes? Or was it the sickness pills? Should she have gone to church? My own family’s joy was tinged with compassion for the poor girl. My mother stayed in the maternity bed beside her for five days while she was taken for pelvic surgery, with nothing to bring home but sadness and stitches.
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Stephen Westaby
Тип: электронная книга
Жанр: Современная зарубежная литература
Язык: на английском языке
Издательство: HarperCollins
Дата публикации: 16.04.2024
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О книге: An intimate and compelling exploration into the unique psyche of the heart surgeon, by one of the profession’s most eminent figures.Although Professor Stephen Westaby was born with the necessary coordination and manual dexterity, it was a head trauma sustained during university that gifted him the qualities of an exceptional heart surgeon: qualities that are frequently associated with psychopathy. His thirty-five-year career has been characterised by fearlessness and ruthless ambition; leaving empathy at the hospital door as thousands of patients put their lives in his hands.For heart surgeons, the inevitable cost of failure is death and in The Knife’s Edge, Westaby reflects on the unique mindset of those who are drawn to this exhilarating and often tragic profession. We discover the pioneers who grasped opportunities and took chances to drive innovation and save lives. Often difficult, uninhibited and fearless, theirs is a field constantly threatened by the risk of public failure.Like those before him, Westaby refuses to draw the line in his search of a lifetime solution to problems of the heart. His determination is unerring – a steadfastness underpinned by his unusual mind. But as we glimpse into the future of cardiac surgery, for all its remarkable scientific advancement, one question remains: within the confines of socialised medical healthcare systems, how can heart surgeons – individuals often hardwired with avoidance of self-doubt, a penchant for glory and a flagrant disregard for authority – truly flourish?