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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.
