Fragile Lives

By now Baron Brock of Wimbledon was seventy and had stopped operating, Paneth alluding to his having ‘perpetual disappointment at the unattainability of universal perfection’. He was President of the Royal College of Surgeons when I was at medical school and stayed on as Director of the Department of Surgical Sciences, and now I’d be following in his footsteps. Literally. I strode out of the surgeons’ changing room straight into the operating theatre to introduce myself.

The old lady was on the operating table. The scrub sister, who had already prepared her with antiseptic iodine solution and covered her naked body in faded green linen drapes, was now impatiently tapping her theatre clogs on the marble floor, and the long-suffering anaesthetist Dr English and the chief perfusionist were playing chess by the anaesthetic machine. I sensed that everyone had been waiting for some time. I pulled on my face mask and quickly scrubbed up, relishing this first opportunity to showcase my skills.

I carefully located the landmarks, the sternal notch at the base of the neck and the tongue of cartilage at the lower end of the breastbone. The scalpel incision – a perfectly straight line cut from top to bottom – would carefully join the two. The old lady was thin and emaciated with heart failure, and there was little fat between skin and bone to cleave with the electrocautery. At this point there was still no sign of the other assistant surgeon, but I pressed on regardless, seeking to impress the nurses.

I took the oscillating bone saw and tested it. Bzzzz. That was fierce enough. So I bravely started to run it up the bone towards the neck. Then, disaster. After the light spattering of bloody bone marrow there was a sudden whoosh of dark red blood pouring from the middle of the incision. Oh shit! Instantly I started to sweat, but Sister knew the score, swiftly moving around to the first assistant’s position. I grabbed the sucker but she was giving the orders. ‘Press hard on the bleeding.’

Dr English belatedly looked up from the chess board, unfazed by the frenetic activity. ‘Get me a unit of blood,’ he calmly instructed the anaesthetic nurse. ‘Then give Mr Paneth a call in Outpatients.’

I knew what the problem was. The saw had lacerated the right ventricle. But how? There should have been a tissue space behind the sternum and fluid in the sac around the heart. Sister was reading my mind, something she would do many times over the next six months. ‘You do know that this is a reoperation.’ A statement that was really a question.

‘No, absolutely not,’ I replied frantically. ‘Where’s the bloody scar?’

‘It was a closed mitral valvotomy. The scar’s around the side of the chest. You can just see it under her breast. Didn’t Mr Paneth tell you it was a re-do?’

By this point I’d decided to keep my mouth shut. It was time for action, not recrimination.

In reoperations the heart and surrounding tissues are stuck together by inflammatory adhesions, and there’s no space between the heart and the fibrous sac around it. In this case the right ventricle had stuck to the underside of the breastbone and everything was matted together. Worse still, the right ventricle was dilated because the pressure in the pulmonary artery was high, the rheumatic mitral valve having narrowed considerably. We were there to replace the diseased valve but I’d buggered it up right from the start. Great.

Pressing hadn’t controlled the bleeding. Blood still poured through the bone and the sternum wasn’t completely open yet. The patient’s blood pressure began to sag and, as she was a small lady, she didn’t have that much blood to lose. Dr English started to transfuse donor blood but that wasn’t the answer, like pouring water into a drainpipe. In one end, straight out the other. I was the surgeon, it was my job to stop the haemorrhage – and for that I needed to see the hole.

My own perspiration dripped into the wound and trickled down my legs into Lord Brock’s boots. The old lady’s blood flowed off the drapes onto the faded white rubber. By now one of the circulating nurses had scrubbed up and joined us at the operating table. Not so brave now, I lifted the saw again and asked Sister to move her hands. Through a deluge of blood I ran the saw through the remaining intact bone – the thickest part of the sternum, just below the neck. Then we pressed on the bleeding again while more transfusion restored some blood pressure.

As pressure drops the rate of bleeding slows. This gave me a window of opportunity to dissect the heart sufficiently away from the back of the breastbone to insert the metal sternal retractor and wedge open the chest. Now I could see the lacerated right ventricle spewing its contents into the wound. When everything is stuck together like this, spreading the bone edges can tear the heart muscle wide open, sometimes irretrievably. But I’d been lucky and her heart was still in one piece. Just about.

By now my own pulse was galloping. I could see that the problem was a ragged slit 5 cm long in the free wall of the right ventricle, comfortably distant from the main coronary arteries. Sister instinctively put her fist directly on it as I wound the retractor open, and this at last stemmed the bleeding. Dr English squeezed a second unit of blood in through the drips, bringing the old lady’s blood pressure back up to 80 mm Hg, and the back-up scrub nurse divided the long plastic tubes to the heart–lung machine so that we could use it when ready. But as yet not enough of the heart had been exposed for that. First I needed to stitch up the bloody hole. As a surgical houseman I’d stitched skin, blood vessels and guts – never a heart.

Sister told me what stitch to use, and that it was best to stitch over and over rather than using individual stitches. This was quicker and would provide a better seal. ‘Don’t tie the knots too tight,’ she added, ‘or the stitches will cut through the muscle. She’s fragile. Get started and you might finish before Paneth gets here and chews your head off.’

The difficult part was to stitch accurately as blood poured out of the ventricle with every beat. By now my gloves were dripping with blood on the outside and sweat on the inside, and sewing was all but impossible.

Dr English saw this and shouted, ‘Use the fibrillator! Stop the heart beating for a couple of minutes.’

The fibrillator is an electrical device that causes what we’d normally never want to see – ventricular fibrillation, where the heart doesn’t pump but quivers, stopping blood flow to the brain at normal body temperature. In four minutes brain damage begins.

Dr English was reassuring. ‘Just defibrillate it after two minutes. If you haven’t closed it by then we can wait a couple of minutes, then fibrillate again.’

I felt like a puppet with the experienced players pulling the strings. That was fine by me, so I put the fibrillating electrodes on the surface of what muscle I could see and Dr English threw the switch. The heart stopped beating and started quivering, and I began to sew at top speed. Just then Mr Paneth appeared at the operating theatre door. He could see ventricular fibrillation on the monitor and feared the worst. But I didn’t look up and just kept on stitching. By the time Dr English announced the two-minute cut-off I’d almost finished bringing the muscle edges together. I carried on to three minutes. Then the hole was closed, with just the knot to tie.

Putting the defibrillating paddles as close to the heart as possible I said, ‘Defibrillate.’ Nothing happened. The leads to the paddles hadn’t been plugged into the machine, a minor detail. Seconds ticked by. Then came the ‘zap’ I’d been waiting for. The heart briefly stood still then fibrillated again.

Paneth strode across from the door in his smart suit and outdoor shoes. No hat, no mask. He looked over the drapes at the quivering muscle and said the obvious. ‘More volts.’ Another zap. The heart defibrillated and started to beat vigorously.

Paneth grinned, then asked, ‘Anything you’d like to tell me, Westaby? The mitral valve isn’t in the right ventricle, you know. I thought you were bright.’ He winked at Sister, announced that he was going for tea and meanwhile not to let Westaby do anything stupid.

I scraped my nerves from the ceiling, took stock and tied that last knot. The heart seemed to be working fine, despite my assault. There was blood all down my gown, on Lord Brock’s boots and in a pool on the marble floor, but the blood pressure was back to normal. Today’s battle had been won.

I looked at Sister, who was just a pair of cool blue eyes above the mask, and reached for her blood-stained rubber glove to say thanks for saving both of us. By the time Mr Paneth took over it was as if nothing had happened, apart from jokes about the extra needlework on the front of the heart. I felt like screaming at him, ‘Why didn’t you tell me she was a fucking re-do?’, then realised that he probably had no recollection of that as it was many months since he’d talked to her in Outpatients.

The rest of the operation went smoothly. Dr English and the perfusionist continued their chess game, I held the sucker and Paneth chopped out the deformed valve, replacing it with a ‘ball in cage’ prosthesis. Then lots of stitching-up.

There was no end to the day for surgical residents. That night I sat in the intensive care unit waiting for the old lady to wake up, desperately hoping that she wasn’t brain damaged and wondering how I’d have felt had she bled to her death on the operating theatre floor. Would I have had the grit to continue? Or would my surgical career have ended that day? There was such a very fine line between hero and zero, but I’d survived. I just wanted her to wake up now.

Her husband and daughter were keeping vigil by her bedside. Her husband asked whether the operation had gone well. I just glibly said, ‘Yes, very well. Mr Paneth did a great job,’ avoiding any implication that I’d fucked up.

As if to order, she opened her eyes. A wave of relief flowed over me. Husband and daughter jumped to their feet, making sure that she could see them as she stared up at the ceiling, still transfixed by the breathing tube. They reached out for her hand. At that point I realised something – heart surgery might become an everyday occurrence for me, but for the patient and their relatives it is once in a lifetime, and absolutely terrifying. Treat them kindly.

Cardiac surgery is like quicksand. Once in it you’re sucked deeper and deeper, and I struggled to leave the hospital in case something remarkable happened and I missed it. I spent endless hours sitting beside the cots of Mr Lincoln’s babies, listening to the bip, bip, bip of the monitors, watching the blood pressure sag and trying to get it up again, hoping that blood would stop dripping into the drains.

The next débâcle followed quite quickly. One Saturday evening before Christmas, a group of residents were in the pub following dinner in the mess. Because there was no casualty department at the Brompton it was highly unusual for emergency operations to be held at night, particularly over the weekend. With a couple of pints of beer on board we were alerted by the switchboard that an American Air Force jet had taken off from Iceland carrying a young man injured in a road-traffic accident. He had a tear in the wall of the aorta and Mr Paneth was coming in to operate. Bad problem, both the injury and the beer. Not so much the amount of alcohol – we were used to that – more the volume of urine to pass during a four-hour operation. Nor could I avoid being involved, as Paneth would need two assistants. Although there was no way I could maintain concentration with a bursting bladder, I didn’t want to lose face by asking to leave, like a whimpering schoolboy with his hand up in class.

As the senior registrar went off to make arrangements with the operating theatres I pondered the possibilities. What about a urinary catheter and drainage bag for the duration of the procedure? I didn’t really relish the idea of passing the catheter myself. Nor the discomfort of standing with the bag of urine strapped to my leg. And then it dawned on me. Lord Brock’s operating theatre boots! One of them would hold a couple of pints, and with a length of Paul’s tubing – thin-walled rubber tubing that was once used for incontinent males – there would be less risk of a bladder infection than if I inserted my own urinary catheter.

I went to the wards in search of the tubing. This came in a roll to be cut to the appropriate length, in my case that of my inside leg. Once I’d found a supply, off I went to the surgeons’ changing room as I was keen to be in theatre all ready to go – with my clipboard and white boots as usual, tubing attached with sticky tape – when the boss arrived. And I was just in time, the ambulance screeching in from Heathrow much sooner than we’d anticipated. Those jets were fast.

We were opening through the ribs of the left side of the chest by midnight and soon encountered bleeding. Paneth was in an irascible mood, having been called out of a Christmas party. As I predicted the beer soon began to make its effects tell and my registrar colleague became restless, shifting from foot to foot and losing concentration. Eventually he had to excuse himself, so I moved into the first assistant position, coughing loudly to disguise the unusual squelching sound. I stayed in his position after he returned as I had no discomfort, despite the fact that my right Wellington boot was slowly filling. After another twenty minutes the registrar had to go out again.

By now the patient was safe, but Paneth was cross. ‘What’s wrong with him? He’s been in the pub, hasn’t he? He’s been drinking.’

‘I really don’t know about that, Mr Paneth. I’ve been studying in the library all evening,’ I replied, waiting to be struck down by a thunderbolt. But it never came.

‘Well done, Westaby,’ he said instead. ‘You get on and close the chest. He can assist you for a change. See you on Monday.’

I disposed of the evidence and accompanied the young man back to intensive care. No one ever knew.

Now beyond sleep, I sat drinking coffee in the paediatric intensive care unit. I talked with the nurses while watching tiny people struggle for life at Christmas in their cosy incubators. As surgical trainees we were all chronically sleep deprived, but there was little excitement in sleep. Sleep was something for the odd weekend off. We were adrenaline junkies living on a continuous high, craving action. From bleeding patients to cardiac arrests. From theatre to intensive care. From pub to party.

Sleep deprivation underpins the psychopathy of the surgical mind – immunity to stress, an ability to take risks, the loss of empathy. Bit by bit I was joining that exclusive club.

4

township boy

Genius is one per cent inspiration, ninety-nine per cent perspiration.

Thomas Edison

October 1979. I was Senior Registrar with the thoracic surgery team at Harefield Hospital in north London. Everyone training in heart surgery had to learn to operate on the lungs and gullet as well, and this meant working with cancer, which I found deeply depressing. Too often it had already spread to other parts of the body, and for most patients the prognosis was grim, so they were depressed too. Moreover, there was an element of monotony about it. The choices were stark: between taking out half a lung or the whole lung, on the right or on the left, or removing the upper part of the gullet or the lower half. After doing each one of these procedures a hundred times it was no longer very stimulating.

Every so often a more challenging case would present itself. Mario was a forty-two-year-old Italian engineer working on a restoration project in Saudi Arabia. A jovial family man, he’d gone to the kingdom hoping to earn enough money to buy a house, which meant toiling hours on end at a large industrial complex outside Jeddah in the searing desert heat. Then catastrophe. Without warning, while he was working in an enclosed area, a huge boiler exploded, filling the air with steam. Steam under high pressure. It scalded his face and burnt the lining of his windpipe and bronchial tubes.

The shock almost killed him immediately. The scalded tissues were dead and whole sheets of necrotic membrane sloughed off from the lining of his bronchial tubes. This obstructive debris had to be removed through an old-fashioned rigid bronchoscope, a long brass tube with a light on its end passed through the back of his throat and voice box then down into his airways.

Mario needed this done regularly, almost daily, to prevent asphyxiation, and pushing the bronchoscope back and forth through his larynx became more and more difficult. Soon it became so scarred that the bronchoscope would not pass and he needed a tracheostomy – a surgical hole in the neck to enable him to breathe. But the dead bronchial lining was quickly replaced by inflammatory tissue and masses of cells started to fill the airways like calcium blocking water pipes. He became unable to breathe, and his condition took a relentless downhill course.

I took the call from Jeddah. The burns doctor looking after him explained the dire situation and wondered whether we had any advice. My only suggestion was that they airlift him to Heathrow and we’d see if anything could be done, so the building company paid for the medical evacuation and he arrived the following day. At the time my boss was in the twilight of his career and was happy for me to take on as much as I felt confident to do. Which was everything. I had no fear. But this was a disaster in a middle-aged man. I asked that we should take a look down his windpipe together and then try to come up with a plan.

Mario was a sorry sight. He was gasping for breath, with the infected froth pouring from his tracheostomy tube making a dreadful, gurgling sound. His scarlet face was badly burnt, its crusted, dead skin peeling away and weeping serum. Burnt on the outside and burnt on the inside, the fragile and bloody tissue that occluded the whole of his windpipe was going to asphyxiate him. It was a great relief for him to be put to sleep.

As he lapsed into unconsciousness I sucked blood-stained sticky secretions from the hole in his neck, then attached the tubing from the ventilator to the tracheostomy tube and squeezed the black rubber bag. The lungs were difficult to inflate against the resistance. I decided that we should attempt to pass the rigid bronchoscope by the normal route directly through the vocal cords and larynx. This is akin to sword swallowing, but down the airways rather than the gullet.

We needed a view of the whole windpipe and both right and left main bronchial tubes. For this the head needs to be tipped at the correct angle so the vocal cords at the back of the throat can be seen. We do try hard not to knock out any teeth. This technique used to be performed on conscious individuals after lung surgery, when I’d have to hoover the patients out because there were never enough physiotherapists. Rough at the time but better than drowning.

I manoeuvred the rigid telescope over the teeth and along the back of the tongue, then peered down to locate the snippet of cartilage – the epiglottis – that protects the opening of the voice box during swallowing. If you lift its tip with the bronchoscope you should be able to find the glistening white vocal cords, with a vertical slit between the two. This is the way into the windpipe and I’d done the procedure hundreds of times to biopsy lung cancer. Or remove peanuts. But here, with the voice box burned and the vocal cords like sausages, inflamed and angry looking, there was no way through. Mario was entirely reliant on the tracheostomy.

Standing aside, I tried to show the boss by keeping the bronchoscope still, propped on the teeth. He grunted and shook his head. ‘Try pushing it harder. Nothing to lose, I suspect.’

Taking aim again, I pushed the beak of the scope where the slit should be and shoved. The swollen vocal cords parted and the instrument crashed against the tracheostomy tube. We attached the ventilating apparatus to the side of the bronchoscope and pulled out the tube. Normally we’d see the full length of the windpipe to where it divides into the main bronchi. In this case, not a chance. The airways had been virtually obliterated by the proliferating cells, so I eased the rigid implement onward using the sucker to aspirate blood and detached tissue, at the same time pushing in oxygen through the bronchoscope tip. I was hoping to see an end to the burns, and we finally encountered normal airway lining halfway down each main bronchial tube. But now the traumatised lining was oozing blood.

Mario’s bright red face had turned purple and was getting bluer by the minute, so the boss took over, peering down the tube, occasionally inserting the long telescope for a better view. It was a precarious situation without an obvious solution. If you can’t breathe you die. Fortunately with time the bleeding died down and the airway was better than it had been once some gunk had been removed. We reinserted the tracheostomy tube and put him back on the ventilator. Both sides of the chest still moved and both lungs were inflated. This was a triumph in itself, but it was doubtful there was any way forward. We both concluded that his prospects were bleak.

Two days later Mario’s left lung collapsed and we went through the same process again. It was just as bad. The tissue just kept on growing, and he remained fully conscious on the ventilator but very distressed.

Asphyxiation is the most miserable way to die. I remembered my grandmother, strangulated by cancer of the thyroid gland. She’d been told she needed a tracheostomy, only to have the procedure aborted, so she sat propped up in bed day and night gasping for breath. I recalled trying to work out ways to help. Why wasn’t it possible to put a tube further down, past the obstruction? Why couldn’t tracheostomy tubes be made longer? A simple concept but I was repeatedly told it wasn’t possible.

From what I could see through the bronchoscope, the situation with Mario was nearly identical. He needed something to bypass his whole trachea and both main bronchi, otherwise he’d be dead in days. We couldn’t keep opening the airways with a bronchoscope. Not forever. Grim Reaper was winning this battle and was about to swing his scythe.

Ever the optimist, I questioned whether there was anything else we could do. Could we make a branched tube to bypass the damaged airways? The boss thought not, because it would clog with secretions. Surely someone else would have done it before for cancer. Then something else occurred to me – a company called Hood Laboratories in Boston, Massachusetts made a silicone rubber tube with a tracheostomy side limb, called a Montgomery T-tube after its ear, nose and throat surgeon inventor. Maybe I should talk to them and explain the problem.

When I bronchoscoped Mario later that afternoon I took measurements to calculate how long the tube needed to be to reach down each main bronchus, and in the evening I rang Hood. A small family firm who were most helpful, they confirmed that no one had tried such an approach but agreed to make me the bifurcated tube to fit the whole of Mario’s trachea and main bronchial tubes. I said we needed it urgently. They delivered in less than one week, with no invoice, pleased to help with this unique case. Now I had to work out how to get it in.

I’d need to railroad the branched end of the tube into the separate bronchi simultaneously over guide wires. But wires were too sharp and dangerous for the delicate silicone rubber, and I needed something blunt and harmless to do the job. We used to dilate strictures of the gullet with gum elastic bougies. Two of the narrowest bougies would fit down the T-Y tube, and down each limb of the Y branches. I could insert the bougies through the damaged trachea and into one bronchus at a time, then railroad the tube into place over them. I drew the technique step by step and showed it to the other thoracic surgeons. The consensus was that we had absolutely nothing to lose. Without some crazy new approach Mario was definitely going to die.