Fragile Lives

The following day we took him to theatre, removed the tracheostomy tube and inserted the rigid bronchoscope through his burnt larynx. I tried to create as little bleeding as possible this time. We surgically enlarged the tracheostomy hole through which the T-Y tube would be introduced, then the bougies were inserted into the right and left main bronchi under direct vision through the scope, vigorously ventilating with 100 per cent oxygen between each step. So far so good. I lubricated the silicone rubber with K-Y jelly and shoved the tube forcefully downward. The bronchial limbs spread out at the branching point until there was resistance to any further pushing. It was in. Better than sex. The boss took a leap of faith and withdrew the bronchoscope into the larynx.

Ever the Irishman he exclaimed, ‘Crikey, look at this! You’re a bloody genius, Westaby.’ The horribly disintegrating trachea had been replaced by a clean white silicone tube, the Y limbs sitting in perfect position. There was no kinking or compression, and clean healthy airways lay beyond.

Meanwhile Mario was blue and hypoxic. We were all so excited that we had stopped ventilating him, so we needed to blow in oxygen furiously. But he was now easy to inflate through the wide rubber airways. It was a complete revelation. Whether it would last we didn’t know, and only time would tell. It depended entirely upon whether Mario was strong enough to cough secretions out through the tubes, and on our ability to suck them out and ventilate him through the side limb. When the swelling in his larynx and vocal cords subsided we’d keep this closed with the rubber bung. Then he could breathe and speak through his own larynx if it ever recovered. There were many unknowns, but for now Mario was safe. He could breathe. Fifteen minutes later he woke up with fantastic symptomatic relief.

I should have been thrilled that the concept had worked but I wasn’t. I was in a difficult head space. I had a beautiful baby daughter – Gemma – whom I didn’t live with. I lived at the hospital. This was grinding away at me in the background, so I compensated by operating fanatically on everything that I could lay my hands on. I was always available but was possessed by a disquieting restlessness.

In the meantime Mario recovered well, though life was difficult without a voice. He could cough secretions through the tube and keep it clear – something that everyone else had regarded as impossible – and was sent home to his family in Italy. Gratifyingly Hood started to manufacture the T-Y stent and called it the ‘Westaby tube’. We used it often for patients in whom lung cancer was threatening to occlude their lower airways, relieving the dreadful strangulation that my grandmother was forced to endure. Why could no one have done it when she needed help and I was so miserable?

I never knew how many Westaby tubes were manufactured but it stayed in Hood’s product list for many years. My original drawings were published in a chest surgery journal and served as the guide for others. While I still performed thoracic surgery I continued to use it for complex airways problems, often on a temporary basis until radiotherapy or cancer drugs caused the tumour to shrink. It was my grandmother’s legacy. Then came the rare opportunity to use the artificial airways alongside my expertise with the heart–lung machine.

In 1992 I was invited to Cape Town for a conference to celebrate the twenty-fifth anniversary of the world’s first heart transplant by Christiaan Barnard. At that meeting the distinguished children’s heart surgeon Susan Vosloo asked me to see a sick two-year-old who’d been a patient at the Red Cross Children’s Hospital for several weeks. Little Oslin lived in a sprawling Cape Town ghetto situated between the airport and the city, acre upon acre of tin shacks, wooden sheds and tents with brackish water and little sanitation. Nevertheless he was a cheerful little chap whose toys were oil drums, tin cans and pieces of wood. He knew no other life.

One day his family’s faulty gas cylinder exploded in the shack, setting fire to the walls and roof. The blast killed Oslin’s father outright, while Oslin sustained severe burns to his face and chest. Worse still, he inhaled hot gas from the blast, much like Mario. The accident department at Red Cross saved his life, intubating and ventilating him before he asphyxiated, then treating his burns with intravenous fluids and antibiotics. The little lad could survive the external burns, but his burnt-out trachea and main bronchi were life threatening, and without repeated bronchoscopies to clear slough and secretions he was destined to asphyxiate. On top of this his face was badly disfigured, he was almost blind and he couldn’t swallow food, just his own saliva. So he was fed with liquids through a tube directly into the stomach.

It so happened that Susan had read a journal article about Mario and the tube I’d designed, and, although Oslin was much smaller, she wondered whether we could do anything to help him. When I first met the lad he was wearing a bright red shirt, had tight, curly black hair, and was pushing himself around the ward on a kiddies’ bicycle with his back to me. Susan called to him and he turned around. The sight of his face took my breath away. There was no hair on the front of his scalp and no eyelids, just white sclera and a severely burned nose and lips. His neck was webbed from contracting scars with a tracheostomy tube in the middle. And the noise coming from him was heart-rending, a kind of rattling with thick mucus secretions made up by a long, noisy in-drawing of breath then a high-pitched wheeze as he forcibly exhaled. It was worse than a horror movie and tragic beyond belief. My first thought was, ‘Poor kid, he should have died with his dad. It would have been much kinder.’

Strangely enough he was happy, as he’d never had a bicycle before the explosion. I kneeled on the floor to talk with him. He looked straight at me but I couldn’t tell whether he could see my face as his corneas were opaque, so I took his little hand. There would be no objectivity in this discussion. I needed to help him, even if I wasn’t sure how it could be done. We could work that out.

By this point I was chief of cardiac surgery in Oxford and I had to get back there to operate. In any case there was no Westaby tube in Cape Town, and if there had been it wouldn’t have fitted anyway since the adult size was too big. Could I persuade Hood over in Boston to make a smaller tube? Probably, but not within the time frame that we’d been presented with; if he developed pneumonia in the next couple of weeks he’d surely die.

My return flight to Heathrow was the following day, so instead of going for lunch in the harbour I asked Susan whether she’d take me to see Oslin’s township. Cape Town was my favourite city in the world but this was an aspect I’d never seen before, the sort of place that warranted an armed escort through its thousands of acres of misery and depravity. I’d come back in a couple of weeks when I had the tube, and a surgical strategy – that’s what flying time was for. I quickly had it clear in my mind and before the plane touched down in Heathrow I’d drawn up the operation in detail.

I was back at the Children’s Hospital in three weeks. There had already been a fund-raising drive to help Oslin and they expected to pay my expenses. But none of that mattered. I was driven to help the boy as no kid on earth deserved that. I guess thousands of Vietnamese children suffered the same with napalm, but I hadn’t met them. I did know Oslin and I cared about him. So did the doctors and nurses at Red Cross. Perhaps the whole of Cape Town cared. As the airport taxi reached the city I saw the newspaper billboards emblazoned with ‘UK Doc flies in to save dying Township boy’ stuck on lamp-post after lamp-post. No pressure then.

At the hospital I met Oslin’s mother for the first time. She’d been at work when the gas cylinder exploded and was now clearly depressed. She said virtually nothing, but signed the consent form for an operation that even I didn’t understand.

We operated the following morning. I’d needed to trim the adult tube by shortening both bronchial limbs, the tracheostomy T-piece and the top part that would sit below his vocal cords, but even this shortened adult tube wouldn’t fit inside the two-year-old’s scarred windpipe. My objective was to rebuild his major airways around the tube. If it worked he’d have even wider airways than before the accident.

Clearly he wouldn’t be able to breathe or be ventilated during the reconstructive surgery, so we’d do it with him supported on the heart–lung machine. This meant we’d open his sternum as we would in a heart operation. The tricky part was to gain access to the whole length of the trachea and main bronchial tubes from an incision in the front of his chest, these structures being situated directly behind the heart and large blood vessels.

I’d already worked it all out on a cadaver in the dissecting room in Oxford. When a sling was placed around the aorta and the adjacent vena cava they could be pulled apart to expose the back of the pericardial sac, like opening a pair of curtains and looking out onto a tree. Then a vertical incision between the two served to expose the lower trachea and both main bronchi.

My plan was to fillet these damaged tubes then lay in the modified T-Y stent. Next we’d repair the front of the opened airways and cover the tube with a patch of Oslin’s own pericardium. It would be just like sewing an elbow patch onto a worn jacket sleeve. Simple. It should all heal up around the tube and we could maybe remove the prosthesis in time, after the tissues had healed and moulded around the silicone. That was my plan, in any case. Maybe ‘fantasy’ would have been a more realistic term, but no one else had a better solution.

The skin incision started in Oslin’s neck just below his voice box and extended all the way down to the cartilage at the lower end of his breastbone. Since he was emaciated, unable to eat, there was no fat, so the electrocautery cut straight through to the bone, which we then sawed through. I cut out his fleshy, redundant thymus gland and dissected down onto the upper part of his inflammed trachea, all while he was ventilated through his tracheostomy tube. We needed to go on bypass before removing this and exposing the rest of his airways. The metal retractor stretched open his scarred little chest, exposing more of the fibrous pericardium. The front of this was removed for the tracheal patch and I saw that his little heart was beating away happily. Rarely do I see a normal child’s heart, as most are deformed and struggling.

When I was ready to open the windpipe we started the bypass machine. This rendered the lungs redundant so we could remove the contaminated tracheostomy tube from the clean surgical field. Through the hole the devastation was clear to see. Poor Oslin had been breathing through a sewer. I cut down the length of it with the electrocautery and continued the incision into each main bronchus until I could see normal respiratory lining just at the limits of our access. Copious thick secretions poured out of the obstructed airways, then we scraped tissue off the walls, which caused all-too-predicable bleeding.

But the electrocautery eventually stopped the haemorrhaging, so we inserted the shiny white T-Y tube and covered it with a patch of Oslin’s own pericardium. I adjusted the length of the rubber cylinder for the last time to get it just right, then sewed the patch into place to seal the implant. It needed to be airtight, otherwise the ventilator would push air into the tissues of the neck and chest, making him blow up like the Michelin man. With the shiny new breathing tubes attached to the ventilator we blew air into his little lungs. There was no leak. Both inflated then deflated normally. A sense of excitement permeated the room. The high-risk strategy was working.

Oslin’s heart bounced off the bypass machine and his lungs moved freely, needing much lower pressure from the ventilator. Our anaesthetist murmured, ‘Unbelievable. I’d never have believed it possible.’ I covered the repair by closing the back wall of the pericardium, then asked that the registrar put in the drains and close.

Through the theatre window we could see Oslin’s mother sitting in the waiting room, still expressionless and rigid with fear. I anticipated a blunt response to our news. But she was too emotionally drained to register relief, simply holding out her hand and squeezing mine. She whispered, ‘God bless you,’ then a tear zigzagged down her pockmarked cheek. I wished her a better life in the future, one way or another.

The intensive care unit was pleased to have him back. Most of their patients were township kids having heart surgery, and some of the nurses lived in that same environment. They’d cared for Oslin and his depressed mum for weeks, watching them both deteriorate. So ‘UK Doc’ had flown in to save ‘Township boy’ and succeeded. I was proud of that. Now it was time to ride off into the sunset.

Oslin recovered and could breathe freely through the white rubber tube in his neck. He couldn’t speak but went on to have his corneal transplants. Being able to breathe and see at the same time was as much as he could have hoped for. The little family were relocated to better social housing on the outskirts of the city – crude but clean, and safer. A chest infection could still kill him, so for the first few months following the operation I contacted Cape Town frequently. Oslin was doing fine and Mum was faring better on anti-depressives. Then I stopped calling.

Eighteen months passed, and then a letter arrived from the Red Cross Hospital. Oslin had been found dead at home and no one really knew why. Sometimes life is shit.