Читать книгу The Knife’s Edge - Stephen Westaby - Страница 11

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.