Читать книгу The Knife’s Edge - Stephen Westaby - Страница 7

Just weeks after my surgical career came to an end I was invited to present the prizes at a local school speech day. The headmistress urged me to treat the teenagers as adults, and suggested that I convey to them what personal qualities I possessed that enabled me to become a cardiac surgeon. By this stage I had a stock response: ‘To study medicine,’ I said to the assembled schoolchildren, ‘demands an unstinting work ethic and great determination. Then it requires more than a modicum of manual dexterity, together with supreme confidence to train as a surgeon. To aspire to become a heart surgeon and risk a patient’s life every time you operate is a step beyond. For that you need the courage to fail.’

This last phrase wasn’t original – it was regularly used to describe the heart surgery pioneers in the era when more patients died than survived – but the kids didn’t know that. I decided to omit the claim that gender, social class, colour and creed played no part, because I really didn’t believe it myself. Nor did I regard myself as possessing all the qualities I talked about. I was more of an artist. My fingertips and brain were connected.

After rewarding the school swats, I started nonchalantly answering questions about my achievements in Oxford. With considerable insight, one biology boffin asked how it’s possible to operate inside an organ that pumps five litres of blood every minute and whether the brain dies if the heart stops. Another wanted to know how to get to the heart when it’s surrounded by ribs, breast-bone and spine. Then the art teacher asked what causes blue babies, as if someone paints them blue.

Coming to the end of the session, a bespectacled little girl with pigtails raised her hand. Standing up like a poppy in a cornfield, she boomed out, ‘Sir, how many of your patients died?’

So loud was her earnest approach that there was no way I could pretend not to hear. One set of parents tried to disappear under the floorboards while the flustered headmistress began explaining that it was time for the honoured guest to now leave. But I couldn’t ignore this inquisitive individual in front of her friends. I considered the question for a moment, then had to confess: ‘I really don’t know the answer to that. More than most soldiers but fewer than a bomber pilot, I guess.’ At least fewer than Enola Gay over Hiroshima, I thought to myself cynically.

Quick as a flash, Miss Curiosity probed again. ‘Can you remember them all? Did they make you sad?’

Another brief moment of deliberation. Could I admit to a hall full of parents, teachers and schoolchildren that I had no idea exactly how many patients I had dispatched, let alone recall their names. I could only muster one response: ‘Yes, every death upset me.’ I waited to be struck down with a thunderbolt but mercifully that was the end of our brief dialogue.

It was only after I stopped being an inadvertent serial killer that I began to remember patients as people, rather than simply recalling mortality statistics and the many times I went along to autopsies or coroner’s courts. And there were deaths that haunted me, not least the young people who succumbed needlessly to heart failure. Those who were not accepted for transplantation but who could have been saved with the new circulatory support devices that our NHS declined to pay for.

In the 1970s one in five of my boss’s cases at the Brompton Hospital died after surgery. As a cocky trainee I would greet each patient, record their medical history, then listen to their fears and expectations about the upcoming operation. Most were severely symptomatic, having waited months to come to the famous hospital in London. It didn’t take long for me to predict the ones who wouldn’t make it, usually the ones with rheumatic valve disease who arrived in a wheelchair and could barely speak on account of their breathlessness. Breathlessness is uniquely terrifying, likened by the patient to drowning or suffocation. They didn’t die because of poor needlework. They simply couldn’t tolerate their time on the heart–lung machine or the poor protection afforded to heart muscle during surgery in those days. We all knew that the slower the surgeon, the more likely the patient was to die. We would take bets on it. ‘If X does the valve replacement he stands a chance. But he’s buggered with Y.’

That was the way it used to be in the NHS. Treatment was free, so the punters didn’t question what was on offer. Life or death followed from the toss of the dice. But the finality of death was still devastating. The consultants would shield themselves from all the misery by dispatching us juniors to talk with the family.

I seldom had to speak. The bereaved relatives would recognise the slow walk with dropped shoulders and head down as I approached. They could read my unequivocal ‘bad news’ expression. After the reflex indrawing of breath came shock, my words ‘Sorry’ and ‘Didn’t make it’ triggering emotional disintegration. The sudden relief of suspense and the subsequent crushing grief were often followed by dignified resignation, but sometimes by abject denial or frank meltdown. I’ve had hysterical demands for me to return to theatre and resurrect the corpse, to resume cardiac massage or put the body back on the bypass machine. It was particularly heart-breaking for the parents of young children, little ones who had just developed their own innocent personality. As I saw it, newborn babies just screamed and pooed, but toddlers were well on their way to becoming people. They walked in holding Mummy’s hand and clutching their teddy bears, which all too often were carried off with them to the mortuary fridge. Yet the minute I turned and walked away from these families, my sorrow was filed in the out tray. Eventually, when I started to lose my own patients, I became well used to it.

Only once did it strike me that I had murdered someone, and the grim circumstances came as a shocking and bloody reminder that I was not invincible. It was a third-time operation on the mitral valve of a middle-aged patient who had a huge heart on the chest X-ray and excessively high pressures in the right ventricle situated directly below the breast-bone. I always took precautions when reopening the chest after previous surgery, and had started to request a CT scan to determine the gap between bone and heart. This led to me being admonished for adding to the costs of my many reoperations – only committees were allowed to sanction additional expense. The gentleman’s anxious partner accompanied him to the anaesthetic room and I urged her not to worry. I told her I was very experienced and would take good care of him.

‘That’s why we came to you,’ she replied, her voice quivering with apprehension. She kissed his forehead and slipped out.

I drew the knife along the old scar and used the electrocautery to singe the outer table of the sternum. The wire cutter snipped the steel wires from the second operation, which I then tore out with heavy grasping forceps. It was just like pulling teeth – should they break, it makes life difficult. The oscillating saw screeched against them as if screaming, ‘I’m not designed to cut steel.’ Then came the tricky bit, which involved edging my way through the full thickness of bone with a powerful saw designed not to lacerate the soft tissues beneath. I had safely reopened the sternum for hundreds of reoperations, but this time there was a great ‘whoosh’. Dark blue blood hosed out through the slit in the bone, poured down my gown, splashed onto my clogs and streamed across the floor.

I let out a chain of expletives. While I pressed hard over the incision to slow the bleeding, I instructed my jelly-legged assistant to cannulate the blood vessels in the groin so we could get onto the bypass machine. As the anaesthetist frantically squeezed in bags of donor blood through the drips in the neck, it all went dreadfully wrong. The cannula dissected the layers of the main leg artery so we couldn’t establish any flow. With continued profuse haemorrhage, I had no alternative but to prise open the rigid bone edges and attempt to gain access to the bleeding beneath, forcing a small retractor through the bony incision and cranking it open. But there was no gap between the underside of the bone and heart muscle. The cavernous, thin-walled right ventricle had been plastered by inflammatory adhesions to the bone by a previous wound infection. So I found myself ripping the heart asunder and staring at the underside of the tricuspid valve. Both the hand-held suckers, then the heart itself filled with air as I fought for better access. I then found that this tissue-friendly saw had also transected the right coronary artery. My paralysed registrar simply gaped, as if to say, ‘How the fuck are you going to get out of this mess?’

There was nothing I could do in time to save him. Deprived of oxygen, the heart soon fibrillated, so at best – had I persisted – he would have suffered devastating brain injury. So I called time on the gruesome spectacle. The whole shambles had taken less than ten minutes. Apologising to the nurses who had to lay him out and clean the floor, I tossed away my gloves and mask in disgust. The whole bloody catastrophe was straight out of Saw II or Driller Killer. It felt as if I had driven a bayonet into the man’s heart and twisted the blade. Then, just as had been done to me during my formative years, I dispatched the registrar to talk to the man’s wife while I went off to the pub.

I didn’t see the poor lady again until the inquest, where she sat unaccompanied, listening intently. She bore no malice, nor was the coroner critical in any way. The gruesome fact was that I had unintentionally sawn open that heart and emptied the circulation onto my clogs. In my own mind, I knew that a CT scan would have prompted me to cannulate the man’s leg vessels myself, which could have averted the tragedy and was something that I always did after that. Undeterred, I reopened a sternum for the fifth time in front of television cameras just weeks later.

Most deaths in surgery are wholly impersonal. The patient is either covered in drapes on the operating table or obscured by the grim paraphernalia of the intensive care unit. As a result, my most haunting experiences of death stemmed from trauma cases. The sudden, unexpected process of injury pitches an unsuspecting individual into their own Dante’s Inferno. Knife and bullet injuries were predictable and easy for me. Cut open the chest, find the haemorrhage, sew up the bleeding points, then refill the circulation with blood – such cases always provoked an adrenaline rush, but usually involved young, healthy tissues to repair.

My own worst nightmare wasn’t caused by a gun or a knife. As a young consultant I was once fast-bleeped to the emergency department to help with an incoming road accident. It was still what was called the ‘swoop, scoop and run’ era, so the patient was being brought in directly without transfusion of cold fluid to screw up the blood clotting. With foresight and sensitivity, the police had already warned reception what to expect, but unfortunately I’d not been party to that. I was outside in the ambulance bays enjoying the sunshine when the vehicle came thundering up the drive, siren blaring and blue lights flashing. When the rear doors were thrown open, the crew wanted a doctor to take a look before they risked moving the patient again.

I could hear the whimpering before I could see the girl, but I knew from the paramedic’s grim expression that it was something unpleasant. Unusually awful, in fact. The teenage motorcyclist was lying on her left side, covered by a blood-soaked white sheet. This sheet and what I could see of her face were the same colour. The poor girl had been drained of blood. Normally she would have been shunted quickly through to the resuscitation room, but there was every reason not to rush.

The paramedics quietly and deliberately drew back the sheet so I could see that the girl was transfixed by a fence post. A witness had watched her motorcycle swerve to avoid a deer, then she veered off the road, smashing through a fence into a field. She was left skewered like meat on a kebab stick. The fire brigade eventually released her by sawing through the fence and lifting her free. This left the stake protruding from her blood-soaked blouse. The response of the gathering team was to glare incongruously at the gruesome transfixion and ignore that horrified face behind the oxygen mask.

I took her cold, clammy hand more in clinical assessment than humanity. She was in circulatory shock, not to mention profound mental turmoil. Her pulse rate was around 120 beats per minute, but the fact that I could feel it suggested that her blood pressure was still above 50 mm Hg. Before we moved her I needed to scrutinise the anatomical features of the injury so as to predict what damage we would be confronted with. I had seen several cases of transfixion trauma where the patient survived because the implement narrowly missed or pushed aside all the vital organs. Here the degree of shock indicated otherwise. It was time to get some cannulas in place in a calm and controlled manner, and bring group O negative blood ready to transfuse her. And for pity’s sake, she deserved a slug of morphine to take the edge off the sheer terror of her predicament.

Some things I knew instinctively. Had the stake damaged the heart or aorta she would have bled out at the scene. Traumatised small arteries will go into spasm, clot and stop the bleeding themselves as long as injudicious clear fluid infusion doesn’t raise the blood pressure and blow the clots off. So I surmised that most of the bleeding must be coming from the veins, which do not constrict. I asked the nurses for some scissors to remove her clothing, now stiff with dried blood. It was like cutting through cardboard and opening a window on the grim reality of her situation.

Her pleading brown eyes remained firmly fixated on the stake. I could make out the jagged ends of ribs protruding through macerated fat and pale, bruised skin. The post had entered directly below her right breast, marginally to the right of the midline, and emerged from her body higher up in her back, suggesting that she had slid feet first after tumbling from her motorcycle. My three-dimensional anatomical knowledge left me in no doubt which structures had been damaged. The post must have taken out her diaphragm and liver, the lower lobe of her right lung and probably the largest vein in the body, the inferior vena cava. The lung wasn’t a problem. But if her liver was pulped and the veins torn off the cava, I knew that we couldn’t fix her. Scrutiny of the post protruding from her back confirmed my fears – there were fragments of both liver and lung on the wooden shards. Everyone knows what liver looks like from the butcher’s, while youthful lung is pink and spongy. I recognised both, and it made me sad.

In just seconds on a Saturday morning she had gone from vivacious carefree student to dying swan transfixed like a vampire. With every agonising breath, blood slopped from the wound edges. Whatever the way forward, I had to talk to her. I edged around the trolley and knelt by her head to distract her as the emergency doctors painfully probed with needles to locate an empty vein. With blood and froth dripping from her mouth, she was finding it difficult to breathe, let alone speak. We needed to put her to sleep right there in the ambulance, then get a tube into her windpipe – a seemingly impossible task in that awkward position. By now I was pretty sure that whatever we did she would die. If not soon, it would be in days or weeks as a result of infection and organ failure in the intensive care unit. So whatever else we attempted to do for her, we had to be kind. Do as little as possible to add to her pain.

Staring directly into her eyes I asked her name. I was simply trying to inject a semblance of humanity into the proceedings and relieve the brutality of it all. Stuttering between breaths, she told me she was a law student, like my own daughter Gemma, which added to my discomfort. I took her icy cold fingers in my right hand and rested my left hand on her hair, hoping to obscure that stake from her gaze.

With tears streaming down her cheeks she murmured, ‘I’m going to die, aren’t I?’

At that point I ceased being the surgeon because I knew she was right. For her last agonising moments on earth I could only comfort her. So I would be her substitute dad for that time. I held her head and told her what she wanted to hear. That we would put her to sleep now and when she awoke everything would be back in its place. The stake would be gone. The pain and fear would be gone. Her shoulders dropped and she felt less tense.

The gadget clipped onto her index finger showed very low oxygen saturation, so we had to move her to give the anaesthetist his chance with the endotracheal tube. Only then could we begin a token effort at resuscitation. I extended my hand to feel her belly, which was distended and tense. As we explained the need to move her, I could sense her consciousness fading.

She whispered, ‘Can you tell mum and dad that I love them, and I’m sorry? They never did want me to have that bike.’

Then she coughed up a plug of blood clot. As she rolled backwards the stake shifted, grating audibly against her shattered ribs. Her eyes rolled towards heaven and she slipped away. Whatever blood she had left in her circulation was pouring out over me. But I didn’t mind. It was a privilege to be there with her. The junior doctors from the resuscitation room stirred, intending to begin cardiac massage. Without hesitation I told them to back off. What the fuck did they expect to achieve?

The back of the ambulance fell silent with the horror of it all. I would have loved to have dragged that hideous fence post out of her chest – that had to be left to the pathologists. I couldn’t bring myself to watch her autopsy, but it confirmed that her diaphragm had been torn away and her pulped liver avulsed from the inferior vena cava.

That balmy summer’s evening I went walking through the bluebell woods of Bladon Heath with Monty, my jet black flat-coated retriever. While he chased rabbits, I sat on a fallen tree carpeted in moss and wondered if there was a God. Where was he on those fraught occasions when I needed some divine intervention? Where was he today when that poor girl tried to avoid hurting a deer and was killed by her kindness? I visualised her devastated parents sitting with a cold corpse in the mortuary, holding their daughter as I’d done in the ambulance, beseeching God to turn the clock back.

There was no point trying to be logical about religion. I knew that high-ranking Oxford – and indeed Cambridge – academics scoffed at the deity concept. Both Richard Dawkins and Stephen Hawking had that gold-plated atheistic confidence in their own abilities, spurning outside help. I guess I was the same. But I would still sneak into the back of a college auditorium and listen to debates on the subject. Some disputed God’s existence because of all the evil and misery in the world, and while I could identify with that, I had contrary and privileged insight through the odd patient who actually claimed to have reached the Pearly Gates before we clawed them back.

These vivid out-of-body experiences were rare but occasionally compelling. One spiritual lady described floating calmly on the ceiling as she watched me pumping her heart with my fist through an open chest. Forty minutes into this internal cardiac massage my thumb tore through into her right ventricle – she clearly recalled my words: ‘Oh shit, we’ve had it now.’ Fortunately, the perfusionists arrived with the circulatory support system I needed to keep her alive, and I succeeded in repairing the hole.

She uncannily related her memory of the events a number of weeks later in the clinic. Having been party to her own resuscitation attempts from above, she had floated through the clouds to meet with St Peter. This journey amid peace and tranquillity contrasted sharply with our gruesome efforts back down on the ground. But having arrived in heaven she was told she had to return to earth and wait her turn again – a ridiculously close-run thing between me and Grim Reaper. Perhaps God changed as he got older. Maybe he started out with the best of intentions but became cynical and less caring with time. Just like the NHS.

It was only after retiring from surgery that I began to reflect on my role in dispatching so many to that great hospital in the sky. One tranquil spot on the heath still holds a great deal of significance for me. It is a haunted place, a gap in the woodland that overlooks both Blenheim Palace, where my hero Winston Churchill was born, and St Martin’s Church, Bladon, where he is buried. A few yards from this clearing a jet plane that had just taken off from Oxford Airport crashed and exploded.

My son Mark was working for exams in his bedroom and watched the whole spectacle unfold. Heroically, he was the first to reach the drama in the field but could do nothing amid the conflagration. He watched the cockpit burn and cremate the occupants. Obviously at seventeen he had a different constitution to his lobotomised father, so the dismal spectacle disturbed him as it might any normal person. After dropping a single grade in biology he was dumped by his chosen university. I was very bitter about that. I still am.

One day when we reached this sacred ground, Monty spotted a stag silhouetted against the evening sky a hundred or so yards up the ride. A shaft of evening sunlight shone through the trees to illuminate a clump of fading bluebells, their heads dipping at the end of their season. Was that majestic stag in fact God looking down on me, surrounded by the spirits I had set free during my career, the ghosts of operations past?

In truth, I had always been a loner. I was still a restless insomniac who would wake in the early hours and write, making stupid notes on material I would never use, continuing to invent impossible operations that no one would ever perform. Did I miss surgery? Not at all, surprisingly enough. Forty years had been plenty. But it remained a great mystery to me how I had achieved so much from my humble beginnings in the backstreets of a northern steel town. Perhaps it was that battle to escape obscurity that provided the momentum. I wanted to be different, and I had the ruthless ambition to take on the system and overcome my past.

Although I spent my whole career writing textbooks and scientific papers for the profession, I reflected for many years on whether it was appropriate to discuss my battles in a public forum. Ironically it was my own patients who urged me to do so, even the loved ones of some who died. So many were eager for their stories to be told. From my own perspective, I always found the history of modern heart surgery to be among the most compelling stories ever told. As a trainee in London and the US I actually knew a number of the pioneers personally, and they had shared their own trials and tribulations with me face to face, encouraging me to make a difference, not to sit in the shadows avoiding conflict. And I certainly attracted trouble right from the start.

The government’s policy of releasing named-surgeon death rates to the press was another factor that edged me towards writing a tome for consumption by the general public. What is life really like on the other side of the fence? Is it different from being a statistician, politician or a journalist? The barrister and medical ethicist Daniel Sokol wrote in the British Medical Journal, ‘The public has an appetite for glimpses of the private lives and thoughts of doctors. They demystify a profession that was once deemed blessed with magical powers.’ Perhaps some of us still do have mystical powers. There are few things more intriguing than delivering electricity into a patient’s head through a metal plug screwed into their skull like Dr Frankenstein’s monster or reinventing human circulation with continuous blood flow without a pulse. These innovations may be construed as witchcraft, but they were my own practical solutions to the terrible illness that is heart failure. Sokol went on to say that doctors are in the habit of revealing ‘not the chiselled frame of Apollo … but the wart covered body of Mr Burns, the Simpsons character’. But Burns was the rich factory owner. I’m more of a sensitive intellectual, like Bart Simpson’s father Homer.

As is often the case, the French have a phrase for it: ‘se mettre à nu’, to get naked. So that is what I decided to do, although this was a much more interesting spectacle in my younger years than now. My own insight tells me that the public are happier to learn that their surgeon, even a heart or brain surgeon, is human and subject to the same core emotions as anyone else. But because of a freak sporting accident, some qualities possessed by the vast majority of people were lost to me for a while, which proved an unexpected but substantial boost to a career at the sharp end – life perpetually on the ‘knife’s edge’.