Читать книгу Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table - Stephen Westaby, Stephen Westaby - Страница 13

He has been a doctor a year now and has had two patients. No, three, I think. Yes, three. I attended their funerals.

Mark Twain

The best way to prepare for the exams to become a Fellow of the Royal College of Surgeons was to work as an anatomy demonstrator in the dissection room of the medical school, teaching anatomy to the new students in minute detail and helping them to dismantle their cadaver sliver by sliver – skin, fat, muscle, sinew and then the organs. They were given greasy embalmed corpses on a tin trolley, and there were six new and impressionable students to each one. They’d march in with their starched white coats and brand new dissection kits – scalpel, scissors, forceps and hooks in a linen roll – all as green as grass. Just like me when I started.

I moved from group to group to maintain their momentum. A few couldn’t hack it. Spending untold hours picking away at a corpse was not part of their medical dream, so I gave the best advice I could to help them through it: wear strong perfume, don’t skip breakfast and try to think about something else – football, shopping, sex, anything. Just learn enough to pass the tests and don’t let the stiffs drive you out. This worked with some. Others had nightmares, their dissected corpses visiting them at night.

For my first surgery exam I had to master anatomy, physiology and pathology – nothing to do with being able to operate. There were courses in London that just hammered home the facts, taught by past examiners who presented the information in the way that the college wanted it. Pay up and pass was the message, unless you were an idiot. Yet two-thirds of candidates still failed come exam time, including myself on the first occasion.

In the midst of this academic monotony the Royal Brompton Hospital advertised for ‘Resident Surgical Officers’, with Fellowship of the Royal College of Surgeons being ‘desirable but not obligatory’. Could I aspire to this? I’d only just passed the first part. It would be a minimum of three years before I could sit the final exam, but there would be nothing lost by trying for the post.

Despite the odds I succeeded in securing the job and started in the position just a few weeks later. I was allocated to work for Mr Matthias Paneth, an imposing six-foot, six-inch German, and Mr Christopher Lincoln, the newly appointed children’s heart surgeon of similar height. Two very different personalities, but both scary in their own way until I knew them better. In my massively busy junior resident jobs at Charing Cross I learned that the only way to keep up was to write everything down. Record every order or request as it was verbalised. To forget was to be in deep shit, so I always carried a clipboard. This was a source of great amusement to Mr Paneth, who took to saying, ‘Did you get that, Westaby? Did you get that, Westaby?’

My surgical logbook opened in spectacular fashion. The Paneth team had a case scheduled after the outpatient’s clinic, a little old lady from Wales for mitral valve replacement. The boss invited me to go and start while he saw a couple more private patients. I proudly changed into the blue scrubs. Not only that, I found a pair of white rubber surgeon’s boots in an open locker. They were well worn and dirty. I could have had new clogs but coveted these discarded second-hand boots. Why? Because down the strip at the back was written ‘Brock’. I was about to inherit Lord Brock’s boots.

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.