Читать книгу Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table - Stephen Westaby, Stephen Westaby - Страница 15

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

Thomas Edison

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.