Читать книгу: «The Knife’s Edge», страница 3

Groaning deeply under the burden of the day, I gave Nick a resigned look and thought for a moment. The bleeding was still not under control and there was no prospect of repairing the hole while her heart kept on pumping. She would simply bleed to death. The only potential route out of the predicament – I called it ‘deep shit’ at the time – was to get onto cardiopulmonary bypass, cool her down to 16°C, then stop the circulation altogether. Deep cooling of the brain would give us a safe thirty- to forty-minute window without blood flow to identify and deal with the damage.

Given the morning’s conflict, I very politely asked anyone not immediately engaged in the frantic resuscitation to ask one of my perfusionists to bring in and prepare a heart–lung machine. And for a couple of my own scrub nurses and a specialist cardiac anaesthetist to come across. Nick just had to keep on pressing. His anaesthetists kept on squeezing.

Once I’d scrubbed up and joined the team around the body, I couldn’t even see the heart. I needed a much bigger hole in the chest to work around my colleague’s ‘finger in the dyke’. There was no time for finesse. With the scalpel and cautery I virtually split her in half as she lay there, right side uppermost on the operating table. The metal retractor cranked the chest wide apart with a crack that told me that one of her ribs had just broken. This was not unusual. Chest surgery is a brutal business.

Now I could see the pale, empty heart beating rapidly in its fibrous sac. I needed to cut this open and insert two cannulas to connect to the bypass machine. The first went into the aorta as it left the left ventricle carrying cherry-red oxygenated blood. The second was pushed into the empty right atrium, where blue blood from the veins of the body re-entered the heart to be pumped to the lungs. This venous blood, low in oxygen, would now pass through a heat exchanger and mechanical oxygenator before re-entering the aorta. Then we could cool and protect the brain and other vital organs. The heart is rarely approached through the right chest, but I had done it on a number of occasions for complex reoperations on the mitral valve. With a daunting challenge like this, every ounce of experience counted.

Thinking ahead, I told one of the watching cardiac registrars to go in person to the homograft bank and ask for a tube of antibiotic-treated aorta from the supply of spare parts we obtained from dead donors at autopsy with the relatives’ permission. Human tissue is more resistant to infection than synthetic vascular grafts made from Dacron fabric. I often used donated heart valves, patches of aorta or segments of blood vessels from the dead to repair the living. This is recycling. God’s stuff is still better than man-made.

At 2 pm the registrar from Theatre 5 came in to announce that he had put in pacemaker wires and chest drains, and had closed the baby’s chest. All was well.

It took us around thirty minutes to cool down for the next stage of the operation. While his hands grew colder and colder, I congratulated Nick for saving the woman’s life. I told him not to risk moving and that cold was good as it meant the woman’s brain was cooling too. Then I asked the enthusiastic registrar to scrub up and babysit the bypass circuit so I could duck out for coffee and a piss. What I really wanted to do was to phone Gemma, but when I did there was no answer. She was still in a seminar. Although time was passing relentlessly, I remained hopeful that I would be in Cambridge by the evening.

At 18°C I was too impatient to wait any longer. Gowned and gloved for the third time that day, I told the perfusionist to stop the pump and empty the lady’s circulation into the blood reservoir. Nick could finally withdraw his cold, stiff arms from her chest after having had them in there for more than an hour, while I took the first operator’s position. In turn, Nick moved the registrar out of the way, eager to get a look at the damage for himself.

With no blood flowing around the body, we were working against the clock. The infected tissues had the consistency of wet blotting paper and the stench of rotten cabbage. We could not repair the damaged oesophagus, and Nick agreed it had to go. I chopped through the precious muscular tube above and below the abscess, and dissected it away from the aorta. Nick passed a wide-bore suction tube down into the stomach to prevent it from spewing acid and bile over my aortic repair.

Now we had a clear view of the ragged hole, which really should have been a fatal problem. I reluctantly decided to replace the whole infected segment of aorta with the homograft tube rather than risk just a patch. No time to debate this. I trimmed the donor tube to the correct length, then sewed at top speed using blue polyester thread on a fine stainless-steel needle, held in a long titanium needle holder; deep bites into healthy tissue – aesthetically pleasing, bordering on the erotic. Throwing the final knot left-handed, I told Richard the perfusionist to ‘go back on’ and rewarm. Cold blood from the machine expanded the flaccid graft and air fizzed through the needle holes. It needed a couple of extra stitches to make the whole repair blood tight, but we restored blood flow to the brain after thirty-two minutes. Happy days. Though not so happy in my own case.

I really didn’t have time to loiter and admire my needlework. Between us we agreed that Nick would divert the upper end of the oesophagus out of the left side of the poor lady’s neck to drain saliva and enable her to swallow liquids for comfort. The lower end would then be closed off and an entrance to the stomach fashioned through the abdominal wall through which she would now be fed. We call this a gastrostomy. Months down the line Nick would restore her swallowing with a new gullet made by transposing a length of large bowel between her neck and stomach. But for now she was safe. In life, and for that matter death, timing is everything. Heart surgeon close at hand. Heart–lung machine and perfusionist available between cases. Spare parts on the shelf. Otherwise she was dead, killed by a fish.

Nick’s gastro team were happy to close the chest, put in the drains and finish off. Stepping backwards from the table into a pool of slippery blood clot, I skidded gracelessly onto my backside, hard down on the tiled floor with a crack – retribution perhaps for leaving Nick for so long with his cold hands in the chest. Now with a soggy red patch on my trousers and the suspense of a near-death drama lifted, it gave the nurses something to laugh at. Some proffered concern for the integrity of my coccyx. But, pain apart, I was content to have dispelled the gloom.

The levity was short-lived as no fewer than four messages with my name attached were taped to the door. First, the lady waiting for the mitral repair on the ward was agitated and wanted to see me. Predictable. Second, would I go to the paediatric intensive care unit where the baby was losing a little too much blood into the drains? Shit. Next, a lady doctor in the accident department of the Norfolk and Norwich Hospital was trying to get hold of me. Why on earth would that be? It was many miles away. And last, the medical director would like to see me in his office with the director of nursing at 4 pm.

Bugger that. It was already 4.10, and I was in no doubt what the chat would be about – swearing at the unhelpful agency nurse, quite inappropriate conduct for a consultant surgeon. Another ticking off. Nor was I in the mood for an acrimonious discussion with the cancelled mitral lady. After 5 pm there were only sufficient nurses to staff one emergency theatre. The nurses would never allow me to begin an elective operation at this time of day. So my only concern was for the baby. Was it significant surgical bleeding or just oozing through compromised blood clotting after being on the bypass machine? Still hoping to leave town, I went directly to the unit to find out.

The afternoon ward round was congregated around the cot. On either side crouched an anxious parent holding a cool, sweaty little hand. Suspended from the drip stand was a tell-tale bag of donor blood dripping briskly through the jugular vein cannula in the baby’s neck. Without reading the levels I could see that there was too much blood in the drains. The precious red stuff was dripping in one end and straight out the other. What’s more, they had checked the clotting profile and it was virtually normal.

With that one glance my plans for the evening were dashed. Cambridge might as well have been on a different planet. I had to take the baby back to theatre and stop the bloody bleeding. Abject despair turned to anger. I should have closed the chest myself – but then fishbone lady would be dead now. Acrimoniously I rang my so-called ‘helper’, telling him to lay claim to the emergency operating theatre and that I would push the cot around myself. Five minutes later Mr Putty Fingers called back to say that they couldn’t staff an emergency theatre because the chest surgeons were running late with a lung cancer operation. We would have to wait for them to finish. Until then, no room for emergencies, so keep squeezing in the blood. In the meantime, any remaining chance of seeing my daughter on her birthday had gone. More of the same. Useless absentee father ridden with guilt, and made worse by the fact that I had still not made contact. I was a sorry sight with my bloody trousers and sore bum.

There was no point in trying to rush the chest surgeons. They operate slowly through small holes with telescopes and invariably overestimate what they can squeeze in to an operating list. Yet no access for emergency surgery spells trouble. I was now glued to the cot side, with the fretting parents wanting me to stop the bleeding. I deployed that old chestnut: ‘It was alright when I left. It can’t be bleeding from the heart.’

Sure enough, over the next thirty minutes the bleeding slowed to a trickle. I fantasised that blood clotting had finally sealed the needle holes, which would allow me to escape the hospital without reopening the chest. Except the jugular veins were distending as the blood loss slowed. Perhaps there was too much transfusion. More likely, the chest drains had blocked off and blood was now accumulating under pressure in the closed space within the pericardium so the right atrium couldn’t fill properly – what we call cardiac tamponade. Should the blood pressure begin to fall, we would be in real trouble.

The baby’s blood pressure drifted down. We couldn’t wait any longer for an operating theatre. Now I needed to reopen the chest right there in the cot and scoop out the blood clot. Sister carried the heavy pre-sterilised thoracotomy kit to the cot side and dumped it on a trolley. Still wearing theatre blues, I hastily scrubbed up at the sink while calling for the registrar who had left me in this mess. He had already gone home, so we tried to find the on-call registrar. It was a locum, who was already scrubbed up in the thoracic theatre.

So I got on and did it without help – it was a very small chest, after all – getting the baby prepared, draped and her sternum wide open in less than two minutes. The suction tubing was not connected yet, so I scooped out the clots with my index finger, then packed the pericardial cavity with virginal white swabs. An expanding bright red spot soon showed me the bleeding point, a continuous trickle from the temporary pacing wire site in the muscle of the right ventricle, ostensibly trivial but life-threatening. That’s the way with cardiac surgery. It has to be perfect every time or patients die needlessly.

The cardiac rhythm was normal, so I pulled out the wire and stemmed the dribble with a single mattress stitch. Sure enough the drains were blocked. I changed them for clean ones and closed up. The whole process took ten minutes, but it had been a completely avoidable charade. It transpired that the trainee surgeon lacked the confidence to put a stitch into the baby’s twitching ventricle, simply hoping that the oozing would stop. He would not make it in this specialty.

7 pm. I was intrigued by that message from Norwich A&E. Were they still waiting to talk to me in the hospital? At first bewildered, I now became uneasy, paranoid even. Norwich was not far from Cambridge. Could Gemma have been out with friends and had an accident? Why did that not occur to me earlier? So I fretfully called her mobile. This time birthday girl answered cheerily and asked whether I was well on my way. The ensuing silence spoke volumes. There was no way I would get to see either of my children that night. Both patients survived, but part of me died. Again.

2

sadness

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.