Soon I could identify a coronary thrombosis, a myocardial infarction, a rheumatic heart valve and a dissected aorta, or cancer spread to the liver or lungs. The common stuff. Charred or decomposed bodies smelt bad, so Vicks ointment stuffed up the nostrils spared your olfactory nerves. I found suicides to be terribly sad, but when I verbalised this I was told to ‘Get over it if you want to be a surgeon’ and that it would all be easier when I was old enough to drink. I sensed that alcohol was high on the list of surgeons’ recreational activities, and this seemed more obvious when they were called in at night. But who was I to judge?
I began to wonder whether I could really get in to medical school. I was no great academic, and I struggled with maths and physics. For me these subjects were the real barometer of intelligence. But I excelled in biology and could get by in chemistry, and in the end I passed a lot of exams, stuff I would never need like Latin and French literature, additional maths and religious studies. These I saw as a function of effort, not intelligence, but hard work bought me my ticket out of the council estate. In addition, the time spent in the hospital had made me worldly. I’d never been out of Scunthorpe, yet I knew about life and death.
I started to search for a place at medical school, and returned to the hospital during every school holiday. I progressed to working as an ‘operating department assistant’, becoming an expert in cleaning up blood, vomit, bone dust and shit. Humble beginnings.
I was surprised to be called for an interview at a magnificent Cambridge college. Someone must have put in a good word but I never learned who it was. The streets bustled with lively young students in their gowns chatting loudly with public school accents, all seeming much smarter than me. Erudite, bespectacled professors cycled down cobbled streets in their mortarboards off to college dinners for wine, then port. My mind flashed back to the grimy steelworkers silently making their way home in flat caps and mufflers through the smog for bread and potatoes, and then maybe a glass of stout. My spirits started to sink. I didn’t belong here.
The interview was conducted by two distinguished fellows in an oak-panelled study overlooking the main college quadrangle. We sat in well-worn leather armchairs. It was meant to be a relaxed atmosphere, and nothing was said about my background. The anticipated question, ‘Why do you want to study medicine?’ never came. Wasted interview practice. Instead I was asked why the Americans had just invaded Vietnam and whether I had heard of any tropical diseases their soldiers might be exposed to. I didn’t know whether there was malaria in Vietnam so I said, ‘Syphilis.’
That broke the ice, particularly when I suggested that this might be less of a health problem than napalm and bullets. Next I was asked whether smoking cigars may have contributed to Winston Churchill’s demise (he’d only recently died). Smoking was one of the key words I was waiting for. My mouth fired off in automatic mode: cancer, bronchitis, coronary artery disease, myocardial infarction, heart failure, how the corpses of smokers looked in the autopsy room. ‘Had I seen an autopsy?’ ‘Many.’ And cleared up the brains, guts and bodily fluids afterwards. ‘Thank you. We’ll let you know in a few weeks.’
Next I was called down to Charing Cross Hospital, between Trafalgar Square and Covent Garden on the Strand. The original hospital was built to serve the poor of Central London and had a distinguished war history. Although I arrived early I was always last alphabetically, so I twiddled my thumbs anxiously to while away what seemed like hours. A kindly matron received the candidates with tea and cakes, and I made polite conversation with her about what had happened to the hospital during the war.
The interview took place in the hospital board room. Across the other side of the boardroom table from me was the chief interviewer – a distinguished Harley Street surgeon wearing a morning suit – together with the famously irascible Scottish professor of anatomy upon whom the Doctor in the House films were based. I sat straight-backed to attention on an upright wooden chair – no slouching here. I was first asked what I knew about the hospital. Thank you, God. Or Matron. Or both. Next I was asked about my cricketing record and whether I could play rugby. And that was all, the interview was over. I was the last of the day, they’d had enough and they’d let me know.
I wandered out into Covent Garden past the colourful market stalls and bristling public houses. All life was there: tramps, tarts, buskers and bankers, the Charing Cross Hospital clientele, and the black cabs and scarlet London buses that drove up and down the Strand. Meandering between the crowds and the traffic I came to the grand entrance of the Savoy Hotel. I wondered whether I dared go in. Surely I looked smart enough in my interview suit and Brylcreemed hair. But the decision was swiftly made for me when the immaculate doorman pushed the swing doors open and ushered me through with a ‘Welcome, sir.’ The seal of approval. From Scunthorpe to the Savoy.
I strode purposefully through the atrium, past the Savoy Grill, hesitating only to scrutinise the menu in its gilt frame. The prices! I didn’t stop. A sign pointed to the American Bar. The hall was lined with signed cartoons, photographs and paintings of West End stars, and when I reached it there was no queue as it was only 5 pm. Perched on a high stool I furtively devoured free canapés and perused the cocktail menu. Devoid of insight – this was my first alcoholic drink – I was pushed to make a decision. ‘Singapore Sling, please.’ Like flipping a switch, my life had changed. Had I ordered a second I’d never have found King’s Cross station.
Within the week a letter arrived from Charing Cross Hospital Medical School. Opening it surrounded by my anxious parents felt like defusing a bomb. There was the offer of a place. The conditions? Just pass my biology, chemistry and physics exams, no grades specified. Charing Cross was a small medical school with an intake of only fifty students each year, but I’d be following in the footsteps of distinguished alumni such as Thomas Huxley the zoologist and David Livingstone the explorer. I was the first in my family to go to university, the first to attempt to become a doctor and, hopefully, the first heart surgeon.
3
lord brock’s boots
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 fin
al 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.
Fragile Lives Page 3