Fragile Lives

by Stephen Westaby

  We needed another fifteen minutes on the bypass machine for the effects to wear off. During that time I put temporary pacing electrodes on the right atrium and ventricle. We’d control his heart rate until the cardiologists could implant a permanent pacemaker. Gradually the heart function improved. Obstruction gone, lungs relieved of congestion, his life relieved of heart failure and breathlessness. Or so I hoped.

  The boy’s pulse rate was only forty beats per minute, less than half of what it should have been. We increased that to ninety with the external pacemaker, and with this improvement the blood started to well up from behind the heart. I assumed that this was persistent bleeding through my stitching, so I told the perfusionist to turn the bypass machine off and empty the heart while I lifted it up to inspect the join. Nothing. It looked great. No leak.

  When we restarted the machine thirty seconds later there was more blood. I inspected the joins of the aorta and pulmonary artery. No leak there, either. Eventually my first assistant spotted oozing from the aorta. The needle used to evacuate air had gone through the back, making a small hole. This would be inconsequential when blood clotting was restored, so we separated the boy from the heart–lung machine and closed the chest.

  I didn’t have long to reflect on our success as a message came in from the adult cardiologists. They had just admitted a young male following a high-speed road-traffic accident. He’d not been wearing a seatbelt and his chest had impacted against the steering wheel with great force. He was in shock and his blood pressure could not be restored by fluid resuscitation.

  Chest X-rays at the referring hospital had shown a fractured sternum and an enlarged heart shadow, and the veins in his neck were distended, suggesting blood under pressure in the pericardial sac. Not only that. The echocardiogram showed that the tricuspid valve, between his right atrium and ventricle, was leaking badly, hence the persistently low blood pressure and severe shock. The man needed urgent surgery, and could I please come and see him before it was too late?

  I was distinctly uneasy about abandoning the boy but there was no choice. Leaving the operating theatre complex I found the mother sitting cross-legged in the corridor, alone and desolate. She’d been waiting there for five hours, and I sensed that she was about to implode mentally, her emotions bottled up for too long owing to her inability to communicate for whatever reason. And finally we’d taken away her bundle of rags. She saw me, sprang to her feet and panicked. Was the operation a success? I didn’t need to speak. Our eyes met again, pupil to pupil, retina to retina. My smile was enough, and with it the message that her son was still alive.

  Bugger protocol and the audience of cardiologists. I needed to show her some affection so I held out a sticky hand, wondering whether she’d take it or remain aloof. This act of kindness unlocked the tension. She grasped it and began to shake uncontrollably.

  I pulled her in and held her tight, as if to say, ‘You’re safe now, we won’t let anyone harm you any more.’ When I let go, she held on tight and started to weep uncontrollably, waves of emotion discharging onto the hospital corridor and leaving my Saudi colleagues standing in an embarrassed silence. It took a while to calm her, and they were becoming increasingly anxious about their trauma patient.

  I told her that her son would shortly leave the operating theatre, that they would bring him out in an intensive care cot attached to drips and drains, and that this might frighten her. She could certainly walk with them but not interfere. Again I sensed that she understood English, but in case she didn’t one of the cardiologists repeated my words in Arabic. Then we left to review the injured man’s echocardiograms, the ultrasound examination of his heart chambers.

  By now the trauma patient was dying. He had a torn tricuspid valve, a rare, high-speed deceleration injury we never see with our mandatory seatbelt law. The right ventricle was pulverised as the sternum fractured and had been driven back against the spine, the rapid increase in pressure causing the valve to burst. Now, when the heart contracted, as much blood went backwards as forwards, little was passing through the lungs and the heart couldn’t fill adequately because of blood in the pericardium. Cardiac tamponade, we call it.

  Once I’d seen the pictures I didn’t waste time visiting the patient. I just needed to crack that chest, relieve the tamponade and if possible repair the tricuspid valve. We had to get him onto the heart–lung machine quickly to restore blood flow to the brain and correct his dire metabolic state. Then someone behind me whispered, ‘Don’t rush. He’s a madman. He killed the other driver.’ I said nothing. That wasn’t my business. Striding purposefully back to the operating theatre I encountered the little entourage in transit to paediatric intensive care. The fast, regular beeping of the heart rate monitor was reassuring. Without diverting her gaze the mother held out her hand as we crossed over, and I did the same. Contact.

  I should have been with the boy in intensive care, at least for the first couple of hours until I was confident that he was stable. But now I couldn’t be. Soon the trauma patient was on the operating table being resuscitated. He had disfiguring facial injuries and extensive bruising over the chest wall, and the edges of the fractured sternum were overlapped with a step deformity. But it was nothing we couldn’t fix with pins and wires.

  Within minutes I had the chest open and was scooping clumps of blood clot into a kidney dish. This improved his blood pressure, but his right ventricle looked like tenderised steak – and it didn’t contract any better than a steak – and his right atrium looked like it would burst. So I put the pipes directly into the major veins. As we started cardiopulmonary bypass, his struggling heart emptied out and flapped around at the bottom of the pericardial sac like a wet fish. He was safe – and just in time!

  With an incision directly into the right atrium the ruptured valve was there in front of me. It was torn like a curtain, but when I stitched it like torn cloth it was easily repaired. I tested it by filling the right ventricle through a bulb syringe. No leak. So I closed the atrium and removed the snares to fill it again. The job was done. The tenderised meat functioned better than anticipated and eased itself off the bypass machine. By then I’d had enough. I left my assistants to repair the fractured sternum and close the chest. No doubt he’d survive to go to prison.

  The sun was setting on a hot and difficult day. For a while I felt content, satisfied after two ‘out on the edge’ operations, difficult cases that few heart surgeons would ever encounter in their whole career. I needed a beer, many beers, but there was no chance of that. I wondered whether the mother was happier now. She’d achieved what she set out for – treatment for her dying child.

  Having heard nothing from intensive care I assumed that the boy was doing fine. Wrong. They were already in trouble. For some reason the doctors had tampered with the temporary pacing box and the electric stimulus from the generator had coincided with the heart’s natural beat, fibrillating it and instantaneously inducing that uncoordinated, squirming rhythm, a herald of imminent death.

  To counteract this they’d used external cardiac massage until a defibrillator was brought to his bedside. The vigorous chest compressions he’d been given had displaced the pacing wire from the atrium and, although the heart defibrillated at the first shock, the sequential pacing of atrium then ventricle no longer worked. Now only the ventricles could be paced. As a result there was a precipitous drop in cardiac output and his kidneys had stopped producing urine. The boy was deteriorating but no one had told me because I was in the middle of another big case. Shit.

  Throughout this débâcle the poor mother had stayed by the cot where she’d watched them pounding on her little boy’s chest, then witnessed the electrical shock that caused his little body to spring from the bed and convulse. At least he only needed one shot at defibrillation. The resulting beep, beep, beep was of little comfort to her, however, and like her child she was spiralling down.

  I found her clasping his tiny hand, tears running down her cheeks. She’d been so happy as she escorte
d him from the operating theatre. Now she was desolate and I was too. It was clear that these intensive care doctors didn’t understand cardiac transplant physiology.

  And why should they? They’d never been involved with heart transplants so they failed to grasp that taking the heart out of the body cut off its normal nerve supply. They were pacing the heart at 100 beats per minute with an insufficient volume of blood while simultaneously flogging it with high doses of adrenaline to raise the blood pressure. This constricted the arteries to his muscles and organs, substituting blood pressure for flow and once again producing metabolic mayhem.

  The nurse looking after the boy on the intensive care ward seemed anxious and was pleased to see me. A very capable New Zealander, she clearly did not rate the critical care registrar. Her opening remark was, ‘He’s not passing urine and they’re not doing anything about it,’ followed more directly with, ‘If you’re not careful they’re going to fuck up your good work!’

  I put my hand on the little boy’s leg, the best way to judge cardiac output. His feet should have been warm, with bounding pulses. They were cold. He needed dilated arteries, less resistance to flow and less demand for oxygen. So I changed everything. Now the nurse was happier but the registrar was put out and phoned the on-call consultant. That was fine. I told the consultant to get himself in from home and discuss it.

  We now walked the fine line between recovery and death. Much depended upon expert management, minute by minute, beat by beat, balancing the cocktail of powerful drugs and maximising this buggered little heart’s pumping capacity. The boy’s lungs were inflamed and stiff after his long stint on the heart–lung machine so the oxygen levels in his blood were falling. Already the kidney failure warranted dialysis through a catheter inserted into the abdominal cavity using concentrated fluids to draw the poisons out through his own membranes. I needed the help of someone I could trust. Mayo man. I would stay in one of the on-call rooms a couple of minutes away where the residents slept.

  The mother didn’t want me to leave. She fixed her eyes on me, tears spilling over her high cheekbones. Profound separation anxiety was trying to pull me back but by then I was physically exhausted and fearful of how it would be if the boy died. She had no one else in the world, and although I wanted to be kind it was time to take a step backwards. Call it professionalism or self-protection. Perhaps both. So I reassured her that Mayo man was on his way, then I left.

  By now it was well after midnight. The on-call rooms overlooked the rooftops, the club room opening onto a veranda under the night sky. Not as spectacular as the sand dunes at night, but good enough. There was juice, coffee, olives and dates. And Arab pastries. Best of all, a telescope for stargazing. I looked out at nothing in particular, wishing I could see England and home. And most of all my little family.

  Now I tried to switch off. Mayo man knew I had more babies to operate on in the morning, so they’d call me only if it was absolutely necessary. I was desperate to find an improving child, with hot little legs and liquid gold in the urinary catheter. And I wanted to see his mother happy, cradling her boy in rags again.

  I passed out in a heap, those deeply penetrating eyes still fixed on me, pleading with me to make things right.

  Chanting from the minarets roused me at dawn. It was 5.30, and the fact that there had been no night call from intensive care was cause for guarded optimism. Today’s operations were easy enough: holes in the heart to be closed with a cloth patch, careful stitching, then cured for life. Happy parents.

  Soon I was thinking about the mother. How was she feeling now? I took tea out onto the roof as the blistering sun hauled itself into the sky, the air still cool and fresh, the temperature bearable.

  At 6 o’clock Mayo man called. After a pause with heavy breathing he said, ‘Sorry to wake you with bad news. The boy died just after 3 am. Quite suddenly. We couldn’t get him back.’ Then silence in anticipation of my questions.

  I’d had calls like this my whole career but this one made me miserable. I asked what had happened. At first the boy had started fitting, perhaps in response to the metabolic mess and high temperature, quite violent fits that were difficult to control with barbiturate drugs. The acid and potassium in his blood were still high because dialysis had not yet been started. And then when he had a cardiac arrest they couldn’t get him back. Mayo man had been hesitant to wake me with bad news and he was sorry for my loss.

  A kind thought, but what about the girl? Did they want me to come across and try to communicate with her? Mayo man didn’t think that would do any good. Once again she’d been beside the cot during the resuscitation efforts. She was now obviously very distressed, and had been hysterical beyond reason when told that her child had died. They’d moved the cot into a single room away from the unit, where she could hold him and grieve in private. All the catheters, drains and pacing wires had to be left in place until the autopsy. I felt bad about that. How could she cuddle the lifeless infant with plastic tubes emerging from every orifice?

  This is cardiac surgery. Another day at the office for me, the end of the world for her.

  I was drawn to her like a magnet but had to stay away. In an hour I was due back in the operating theatre, needing to be on top form for someone else’s baby. Another mother who cared just as much. What a fucking job. I was a sleep-deprived, psychological wreck operating on tiny babies on the other side of the world.

  I called adult intensive care to enquire about the trauma patient, the man who’d recklessly crashed his car and killed another driver. He was doing fine. They were going to try to wake him up and take him off the ventilator. There was a certain irony in that. Thinking of the boy, I just wished it had been the other way round. Forbidden thoughts. Surgeons are meant to be objective, not human.

  I took my despair to the canteen, where I glimpsed the miserable paediatric registrar devouring breakfast. My instinct was to avoid him, but it wasn’t his fault. It was me who had done the surgery and I regretted not staying up all night to see it through. When he saw me I could tell he was bursting to tell me something.

  He told me that the mother had disappeared from the room, taking her dead child with her. No one had seen or heard her take off, and there had been no sight of her since. I uttered one word – ‘Shit.’ I didn’t want to continue that conversation. I assumed she had taken off into the night like her flight from Yemen, but this time carrying a lifeless bundle. By now she could be anywhere and I was anxious for her.

  I heard the news as I was stitching the patch into the first ventricular septal defect. When the Saudi hospital staff turned up for work they’d found them, two bodies lying lifeless in a heap of rags at the bottom of the tower block. She’d removed the drips and drains from the little body before leaping into oblivion to catch up with him in heaven. Now they were both together in the cool of the mortuary, inseparable in death. Two hundred per cent mortality for me.

  Most writers would end this tragic tale with the mother’s suicide and the discovery of the bodies at the foot of the tower block. A devastating end to two fragile lives. But real-life heart surgery is not a soap opera. The job goes on, and there were too many unanswered questions. I always attend the autopsies of patients I operate on. First, to protect my own interest – to make sure the pathologist understands what has been done and why – second, as a learning experience to see if anything could have been done better.

  To spend all day, every day with the dead makes mortuary people different, as I knew from my time at Scunthorpe War Memorial Hospital. The technicians work like butchers, slicing open the carcass, removing the entrails, sawing off the cranium to lift out the brain. Here an ageing Scottish pathologist ruled the roost. Resplendent in green plastic apron and white Wellington boots, sleeves rolled up, cigarette dangling from the corner of his mouth, he was grunting away to himself, documenting the cause of death of the man killed by my trauma patient. Fractured neck and brain haemorrhage, together with ruptured aorta – high-speed crash injuries. I was ne
w to him as surgeons didn’t visit the mortuary very often. Mercenaries were rarely interested in learning from their failures.

  That morning there were seven naked corpses lined up on separate marble slabs. My attention was immediately drawn to the mother and child on tables side by side, so far untouched. I explained to the Scotsman that I was pressed for time. He was grumpy but cooperative as the technician joined him. Only the child was officially my patient. His head had hit the ground first and the skull was split open, with the brain shattered like a fruit jelly dropped onto the floor. There was little blood because he was already dead. I had an important question about the brain. Did the boy have tuberous sclerosis, the brain pathology that goes with rhabdomyomas in the heart? This causes fits and could have precipitated his death.

  I reopened the chest incision myself, unpicking the stitches. Was I correct about the disconnected pacing wire? It was difficult to know because the mother had pulled it out after he died. But there was a clue: a blood clot squelched out from beside the right atrium. In every other respect the surgery had been successful, the tumour had virtually gone and the obstruction relieved. The Scotsman dropped the heart into a jar of formaldehyde and kept it on the shelf as a rare specimen.

  Eager to maintain the momentum, the technician sliced open the abdomen and eviscerated the child. All organs back to front, floating in heart-failure fluid but otherwise normal. Cause of death: congenital heart diseases – operated. A second technician came along, stuffed the brain and guts back into the abdominal cavity, then sewed the boy up. After repairing the rent in his head, the boy was disposed of in a black plastic bag. End of story. Blood and body fluids were washed from the marble slab, and then no further trace of his tragic short life remained. There was no one to bury him.

  I was drawn to the mother’s jet black broken body, now naked on the adjacent slab. So thin. Still proud. Mercifully her beautiful head and long neck were intact, her once-sparkling eyes wide open but dimmed and fixed on the ceiling. Her injuries were obvious without slicing her open: arms broken, legs horribly distorted, abdomen swollen from liver trauma. No one survives such a fall and she knew it. How different all this could have been had the boy survived. The happiness she’d have experienced watching him grow up with a heart that worked. I watched the technician fold the scalp over her face and remove the top of the skull with a circular saw, lifting the lid on her tragic memories. Why did she never speak?