Fragile Lives

by Stephen Westaby

  Then another intuitive question – if he lost consciousness away from the hospital how would anyone know whether he was alive or dead? This was moving away from my comfort zone, so I sidestepped with a speculative response. But he was right to ask. Months later over the winter another pump patient fell and hit his head at home. He was found some time later, unconscious, cold and pulseless. The ambulance crew took him directly to the mortuary.

  Now Peter’s final question – was I nervous about attempting the operation, a procedure that was pure science fiction and quite likely to snuff him out?

  ‘Absolutely not,’ I replied. ‘Not if you want me to do it. I’m not the nervous type. Doesn’t suit the job.’

  These words prompted a direct response.

  ‘Let’s go for it then.’

  I told him that he should take just a little time to discuss it with his family and friends.

  There was one more thing. I needed to see echo pictures of his heart myself. We pushed him round to the cardiology department and helped him up onto the couch. He was breathless again, and we could soon see why. His huge left ventricle was massively distended and barely moving. The mitral valve was held open by the stretched heart wall but this wouldn’t matter with the pump in, as long as the aortic valve was not leaking – and it wasn’t. The pump simply sucks blood through. His right ventricle seemed to be working well enough, and all in all his anatomy looked good for the surgery. I just needed to stop focusing on the risks. Failure was not an option, as death in the first patient would destroy the programme.

  Peter got himself down from the couch and insisted on walking to the door. It would be wrong to say that he had a spring in his step, but he left with something much more important – hope. Hope for the first time since staggering away from the transplant assessment in despair. Now we simply had to get on with it.

  Peter’s wife Diane and some of the foster children took part in emotional discussions. Should Peter hang on for the short time he had left or risk dying during surgery for the chance of a better life? Diane told her husband that she couldn’t make the decision for him or tell him what to do, but that whatever he decided she’d give him all her support.

  Two days after our meeting Peter confirmed that he’d consent to the operation. Now I needed to ask Philip Poole-Wilson, Europe’s leading heart failure cardiologist, to confirm Peter’s poor prognosis. He could come to Oxford late on the evening of 19 June. Confident as to what he’d say, I reckoned that we’d proceed with surgery on the 20th.

  I had to coordinate the team from Houston and New York. Bud Frazier, who’d undertaken the animal work at the Texas Heart Institute and had implanted far more mechanical hearts than any other surgeon, would be an important member of the surgical team. Dr Jarvik himself would bring the device over from New York, and we’d admit Peter to the hospital two days before the operation. We needed to optimise his heart failure treatment and teach him how to manage the controller and batteries. It was equally important that other members of the team should get to know him.

  On the afternoon before surgery we bought Peter to the cardiac intensive care unit. Sister Desiree shaved the left side of his head in preparation for the skull pedestal incision. Dave Pigott, the anaesthetist, inserted a cannula into the artery in Peter’s wrist, followed by a large-bore venous cannula into the internal jugular vein on the right side of his neck. He then floated a balloon catheter through the veins across the right side of the heart and into the pulmonary artery.

  I brought Jarvik and Bud to visit Peter in the early evening. The conversation was animated and uplifting for a man who faced 50/50 odds in less than twelve hours. For the first time in months he talked about his future – what he could do to support our programme if he survived and where he would go for his first holiday in years. Positive stuff, which helped all of us. Now we needed the professor to come.

  Philip arrived at 10.30 pm. He talked at length with Peter, looked through the data, then emerged just after midnight. He wished us luck. Adrian Banning, Peter’s cardiologist in Oxford, likened his predicament to that of a man on a diving board who was about to jump but had no certainty that there was water in the pool. According to Adrian:

  Houghton was functionally dead. All he had left was a mind full of frustration. Heart failure has a worse prognosis than any type of cancer. Once you have fallen off the threshold for the transplant waiting list, conventional medicine has little to offer. Every cardiologist has clinics full of these people, unable to work, just hanging on, waiting to die.

  We all assembled in the anaesthetic room of Theatre 5 at 7.30 am. As usual, Bud arrived in his Stetson and cowboy boots – normal for Texas, less so in Oxford. I asked Peter whether he had any reservations or last thoughts. He replied that he’d be in a better place after the surgery, one way or another. I glibly told him that he’d be fine, something that every patient should hear before their anaesthetic.

  Once he was asleep, we positioned him left side up on the operating table with the side of his head and neck exposed, and I marked the anticipated site of the surgical incisions with indelible black marker pen. We’d bring the power cable out of the apex of his chest, through his neck and to the left side of his head. Andrew Freeland, my cochlear implant specialist colleague, would screw the pedestal to the skull, while we’d expose the pericardium and aorta through the left side of his chest. This needed a large incision between the ribs.

  With a degree of trepidation I exposed the leg artery and vein in Peter’s groin to attach him to the heart–lung machine, then performed the chest incision through fat and wasted muscle. The metal retractor cranked open the ribs, bringing the lung and pericardium into view. Behind the lung was the aorta. Through a separate wound on the shoulder we passed the black insulated power cable up into his neck, then through the neck and out behind his left ear. This was difficult, as there was some important clockwork in close proximity to large arteries and veins, not to mention the vital nerves.

  On the end of the electric cable was a miniature three-pin plug. Literally. This plug was inserted through a titanium pedestal that had six screw holes to fix it rigidly to the outer table of Peter’s skull. Andrew made a C-shaped incision behind the ear and scraped the fibrous surface off the bone. Then a power drill was used to create the screw holes in his skull. The plug was screwed securely onto the skull with dry bone dust incorporated to promote healing around the titanium. We were making it all up as we went along.

  All that remained was to punch a hole into the centre of the skin flap through which the plug would protrude, so that we could plug in the external power line leading to the batteries and controller. The head and neck incisions were then closed and we were ready to implant the pump itself.

  I opened the sac around Peter’s heart. It was a sorry sight. The huge, quivering left ventricle was more fibrous tissue than muscle. It barely moved, and by now, an hour into the surgery, Peter’s blood pressure was uncomfortably low, lactic acid was building up in his blood and we had to start the bypass machine to support the circulation. Bud held the titanium pump, while I pulled the lung forward to expose the aorta. We needed to sew the graft end onto the aorta before the pump could be implanted into the heart. And the graft had to be just the right length – not so long that it could kink, but worse still if it was too short. What’s more, the stitching had to be pristine to avoid bleeding.

  Now we were ready for the big event. We started to stitch the restraining cuff onto the rounded apex of the heart, which resembled nothing less than a rotten melon. Never again would Peter’s heart bear sole responsibility for his circulation. From now on his life was reliant upon technology.

  All that there was left to do now was to core out the plug of heart muscle through the centre of the cuff then insert the pump, just like coring an apple and sliding in a torch battery. This was Peter’s life raft. We were about to create a pulseless human being, and so far it was going well. I cut a cross in the muscle encircled by the cuff, and with a co
ring tool we punched out the hole and slid the pump through. It was in. The plan had worked – so far.

  Desiree was holding the controller and batteries, waiting for the instruction to switch it on. Once I was satisfied that there was no more air in the pump or vascular graft we turned up the pump speed to 10,000 rpm, the flow probe showing that it was now pumping four and a half litres per minute. We then cut back on the heart–lung machine flow to let the combination of the device and Peter’s own heart take over, slowly shifting support from one system to the other. I finally told Brian to ‘Come off.’ The whole process up to this point had taken two hours.

  All of our attention was now fixed on the monitor screen. The arterial pressure trace was an absolutely flat line measuring no more than two-thirds of normal blood pressure, and pressure in the veins was also less than normal. While this suggested that the right ventricle was managing well, it was still too low. Peter’s circulation needed to be well filled, otherwise the powerful turbine could suck the left ventricle empty, causing an obstruction. We aimed for a balance whereby the pump did most of the work but Peter’s left ventricle continued to eject some blood.

  Now we needed to adapt our treatment strategy to a completely new pulseless physiology – flatline physiology. We’d looked after a lot of sheep, so we knew just how to handle it.

  The remaining and most troublesome issue was to stop the bleeding. Every cut surface and every needle hole was oozing blood because Peter’s distended liver had not been making clotting factors, an issue common to most patients who needed artificial hearts. So we gave donor clotting factors and the sticky cells called platelets that plug needle holes, leaving the registrars to close his chest.

  Outside the theatre we reviewed the power consumption, which was seven watts. The pump flow oscillated between three and a half and seven and a half litres per minute, the rate depending upon the pump rotor speed and Peter’s own blood pressure, now providing resistance to pump flow. This was counterintuitive physiology: when Peter’s blood pressure increased, flow decreased substantially. If flow to the body and brain was insufficient, lactic acid would accumulate in the blood and the kidneys would stop producing urine. But right now things were all right. The pump was doing its job.

  With his chest closed, the drapes were removed and Peter was placed onto the trolley for transfer to the intensive care unit. We had an elite nursing team who were carefully prepared and knew what to expect. He was hooked up to the monitor and an audience gathered to see the flatline patient, the first to be fitted with a revolutionary new type of artificial heart on a permanent basis. We left the nursing team in charge, with orders to call us if anything went awry.

  I was overstimulated after one of the most exhilarating operations I’d ever performed and could barely sleep. So, when the sun rose at 4.30 am, I visited Peter in his room. Listening to his heart with a stethoscope there was now no lub dub, lub dub, lub dub, just the characteristic continuous whirr of the pump rotor. His single functioning kidney had stopped producing urine, but we expected that. What worried me most was that blood transfusion is bad for the lungs and he’d already had thirty units of the stuff. With blood now flowing backwards up the descending aorta to the brain I wondered how long it would take him to wake up. Only time would tell.

  Peter remained stable for the next thirty-six hours and began to regain consciousness. As soon as he was sufficiently awake to breathe, cough and understand instructions, we propped up his large frame and took out the breathing tube.

  The first thing he said when he saw me was ‘You bastard.’ A thoracotomy between the ribs is very painful, and he had other incisions in his head, neck and groin. But it was said with a smile on his face, with a sense of humour. He was glad to be alive. We talked for a while about how the operation had gone. I joked that despite his Christian faith he was now Frankenstein’s monster, powered by a bolt in his head, the thing that was currently giving him a headache. But he was extremely motivated to get well and make the most of his new life.

  Within the first week his kidney function improved and we no longer needed to dialyse him. He worked hard to get out of bed and regain mobility with the help of the physiotherapists. Although the pump immediately restores blood flow to normal levels, it still takes months to reverse the debilitating wasting effects of chronic heart failure. It’s just the same as with a transplant. But it was already a source of wonder and relief that his breathlessness had gone, and that there was no more back pressure from the failing left side of his heart on his lungs. He began to lose the litres of fluid that had chronically accumulated in his tissues, his leg ulcers began to heal, and his face and nose were now pink, not blue.

  Remarkably Peter left hospital just eleven days after his operation, taken home to Birmingham by his family. Such a swift departure could have never happened in the States. Before he left, Peter appeared in front of the press, with numerous photographers waiting at the hospital entrance. He was in his element and enjoyed himself immensely. Our Anglo-American team had achieved a world’s first, but Peter was the star – the bionic pulseless man. He described himself as the model cyborg.

  Peter’s ability to exercise increased progressively. Within weeks his belly began to shrink as the fluid around his guts dissipated, then his huge legs became slim again. At an outpatient appointment five months after the operation in November even his heart rhythm was back to normal.

  He was really chatty, telling me that events since June had taken him from the position of a refugee, forced to pack up and abandon all the trappings of life, to that of a man given uncertain leave to remain. All the while his engaging personality shone through. He’d shifted from inexorable fear and bewilderment to undisguised pleasure at avoiding death, and was now fitter and healthier than he’d been in years. He reflected:

  It really annoys me when people say I was brave; I wasn’t brave at all. I was swapping a certain slow death for the risk of a quick one, or the chance of a complete recovery. When I first left hospital I didn’t dare plan ahead. I was literally living my life from one day to the next. Now I’m thinking about what to do with my time, and contacting all my friends to tell them I’m not dead.

  Out and about in Birmingham, Peter was a curiosity. It took time for the hair to grow back on the side of his head, and at first his plug and black power cable were obvious to passers-by. Children would come up to him and ask why he had a bolt in his head. Was he a robot? Peter was more than happy to stop and explain things to them. He had a particularly happy Christmas that he never expected to see.

  Out shopping one day during the January sales he felt a sharp and painful jerk at his head. A would-be thief had snatched at the shoulder bag containing his controller and batteries, thinking it contained a camera. His skull pedestal plug was torn off and his pump stopped. The teenage mugger attempted to flee with the bag in his hand but the power-failure alarm sounded noisily. Sensing a trap, the lad discarded it and ran off. Some shoppers helped to retrieve Peter’s power cable and he fumbled to get the plug reattached to his head as fast as possible. An old lady sorted it out for him but was bewildered by what she’d achieved. Reconnected, the pump whirred undeterred.

  ‘I did feel faint,’ Peter recalled, ‘but I think it was more the shock than anything else. The wrench to my head really hurt for several days.’

  He spent the first year getting as physically well as possible, then the second finding some meaningful purpose to make his ‘extra life’ worthwhile. This second chance would constitute more than 10 per cent of his overall life span. It was vital for him to have a purpose for his existence beyond being an exhibit, so he worked tirelessly to raise money and draw attention to our efforts, desperately keen that others should benefit from the same opportunity. Soon he became an integral part of our team, counselling other potential assist device patients and their families.

  Peter was never the most compliant of patients. He suffered from nosebleeds and would reduce his anticoagulant dose to cope with these. And
then there was the price to pay for his reprieve: he needed to change his batteries every eight hours, recharging the spent set, and he had to carry his equipment everywhere as a matter of routine. Sometimes he’d forget to change the battery for a fully charged one before going out. On one occasion he was in the middle of having a tooth filled when the battery near-expiry alarm went off and the dentist had to drive him home rapidly.

  He was a prolific writer and published his own book, Death, Dying and Not Dying. He gained considerable satisfaction when his charity was able to contribute to pump implants for other patients, then greatly enjoyed the camaraderie of his new bionic colleagues, most of whom resumed active and sometimes adventurous lives.

  In the back of his mind he always hoped for his own heart to recover sufficiently to enable the removal of his hardware. Although this happened up to a point, we resisted the temptation. This was fortunate since his heart deteriorated again, and for the last three years of his life he was wholly reliant on the device. Ironically, he was offered a heart transplant but pointedly refused to discuss it.

  In his sixth and seventh extra years he was troubled by ageing problems that at one time he’d never expected to encounter. He developed rheumatoid arthritis in the hands, which hindered his writing, and his prostate enlarged to the point that it required surgery. We arranged this for him in Oxford, since no other hospital would operate on a patient in his circumstances. As Peter put it, ‘I wonder if one day the burdens of living a worthwhile life might come to outweigh the wonder of it.’

  On his last trip to the States in August 2007 Peter gave a revealing interview to the Washington Post. He admitted that his artificial heart had precipitated some religious crises, causing him to question his Catholicism. Questioning the very afterlife he wrote, ‘Who knows? These are only priests. They are not very good at being challenged on the subject.’ He went through bouts of clinical depression and was prescribed anti-depressants for eighteen months, but never took them. He stated that ‘several times I thought it would be better if I wasn’t here. Let everyone else get on with their lives. I felt I’d like to put an end to it. But choosing the method put me off. I felt cowardly about killing myself.’ He talked to a psychiatrist about suicidal thoughts: