copyright
Certain details, including names, places and dates, have been changed to protect privacy.
Mudlark
An imprint of HarperCollinsPublishers
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First published by Mudlark 2019
FIRST EDITION
© Stephen Westaby 2019
Cover layout design Claire Ward © HarperCollinsPublishers 2019
Cover images © Granger/Bridgeman Images (heart engraving), Shutterstock.com (scalpel)
Stephen Westaby asserts the moral right to be identified as the author of this work
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Source ISBN: 9780008285777
Ebook Edition: April 2019 ISBN: 9780008285807
Version: 2019-04-17
dedication
For Sarah, who saved me from myself, together with Gemma and Mark, then Alice and Chloe, the children and grandchildren who give me so much pleasure.
contents
Cover
Title Page
Copyright
Dedication
Preface
Introduction
1 Family
2 Sadness
3 Risk
4 Hubris
5 Perfectionism
6 Joy
7 Danger
8 Pressure
9 Hope
10 Resilience
11 Misery
12 Fear
Acknowledgements
Glossary
By the Same Author
About the Publisher
preface
Every single heart operation risks a life. This tension between kill or cure is unique to my specialty, with no professional equivalent, and few people can live with it on a daily basis. During my formative years, to operate within the heart was seen as the last surgical frontier. Direct vision repair was considered as difficult as landing on the moon or splitting the atom. Then the heart–lung machine and the swinging sixties changed everything. Heart transplants and artificial hearts both emerged during my impressionable medical school years. When I embarked on training in the 1970s, heart surgery remained an exclusive and remote club that was exceptionally difficult to join. Yet I was eventually granted the profound privilege of being able to improve thousands of lives.
Each heart is unique in its own way. Although most operations prove straightforward and uneventful, some evolve into an extraordinary battle for survival and a few are quite literally a bloody disaster. As my experience and knowledge increased, I became a last port of call for the cardiologically destitute, a depository for cases that no one else wanted, at home and abroad. Ultimately I lost patients whom I knew could be saved with equipment we were denied in the NHS. The recriminations that accompany death soon followed. An agonising interview with the bereaved, dismal discussions at the ‘Morbidity and Mortality Meeting,’ then a joyless visit to the coroner’s court. I was vehemently outspoken about the system’s deficiencies, and suffered as a result. The NHS doesn’t care for those who do not conform.
In this book I have set out to describe how it felt to be a heart surgeon as the specialty emerged and what it is like in the current hostile environment. I have depicted the physical and the psychological endeavour, the emotional highs and lows, the triumphs and the disappointments, and how being a surgeon affected me and my loved ones. When I was a young man, as we shall see, a peculiar quirk of fate helped me by dispelling my inhibitions and rendering me immune to fear. It’s not something I would freely recommend and it was a curious launchpad for a career at the sharp end, one that enabled me to embrace challenges that others would wish to avoid.
For someone who is not a professional writer, it takes an inordinate amount of time and effort to write a book for public consumption. You will undoubtedly conclude that I was more the surgeon than the literary genius, yet to my delight my first book, Fragile Lives, became an award-winning bestseller. As the title suggests, the book largely focused on remarkable cases. The Knife’s Edge is darker. It describes my humble beginnings, my struggle to succeed, and my priceless relationships with some of the pioneers and great leaders of the specialty. Because of the huge risks involved and the pile of bodies that ensued, the pioneers all manifested a particular personality type – bold, determined, often flamboyant, with resilience and immunity to grief. Sadly, so taxing is the lifestyle that by the end of my career few UK graduates were prepared to make it their calling and career. The ‘end of an era’, or the ‘end of the beginning’ as some would put it.
The whole riveting story of modern heart surgery evolved during my lifetime, and I was proud to be part of it.
introduction
Just weeks after my surgical career came to an end I was invited to present the prizes at a local school speech day. The headmistress urged me to treat the teenagers as adults, and suggested that I convey to them what personal qualities I possessed that enabled me to become a cardiac surgeon. By this stage I had a stock response: ‘To study medicine,’ I said to the assembled schoolchildren, ‘demands an unstinting work ethic and great determination. Then it requires more than a modicum of manual dexterity, together with supreme confidence to train as a surgeon. To aspire to become a heart surgeon and risk a patient’s life every time you operate is a step beyond. For that you need the courage to fail.’
This last phrase wasn’t original – it was regularly used to describe the heart surgery pioneers in the era when more patients died than survived – but the kids didn’t know that. I decided to omit the claim that gender, social class, colour and creed played no part, because I really didn’t believe it myself. Nor did I regard myself as possessing all the qualities I talked about. I was more of an artist. My fingertips and brain were connected.
After rewarding the school swats, I started nonchalantly answering questions about my achievements in Oxford. With considerable insight, one biology boffin asked how it’s possible to operate inside an organ that pumps five litres of blood every minute and whether the brain dies if the heart stops. Another wanted to know how to get to the heart when it’s surrounded by ribs, breast-bone and spine. Then the art teacher asked what causes blue babies, as if someone paints them blue.
Coming to the end of the session, a bespectacled little girl with pigtails raised her hand. Standing up like a poppy in a cornfield, she boomed out, ‘Sir, how many of your patients died?’
So loud was her earnest approach that there was no way I could pretend not to hear. One set of parents tried to disappear under the floorboards while the flustered headmistress began explaining that it was time for the honoured guest to now leave. But I couldn’t ignore this inquisitive individual in front of her friends. I considered the question for a moment, then had to confess: ‘I really don’t know the answer to that. More than most soldiers but fewer than a bomber pilot, I guess.’ At least fewer than Enola Gay over Hiroshima, I thought to myself cynically.
Quick as a flash, Miss Curiosity probed again. ‘Can you remember them all? Did they make you sad?’
Another brief moment of deliberation. Could I admit to a hall full of parents, teachers and schoolchildren that I had no idea exactly how many patients I had dispatched, let alone recall their names. I could only muster one response: ‘Yes, every death upset me.’ I waited to be struck down with a thunderbolt but mercifully that was the end of our brief dialogue.
It was only after I stopped being an inadvertent serial killer that I began to remember patients as people, rather than simply recalling mortality statistics and the many times I went along to autopsies or coroner’s courts. And there were deaths that haunted me, not least the young people who succumbed needlessly to heart failure. Those who were not accepted for transplantation but who could have been saved with the new circulatory support devices that our NHS declined to pay for.
In the 1970s one in five of my boss’s cases at the Brompton Hospital died after surgery. As a cocky trainee I would greet each patient, record their medical history, then listen to their fears and expectations about the upcoming operation. Most were severely symptomatic, having waited months to come to the famous hospital in London. It didn’t take long for me to predict the ones who wouldn’t make it, usually the ones with rheumatic valve disease who arrived in a wheelchair and could barely speak on account of their breathlessness. Breathlessness is uniquely terrifying, likened by the patient to drowning or suffocation. They didn’t die because of poor needlework. They simply couldn’t tolerate their time on the heart–lung machine or the poor protection afforded to heart muscle during surgery in those days. We all knew that the slower the surgeon, the more likely the patient was to die. We would take bets on it. ‘If X does the valve replacement he stands a chance. But he’s buggered with Y.’
That was the way it used to be in the NHS. Treatment was free, so the punters didn’t question what was on offer. Life or death followed from the toss of the dice. But the finality of death was still devastating. The consultants would shield themselves from all the misery by dispatching us juniors to talk with the family.
I seldom had to speak. The bereaved relatives would recognise the slow walk with dropped shoulders and head down as I approached. They could read my unequivocal ‘bad news’ expression. After the reflex indrawing of breath came shock, my words ‘Sorry’ and ‘Didn’t make it’ triggering emotional disintegration. The sudden relief of suspense and the subsequent crushing grief were often followed by dignified resignation, but sometimes by abject denial or frank meltdown. I’ve had hysterical demands for me to return to theatre and resurrect the corpse, to resume cardiac massage or put the body back on the bypass machine. It was particularly heart-breaking for the parents of young children, little ones who had just developed their own innocent personality. As I saw it, newborn babies just screamed and pooed, but toddlers were well on their way to becoming people. They walked in holding Mummy’s hand and clutching their teddy bears, which all too often were carried off with them to the mortuary fridge. Yet the minute I turned and walked away from these families, my sorrow was filed in the out tray. Eventually, when I started to lose my own patients, I became well used to it.
Only once did it strike me that I had murdered someone, and the grim circumstances came as a shocking and bloody reminder that I was not invincible. It was a third-time operation on the mitral valve of a middle-aged patient who had a huge heart on the chest X-ray and excessively high pressures in the right ventricle situated directly below the breast-bone. I always took precautions when reopening the chest after previous surgery, and had started to request a CT scan to determine the gap between bone and heart. This led to me being admonished for adding to the costs of my many reoperations – only committees were allowed to sanction additional expense. The gentleman’s anxious partner accompanied him to the anaesthetic room and I urged her not to worry. I told her I was very experienced and would take good care of him.
‘That’s why we came to you,’ she replied, her voice quivering with apprehension. She kissed his forehead and slipped out.
I drew the knife along the old scar and used the electrocautery to singe the outer table of the sternum. The wire cutter snipped the steel wires from the second operation, which I then tore out with heavy grasping forceps. It was just like pulling teeth – should they break, it makes life difficult. The oscillating saw screeched against them as if screaming, ‘I’m not designed to cut steel.’ Then came the tricky bit, which involved edging my way through the full thickness of bone with a powerful saw designed not to lacerate the soft tissues beneath. I had safely reopened the sternum for hundreds of reoperations, but this time there was a great ‘whoosh’. Dark blue blood hosed out through the slit in the bone, poured down my gown, splashed onto my clogs and streamed across the floor.
I let out a chain of expletives. While I pressed hard over the incision to slow the bleeding, I instructed my jelly-legged assistant to cannulate the blood vessels in the groin so we could get onto the bypass machine. As the anaesthetist frantically squeezed in bags of donor blood through the drips in the neck, it all went dreadfully wrong. The cannula dissected the layers of the main leg artery so we couldn’t establish any flow. With continued profuse haemorrhage, I had no alternative but to prise open the rigid bone edges and attempt to gain access to the bleeding beneath, forcing a small retractor through the bony incision and cranking it open. But there was no gap between the underside of the bone and heart muscle. The cavernous, thin-walled right ventricle had been plastered by inflammatory adhesions to the bone by a previous wound infection. So I found myself ripping the heart asunder and staring at the underside of the tricuspid valve. Both the hand-held suckers, then the heart itself filled with air as I fought for better access. I then found that this tissue-friendly saw had also transected the right coronary artery. My paralysed registrar simply gaped, as if to say, ‘How the fuck are you going to get out of this mess?’
There was nothing I could do in time to save him. Deprived of oxygen, the heart soon fibrillated, so at best – had I persisted – he would have suffered devastating brain injury. So I called time on the gruesome spectacle. The whole shambles had taken less than ten minutes. Apologising to the nurses who had to lay him out and clean the floor, I tossed away my gloves and mask in disgust. The whole bloody catastrophe was straight out of Saw II or Driller Killer. It felt as if I had driven a bayonet into the man’s heart and twisted the blade. Then, just as had been done to me during my formative years, I dispatched the registrar to talk to the man’s wife while I went off to the pub.
I didn’t see the poor lady again until the inquest, where she sat unaccompanied, listening intently. She bore no malice, nor was the coroner critical in any way. The gruesome fact was that I had unintentionally sawn open that heart and emptied the circulation onto my clogs. In my own mind, I knew that a CT scan would have prompted me to cannulate the man’s leg vessels myself, which could have averted the tragedy and was something that I always did after that. Undeterred, I reopened a sternum for the fifth time in front of television cameras just weeks later.
Most deaths in surgery are wholly impersonal. The patient is either covered in drapes on the operating table or obscured by the grim paraphernalia of the intensive care unit. As a result, my most haunting experiences of death stemmed from trauma cases. The sudden, unexpected process of injury pitches an unsuspecting individual into their own Dante’s Inferno. Knife and bullet injuries were predictable and easy for me. Cut open the chest, find the haemorrhage, sew up the bleeding points, then refill the circulation with blood – such cases always provoked an adrenaline rush, but usually involved young, healthy tissues to repair.
My own worst nightmare wasn’t caused by a gun or a knife. As a young consultant I was once fast-bleeped to the emergency department to help with an incoming road accident. It was still what was called the ‘swoop, scoop and run’ era, so the patient was being brought in directly wi
thout transfusion of cold fluid to screw up the blood clotting. With foresight and sensitivity, the police had already warned reception what to expect, but unfortunately I’d not been party to that. I was outside in the ambulance bays enjoying the sunshine when the vehicle came thundering up the drive, siren blaring and blue lights flashing. When the rear doors were thrown open, the crew wanted a doctor to take a look before they risked moving the patient again.
I could hear the whimpering before I could see the girl, but I knew from the paramedic’s grim expression that it was something unpleasant. Unusually awful, in fact. The teenage motorcyclist was lying on her left side, covered by a blood-soaked white sheet. This sheet and what I could see of her face were the same colour. The poor girl had been drained of blood. Normally she would have been shunted quickly through to the resuscitation room, but there was every reason not to rush.
The paramedics quietly and deliberately drew back the sheet so I could see that the girl was transfixed by a fence post. A witness had watched her motorcycle swerve to avoid a deer, then she veered off the road, smashing through a fence into a field. She was left skewered like meat on a kebab stick. The fire brigade eventually released her by sawing through the fence and lifting her free. This left the stake protruding from her blood-soaked blouse. The response of the gathering team was to glare incongruously at the gruesome transfixion and ignore that horrified face behind the oxygen mask.
I took her cold, clammy hand more in clinical assessment than humanity. She was in circulatory shock, not to mention profound mental turmoil. Her pulse rate was around 120 beats per minute, but the fact that I could feel it suggested that her blood pressure was still above 50 mm Hg. Before we moved her I needed to scrutinise the anatomical features of the injury so as to predict what damage we would be confronted with. I had seen several cases of transfixion trauma where the patient survived because the implement narrowly missed or pushed aside all the vital organs. Here the degree of shock indicated otherwise. It was time to get some cannulas in place in a calm and controlled manner, and bring group O negative blood ready to transfuse her. And for pity’s sake, she deserved a slug of morphine to take the edge off the sheer terror of her predicament.
The Knife's Edge Page 1