The Knife's Edge

by Stephen Westaby

  The oesophagus and aorta descend side by side in the chest, nestled behind the heart and in front of the spine – oesophagus on the right, aorta to the left. Tiger country. Under high-dose antibiotic cover, Nick planned to open the right side of the chest through the ribs and locate the abscess behind the lung. Then, by opening the abscess cavity, the pus could be washed out and drains left in place for a few days until the antibiotics clobbered the infection. Nick thought that the small perforation through the muscular wall of the oesophagus would seal itself. While awfully simple in theory, it was destined to be simply awful.

  Through the glass door of Theatre 2, I could see Nick, sweating profusely with his face covered in blood, and both arms up to the elbows in the woman’s chest. Blood was slopping out of the chest cavity and down his blue gown, while anaesthetists were squeezing in bags of blood. It transpired that all had gone according to plan until he swept an index finger around the abscess cavity to clear the infected debris. First came the noxious odour of anaerobic bacteria and rotting flesh. Then, whoosh! Blood hit the operating lights. The abscess had eroded through the wall of the aorta. Behind the heart lay an infected swamp. All Nick could do was to stick his fist into the fountain and press hard. Big problem. They had already lost more than a litre of blood and if his fist moved she would bleed out in seconds.

  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!