The Knife's Edge

by Stephen Westaby

  Lucy sensed that I was wavering. Hedging my bets, I told her that I had no idea whether we had any intensive care beds available.

  So Lucy played her trump card. ‘The family asked that he be sent to you personally. Apparently you were at medical school together. I think he was a friend of yours.’

  What was that question I never asked? Something we don’t regard as important – the patient’s name. Surgeons are less interested in people. We want problems to fix, but I had already had enough problems for one day.

  Suddenly the penny dropped. A GP in Suffolk. My own age and with previous heart surgery. He was a jovial rugby prop forward, captain of the 2nd XV at Charing Cross Hospital, my old mate Steve Norton. We met on our first day at medical school in 1966. I was a shy, unassuming backstreet kid, frightened by my own shadow, and no one from my family had ever been to university before. Steve was an ebullient extrovert, full of confidence, destined to become a much-loved GP in rural Suffolk while I underwent metamorphosis into a fearless operating machine. Same profession, worlds apart. How did that happen?

  I just said, ‘Bugger the beds. Send him across as fast as you can. I appreciate you should be going off duty, Lucy, but someone must come with him to screw that pressure down. And please send the CT scan.’

  With no one to delegate to at this time of the evening, I had to make all the arrangements myself. The on-call nursing team had already worked all day and were just finishing a routine lung cancer operation. They were less than delighted by the prospect of a protracted emergency reoperation, one they expected to take all night. With foot down and blue lights flashing, the ambulance ought to be with us by 11 pm. If Steve survived to see Oxford alive, I would wheel him directly to the anaesthetic room.

  Now the battle had started. Was there an empty intensive care bed? If not, there would be a bloody row about accepting a patient from outside the region without asking. Who was the on-call anaesthetist? I got lucky with Dave Pigott, a dour South African who helped with my artificial hearts and revelled in a challenge. Then lucky again that Ayrin was the scrub nurse. She was a diminutive, ultra-polite Filipino girl who never complained about anything because she was proud to work for the NHS. Her invariable response to any expression of gratitude was ‘Welcome.’ I used to think that this was the only English word she knew. The perfusionists always moaned and groaned when called at night, but they were all ultra-reliable. I just asked switchboard to call in whoever was on the rota and I looked forward to the surprise.

  As the sun went down, we waited. I called home and spoke to my long-suffering wife Sarah, who thought I was in Cambridge and was sad for me that I wasn’t. I explained that I was waiting to operate on Steve Norton from medical school and wouldn’t be home tonight. That concerned her. I wasn’t the duty surgeon, and she remembered the heated discussions when I was faced with the prospect of operating on my own father during his heart attack. In the end, my cardiology colleague Oliver spared me the moral issues by curing him with coronary stents.

  Sarah asked tentatively whether I should ask the on-call surgeon to do it. How did I feel about operating on a good friend at such high stakes? Cardiac surgeons are rarely introspective and self-effacing. I answered her question with a question: ‘If you had an aortic dissection, who would you want to do the surgery?’ Response: ‘You.’ Well then, why are you surprised that Steve’s family felt the same?

  As she’d sat by the bedside, Steve’s wife Hilary knew the situation was dire. What was the anticipated mortality rate for aortic dissection? An international registry from top cardiac centres in Europe and the United States reported 25 per cent. What is the lowest recorded mortality in any series of cases? Six per cent. Who had operated on those cases? A surgeon in Oxford. So who would give Steve the best chance of coming through this catastrophe? I had no reservations whatever about battling to save my mate. As the phrase goes, ‘That’s what friends are for.’

  Sarah’s next question was whether I’d eaten anything that day. This took some time to think about. I recalled a bacon sandwich at the crack of dawn. I told her that I’d find a bag of crisps from a vending machine before we launched into the night’s work. But food was the least of my concerns at that point. I needed an experienced first assistant, someone who had operated with me on dissections before, not an inexperienced locum brought in to cover a few night shifts. When the shit hits the fan, a coherent team makes a massive difference. Bums on seats is not the same. Amir was not on call, so I picked up the phone and asked him if he was doing anything. One thing he certainly wouldn’t be doing was drinking. He was effusive in his willingness to help, honoured to be dragged in at night to help the boss with a complex case. And I knew that he was capable of standing at the table for hours when I needed someone to stem the bleeding then close up. That was a young man’s game.

  Steve and Hilary were at my wedding to my first wife Jane. Our pack were all young interns at Charing Cross Hospital after graduating, part of the rugby crowd that never took life too seriously. It was Steve who placed the bet that saw me streak naked the length of Pembridge Gardens to Notting Hill Gate tube station during rush hour. And we had both been fished out of the fountains in Trafalgar Square after a rugby club bash in Fleet Street, only to spend a cold night in Bow Street nick. I failed anatomy that term. Escapades long forgotten, just flashbacks for me as he travelled paralysed and semi-conscious through the night, unexpectedly perched on the edge of life. Once good friends, we were now surgeon and patient, something I never expected nor wanted to happen.

  I wandered the silent hospital corridors to pass the time, consciously avoiding a confrontation with cardiac intensive care. I would let Pigott tell them we had an emergency once we were in theatre. Or maybe I’d ask Amir, who joined me in general intensive care, where we visited the fishbone lady. The ‘great save’, whose name I never knew, was beginning to wake up, her bed surrounded by her anxious daughters, arms extended to their mother’s cold hands under the warming blanket. Predictably, she had ‘after-cooled’ down to 34°C following the hypothermic circulatory arrest and was now shivering violently. Shivering, and the vasoconstriction response to cold, had pushed her blood pressure up to astronomical levels and Amir realised that this was likely to burst the repair.

  The lady night registrar nonchalantly strolled across, clearly uncertain about whom she was about to address.

  ‘Can I help you?’ she enquired in an aloof manner, presuming that this scruffy visitor in theatre blues was a porter or something. My response must have come as a surprise.

  ‘No, but you can help this lady by getting her blood pressure down before she blows her bloody graft off. Paralyse her and keep her asleep until morning.’

  The daughters were wide-eyed. The implications of my reply were lost on them, but they sensed an air of tension between the players.

  ‘Give her a bolus of propranolol right now,’ Amir chipped in assertively.

  Registrar lady was now defensive and flustered, verging on shocked. She was not much older than my birthday girl and I immediately regretted being short with her. Maybe we should have done this differently. I could have taken the time to introduce myself and immodestly taken credit for saving the woman’s life, have the relatives fawn around and worship me for the bizarre and heroic rescue. But this was Nick’s case. He had already explained everything to the relatives. I didn’t want to intrude, but I certainly didn’t want to see the repair blown to pieces after all that effort. Having made the point, we wished them all a peaceful night and moved on. Sensitive souls, the intensive care doctors.

  10 pm. Amir and I slipped silently into children’s intensive care to check on the morning’s case. Yet I was first drawn to the mother of the meningitis child whose black, gangrenous arms were now gone, replaced with rolls of pristine crepe bandage. Stark contrasts. Was she happy or sad that those mummified little hands had been removed? I wondered whether I would have asked to keep them had it be
en my child. I set that morbid thought aside and simply asked how the operation had gone. Was she, the mother, OK? Could I help her with anything? Fetch her a coffee? Anything at all to ease her pain? She just looked up at me with tears rolling down her cheeks and said nothing. The nurse knew me well enough and shook her head. It was time to move on to my own little patient.

  The chest drains were dry now, with a steady pulse and blood pressure. Nurse told me that Dr Archer had done an echo and was very pleased – no leak on either valve or across the patches. Fixed for life. The parents had drifted down from the ceiling after the shock of the sudden reoperation and had gone to crash out in their hospital room. They understood the difficulties we faced, which was what really mattered. Not the daily battle for the privilege of bringing a patient to the operating theatre, nor the repeated conflict over intensive care beds. As night fell, we hoped for stable patients, cheerful parents, happy husbands or wives, and a brighter future for them all. While they drifted off to bed, I strolled down a long, dark corridor to the doors of the accident department.

  Out in the fresh air for the first time in sixteen hours, I stared at the night sky and waited for the ambulance to arrive. The operating theatre lay ready, the heart–lung machine was primed, and the team were watching Newsnight in the coffee room, yawning with boredom and resigned to the fact that we were likely to be there all night. My own thoughts drifted back to Gemma and the disappointment I must have caused her once again. But maybe I was wrong. Maybe she had a much better time without me.

  11.50 pm. The ambulance with East Anglia Health Authority painted across the side finally arrived, its blue lights flashing. Paramedics threw open the rear doors and the long-off-duty Lucy stepped down the ramp. I just knew it was her. Like a scene from Casablanca, she walked towards the Emergency entrance carrying a stack of medical notes. I thought at that moment how beautiful she was.

  ‘You’re the Prof, aren’t you?’ she said. ‘Mrs Norton told me about you. I trained in Cambridge and they still talk about you there.’ Nothing positive, I expected.

  The trolley bearing Steve’s broken brain and body was being pushed towards us. The last time we met was barely six months before at a medical school reunion. He had delivered a very amusing speech celebrating the fact that all present were still alive despite his open heart surgery. I responded by jesting that things could have been different had he come to me for surgery. Now he was in Oxford in dire straits, not the next reunion we’d all anticipated, with his family still somewhere on the M25. I took his left hand, which firmly gripped mine. The good side that still moved. Then, along with Lucy, we walked in procession through the accident department down the corridor and straight into the operating theatres. A cursory glance at the CT scan confirmed the lethal diagnosis.

  We can’t operate without consent, but he was alone and I didn’t want to be too explicit. I just told him that I would repair the dissection and with luck the stroke might recover. He struggled to tell me that he wanted to see Hilary and his children again before being put to sleep. Lucy had a number for Hilary, so I called. They were forty-five minutes away at best. Every extra minute meant less likelihood of neurological recovery, and too many hours had been wasted already. When I promised not to let him die, Steve used his left hand to mark a cross on the form. I counter-signed beneath, then Dave Pigott dispatched him to oblivion with a brain-protective barbiturate.

  We had kept the interpersonal rapport to a minimum. Surgery has to be dispassionate, anonymous even. It was less of a problem because Steve couldn’t speak and I simply couldn’t verbalise the real risks to a friend who faced certain death if no one was prepared to operate. He was a doctor and knew the score. I didn’t need to render him any more anxious in his last conscious moments.

  I sat in the coffee room until the lily-white body had been painted brown with iodine and covered with drapes. I didn’t want to see his flabby torso. I preferred to remember him the way he once was, that fine physical specimen striding out onto the pitch on a winter’s afternoon, adrenaline pumping, ready for the scrap. Closely aligned in those days, we were very different characters now. Steve would sit in an office chatting affably to patients and dishing out pills. A proper doctor. There I was at midnight, ready to wield the knife and drive an oscillating saw through his chest, all after an endless day of disappointment, conflict and misery. But adrenaline dissipates the tiredness, wipes out time as the contest begins.

  After the previous surgery, Steve had no pericardium or thymus gland between the back of the breast-bone and the front of his heart. So with an expanded, tissue-paper-thin aorta immediately beneath, chest re-entry with an oscillating saw was extremely hazardous. I reduced the risk of catastrophic bleeding by exposing the main artery and vein of the leg, and connecting them to the heart–lung machine. Should the saw lacerate the heart or aorta, I could go rapidly onto cardiopulmonary bypass, take pressure out of the circulation, then suck away blood from the bleeding site. Mostly that works. Sometimes it doesn’t. If heart surgery were easy, everybody would be doing it.

  Fixing Steve was like replumbing a Victorian house. All the main pipes were buggered and those coming out of the boiler needed to be replaced as they were rusty and might fall to bits at any moment, so I couldn’t do it with hot water flowing through them. I needed the same conditions as fishbone lady – a cold brain and all the blood drained off into the machine. Dave put electroencephalogram leads onto the scalp to monitor the brain waves, which gradually disappeared as Steve’s temperature fell but were already grossly abnormal after his stroke. Amir began by cutting the skin straight down the line of the scar from the previous operation, then used the electrocautery to sizzle through fat onto bone. He snipped through the old stainless-steel bone sutures with a wire cutter, then ripped them out. I was always going to open the sternum myself. Getting the depth of the oscillating saw just right is a matter of fine judgement. You must gently feel it pass through the back of the sternum, then pull back in case the posterior table of the bone and the muscle of the right ventricle are adherent.

  The dissected aorta had the intimidating appearance of a tense aubergine, purple and angry, and I could see blood swirling beneath its perilously thin outer layer. Dave had positioned an echo probe in the oesophagus, directly behind the heart. This showed the original tear in the wall around 1 cm beyond the origin of the coronary arteries, the vital branches that supply the heart muscle itself. My job was to replace the torn part and redirect blood flow back to where nature intended, in the hope that this would restore flow to Steve’s blocked brain and kidney arteries. The compromised kidney would undoubtedly survive, but the injured brain was unlikely to. It had been starved of blood and oxygen for too long, although barbiturates and cooling might help.

  I told Brian the perfusionist to go onto bypass and cool to 18°C. Draining the whole living body of blood is a curious thing to do. Only vampires and the few heart surgeons who operate on congenital heart defects and extensive aortic aneurysms ever do it. I specialised in both, so I emptied people out on a regular basis. I once gave a spoof lecture about halal humans at Dracula’s castle in Romania. I felt at home there. The Count and I had much in common.

  I was normally relaxed about working against the clock, even when the brain had no blood flow. I didn’t stand there contemplating the nerve cells as they died, nor did I rush the job. At 1.30 in the morning I told Brian to come off bypass and drain, the second time I had done that in twenty-four hours. Steve’s cold, anticoagulated blood emptied into a reservoir and would sit there like a jug of Ribena until we pumped it all back again. I chopped away at the empty disintegrating aorta until I could see the inside of those vital branches coursing up into the head and arms.

  The first step was to reapproximate the dissected layers of the filleted vessel with tissue glue. I was one of the first surgeons in the world to use the glue and it undoubtedly contributed to my gratifying survival rate. Then, with care bordering on ob
session, I sewed in the vascular tube graft buttressed with strips of Teflon felt to prevent the stitches from cutting through the fragile tissue. Every patient’s survival relied upon the connections between my cerebral cortex and fingertips, but this was especially the case in aortic dissections. Amir’s eyes fixed on my every movement. He wanted to learn all the nuances of technique, which is why he willingly came in. Amir would definitely make it one day.

  The repair to the aorta and inserting the graft without blood flow took thirty-four minutes. This lay within the window of safety for a normal brain, but Steve’s brain was not normal. We carefully refilled the vascular tree with blood and evacuated air from the head vessels. Once back on cardiopulmonary bypass, blood oozed through the needle holes. These would continue to bleed until we reversed the anticoagulation that prevented blood from clotting on the foreign surfaces of the circuit. So many detailed steps to recall, but the whole sequence was ingrained in my neural circuits, with everything done on autopilot, even in the early hours of the morning.

  It was now time to re-warm to normal body temperature. With warm blood coursing through his coronary arteries, Steve’s heart muscle came to life again, first wriggling in what we call ventricular fibrillation, followed by spontaneous defibrillation and then the slow, lazy contractions that sped up as his temperature rose. Soon brain waves reappeared on the electroencephalogram. Dave thought it looked a bit better already.

  The only other time that we watched this process of reanimation was when we tried to save children who had fallen through ice and drowned in a frozen pond, and there are rare cases of survival from Canada. Our Oxford trauma doctors pressed us to rewarm these lifeless bodies, and while we succeeded in salvaging hearts, lungs, livers and kidneys, the children were always fatally brain injured. We gave hope to their parents, then snatched it away again.