The Knife's Edge

by Stephen Westaby

  I was in New York City when I first registered the reckless absence of fear that enabled me to live life out on the edge. There is a saying – ‘Courage is not the absence of fear but the willingness to face it.’ It was 1972, and as part of a medical students’ scholarship at the Albert Einstein School for Medicine I was working a night shift in the emergency room of Morrisania Hospital in Harlem. In the gloom of the early hours the whole department was struggling with the consequences of drug abuse and gang warfare. A young nurse tried to confiscate some contaminated syringes from a drug-crazed addict who had been wounded in a fight. He went berserk with a flick knife and tried to kill her. I saw this coming and went for him before he reached her, a full-on rugby tackle sending the two of us sailing over the chairs in the waiting room.

  The addict’s knife sliced open the thumb of my right hand and blood splattered in streaks over my pristine white intern’s vest, but the set-to didn’t last for long. One of the guards hit my combatant over the head with a riot stick and he ended up in neurosurgery. The grateful chief nurse stitched my wounds, then I went to watch the burr holes being drilled in the lad’s skull. And believe it or not I felt sorry for him. I felt sad for his miserable life.

  A report was sent back to the medical school about my heroism. But in reality it was actually less than heroic, because I simply didn’t need courage to face it. It did, however, bring me the glittering prizes. ‘The student most likely to succeed’, then the prestigious residency posts for both the professor of medicine then the professor of surgery. Did the head injury stop me playing rugby? Not at all. I just became even more aggressive.

  Psychopathy is widely acknowledged in the surgical world. As recently as 2015 the Bulletin of the Royal College of Surgeons published an article entitled ‘Are surgeons psychopaths? And if so, is that such a bad thing?’ The authors argued that complete emotional detachment from the fraught discussions surrounding life-or-death decisions resulted in better choices being made. While this sounds reasonable, the dictionary describes psychopaths as cold-hearted, grandiose and overconfident, with an overblown sense of self-worth and capable of ‘blame externalisation’ by dismissing culpability and failing to exhibit remorse. Certainly, that description fits well with other accounts of the surgical stereotype, and of risk-takers in the financial world.

  But when the risk-taker in medicine wins, everyone else does too. We have to be kept free to experiment and push the boundaries, just as our predecessors did. But I fear that this has now all gone. Risk management is a substantial industry these days and the regulatory authorities are such that everyone strives for a risk-free environment. Even our so-called clients are routinely risk stratified, with the implication that while it is not satisfactory to terminate a low-risk candidate, bumping off the odd high-risk patient is excusable. What a miserable way to view any profession.

  I never looked upon surgery that way. I attracted high-risk cases like a magnet, then revelled in the contest, me versus Grim Reaper. I was repeatedly told that my schemes would never work – that silicone rubber tubes in the windpipe would clog (they didn’t); that pulseless people couldn’t survive (they did); that putting electricity into people’s heads was dangerous (it wasn’t); that injecting stem cells directly into scarred hearts would cause sudden death (not so; we use them to treat heart failure now). Risk-taking is a vital part of medical innovation, and life itself is a risk. If deprived of the opportunity to innovate, cardiac surgery is finished.

  4

  hubris

  Through that retrospectoscope I viewed the next stages of my career with deep embarrassment. I wasn’t born an egotistical maniac. In my youth I had been a shy, caring grammar-school boy who wanted to help people. Until that peculiar quirk of fate on a Cornish rugby pitch I lacked confidence. Afterwards, the pendulum swung way over in the opposite direction. My self-belief and unbridled enthusiasm were rarely tempered by the fact that there was a human life at the sharp end of my scalpel. That didn’t register. In short, I was out of control.

  My post-traumatic boldness and lack of inhibition repeatedly got me into trouble. Had my personality not been so far towards the timid end of the spectrum beforehand, I might have ended up like Phineas Gage, unemployable and potentially criminal. As it was, I was simply regarded as an unflappable, overconfident and ruthlessly ambitious young man who could operate. I was bored easily, neglected paperwork, drove too fast and left my little blue sports car anywhere that suited me.

  I was also an opportunist. While working as a junior doctor in the Liver Unit at King’s College Hospital in London, I learned that the senior registrars were travelling to Cambridge to supervise the post-operative care for Professor Roy Calne’s pioneering liver transplants. These were young physicians well into their training who had absolutely no interest in surgery, let alone staying up at night to watch blood drip relentlessly into drainage bottles. One weekend when no one else was prepared to do it, I volunteered and ventured up to Addenbrooke’s Hospital. This was my opportunity to watch a liver transplant over the great man’s shoulder, albeit under the pretence of gaining a better understanding of what was required afterwards. The strategy paid off. The patient recovered without any complications and everyone thought that I was another Liver Unit senior registrar.

  The Cambridge surgical training rotation was the most prestigious in the country and I loved the city. Only childhood introspection and an ingrained inferiority complex had stopped me from accepting an offer to study medicine at the university. My Jekyll and Hyde transformation changed all that. When the next surgical posts were advertised, I applied and gave my references from Charing Cross and the Brompton. On the basis of my work with his transplant patients, Professor Calne waved me through. Apart from my Brompton adventures and a few appendicectomies done as a house officer in London, I had no practical surgical experience, but that made little difference in those days. What mattered was the confidence – indeed, the recklessness – to just get on and operate. I threw myself into the job and like a dog cut my teeth on bones. It’s hard to kill people during orthopaedic surgery, although not quite impossible.

  Over an icy Christmas period in 1976 I lived in the hospital and operated on more than a hundred fractured hips in the elderly after falls. Two of them died just because the stress of surgery was too much for them. The over-nineties are difficult to mobilise after surgery, so they lie in bed, get pneumonia, then Grim Reaper calls. But we can’t just put them down or leave them in pain, so we go through the motions. After six months of human carpentry and gruesome trauma calls I had mastered the basics – simple stuff like handling the instruments, stopping bleeding and having the balls to operate independently without having to call for help – and I revelled in the great romance of learning to be a surgeon. Next came general surgery, full-blown blood-and-guts stuff, especially when on call at night. I soon acquired the nickname ‘Jaws’ because of the short time it took me to amputate a leg.

  In the 1970s there was no medication to cut down stomach acid, so every night brought perforated duodenal ulcers with peritonitis, or exsanguinating stomach bleeding. Then there was intestinal obstruction through bowel cancer, or traumatic injuries to the liver or spleen. The more dramatic the problem, the better I liked it. I operated all day and most of the night, and my bosses were happy for me to do so. Except for one tedious issue that I blamed on attention deficit disorder – I never got around to the paperwork. Patients’ notes piled high in the registrars’ room, waiting for discharge summaries or letters to the GP. Benign retribution went unheeded, so I was eventually banned from the operating theatres until I had cleared the lot.

  Late one Saturday evening, ‘Jaws’ was called to see an eight-year-old girl brought in by ambulance with sudden severe abdominal pain. Her parents were Jehovah’s Witnesses who were clearly concerned about the prospect of her needing surgery. She had a bit of a temperature and generalised abdominal tenderness, worse over the site of her appendi
x. Common things are common. I informed the parents that she had signs of peritonitis and I thought her appendix might have ruptured. I needed to take her to theatre immediately, whip out the useless worm and give her belly a washout. They asked whether she would lose any blood.

  ‘Absolutely not. It will be all done in fifteen minutes.’

  Already they had the utmost confidence in me, given the straightforward and unequivocal advice.

  ‘And we won’t even think about testing her blood group,’ I assured them.

  I went off to theatre, with an anaesthetic registrar and the houseman on call to assist me. This was the last case in line for surgery, and there was a party waiting for us all in the nurses’ quarters. I made a small gridiron incision in the right iliac fossa directly over the usual location of the appendix. When I reached the transparent peritoneal lining of the abdominal cavity, I expected to see straw-coloured fluid before lifting out the inflamed wiggly appendage with a hole in the end. Not this time. It was dark in there. When I tented up the membrane with forceps and nicked it with scissors, fresh blood spilled out.

  I got that sinking feeling. I had thought she looked pale because she felt bad.

  ‘Did we get the haemoglobin and white blood cell count back yet?’ I asked my anaesthetist.

  ‘Not yet. Why?’

  ‘Because the fucking peritoneum is full of blood.’

  The anaesthetist’s head appeared swiftly over the top of the blood–brain barrier, that green drape hanging on drip poles that keeps their nose out of the wound because they never bother to wear masks.

  ‘Shit, what’s going on?’ he said.

  He told the anaesthetic nurse to fetch blood from the fridge and frantically started measuring the blood pressure: 100/70, pulse rate 105. I immediately made it clear that we would get sued if we gave blood without first raising the issue with the parents. They would certainly refuse it.

  He wanted the on-call consultants. I didn’t. I wanted to find out what was wrong and fix it myself. I remained irrationally calm and made a second, much larger incision in the midline of the belly. More blood spewed out. By then, my rational colleagues had become ditherers who needed to abrogate responsibility as quickly as possible. Quite reasonably, they thought she might be an abused child and that this was trauma to the liver or spleen. But if that were the case, there should be bruising on the skin, together with other evidence over the rest of her body.

  What did I feel? Just curiosity and excitement, because this had to be something rare. My prefrontal cortex should have been dispatching messages of alarm and anxiety to the amygdala, but I’d left fear on the pitch in Penryn. I was there to score points and prove that I was the most competent of the registrars. What was that assessment from medical school? ‘The one most likely to succeed. Brave but lacking insight.’ Not my fault, as I would have to explain on numerous occasions until I became a consultant myself.

  I dragged the intestines out through the incision to search for the major blood vessels. Logically, if any of these had been pissing blood the girl would never have reached hospital. Intuition told me that the initial bleeding had already stopped, as her blood pressure and pulse rate were now stable. I inspected the liver and spleen but they were blameless, so I ruled out injury. Next, I worked through the gut inch by inch, finally locating the problem not far from where the appendix should have been. It was a vanishingly rare congenital anomaly that I would never encounter again, a ruptured duplication cyst of the large bowel. I identified a few residual bleeders and dealt with them with the sizzling electrocautery. I could now tell the rest of the team that the bleeding was under control. The girl was safe … so relax.

  ‘What are you going to do about the duplication cyst?’ asked the emotionally drained anaesthetic registrar, whose boss was on the way in.

  ‘Cut out the bloody colon,’ I snapped, somewhat irritated by his persistent feebleness. ‘Why don’t you go and be a GP?’

  A nonsensical rhyme drifted back and forth through my disinhibited brain: ‘Pass the gas, then kiss my ass!’ I tied off the relevant blood vessels, clamped the slithering guts, then chop, chop, out it came. I joined the two ends with an obsessional continuous stitch, then washed blood and shit out of the peritoneal cavity with warm saline solution. Suck it all out and close up the two incisions. Job done. It was really just plumbing, when all the angst and empathy were set aside.

  By then the consultant anaesthetist had arrived. With crass disregard for seniority I asked what had kept him, as I cheerfully sewed up the skin. The first thing anaesthetists do is to peer over the top of the drapes and ask whether everything is under control. So I reached over to the specimen bucket and proudly presented the offending pathology.

  ‘Never heard of it,’ he said.

  ‘Neither have I. It must be rare. What’s the blood pressure now?’

  ‘100/70.’

  ‘And pulse?’

  ‘100.’

  ‘Did you get a haemoglobin yet?’

  ‘It’s 10.’

  ‘Good enough,’ I concluded. ‘She’s safe now.’

  The consultant politely enquired whether I had let my paediatric boss Mr Dunn know about the case.

  ‘No time,’ I lied. ‘I thought the girl was still bleeding and Mr Dunn’s at a college dinner. I’ll surprise him on the ward round in the morning.’

  I now needed to explain to the girl’s parents why she had both an appendix incision and a bloody great scar down her middle, and why it hadn’t been the fifteen minutes I had told them to expect. As with all parents waiting for news about their child’s surgery, they were in meltdown by this stage. My broad grin in the doorway of the waiting room told them all they needed to know – their daughter was safe, despite my incorrect diagnosis.

  I switched from psychopathic cerebral cortex to defensive and compassionate cerebral cortex, which earned me a generous present when the girl left hospital. Like my willingness to help Down’s syndrome children, I always looked after Jehovah’s Witness patients in the coming years. At least they have solid values and a religion that doesn’t hurt anyone. They sometimes left theatre with a haemoglobin level one third of normal, but they usually recovered.

  Professor Calne encouraged me to play rugby for the local team and get my name in the newspapers – the crazy wing forward who scored the tries. When I walked into the operating theatre or charged out onto a rugby pitch, the psychopathy switch was thrown on. And the injuries kept coming. During one game, a metal stud tore through my scalp, leaving a 12 cm groove in my skull. I insisted on going back to Cambridge where Sarah, the nurse who would eventually become my wife, was on duty in the accident department. I asked her to stitch me up and give me a tetanus jab, but not to bother with the local anaesthetic. Soon I was screaming pathetically for it.

  Then came the fractured jaw at Christmas, when I ended up opening a motorcyclist’s chest in the accident department. I was still wearing my rugby kit, covered in mud, spitting my own blood into the scrub sink, but I was right there in the waiting room and there was no other surgeon in the hospital who could try to save him. I then did a stupid thing by declining surgery for my own jaw fracture, after which I had to endure monster doses of intramuscular penicillin injected into my backside to prevent infection in the bone. The nurses revelled in using my arse as a pin cushion. Ultimately it was this injury that helped me pass the miserable Royal College of Surgeons final examination. I could barely speak in the oral tests, so there was none of the bravado and bullshit that had failed me the first time round.

  I left Cambridge replete with qualifications and priceless surgical experience. I was as confident as I possibly could be, but carrying way too much emotional baggage. Lack of inhibition promotes sexual promiscuity and its fair share of trouble. The Oxford English Dictionary associates psychopathy with ‘disinhibition and callous lack of concern for others’. It certainly goes with little blue sp
orts cars and an inflated ego.

  The Hammersmith Hospital and Royal Postgraduate Medical School invited me to take a post as cardiac surgical trainee during my last few weeks at Addenbrooke’s. This obviously came as a pleasant surprise. Perhaps the job had been advertised and there were no suitable applicants, but I was still pleased to be asked. The euphoria didn’t last long, however, as I was soon irritated by constantly having to assist putty-fingered senior registrars who struggled to stitch the beating heart. It is slippery, moves constantly, and I was convinced I could do better myself. As I became progressively more stroppy about assisting and not wielding the knife myself, I was dispatched to the chest surgery limb of the rotation at Harefield Hospital, which had all the appeal of a wet weekend in Scunthorpe, something I was far too familiar with. Lungs just inflated and deflated – not very challenging. So I went AWOL.

  I saw a job advertised for a locum consultant general surgeon in Hong Kong. Intriguingly, it was with the island’s oldest medical practice, involved operating in two private clinics on the Peak, and while the resident surgeon was away on sabbatical the successful applicant would have use of his apartment, his Porsche and membership of the Hong Kong Club. This was an opportunity to put my glittering Cambridge experience to the test on the other side of the world in a completely different culture. And why not? When I was given the job, I demanded three months’ leave from the cardiac rotation and took off. It was a gamble, but I was frustrated and restless in London, verging on the self-destruct mode. Ultimately, it saved me from being thrown out.