At the Canossa and Matilda hospitals I worked single-handed, with Roman Catholic nuns as assistants. No registrars or housemen to help here. But the nuns brought a sense of calm and harmony to an operating theatre. After all, who could rant and rave at the Holy Sisters? Better still, they were experienced and trustworthy to an extent rarely found at home. Their job was to assist the surgeons, and they kept my roving eye focused on the task at hand. Even I couldn’t flirt with a nun. In turn, I was eager to impress and to instil them with confidence in the young upstart from England.
An opportunity to do just this arose sooner than I might have wished. The practice gastroenterologist referred a nineteen-year-old Chinese girl to me with a problem I had never encountered in the West. The slightly built but beautiful young woman from a wealthy Chinese family had come along with bleeding from the back passage. Surely it must be haemorrhoids, but the gut doctor’s well-educated index finger had located a mass in the rectum. Rectal cancer at nineteen? I didn’t believe the referral letter, but apparently a biopsy had already confirmed it. I met with the devastated girl and her mother in my outpatients’ clinic at the Peninsula Hotel, across on the Kowloon side via the bustling Star Ferry.
In those days the only treatment for a low tumour in that part of the bowel was to radically excise the rectum and leave the patient with a lifelong colostomy stoma. For a teenage Chinese girl, voluntary euthanasia would have been preferable. I was cautioned by the nuns about that when I discussed whether I could do what we call an abdominoperineal resection. Two experienced surgeons would usually operate together, one mobilising the rectum from above through an incision in the abdomen, the other working up to the tumour from below after excising the poor girl’s anus. I needed to think carefully. Should I take this on myself or refer the girl on to an experienced team at the University Hospital? As usual I felt that I was the man for the job, even though I had never done the procedure before. How stupid and deluded was that? Which mattered most – my reputation or the girl’s life?
When I first met the family the mother wasn’t prepared to let me examine her daughter and they clearly didn’t want surgery. I immediately felt desperately sorry for the girl. Next to surgeons, children’s cancer doctors score highest on the psychopathy scale and I can understand why. Human nature normally cannot tolerate witnessing such angst in young people or their parents on a daily basis. Through a Cantonese translator I confronted the mother with a harsh question. Was she prepared for her daughter to die a horrible death from cancer merely because the colostomy bag might destroy her marriage prospects? This abrupt provocation broke through the ethnic barrier and made her cry, so I apologised, something they didn’t expect from a bullish Western surgeon.
I simply had to keep talking until I persuaded them that the English doctor could cure her cancer. In fact, the gods had persuaded me to fly from London to do just that. As they left I genuinely believed that I would never see them again. There was an element of relief in that. I feared that the girl would terminate her own life rather than bring shame on her family. Shame merely for being dealt that genetic self-destruct button. But they did come back, so I had to face up to it. Was I anxious? No. Was I concerned by the extent and complexity of abdominoperineal resection? Certainly. I had seen a few, although a long time ago. But I was sure it would all come back to me once I got started.
Barely a word was said during the five-hour operation. Occasionally I had to ask for an instrument. The correct implement was robotically slapped into my palm, as if by remote control. There was the occasional ‘Oh shit’ or ‘Bugger’, and a constant trickle of perspiration down my back. The nuns moved the lights and – straight out of good old medical movies – mopped my brow. Thankfully the liver was clean, with no sign of the tumour having spread. For once I moved slowly and deliberately through tiger country, mobilising the colon from above, then the rectum behind her uterus. As a budding heart surgeon, this was the first and last time I would do it, so I wanted it to be a success. Most of all I needed to get the site of the colostomy right. This is where the colon and its contents would forever emerge from the abdominal wall. It had to be neat like a rose bud and in the perfect spot so as not to interfere with her clothes.
Although the combination of incisions was excruciatingly painful for her, she recovered rapidly, as only the young can. I was able to reassure the family that there was no obvious sign of tumour spread. Then the pathologist’s microscope indicated that there was no invasion of tumour right through the bowel wall or into the lymph nodes. Nor did she experience any complications. The nuns said that they were proud of me – I was exceptionally proud of myself, happier than I had been after any operation, and thoroughly relieved for myself and that family.
That night I had a few drinks at the enigmatic Hong Kong Club, then sat alone in the haze of the sauna. Time after time my brain worked backwards through the steps of the operation. Should I have risked it in the first place? What was more important to me? Demonstrating to myself that I was invincible, or that poor girl’s safety? It was a career-defining moment. While I still had no fear, my insight was returning. Hong Kong put my own privileged existence in perspective. Working alongside the nuns and sharing some of my own problems with them restored an inner peace that I had lost several years before.
It was then that I started to operate on chests in the public hospital in Kowloon. Lung cancer was common there and there was no one else to do it. I treated traumatic injuries, drained pus and corrected chest deformities in children, all on a philanthropic basis, which restored my self-respect. Unexpectedly I found myself sticking my index finger into hearts to relieve rheumatic mitral stenosis because it was that – or nothing at all.
The more I took on, the more they wanted me to do, and I revelled in it. They wanted me to stay, and I was certainly tempted. Chinese patients didn’t complain about their lives, nor did their surgeons. They did the best they could with what they had, and much of this was a throwback to the previous century. Instead, I resolved to begin all over again in England and use what I had learned on the other side of the world. I would try to be less arrogant and detached, perhaps less of a loner, although none of this would be easy.
I hadn’t been long back at the Hammersmith before I was in trouble again, and I was already close to being ejected from the training rotation for disappearing for three months. Same shit, different day. This time I had taken a stab wound of the heart to the operating theatre without telling the consultant on call. ‘So what?’ I thought to myself. ‘The man was dying. I saved him and prevented a murder.’ I argued that there had been no time to get in touch with him on the way to theatre because my mind was on the business in hand. But that was not the point. However confident I was of my abilities, there was always protocol to be followed. So much for my Chinese New Year resolutions. I was a recidivist, undisciplined and evidently uncontrollable.
After the stab wound, Professor Bentall, whose eyes and hands were not what they used to be, adopted me as his personal assistant. I would do the surgery, he would assist, even for his overseas private patients. I could certainly operate, no one doubted that. My temperament was the issue – the rough edges, the blatant disregard for authority and lack of insight still lingered after my skull fracture. I had morphed into a ruthlessly ambitious prat who needed to be reined in or chucked out. One or the other. Remaining the same was not sustainable in an NHS hospital. Hong Kong was one thing, Du Cane Road W12 quite another.
One morning, after parking my blue MG in the hospital manager’s space outside the main entrance, Professor Bentall called me to his office. I anticipated a complaint from on high and a bollocking for yet another misdemeanour. I would respond with Communist China stuff about equality and what really mattered in life. But no. There had been a complaint, of course, but it simply precipitated a conversation that had long been in the offing. He could see that I was still not happy. Did I want to go to America and work with some of the big na
mes? I didn’t need to think about that. I just said yes. I would go to California and work with Norman Shumway, the heart transplant pioneer.
That was not at all what Bentall had in mind. He was magnanimous enough to acknowledge my surgical potential but re-emphasised the fact that I was completely off the rails. If I went to Stanford, I would only get worse. I should go to John Kirklin, the well-known disciplinarian, who had moved from the Mayo Clinic to establish the world’s foremost academic surgical programme at a new hospital in Birmingham, Alabama. The steamy Deep South. Prof had already spoken to him about me. Kirklin would sort me out, then I could return to a senior post at the Hammersmith. This was a take it or leave it ultimatum. So I took it. That was my only option. I was notorious in the specialty, mostly for the wrong reasons. But remember, it wasn’t my fault. It was those buggered-up brain pathways. Hopefully they would regenerate one day, but hopefully not too soon. I had succeeded in China. Could I emulate that in Alabama?
5
perfectionism
29 December 1980. The great wrench. Leaving behind the car crash of my personal life, and my precious young daughter, Gemma, I set out for Birmingham, Alabama. This was make-or-break time for my career prospects as a cardiac surgeon. My wild antics and derisory approach to the surgical training programme had ruffled too many feathers in London. Now I needed to make it in America. My scholarship in New York had given me some insight as to what to expect, but the Deep South was different, hot and steamy in ways other than the weather.
For me, 1981 had to be about change. It was high time for the caterpillar to morph into a butterfly, then protect his wings from being singed in the fire. Heart surgery was evolving continuously, with rapidly improving results. The cavalier approach of ‘Let’s give it a go and see if the patient makes it’ had passed. It wasn’t manual dexterity or operative technique that now made the difference, it was surgical science. To operate inside the heart, the organ has to be flaccid and still. This can only be achieved by the temporary interruption of the blood flow to the muscle itself. The chemical protection of ischemic myocardium, put simply as heart muscle deprived of oxygen, became an industry in itself. And as the techniques improved, the operations themselves became longer and more complicated – but increasingly safe.
Because progress was predicated upon applied science and evolving technology, the United States was the place to learn about them. Money mattered, details mattered and Bentall knew that the best surgical scientist in the world was John Webster Kirklin. Kirklin didn’t suffer fools gladly. In fact, fools didn’t last five minutes in his department. Lord Brock was said to give ‘the impression of perpetual disappointment at the unattainability of universal perfection’. Kirklin refused to accept that perfection wasn’t attainable. On the contrary, he insisted upon it – and that was hard to live with.
It was in September 1966 – on the same day that I started at medical school in London – that Kirklin relocated from the Mayo Clinic to Birmingham, Alabama. By the time I arrived there fifteen years later, the University of Alabama was a magnet for ambitious young cardiac surgeons from all over the world. Other centres such as the Texas Heart Institute and the Cleveland Clinic might have had greater patient throughput, but none could rival Kirklin’s group for its scientific approach and academic output. My task was to assimilate that knowledge and energy, then bring it back to the NHS. If I couldn’t make a name for myself in this environment, I might as well pack up and go home.
Those who had already visited Kirklin described him as an ascetic and exacting individual who strove to be the best in every aspect of the profession. He was a difficult and often intimidating man who surrounded himself with an outstanding team. ‘Be under no illusion,’ they told me, ‘Kirklin is the boss. Cross him and you’ll be out within the hour.’ He held supreme power at the University of Alabama School of Medicine and, indeed, over the whole of the specialty in the US. There were good reasons for that, and Professor Bentall was absolutely right: I would be afforded no leeway here. For the first time in my career I’d need to conform, however contrary that was to my instincts.
Kirklin’s legacy will always be his success in pursuit of direct vision open heart surgery with the heart–lung machine at the Mayo Clinic. This goal had initially been sought by a young Philadelphia surgeon called John Gibbon. Gibbon had been profoundly affected by watching a new mother die miserably with pulmonary embolus, a blood clot in her lungs. He set out to develop an artificial lung working in conjunction with a blood pump; this might have kept the woman alive and enabled surgeons to remove the obstruction. His complex circuit of pipes with a gas-exchange mechanism evolved into the heart–lung machine, which allowed a patient’s heart to be stopped, opened and repaired under direct vision.
Yet it was not Gibbon himself who gained the ultimate prize of initiating a reliable operative technique. The first child he operated upon to close a hole in the heart died because the diagnosis was wrong, but soon afterwards on 6 May 1953 came the breakthrough the world had been waiting for. Gibbon operated on an eighteen-year-old girl and succeeded in closing an atrial septal defect. But when he attempted to repeat the operation on two five-year-old girls they both died. Gibbon walked away from the failure a broken man. In his misery and disappointment, the significance of that one success was lost on him. He lacked the resilience to recover from the girls’ deaths and simply didn’t possess the requisite traits to succeed as a cardiac surgeon. Uncertainty, modesty and self-doubt just don’t cut the mustard.
In stark contrast, Kirklin felt that the heart–lung machine would enable the repair of more complex heart defects, so he embarked on building a ‘modified Gibbon’ machine in the laboratory at Mayo. On his first cardiopulmonary bypass operation in March 1955, a child underwent closure of an atrial septal defect and survived. At this point, many of Kirklin’s critics at Mayo were unconvinced by the laboratory and clinical progress. The American Heart Association and the National Institutes of Health had stopped funding further projects with heart–lung machines because they considered the problems generated by the interaction of the patient’s blood with the foreign surfaces of the machine to be insurmountable.
Then in the spring of 1954 came the astonishing news that Walton Lillehei had connected the blood vessels of a baby to his father’s circulation to enable him to repair a hole in the baby’s heart. After this, Kirklin’s critics suggested that too much money and effort had already been wasted on a blind alley. But they were wrong. When Kirklin’s improved bypass circuit was used in the operating theatre, twenty-four of the first forty open heart surgery patients survived.
Kirklin undoubtedly succeeded because of his persistence and scientific approach. Even when I was with him, every operation was carefully recorded then analysed, and the information was used to assist decision-making on other patients. As he wrote:
Academic surgery is the fusion of clinical surgery, research, teaching and administration. Those who have experienced only one of these components cannot understand the whole.
He instilled this principle is us trainees, and those who could not aspire to it found him very intimidating.
With more widespread adoption of cardiopulmonary bypass, it became apparent that the contact between the patient’s blood and the synthetic materials within the extracorporeal circuit caused a pseudo-allergic reaction that would be referred to as the ‘post-perfusion syndrome’. This sinister and sometimes fatal problem was never experienced by Lillehei’s cross-circulation patients because their blood remained within a biological circuit. Some bypass patients developed fever lasting several days, with stiff, waterlogged lungs, bleeding tendencies and kidney failure. While the syndrome was often inconsequential after most straightforward adult bypasses, the more vulnerable patients, including small children or the very sick and elderly, would require prolonged periods on the ventilator, blood transfusions or kidney dialysis to survive. The longer the time spent on the bypass machine, the mo
re likely were these complications to occur. Sometimes they resulted in the patient’s death despite an effective heart repair, obviously a great disappointment to the surgeons.
At the time the heart–lung machine consisted of plastic pipes, a simple roller pump, a complex blood oxygenator and reservoir, then a suction system, all of which required priming with around two litres of anticoagulated blood containing the chemical citrate. It used to be thought that blood-type incompatibility or biochemical disturbances caused by drugs were responsible for the post-perfusion syndrome, but the problem persisted even when whole blood was replaced by other priming fluids such as dextrose or salt solution. Then a heat exchanger was included in the circuit to enable whole-body cooling. Cooling permitted a reduction in flow rates on the machine, which many thought would reduce blood damage. But this still did not prevent fever or lung and kidney damage, and the bleeding tendencies persisted.
On my first day in Alabama I found myself wandering around the hospital corridors completely lost. When I first set eyes on the great man he was surrounded by a group of grim-faced residents. By then, Kirklin was sixty-four and easily recognisable from pictures I had seen in cardiac surgical journals. He was slightly built, around 5 foot 10 inches tall and grey-haired, but it was the heavy, dark-rimmed glasses that immediately gave him away. He wore a freshly starched white lab coat with his name embroidered on it, although I was too far away to read this at the time. All I could see was a face that looked like thunder. He was angry, while his audience looked anxious and crestfallen. Had one of his patients died? No. It was just that the night team had failed to call him about a significant complication. A stroke.
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