For me, Birmingham had worked its magic. I had seen and participated in so much that I now felt like a real cardiac surgeon. What’s more, I was given the chance to remain in the States – the highly disciplined environment had smoothed away my rough edges and my technical skills were considered to be worth keeping. But that could never happen. I had a daughter back home and I had to return.
6
joy
9 pm, Christmas 1985. I was slumped on an uncomfortable wooden bench in the accident department of St Thomas’ – Florence Nightingale’s famous hospital opposite the Palace of Westminster – in the company of bandaged heads, bleeding noses and puking drunks. In reality they were more mental health problems than actual emergencies. ‘Joy to the World’ played incongruously over the intercom and for this tramp it was the perfect place to spend the evening.
As the night staff reluctantly dribbled in, the late shift were desperate to get home, so none of them were at all interested in a sad character in a tatty Santa Claus outfit slouching by a dying tree whose lights had fused. Sister in charge was gliding in and out of the waiting area, doing her best to raise spirits. At St Thomas’, nursing sisters still looked the part. This Christmas angel was tall, slim and elegant in a navy spotted dress and sheer black tights. With her small waist and a silver belt buckle, her jet-black hair framed between a starched white collar and a formal cap adorned with mistletoe, this woman – equally renowned in body and mind – was known throughout St Thomas’ as ‘Sister Beautiful’. Doctors, ambulance men and police fawned round her, trying to pick their moment, hoping to take advantage of that seasonal invitation on her cap – a kiss from an angel, just for that one night of the year, a consolation for having to work on Christmas Day.
She glanced across the room at me and asked one of the staff nurses to find out what Santa Claus needed. Had I just come in to escape the cold night? If so, they should give me hot tea and some cake that she had brought in herself for her frequent flyers, the vagrants and destitute of south London. She didn’t recognise me behind the beard. She wasn’t meant to.
Outside, an ambulance pulled up on the frosty gantry, sounding its siren by the main entrance. Anticipating trouble, Sister Beautiful and the duty casualty officer headed towards the swing doors. It was a heart attack patient already in shock. As the paramedics lowered the trolley to the pavement, the blip, blip, blip of the monitor ceased and the random spikey waves of ventricular fibrillation triggered an alarm. They moved swiftly to the resuscitation room through the piped strains of ‘Silent Night’, and with a sense of urgency Sister climbed onto the trolley, straddled the man’s waist and began pumping frantically on his chest. She shouted to the mesmerised casualty officer to run ahead and charge the defibrillator. ‘All is calm’ and ‘sleep in heavenly peace’ seemed lost in the moment.
This cardiac surgeon could only watch anonymously in admiration, unable to do anything to help. I didn’t belong there. Sister Beautiful had the presence of mind to instruct the night staff to look after the man’s wife, then, still pounding away, she disappeared from sight. I glanced across the waiting room to the crib in the corner. There were angels there too. With a flurry of activity the cardiac resuscitation team arrived from the wards and piled in behind this extraordinary woman. Then the door closed behind them.
I had been Santa Claus for the Hammersmith Hospital children’s ward early that morning. Only really sick kids stay in for Christmas and some of them had cancer. Emaciated, anaemic and bald from chemotherapy, they had swung their bony little legs out of their beds, waiting for me to arrive with their present. Their loving parents propped them up and tried to divert their minds from the exhaustion and misery of it all, if only for a few minutes. There were smiles and a few tears, not least from Santa himself. I knew it could be their last time. Then, with a sense of relief and a huge sack of my own daughter’s presents on the back seat of the car, I headed for the North Circular road and the A10 to Cambridge. Gemma was seven now and I made the same journey each year. It was always a happy day, until I had to leave. Watching her wave me goodbye on the doorstep cracked me up every time, and I’d weep pitifully all the way back to London. Yet there was no one to blame but myself.
Although I spoke with her every single day, I was obsessed by the fact that I had deprived her of a normal childhood. A huge surgical ego was one thing, but I had little self-respect, seeing myself as a shit parent with no moral compass who worked perpetually. The more I did, the less my aging bosses had to do – and that suited them.
Sarah – Sister Beautiful – was gone for an hour. Eventually she emerged from the resus room looking dishevelled and dejected, her white cap and collar long gone, her tights laddered and the top buttons of her dress open. Performing cardiac massage for a prolonged period is equivalent to a vigorous workout at the gym. Beads of sweat were rolling from her neck and disappearing down the valley between her breasts. The medical students stared at her shamelessly as she disappeared into the relatives’ room, where the wail of despair from the disconsolate wife told most of the story. Meanwhile the tape had gone full circle and the waiting room was treated once more to ‘Joy to the World’.
It was close to 11 pm and the bossy night sister was making strenuous efforts to clear the department of the alcoholics and walking wounded. The charade was over. I had spied on my lover for long enough, but it had been worth it. I hadn’t watched Sarah do what she did best since Cambridge, where she had looked after my rugby injuries – fractured jaw, torn scalp, cracked ribs, none of which stopped me getting straight back to the operating theatre.
Despite being two hours beyond the end of her shift, she still had one last task. The anguished wife wanted to see the man with whom she had shared her life one last time before that plaque ruptured in his main coronary artery and acute heart failure killed him. I might have rushed him onto a heart–lung machine and bypassed the blockage, but not here in St Thomas’. This was Sarah’s hospital, not mine. The on-call cardiac surgeons were miles away at home, not hanging around for some excitement.
When Sarah finally emerged from that room of death, Santa was standing right outside so she couldn’t miss me. She looked pale and stressed. It had been eleven hours of verbal abuse, being spat at, then mauled by drunks and boisterous junior doctors who were queuing to give her a ride home because her anticipated lift had not turned up. Or so it had seemed. Now she had to cope with an emotional car crash of a lover before coming back for 8 o’clock the following morning.
Both of us needed to wind down and talk, and Westminster Bridge at midnight was made for that. We leaned over the parapet and stared down into the ice-cold Thames, me in Santa’s coat, Sarah in her black nurse’s cape, as Big Ben commenced its countdown to midnight. By now it was an unusually silent night, everyone at home in bed apart from the human flotsam and jetsam that was still drifting into the accident department. Same at the Hammersmith, same at Charing Cross, same everywhere. Sarah had seen three deaths that shift – the cardiac man, and two lonely young suicides for whom Christmas had become unbearable. She was upset about the girl in particular, a sixteen-year-old thrown out by her family for getting pregnant. She had sought an abortion but couldn’t afford it, so had leapt from a railway bridge. And when it didn’t seem that I was there at the end of her shift, Sister Beautiful had thought the worst about me too. One way or another.
Christmas 1987. I was three months into my consultant post in Oxford, excited to have been taken on by the world’s foremost academic brand to set up a new cardiothoracic centre. For anyone who lacked my disinhibited brain, starting out single-handed as a heart surgeon would have been a daunting prospect, with no one to call upon for help or advice and no senior colleagues with whom to discuss difficult cases. But that was exactly what I loved about it, as it meant that I could stand on my own two feet. Professionally I was ruthlessly ambitious and supremely confident, and I wanted to do things differently.
The vari
ous factions in Oxford all had differing requirements – the adult cardiologists wanted an accomplished coronary artery and valve surgeon; the chest physicians insisted that lung surgery should be done by an experienced thoracic surgeon; the paediatric cardiologists were hoping for someone who could develop a congenital heart programme for them. The first surgeon in was expected to set up the whole service. In reality it was complete madness, but I revelled in the challenge.
In the background I had the most caring and selfless woman I knew, paddling hard to keep me afloat. Although Sarah was thirty-eight weeks pregnant, she still insisted that I drive to Cambridge to spend the day with Gemma and her mum. As New Year came then passed, so did Sarah’s due date; but I was so absorbed in my own personal indispensability that our impending childbirth barely impacted on me. Nothing seemed more exciting than operating on hearts, which says something about my cerebral cortex at the time. Still bruised, I guess. Sarah was trying to educate me in the ways of empathy, but I had some distance to go.
20 January 1988, now ten days overdue. The midwife started talking about induction. Mark was a good-sized baby but his head was still not engaged (no change there, then!). But with a good, steady foetal heart rate there were no real concerns and Sarah wanted to let nature take its course.
In my parallel world things were about to kick off. I was on the wards, conducting an early morning round before theatre. Today there were just boring coronary bypasses on the operating list, patients who had waited months for surgery in London hospitals before being clawed back for the new surgeon to operate on. Unexpectedly I received a call from the duty cardiology registrar. His boss Dr Gribben, a dour Scotsman, had requested an urgent opinion on a sick patient before I committed myself to the operating theatre for the whole day.
This was an unfortunate twenty-two-year-old woman with Down’s syndrome, who had come in with an infection in her blood stream – sepsis, as we call it. I could have made up the rest of the story without asking. As with many Down’s children, Megan had undergone repair of a complete atrioventricular canal defect in infancy – literally a void at the centre of the heart, with valves that had not formed properly. The reconstructed mitral valve had always leaked, and now it was infected with the aggressive Staphylococcus aureus bacterium. Endocarditis is the medical term for this, and it would undoubtedly progress rapidly and prove fatal. She would certainly need a mitral valve replacement as soon as possible.
My initial response was that we should get on and do it that same day. As I’ve mentioned, I’d had an affinity for these affectionate, genetically disadvantaged kids since they were denied corrective operations at the Brompton ‘because it wasn’t worth it’. They were said not to fare as well as normal children with congenital heart disease, but that simply wasn’t true. I was destined to correct more than two hundred atrioventricular canal defects in Oxford, with a vanishingly low mortality rate. But there was more to come. Dr Gribben came along himself and, looking me straight in the eye, said that there was something else I needed to know. It transpired that the parents, who had adopted Megan from an orphanage, were Jehovah’s Witnesses and that there was no way they would accept a blood transfusion.
These few words added a new dimension of agonising complexity to the case, and I could tell that Gribben expected me to flatly turn her down at this point. First, unlike non-cardiac surgery, the heart–lung machine dilutes the circulation with its priming fluid. Then reoperations always bleed more. Finally, patients with sepsis have abnormal coagulation and may bleed heavily, so without blood they are likely to die. Heart surgery only became possible after the emergence of both blood transfusion and antibiotics during the Second World War. But in 1945 the governing body of Jehovah’s Witnesses introduced the blood ban based on a strict literal interpretation of the Bible. Interestingly, Jehovah’s Witnesses celebrate neither Christmas nor birthdays, are politically neutral, do not enlist in the military nor salute flags. I always accepted them for surgery, but it was a challenge to get them through. These days, with death rates thrust into the public arena, many of my colleagues will not take the chance.
Although Megan was twenty-two, I did not feel that she had sufficient understanding of her plight either to consent to the operation or consciously reject transfused blood if her life were threatened. So it was down to her adoptive parents to make decisions on her behalf. Sure enough they produced a legally binding ‘advanced directive’ prohibiting a blood transfusion. I had long since learned to avoid unnecessary polarisation and potential conflict over religious beliefs, and would never have confronted them by saying that their daughter was going to die without blood or that I wasn’t prepared to operate unless I could transfuse her. To be honest, blood transfusion is undesirable for many reasons and inherently increases surgical mortality. I would avoid it myself unless I was otherwise doomed. Yet in my own mind I was not going to let this girl bleed to death. She had been born with enough bad luck without me terminating her life needlessly.
The parents took the position that they would only sign the consent form if the anaesthetist, the intensive care doctors and I promised that we would not use blood. We were also asked not to pursue a court order to do so. So what was acceptable to them? I explained that there was a new machine called a cell saver that would scavenge spilled blood and give it back to Megan. Blood lost into the wound is suctioned, centrifuged and washed, then mixed with an anticoagulant before being put back into the patient via a filter. The filter removes bacteria and white blood cells, making it an important tool in the treatment of sepsis. That was not so different from the heart–lung machine, whose tubing we primed with clear fluid. The cell saver was acceptable because it was her own blood circulating continuously, and Jehovah’s Witnesses were usually content with that, as with kidney dialysis. They both nodded in agreement. I had a couple of other tricks up my sleeve that I did not want to discuss at this stage, so we agreed to proceed on their terms.
Clearly I was sticking my neck out with this case. I had only been operating in Oxford for three months and had encountered a particular arrogance that was hard to justify, something along the lines of ‘We are Oxford, so we must be good.’ It was curiously different from Addenbrooke’s in Cambridge; indeed with his usual pragmatism Roy Calne had already warned me about what to expect. I was only allowed to use eight beds on a general surgical ward, then after surgery the patients had to go to the general intensive care unit shared by trauma, acute medicine, obstetrics and other surgical specialties. As a result I needed to fight for a bed for practically every case.
Then it transpired that good old Theatre 5 was completely unsuitable for cardiac surgery, much more so than I had initially realised. There was no piped oxygen into the room and its single heart–lung machine belonged in a museum. Alarms would sound and Ted, my only perfusionist, would jump up, disconnect the empty oxygen cylinder and dash outside for a replacement. A perfusionist must never leave his machine during a case, but Ted left during every single one. He had no alternative in his efforts to keep us afloat.
Soon after my arrival there was a catastrophic failure of the antique machine’s heater–cooler system at the beginning of an operation. We needed to cool then rewarm the patient to repair her heart, but we’d lost our ability to do so. Before we could attach the unsuspecting woman to the circuit, Ted ran out of theatre and returned with a bucket and a bowl. He filled the bucket with tap water and ice for cooling, then prior to rewarming he fetched a kettle of warm water for the bowl. The bypass tubing with the blood flowing through it was simply flipped from bucket to bowl when I gave the order to rewarm. This tableau was more suited to a Monty Python film than a major teaching hospital, but I soon learned that it had been going on like this for years.
Then the scrub sink blocked. The overhead lights had a life of their own, so I would perpetually be desterilising myself when adjusting their position. Next, sewage leaked through the ceiling from the toilets above. Eventually I decided to
call the long-suffering hospital manager Mr Stapleton when anything went wrong. I would stamp my foot and tell Sister Linda, ‘Send for Mr Stapleton.’ More often than not he would actually appear in his suit at the door of Theatre 5 and say, ‘What is it now, Westaby?’ Without shifting my gaze from the heart, I would bellow that it was the bloody this or the bloody that, while the anaesthetist Tony Fisher would duck behind the anaesthetic screen giggling to himself. But in the end we didn’t lose anyone. Against all odds, my first hundred patients in Oxford all survived.
Now came the tricky bit. We obviously didn’t have the cell saver machine I needed to attempt a reoperation on a Jehovah’s Witness, so I frantically set about trying to locate the company representative to persuade him to lend us one. The earliest this could happen was the following day, late in the morning. That would give us twenty-four hours to soak Megan in high-dose antibiotics, but I insisted that in the meantime she should be carefully observed in the intensive care unit. I had an ulterior motive for this – at least she would be guaranteed a bed after the surgery, and we couldn’t wait any longer. I also insisted that she be given a hormone called erythropoietin – the infamous EPO of professional cycling – which boosts red blood cell formation in the bone marrow. This, together with high-dose iron, vitamin B12 and folic acid, would help her make up her haemoglobin levels in the days and weeks after surgery, when I expected her to be severely anaemic. Tomorrow I would also give her an agent called aprotinin, which I had personally, albeit inadvertently, found to assist blood clotting in patients on cardiopulmonary bypass. Another landmark advance for the specialty.
The Knife's Edge Page 11