Halfway through the first coronary bypass that morning, Tony the anaesthetist leaned over the screen and whispered something to me. I was concentrating on sewing a vein to a tiny but critical coronary artery and didn’t hear, so I asked him to repeat what he’d just said. This time the whole operating theatre heard.
‘We’ve just had a call to say your wife is having contractions and there is no one who can drive her to the hospital.’
My reply – ‘Can’t she still drive herself?’ – was insensitive, to say the least.
In unison the nursing staff groaned. Nul points for that suggestion.
I touted the next option – ‘Tell her to call for a taxi.’ What else could I say? I was operating on someone’s heart, with another hugely difficult case in waiting.
As it was, Sarah called her midwife, who went to the house, stuck in a fist and said, ‘You’re not dilating yet. Better to stay here for now. The hospital will only send you home.’
It might sound like callous disregard for me to have carried on operating all day, but there was no one else to take over. What’s more, I considered childbirth to be a natural physiological event, not something to go ‘gaga-gooey’ about, then turn it into some sort of cataclysmic phenomenon, as normal people do. When I’d been a medical student I had delivered my allocated two dozen babies at Neasden Maternity Hospital in north London, although I found the repair of ragged perineal tears more compelling than catching the greasy neonate before it slipped out onto the floor. Having said that, I was always very sympathetic to the mothers. I wouldn’t want to push a melon out of my arse, let alone a whole baby. But however much fussing and fawning I might have done for Sarah, it wouldn’t have made the following few hours any more comfortable for her, so I was better employed plumbing hearts.
That’s what I tried to persuade myself, at least. But it wasn’t the whole story, and I think Sarah knew the truth of the matter – that I wasn’t there with my first wife Jane when Gemma was born. My own dear mother was around to help, but I was miles away and my conscience was considerably troubled about that. So this was a difficult time for me, although Sarah was such a bloody saint that she was mentally adjusted to go it alone. Gradually she was chipping away at my neuroses without arguments or conflict, just unwavering support. She realised I had massive professional challenges ahead but was willing me to succeed in Oxford, whatever it took. What’s more, people used to think I must be a good guy for someone that special to have married me.
When I finally got back home in the evening, Sarah’s contractions were becoming more intense and painful. Mark had decided it was time to escape. I prepared a warm bath for her but as she clambered out her waters broke, gushing amniotic fluid all over the bathroom floor. I had absolutely no recollection of those student deliveries yet suspected that breaching of the dam was a good reason to seek help from someone who knew what they were doing. We arrived at the John Radcliffe maternity unit at 10.30 pm and went directly to the prenatal ward. As always, they were busy. Once more they wanted to gauge the degree of cervical dilation before committing Sarah to a bed. Again the lad’s head wasn’t engaged. Delivery would not be any time soon.
To the surprise of the ward sister, my response was stern and to the point. ‘Please take good care of them both. I have two heart operations tomorrow and need to get some sleep. I’ll come back at around 6.30 in the morning.’
Stoical saintly Sarah was fine with that. Maternity sister looked as if she had just pissed her pants. So this was the new heart surgeon everyone was talking about.
The only phone call overnight was from the intensive care unit to bleat that they were worried about Megan. She was febrile, her blood pressure was bumping along the bottom at around 90/60 and there was precious little urine in the bag.
I was a bit direct with the duty registrar, along the lines of, ‘The cell saver arrives tomorrow. If you want to operate on her without it, get the fuck on with it. Otherwise get your own consultant to come in and help.’
Working single-handed, on call every night and every weekend for months on end, is wearing. I was perpetually exhausted and sleep deprived. Not that anyone could give a shit, except my wife. I felt desperately sorry for her now. She deserved much better. In fact she’d had much better, until I screwed things up for her. I picked up the phone again and called the prenatal unit to ask about her. Essentially no change; the pain was rumbling on. That’s the way it is in obstetrics. Pain is the price women pay.
27 January 1988, 6 am. It was going to be a difficult day. I was with Sarah early for a few minutes’ commiseration, then hurried to intensive care at 7 o’clock with the intention of being pleasant to the young doctor I’d abused on the phone. Sarah had been pale and drawn after a night in agony. Would I have let one of my own patients suffer like that? Absolutely not. I resolved to ring her obstetrician before I began operating and tell him I wanted to see my son between cases. My cases, that is, not his. I didn’t want to embark on a complex reoperation on a septic young woman while I was worrying about my own wife and child. But in the end I didn’t make the call. It would have been stupid to antagonise those who were caring for her when I was so bloody useless myself. I was the passive partner in all this, not occupying my usual role of dishing out orders.
My first patient that morning had an aortic valve replacement and was safely back in intensive care by 11 am. But where the hell was the cell saver? Instead of returning to maternity to check on Sarah, I needed to make sure that everyone knew what to expect during the battle that would be Megan’s operation. It was too late now for Ted to learn how to put the cell saver together, so the company representative would have to stay with us in theatre and set it all up himself. Tony needed to get on and infuse the aprotinin before I ran the saw up Megan’s chest.
This was all new for Theatre 5. It all felt like we were on stage at the first night of a West End play for which we hadn’t done any rehearsals, with the lead actor wanted in another part of the hospital to play a crucial supporting role. The curtain was about to go up for his leading lady, but the cad was nowhere to be seen.
I expect that was how Sarah’s obstetrician and midwives must have felt about it. They were used to sycophantic, fawning husbands who sat clinging to their wives’ hands and rubbing their backs, very different from my own birth in 1948 when the father of the blue baby in the next cot couldn’t even get an hour away from the steelworks.
We had chosen Sarah’s obstetrician because I had operated with him on a pregnant endocarditis case in which we’d performed a caesarean section then an aortic valve reoperation at the same sitting. Mother and baby both survived, but I knew of similar cases with 200 per cent mortality. I was sure he would take good care of Sarah when the time came, although I was now scrubbing up for another long operation without knowing when that would be. Secretly I hoped that the delivery would be over for Sarah by the time I emerged.
Across in the maternity suite the prolonged and painful birth process that I had hoped would be physiological was gradually evolving into pathological. Sarah was now physically and psychologically exhausted. As understanding as she had been of my personal demons, she was now justifiably pissed off that I wasn’t around when she needed me, although the fact remained that I wouldn’t have been any bloody good had I been there. Temperamentally I am not someone who can wait for things to happen and allow someone else to be in charge. Surgeons are not built that way, and being irritated and aggressive with the staff wouldn’t have helped either one of us. The ‘C’ word had been discussed, but Sarah still wanted to avoid that if at all possible. Yet after twenty hours in labour my boy’s head still wasn’t engaged. He was having second thoughts about leaving his warm cocoon and the reassurance of his mother’s heartbeat.
Back in Theatre 5, Megan’s situation was so precarious that she was anaesthetised on the operating table, with her mother trying to keep her calm. Because of her Down’s syndrome she unders
tood little of her plight, and was terrified by the glaring lights and the cold, clinical surroundings. Her anaesthetist Mike Sinclair, with Asterix the Gaul tattooed on his arm, appreciated that a needle hovering above her might well precipitate a panic attack. So he was talking to her kindly while wafting sleepy gas over her face through a rubber mask. This was nothing to do with pity or indeed compassion. It was simply smart and engaged anaesthetics. Had the girl thrown a fit and rolled off the table, she might well have suffered a cardiac arrest and died.
I never allowed myself to empathise with someone I was about to operate on. Empathy means sharing the patient’s emotions or distress and is a huge mistake for a cardiac surgeon. I never dared to imagine how it would be to lie on cold, black vinyl waiting for my blood to be drained into a machine by some psychopath. To carve open someone’s chest I needed calm and clinical objectivity. Bugger empathy. Imagine being an empathetic psychiatrist or children’s cancer doctor. You wouldn’t last the week without suffering a breakdown.
At that moment my concern for Sarah caused me to stop scrubbing and walk to the phone in the anaesthetic room. I felt huge pangs of guilt that I was applying the same cold objectivity to my own wife. I had reverted to where I was when Gemma was born, and probably because of those very circumstances. Clearly I still hadn’t shaken off my post-traumatic psychopathy. On the flip side, had my boldness abated I might have taken the sensible decision and refused to operate on Megan without blood, confronting her adopted parents with a court order and making their lives miserable. We still could give blood against their wishes, which would see them excommunicated from their church. So counterintuitively, my disinhibited approach was an act of kindness for these people. But where was I when Sister Beautiful and my own child needed me? In the fucking operating theatre, as usual.
The maternity unit phone kept ringing, but nobody answered. I tried to call Sarah’s mobile, then the nurses’ station – no one wanted to talk to me. Mike shouted to let me know that Megan’s blood pressure was dropping, so I was obliged to get cracking on a taxing operation that could easily last six hours. It required my utmost concentration, with every millilitre of spilled blood having to be scavenged and returned to the circuit. I needed to set aside all thoughts of the maternity unit and my own anxieties for that entire time.
I heard the phone ring in the anaesthetic room about forty-five minutes into the case, when we’d already gone onto the bypass machine. A nurse soon appeared in theatre to announce that the obstetrician needed to talk with me, so I asked her to find out what he wanted while keeping my gaze fixed on the heart as it emptied out then flopped about in a meaningless way.
‘He won’t say. It’s confidential,’ came the reply, as a wave of anxiety rippled through me.
I asked Mike to ring back and see what he wanted, hoping that the obstetrician would pass on the message through a fellow consultant. Again no one answered from maternity. Mike, who had an anaesthetic senior registrar with him, said he would go across himself to find out what was happening.
‘Typical cardiac surgeon,’ my scrub nurse whispered. ‘Sends an anaesthetist to sort out his wife’s delivery.’
It would have been like an Ealing comedy had it not been so bloody worrying.
I was sewing in the artificial mitral valve when Ted chipped in. ‘Steve, we seem to be getting low on volume. Have you lost any blood?’
To my knowledge we hadn’t, but I asked our guest cell saver expert to put back what we had scavenged into the heart–lung machine. Ted said that this wasn’t making much difference and asked me to check the pleural cavities, the space around the lungs, which are not ventilated during cardiopulmonary bypass. Sure enough, Ted was right. Around a litre of fluid had collected on the left side via a hole in the pericardium behind the heart. When we sucked that back into the circuit, things improved.
Fifteen minutes later, Mike returned.
‘What news, Mike? Did you see Sarah?’ I asked tentatively, not sure what to say.
‘Yes, she’s OK but very pissed off with you. She needs a caesarean, but they don’t want to go ahead without discussing it. They’re fucking scared of you.’
Our cell saver man was intrigued but bewildered by the situation. He was bold enough to suggest that I might invite a colleague to finish the operation, then even more confused to hear that I had no colleagues. The band had to keep playing even if the ship was sinking, and I was already sewing as fast as I could. Eventually Megan crept off bypass, with a shedload of vasoconstrictor drugs to combat the sepsis. But she still needed clear fluid transfusion to keep her blood pressure up, and I had to stem bleeding from the heart and wound edges before I could think about leaving.
It was 6 pm before we were ready to close Megan’s chest, but her blood pressure was sagging and her plasma haemoglobin level was now critically low, so much so that I made the decision to risk lowering her body temperature with a cooling blanket to reduce tissue oxygen consumption. Red blood cells are needed to carry oxygen to the tissues, but dropping the temperature from 37°C down to 32°C would decrease oxygen consumption almost by half, around 7 per cent for each degree of cooling. The lower the temperature, however, the greater the risk of lethal heart rhythm problems. I still didn’t want to ruin Megan’s parents’ lives by giving her blood, nor was I prepared to let her die on what I expected would be my son’s birthday.
I was arranging the cooling blanket when we had another call from maternity, this time with greater urgency. They wanted me across there directly, but until Megan was safely ensconced in intensive care I was morally obliged to stay with her. My registrar Neil Moat, who would become a distinguished heart surgeon at the Brompton, went over with the message for them to get on with whatever they needed to do and that the boss would be there as soon as possible. In other words, ‘You do the obstetrics, he’ll do the cardiac surgery.’
At 6.30 I called Megan’s parents in the relatives’ room to say that the operation was over and we had not given her any blood. I told them that the recovery period would be long and difficult, and that we could not guarantee her survival. Should they reconsider the blood issue at any stage, I encouraged them to let us know, although I appreciated that this would be impossible, even with Megan at death’s door. Now I had to see Sarah. She’d been in labour for twenty-six hours without me, so I wasn’t expecting a warm welcome. I met Neil on his way back. He told me that Sarah was already on her way for the caesarean and urged me to go to her, leaving Megan to him.
Wearing blood-stained theatre gear, I arrived in the labour ward still secretly hoping that the job was done. The nursing sister darted from one noisy cubicle to another, doing her best to ignore me. I guess I deserved that, but it was not what I needed after a difficult day. When I was agitated enough to ask where the obstetrics theatre was, I received an ear bashing.
‘Do you think your poor wife has had an easier day? She went to theatre half an hour ago. Perhaps you might like to join her.’
I dug the hole ever deeper by suggesting that Sarah would already be asleep, and I should wait to see mother and baby in the recovery room. Wrong. After many hours of pain and suffering, she had insisted on staying awake to see him arrive – no general anaesthetic, an epidural catheter instead. And because of that, she had requested that I join her if I could find the time.
The anaesthetic room was empty, but I noticed the remnants of drug vials, drips and catheters that had already been shoved into my wife. I shuffled past her discarded slippers on the trolley and peered through the crack in the theatre doors. It was the same team that I had worked with on the combined caesarean section and valve replacement, including the affable rugby-playing neonatologist Peter Hope, whose giant hands regularly performed miracles for diminutive premature babies. The empty swab rack and rattling of instruments told me that they hadn’t started yet. As Sarah’s anaesthetist turned to hang a bag of dextrose on the drip pole, I could see her black curls turning to
follow his movements. They seemed to be chatting calmly as the overhead lights were adjusted to shine on the bump that would soon be my delivered son. This had got to be the time to go in, but there was one thing to do first – leave my phone in one of Sarah’s slippers. Being called out of this operation was simply not an option.
At least my appearance was well received this time. As the door creaked open there was a collective chorus of ‘He’s here at last.’ This was undoubtedly the sole occasion to date that I had entered an operating theatre without my usual swaggering confidence. Exuding self-assurance was the obstetrician’s role here, but what really struck me was the air of calm that emanated from Sarah herself. Her pain had gone now and she could feel nothing below her breasts. Just as well, since they were painting her naked body with cold iodine solution from nipples to knees.
I watched as the sponge swirled over her breasts, around the smooth contours of her protuberant belly, then deep into the crevices of her groin. Soon light blue linen covered her chest, flanks and pubic hair before a sticky plastic sheet sealed the drapes against her body. The surgeon gave her a muted indication that the preparations were ending with ‘We are going to get started now Steve is here.’ Was that comment intended to camouflage the fact that they had waited too bloody long? Or was that just my paranoia? At this point I squeezed Sarah’s hand, kissed her forehead, then fixed my gaze on the one and only operation that I ever found emotional. Empathy had arrived at last.
The liability insurance premiums for obstetrics are higher than for all other specialties, and it was always obvious to me why this was the case. Obstetricians are very direct in their approach, their knife slicing directly through skin, fat and abdominal muscle to the base of the dilated uterus, with little regard for bleeding. Late in pregnancy, blood volume is expanded, so, unlike my Jehovah’s Witness adventure, a little bleeding is neither here nor there.
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