The Knife's Edge

by Stephen Westaby

  The blade kept on slicing within millimetres of my son’s eyes and brain. After a skilfully judged, full-thickness incision through the uterine wall, in went the index and middle fingers of both hands to stretch the hole wide open. Digits are safer than cold steel around the baby’s head. From knife to skin it took less than two minutes to deliver Mark’s huge head. Although he looked very pissed off to be manhandled in this way, it should have been a relief to him not to have his head squeezed out through the claustrophobic pelvis by powerful contractions. As his torso emerged, the slimy umbilical cord spewed out from around the lad’s neck and delivered itself.

  All the while Sarah had been remarkably peaceful about the process. She squeezed my sweaty palm from time to time as if to reassure me, then, as the lad finally slithered from his nest, she said that it felt like a washing machine churning away in her belly. For a while our greasy blue bundle seemed lifeless. Newborn babies with airless lungs always appear slate grey, but I didn’t recall that. All I remembered from our caesarean section just weeks earlier was that the slippery premature infant was almost dropped onto the floor as the umbilical cord was divided. Right now the placenta was the key to my anxiety. While still connected in the uterus, the baby doesn’t need to breathe. Oxygen continues to be supplied to it, and blue blood returning to the heart is still diverted away from the unaerated lungs and back around the body. Blue had me worried, but it didn’t trouble the special care team.

  Once the umbilical cord was severed, Peter took our son to an incubator and sucked out his throat. Then we could hear him trying to breathe at last. There followed a howl as he inflated his lungs for the first time from their airless state. To me he still looked blue – I was clearly paranoid about blue babies – but Peter reminded me it was all to do with foetal haemoglobin molecules. A few more breaths and the colour improved. While the placenta was being scraped out and the uterus repaired, Peter handed Sarah her warm and now pink baby boy, and she burst into tears. Stupidly I needed to ask why she was crying and received an obviously feminine response – ‘Because I’m so happy.’ Twenty-six sleepless hours of painful labour were dispelled in an instant by the miracle of childbirth.

  And what were her next words? ‘Is your patient OK? Shouldn’t you go and check?’

  Sarah’s wholly unselfish remark affected me deeply. This was the real reason St Thomas’ had christened her Sister Beautiful – her beautiful selfless mind. So what on earth was she doing married to me, the Phineas Gage of cardiac surgery? That night I parked my demons and allowed myself some joy. The day had brought back empathy, something that usually caused me pain. The struggle to save poor Megan and preserve the dignity of her parents, then arriving in time to see my son born – it had all been an emotional rollercoaster. As Steinbeck wrote, ‘It means very little to know that a million Chinese are starving unless you know one Chinese who is starving.’

  I sat with Sarah for an hour in the recovery area, wrestling with my conscience about not having been there for Gemma’s birth. I would spend a lifetime trying to make up for that. Then I thought about what Megan’s parents must be going through, knowing that if she didn’t survive it would be down to them. Whether it was through sympathy or compassion, I decided to relieve Neil Moat and spend some time talking with them on what must have been the worst day of their lives.

  My baby was safe now. Theirs was lying under a cooling blanket now at 30°C, fighting for her life, with her brain’s metabolic rate reduced by half to tide her over the profound anaemia. But I could see that we were winning. There was no bleeding, and her modest blood pressure was sufficient for the kidneys to produce urine – liquid gold, as we called it when the chips were down. Her grateful parents said God would reward me for this day’s work. I said that he already had. I was blessed with a fine baby boy who had arrived at the end of Megan’s operation. They interpreted this as divine intervention. Dr Gribben had already heard about the day’s events and called into intensive care on his way home. Joy spread around the hospital that night, as my team were pleased for me too. Yet I was sad at the same time. And a bit lonely with my demons that night.

  In the aftermath of Megan’s miraculous recovery, the Jehovah’s Witness Hospital Liaison Committee held a fund-raising campaign to acquire a cell saver machine for me. In turn I operated on their members from all over the country, combining the anti-bleeding agent aprotinin with the equipment they kindly donated. On one notable occasion a Jehovah’s Witness with a leaking thoracic aortic aneurysm survived after being driven all the way from Wales by his wife when he was refused surgery elsewhere.

  Sarah and Mark came home three days after the birth, and I became even more sleep deprived than usual. Brian Gribben became Mark’s godfather. The kindly neonatologist Peter Hope sadly died from cancer just a couple of years afterwards. Between us we had established a service for tiny premature babies in which I would open their chest and close a persistent ductus arteriosus – a common defect between the pulmonary artery and aorta – without taking them out from their incubator. This removed the risks of transfer from the maternity block to the main operating theatres, during which they lost heat. Mike Sinclair and I would travel to other regional premature baby units to provide the same service, but Mike eventually had to retire. A real character, he still has a great sense of humour and remains well.

  Two years after her reoperation in Oxford, Megan’s artificial mitral valve became infected. I was abroad when the family tried to contact me, and her closest cardiac centre was unwilling to attempt a third procedure without blood transfusion. She died from sepsis.

  That cold winter’s day in 1988 helped change my perspective on life and probably made me a better surgeon – not technically, needless to say, but as a result of becoming a much better human being. Love brings joy, yet until then I had been afraid to admit it.

  7

  danger

  Many infectious diseases are transmissible through skin penetration, so wallowing in blood while handling sharp instruments is not without its dangers. Needle-stick injuries were a daily occurrence for me, but surprisingly enough, patients in most countries are not tested for blood-borne viruses before surgery. As a result, hospital staff are continuously exposed to risk through unsuspected contamination, a danger that is easily passed on to our families. On the flip side, irresponsible surgeons who are fully aware that they have hepatitis have infected hundreds of patients by failing to disclose the risk. Dangerous place, the operating theatre.

  The No. 11 scalpel blade is sharply pointed. I used it at the end of every case to make those stab wounds through the body wall where the chest drains emerge. In the cardiac theatres in Oxford we had a polite and gentle Filipino staff nurse named Ayrin, who assisted me in my friend Steve Norton’s case. As we finished an emergency case late one evening Ayrin was distracted by her runner nurse, who wanted to get the swab count done and make for home. She inadvertently thrust the blade end of the scalpel into my palm instead of the handle. As I reflexively grasped it, the glistening metal sliced through my rubber glove, breached my skin and painfully embedded itself in the muscle of my thumb. Bright red blood pissed out under the latex, forming a crablike pattern as it oozed through the tunnels of the rubber fingers. I squealed in shock and dropped the bloody implement, which fell to the floor like a dart and impaled itself bolt upright in the leather of my operating clog. After that I renamed her ‘stab nurse Ayrin’.

  Apart from my pain and the hilarity it provided for the rest of the team, this charade was no big deal. It was a clean blade, so I could not be contaminated with any blood-borne virus. Nothing was said nor done about the incident, except I was forced to leave the operating table and seek first aid. As I backed away, I thanked the mortified stab nurse for her help with the case. With time, a great deal of experience and progressively improving spoken English, ‘stab nurse Ayrin’ became sister in charge of the cardiac operating theatres.

  For most operations
I would work with two surgical assistants and a scrub nurse who slapped the instruments into my palm in an automated fashion that involved little forethought or deliberation. They knew all the steps of the operation as well as I did. I just presented my palm upwards and reflexively grasped whatever was thrust into it. My gaze was never diverted from the heart, unless to give an order. The surgeon conducts the whole team like an orchestra – ‘Give the heparin, go on bypass, get the pressure down, come off bypass, give the protamine’ – and the process benefits enormously from the finely honed skills of a consistent team.

  We made every effort to look after each other, but the varied assortment of sharp instruments posed a constant threat. Used blades and needles are contaminated with the patient’s blood, and we had little idea about the personal history of the vast majority. The stainless-steel needles are curved, usually presented on the end of a long metal needle holder and very sharp. They easily prick through thin rubber gloves, and at least twenty-five different blood-borne viruses are known to be transmissible. After operating for more than forty years covered with other people’s fluids and enduring innumerable occasions when needles or blades drew blood, I generally regarded myself as immune to everything. Others were not as fortunate.

  All operating theatre staff are immunised against hepatitis B, but some – like me – are non-converters who never develop the protective antibodies. In the early 1970s, when I worked in the famous Liver Unit at King’s College Hospital, I was constantly exposed to hepatitis patients and their bodily fluids. Patients with cirrhosis of the liver develop varicose veins in their gullet called oesophageal varices. My brother David was a consultant in the Liver Unit and became a great expert at injecting these veins with sclerosing agents, and as a junior doctor I was called upon to stop the bleeding if they ruptured. When the patient started to vomit litres of hepatitis-contaminated blood, my job was to blindly pass a sausage-shaped balloon down their gullets as far as the stomach, the aim being to inflate it under pressure to compress the bleeding veins before they exsanguinated. Before too long the black digested blood poured out of their backsides and the nurses had to clean it up. Many terrified souls gave up the ghost and died at this point. Others absorbed the blood from their gut and turned bright yellow. More often than not, alcohol had been the problem.

  For needle-stick injuries or blood in our eyes we would receive injections of hepatitis B immunoglobulin to counter the viral load, followed by a booster injection of hepatitis B vaccine. Despite repeated injections, this never seemed to impact on my own antibody levels. Moreover, there was no treatment for hepatitis C. We just had to wait and see whether we developed cirrhosis later in life. If the booze didn’t get us first, that is.

  I was tested for the hepatitis viruses every year to make sure I could not pass them on to my patients. But swimming in blood doesn’t suit everyone. Needle-stick injuries petrified the nurses, and the extended periods of uncertainty caused them and their families hours of fear and anxiety. One German study showed that 80 per cent of the victims of needle-stick experienced high levels of stress about their future, damaging their personal relationships and screwing up their sex lives. Some even developed post-traumatic stress syndrome, which could only be helped by knowing whether the patient involved was a virus carrier or not. Yet testing without the patient’s consent was not allowed. Many who were hepatitis positive through drug addiction or sexual promiscuity were not about to disclose their secrets. Sod the staff who were meant to care for them.

  As the senior registrar at the Hammersmith Hospital in west London, I was always the one designated to operate on the intravenous drug abusers, not least because of my insight from King’s. To be honest, I didn’t even bother to ask permission to test their serology beforehand. I just assumed that they were all hepatitis positive, and told the nurses to expect it and take precautions. In the late 1970s this involved double-gloving and wearing impermeable hoods, gowns and goggles. ‘Pigs in space’ I used to call them, as they looked all set for a moonwalk. But at least they felt safer. I changed nothing, carried on as normal and generally was fine. Ironically the spacemen and women were at greater risk of needle-stick because their dread of exposure led to a nervy departure from protocol. I didn’t even double-glove – it both failed to stop needle-penetration and reduced my tactile sense. It was like a paranoid student wearing two condoms then not enjoying sex, as in the days before my head injury took away fear. Life was much simpler after that.

  Every time I operated on a drug addict with infected heart valves, my usually keen assistants seemed to fade into the woodwork. Some had a migraine, some had doctor’s appointments. Others just said, ‘No way – if you want to do it, just go ahead.’ The consultant surgeons took the view that addicts were not worth the time spent in theatre as they always returned to injecting with reused needles and syringes in dirty public lavatories. With further foul abscesses at their injection sites, they would simply go on to infect their artificial valves within months of the operation. Sadly, this scepticism was justified, although it hardly seemed compassionate. Over the course of my whole career I only operated on one addict who did what he promised and gave up. But unlike my sanctimonious colleagues I didn’t have a God complex. I had no wish to be judgemental.

  Perhaps I lacked objectivity because I had a school friend whose miserable childhood was followed by a descent into the abyss of heroin addiction to escape from it all. The two of us used to go and watch Scunthorpe United, but he was soon dragged under by psychosis and received no help whatsoever – ten minutes with his GP and a prescription for Valium tablets didn’t really cut it for schizophrenia. A couple of hours of heroin-induced euphoria was his way of coping, but eventually it killed him. The last time I saw him he was covered in abscesses and had septicaemia, kidney failure and a heart full of infected crap. They’d just let him go.

  By the time I got these young people into an operating theatre they were always desperately sick, their blood boiling with the bacteria and viruses that could destroy any and sometimes all of their heart valves. Because the right side of the heart received the bacteria from their injected veins, it was often the tricuspid valve that disintegrated first. The infected valve leaflets would be covered in lumps of fibrin, resembling seaweed floating in and out of the right ventricle. We called these lumps ‘vegetations’ – they looked bad, often smelled like a sewer, and bits would break off to produce abscesses in their lungs.

  I had already seen how surgeons in New York’s borough of the Bronx handled this problem. The first time I told Professor Bentall at the Hammersmith that I was determined to take an addict to theatre against his advice, he asked which prosthetic valve I was going to use. He expected me to say a pig valve, but I surprised him. I said that I was just going to remove the crap and not bother to replace it, and that if the addict stayed clean for six months I’d take him back and put a pig valve in then. To my great surprise, the New York addicts normally coped without a tricuspid valve for several months, perhaps because it had not functioned as a valve for a considerable time beforehand. But the Americans hadn’t yet published anything about their success in this arcane field because nobody was interested in drug addicts. As a result, Bentall thought I was crazy when I insisted that so-called valvulectomy was the way forward.

  Certainly, most addicts survived tricuspid valvulectomy, but their cardiac output and exercise tolerance were limited. With free reflux of blood from the right ventricle back into the venous system, the liver would distend, swell and become painful. Should they decide to stop injecting, they eventually earned a brand new valve. If not, they faded away with right heart failure, abdominal pain and repeated episodes of sepsis. I did several tricuspid valvulectomies at the Hammersmith. All were cured of endocarditis, but none quit their heroin habit nor survived long enough to receive their pig valve. In that respect, I saved the NHS a couple of thousand pounds each time and eased my own conscience by taking them on in the first place. I never
put the risks to myself before the needs of the patient, but I remained conscious of the fact that others were frightened for their own safety. The problem was, the more anxious they felt, the more likely they were to screw up.

  Summer 1987. I had exhausted the whole year’s budget for cardiac surgery in Oxford and found myself locked out of my own operating theatre by the management. At the same time, a front-line cardiac centre in Saudi Arabia had a sick heart surgeon and needed a locum. No financial problems there, and they were keen to have me. Unfortunately, my wife Sarah was six months pregnant and moving house. Tricky timing, but I soon found myself under the hot desert sun with a fascinating workload and a great international team.

  Soon after I arrived in Saudi, a ten-year-old boy was admitted to the centre with sepsis. Philippe was the young son of a high-ranking official at one of the European embassies in Riyadh. The lad had been sent to public school in England but repeatedly suffered bruising after trivial injuries, then spontaneous bleeding into his joints. The first suspicion was leukaemia, and everyone was relieved when this was ruled out. The next suspected diagnosis was the autoimmune platelet problem known as idiopathic thrombocytopenic purpura. Sarah had that, which led to her spleen being removed when she was a student nurse in London. Her symptoms were the same as Philippe’s.

  When this diagnosis was dismissed, he was found to be clotting factor VIII deficient – a haemophiliac, whose plasma level was around 5 per cent of what it should have been. Now he was dependent upon regular factor VIII infusions, which he’d started in London. It was there that his doctors recognised a heart murmur, and he was shown to have a small ventricular septal defect. The paediatric cardiologists said that it would probably close itself in time, so surgery wasn’t necessary. That was a relief for the parents because cardiac surgery in haemophiliacs is complicated, or at least it was thought to be back in those days. Without shedloads of factor VIII, they bleed and bleed.