So returning to the question as to whether I would train in cardiac surgery in the current era, sadly the answer is no. I would do a ‘Charles Bailey’ and study law just as my daughter did. But would I do it again with my old expansive practice in a well-equipped centre, within an environment where safety mattered more than money? You bet. I gained inordinate pleasure from helping frightened patients and their families through the most uncertain episode of their lives, as well as enormous satisfaction simply from the technical aspects of repairing a failing heart and watching a person walk out of the hospital into a new life. Fragile lives made better. But we shouldn’t have to jump through hoops for that privilege. There are plenty of other countries where cardiac surgeons are still highly valued.
I was now sixty-eight and waiting for surgery on a deformed right hand where the nurses had smacked heavy metal instruments into my palm. Could I face any more GMC revalidation questionnaires, any more mind-numbing ‘statutory and mandatory’ training? Absolutely not. After almost forty years in heart surgery, I knew it was time to move on. So I simply walked out of the hospital one Friday evening and never went back. No Festschrift, no card, no present. But also no regrets – and a huge sense of relief. I had new plans and ambitions. I was already a professor at the University of Swansea, where our bioengineers were working on the new miniature artificial heart, and now a professor at the Royal Brompton, where we were about to undertake a clinical trial with those magic genetically engineered stem cells that removed scar from the left ventricle after a heart attack.
12
fear
That calamity on the Cornish rugby pitch might have shaped my destiny, but it also left me prone to intrusive flashbacks. These spontaneous visual spectacles would invade my thoughts seemingly at random, without any conscious attempt to draw them from memory. It took me a while to realise that there were triggers for the hallucinations. The odour of a particular disinfectant might take me back to the Harlem trauma room where I was stabbed by a drug addict or to the rural Chinese hospital after the Cultural Revolution where I had joined the barefoot doctors to save children dying from dysentery. Just a whiff of burned toast could retrieve gruesome images of the sternal saw tearing through bone into the right ventricle. In the midst of a flashback I was unable to distinguish fantasy from reality. So I always kept them to myself, and once they passed they really didn’t trouble me, just like the prodromal flashing lights of my migraine headaches.
My training in the United States coincided with the finale of the Vietnam War. In Alabama I met several veterans who suffered repeated flashbacks of death and destruction that caused them anxiety and insomnia, ultimately leading to depression or crime. It was a problem also seen in rape victims and Holocaust survivors. In 1980 the American Psychiatric Association named this syndrome ‘post-traumatic stress disorder’. Since then, sophisticated brain-imaging techniques have shown that deeply traumatic events interfere with the normal mechanisms by which memories are stored. Moreover, my Phineas Gage phenomenon undoubtedly had an interface with these neural pathways.
The hippocampus is the brain’s depository for day-to day-memories that are amenable to conscious recall. In turn, the pea-sized amygdala selects out emotional memories of the fear-generating type. Some consider that the amygdala evolved specifically to promote survival through encoding danger. Thus, an individual will rapidly recognise a significant threat if encountered again. Preferentially, the two centres cooperate to encode all experience in long-term memory, but an adrenaline-fuelled fight-or-flight reaction will overstimulate the amygdala while supressing the hippocampus. The creation of cohesive memory is then deprioritised to favour reflex response to danger.
In threatening circumstances that recall a traumatic event, the amygdala spews the memory back into the conscious brain in an unregulated manner. This is why flashbacks automatically activate the sympathetic nervous system, causing rapid heart rate, sweating and heavy breathing in addition to the fear. Because the hippocampus wasn’t keyed in properly to the original trauma, the contextual element of the memory wasn’t stored, so no feedback exists to convince the amygdala that the danger no longer exists. Straightforward neuropsychology – or is it?
It’s easy to understand how my own head trauma that disrupted my ability to register fear, was linked to my propensity for flashbacks and, wholly positively, gave me the courage to be different. I was never concerned about departing from protocol or trying something new, nor was I perturbed by risk. As I’ve said before, it wasn’t me on the operating table. In retrospect, however, I would certainly have avoided some of the inordinately difficult cases had I not been disinhibited at the time. It was the same in my personal life. I consistently drove stupidly fast and on occasion performed reckless deeds to help others in dire circumstances. Sometimes the recklessness was construed as bravery, but it was nothing of the sort – I simply didn’t appreciate danger as others might.
Over the years my psyche gradually reverted to normal, whatever normal is. As apprehension and common sense intervened, my professional life became progressively more uncomfortable, not just psychologically but physically too. In recent years my testosterone-fuelled existence predisposed me to prostatic hypertrophy and miserable urinary symptoms – urgency, poor stream, dribbling, the inability to stand through a whole operation and the need to get up several times each night. Eventually I developed such a fear of urinary retention, fuelled by my own grim endeavours to relieve that problem for others while a urology registrar in Cambridge, that I always travelled abroad with a urinary catheter in my hand luggage.
Eventually aging mind and disintegrating body came together when I experienced anxiety and desperation during a difficult operation, and it was all I could do not to piss my pants. I was attempting to repair a huge aortic arch aneurysm that involved the main blood vessels to the brain, an operation that other surgeons were keen to avoid. Worse still, the patient was a well-known professor at the university whom I knew quite well. Whether I liked it or not, this personal bond carried a particular responsibility. It was another case, involving stopping the circulation, draining out his blood and replacing the aortic arch against the clock. What’s more, this was not a cerebral cortex I could risk damaging …
Forty minutes is the safe duration for circulatory arrest, because at 18°C the brain’s metabolism and oxygen consumption is lowered to 20 per cent of normal. Any longer without blood flow risks brain damage, which worsens by the minute. Unusually I had no reservations whatsoever about that, as I was a plumber who specialised in large aneurysms and had always regarded surgery as an emotionless, technical exercise, comparable to lifting the bonnet of an automobile and repairing the engine. Done skilfully in a reasonable time frame, the patient will survive and prosper. Take too long or bugger it up, then that great hospital in the sky beckons.
I had the aorta wide open and was staring up the two horribly diseased carotid arteries that passed directly into the professor’s distinguished cranium. Both resembled water pipes clogged with limescale. Atheromatous plaques throughout the aortic arch disintegrated on touch, oozing liquid fat like pus. And I was meant to sew a pristine polyester graft to this stuff, then re-implant those crappy carotid vessels, when the slightest speck of debris that detached itself and ended up in the brain could cause a devastating stroke. As I started sewing the diseased arteries they began to disintegrate. I remember thinking, ‘Bugger, will I get this together in time? Yes, I’ll get it sorted, but then again it’s possible I won’t. Shit. Maybe today, just when the whole of Oxford is watching, it will all fall to bits.’ And, of course, it did.
I completed the three suture lines, proximal and distal on the aorta, together with separate implantation of the head vessels. Then I asked the perfusionist to pump a few hundred millilitres of blood from his machine to displace air from the graft, while I hummed ‘Air in the brain, life down the drain.’ At low pressure the repair seemed watertight, but when we rea
ched full flow the distal anastomosis gave way in the back of the chest and blood hosed out into the suckers.
‘So who’s the sucker now?’ I thought. At that point it seemed like my own blood had drained from me. Streams of sweat ran down my back and I felt cold, as if my adrenal glands had been wiped out. It had already taken me thirty-five minutes of circulatory arrest to replace the whole arch, so I was really up against it. With no alternative other than to stop the pump, drain the blood again and re-sew the dehisced suture line, it would be a struggle to keep his brain alive.
This time I used a larger needle with deeper bites and a thick strip of Teflon felt to buttress tissues that possessed all the tensile strength of Stilton. The process took another fifteen minutes of intense concentration, interspersed with bad-tempered exchanges with fearful assistants who were only trying to be helpful, ‘trying’ being the operative word.
Because the circulatory arrest time was beyond the edge of tolerance, the de-airing was perfunctory and he was quickly put back onto cardiopulmonary bypass with a view to rewarming. For another couple of minutes the stitch lines stayed dry, his brain gratefully extracted some oxygen and my mood lifted. Then blood suddenly began to squirt like a fountain from where the head arteries had been re-implanted into the graft. I tried to insert a few extra buttressed stitches while still on the bypass machine, but the needle tore the tissues again and made things worse. Just when ‘Mr Unflappable’ needed an uncomplicated home run, I began to despair.
The spectre of this famous Oxford scientist reduced to a vegetable or terminated by his overconfident surgeon loomed large, and I could anticipate how it would be described in the obituary columns. I thought about what Sarah taught her nurses to do when they were emotionally extended in the accident department – ‘Take slow, deep breaths.’ Deep breathing stimulates the parasympathetic nervous system, the stress-mitigating opposite of the adrenaline-fuelled panic reaction and the basis for mindfulness. She would say, ‘Feel your body. Jettison the turmoil your empathy leaves you vulnerable to. Feel your feet on the floor and wiggle your toes. That helps you out of your patient’s shoes and back into your own.’ A wise woman.
I succeeded in entering that mental tunnel, forcing everything out of my mind but the sheer practicality of sewing rapidly, as if I were stitching a cardboard toilet roll or a tear in my pants. The anaesthetist was agitated, the perfusionist was counting the minutes out loud and the assistants had all turned to jelly. But between us we succeeded in keeping it together and completing the operation. The man’s entire nervous system had experienced sixty-five minutes without blood flow and I fully expected a dismal outcome. Beyond the cerebral hypoxia, the risk of stroke from air embolism or detached chunks of atheroma was huge. What was I going I tell his poor wife? That was a conversation to avoid until the next case was finished. I had suffered enough emotional contagion for one day, whatever that means.
I did what I was now compelled to do after separating from the bypass machine – I took a step backwards, tossed away my bloodied gloves and nodded to the registrar to close up. Pretending to head for coffee, I made directly for the surgeons’ changing room to discharge my aching irritable bladder. Then horror of horrors. Out dribbled bright red wine, followed by frank blood. ‘Oh shit!’ was my immediate thought. ‘I’ve got the Big C.’ I suspected that a stress-related surge in blood pressure had caused either a prostate or bladder tumour to bleed. With an aortic valve replacement still to do, my volatile mood descended into my boots – sheer panic would be a more realistic description.
Type A personalities seek rapid resolution to any worrying issue. Tedious symptoms from benign prostatic enlargement were one thing; bleeding cancer was quite another, ratcheting my anxiety up a considerable number of gears. If feasible, I needed to dispel this worry before the next case. Most people would have to wait a week to see their GP, then months for an appointment with a urologist. I simply dialled the mobile number of my close colleague David Cranston. We operated together on kidney tumours that had spread up the veins and into the heart. I would put the patient on the bypass machine, then drain the circulation just as I had done that morning. David would dissect out and remove the cancer from the inferior vena cava, then I would repair it with a tube or patch. Operating on large blood vessels is simpler when they are empty. And for me, my next operation would be much more relaxed without blood dripping out of my penis. But what were the chances of finding David on this first frantic call?
He answered on the third ring tone.
‘What are you doing right now, Dave?’
‘An outpatient cystoscopy list.’
‘Perfect,’ I said, and I meant it, as cystoscopy is the examination of the prostate and bladder through a fibre optic telescope. ‘Can you fit me in if I come straight across?’
The urology department is located in Oxford’s Churchill Hospital, a short drive across town. I went out to the car park wearing theatre blues and in ten minutes pulled into the No Parking area at the Churchill main entrance. Just another five minutes and I was reclining on the examination couch with my legs in the air, my backside on display and a thick black pipe up my urethra. Uncomfortable, but ultimately satisfying. There was no sign of a bleeding tumour, just dilated veins on the inner surface of the prostate gland that had ruptured and clotted off. Once I’d been given the all clear, the removal of that pipe from my penis was one of life’s great pleasures. I was back in my own operating theatre in less than ten minutes, with the next patient still awake in the anaesthetic room. Everyone thought that I had just popped out to my office.
Once it showed up, I found fear to be a miserably oppressive experience that I could well do without. Had every complex operation provoked these unpleasant responses I would have ditched the specialty much sooner, preferring to operate on bones or guts. Or better still, trained as a barrister and used penetrating words rather than sharp instruments. I wondered precisely what had triggered this emotional rollercoaster while operating on my professor friend. Was it just a rational response to the likelihood of losing a patient, a reaction that I had missed out on thus far? Did surgeons who lacked the benefit of my curiously rewired brain suffer regularly in such circumstances? Or was consideration for my friend something to do with it? Empathy is something I experience perpetually for my own close family, but it would be fucking madness and wholly counterproductive for surgeons to feel the same for every sick patient.
Clearly, the more empathetic we are, the more likely we are to be miserable ourselves. Sarah worked at the sharp end and referred to it as ‘compassion fatigue’. It is the fast track to burnout – and I knew several surgeons with burnout. They ended up apathetic, depersonalised, exhausted and withdrawn, ground down by their working environment. I had always been resistant to all that, but today I saw how it could happen. I was on the verge of destroying my patient’s brain when everyone was expecting me to cure him. But what was the panic really about? His potential demise or the straightforward risk to my own reputation?
I wasn’t expecting the professor to regain consciousness that evening, but he did. I was still in my office when the night registrar bounced in to let me know. It cheered me up immensely, so I set off for intensive care to welcome him back to the land of the living. Waking up doesn’t equate to intact intellect, but it’s an important start. Might it be that the intermittent short bursts of brain reperfusion delivered sufficient oxygen to keep him safe, or did they just do enough to keep his brain stem alive? After all, he might still be a vegetable. These were my thoughts on the way there, but by the time I reached the bedside he was off the ventilator, tracheal tube out, and was talking to his wife. They registered my approach with unbridled, albeit undeserved, elation.
‘Thank you, thank you, thank you. What a wonderful man,’ was their greeting. But my steely eyes locked on to the blood pressure trace. The abrupt stimulus of waking had released a shedload of adrenaline, so the blood pressure was now far too hig
h for a tenuous aorta. I could visualise the stitches cutting through like cheese wire, then unmitigated disaster as he deposited his whole blood volume into his chest. Sometimes I wished I had been a dermatologist. My gaze switched from the screen to the chest drains, as I politely asked the nurse what was being done to counter the lethal blood pressure.
I should have been greeting his grateful wife, lying to her about how well the operation had gone and taking the credit. But with a pressure of 180/110 mm Hg and possible exsanguination, I was verging on a hissy fit, a heart attack even. But if I said something offensive to those not looking after him I would be reported to the medical director for abusive behaviour. So again, I opted for mindfulness – ‘Breathe deeply and feel calmer. Feel your body, then your feet on the floor.’ Then I blasted the anaesthetic registrar for trying to kill my patient. Rather that than scream at the clueless agency nurse who remained oblivious as to what my issues were.
When I left, the professor’s blood pressure spontaneously drifted down – the ‘white-coat syndrome’, not that I ever wore a white coat. When the patient sees a doctor coming, their blood pressure rises in response. Every time I went to the GP myself my blood pressure was too high, but when operating it used to be normal. I had been happy and relaxed plumbing hearts, at least until then.
I was sixty-eight when the contracture in my right hand curtailed my surgical career. The forty years of repeated slapping of metal instruments into my palm was the cause, and eventually I couldn’t grasp them. I knew it would take months to recover from plastic surgery and return to work, but in all honesty I was bored with it all. I could no longer operate on patients with congenital heart disease and was unable to pursue my artificial heart and stem cell research in Oxford. I remained perfectly able to relieve suffering and extend lives, yet was actively prevented from doing so. While wondering about the morality of all that, I decided to move on. I could benefit more patients by dedicating time to these projects than by standing in an operating theatre for just a couple of days each week. But working with universities in other cities involved a fair amount of travel, and those wretched urological symptoms were catching up on me.
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