The Knife's Edge

by Stephen Westaby

  My whole career had been focused on repairing the sickest hearts at the highest risk, while avoiding nervous breakdowns about their owners. Sarah had done the same in her A&E departments. For us it was the patients who were important, not ourselves. Neither of us belonged in this modern medical world of introspection, reflection and compassion fatigue. My old friend Dr Cooley had just died in Houston, and I couldn’t help thinking what he would have said about all this touchy-feely stuff. Of course, many would rejoice that the swashbuckling days of the flashing blade were over, maintaining that operations were meant to be boring and routine. What had we done to educate the public about our world when even the British Medical Journal considered a ten-year wait for a heart transplant to be believable?

  That evening, nurse Sarah brought in a bottle of South African merlot to cheer me up. I was drinking red and pissing out rosé, but for the first night in years I wouldn’t have to jump out of bed four or five times to pass water. A chatty night nurse came in with the evening drug round, so I turned off the lights and abandoned the journals for the evening’s television soaps. Five minutes of Casualty had me reaching for the vomit bowl – or perhaps it was the dose of morphine that did that? In truth I wasn’t feeling in any pain whatsoever, but was interested to be on the receiving end of an opioid shot just once in my life. Merlot and morphine on a Saturday night. What could be better than that? Goodnight mundane reality, hello La La Land.

  Whatever delights I hoped to derive were a far cry from what followed. That fiendish amygdala of mine spewed out a series of terrible medical memories into my cerebral cortex, so it was flashback time all over again. The ghosts of the departed popped by to visit their surgeon in hospital – my special patients, those I’d come to know too well, got too close to. A parade of battery-powered phantoms floated across the ceiling with turbines in their chest and electric plugs in their heads. Before this miracle of modern technology they had all been dying from heart failure, swollen with fluid, breathless after the slightest exertion, unable to lie flat or leave the house. They took their chance with me for a new life. They were the pulseless people.

  For some it worked out well, for others it didn’t. The former occupant of my bed appeared with bitterness in her eyes, blood spraying from her ears and nose as she darted across the room screeching that she should never have consented to it. Floating through the window came that nice chap for whom the drill bit went too deep, his skull thinner than we’d anticipated for such a big man. The brain surgeons removed the blood clot compressing his brain but he was too weakened by heart failure to recover. Pneumonia took him, but tonight he thanked me for our efforts. The phantom postman had been recovering at home when he tripped in the kitchen and struck his head. The paramedics found him unresponsive, cold on the floor without a pulse, so they took him to the mortuary. But it was winter and all my turbine-pump patients were pulseless, so I was really uneasy about it all. Yet his ghost was pleased to see me and presented me with a box containing his own struggling heart flapping around like a wet fish.

  The next pair were good friends and arrived together straight through the closed door. Scotsman Jim was playing a lament on his bagpipes. His operation had been shown throughout the world on the BBC’s Your Life in Their Hands. Two years later, at Christmas, he left home without a spare battery, and when the pump’s low-power alarm sounded he had just twenty minutes to get back and plug it in. He never made it.

  Pulseless Peter was a religious man who had counselled the others about life on a battery before their surgery. He was the pioneer, the first patient in the world to be fitted with a permanent turbine pump and the startling electric plug in his skull. We became close friends, and he raised money to buy pumps for other patients in his situation. He would say, ‘Life on a battery isn’t normal life, but it’s better than the alternative.’ And Lucky Jim would testify to that. Although they were not yet sixty, both of them had been turned down for a transplant, emotionally devastating at the time.

  On this particular night, the spectre of Peter was as cheerful as ever because he loved to be with kindred spirits. He jovially referred to himself as ‘Frankenstein’s monster’ and secretly called me ‘Driller Killer’. He always promised to come back to haunt me, and I deeply regretted being out of the country when he needed me most. After almost eight years of ‘extra life’ on the pump, Peter was by far the longest survivor with any type of artificial heart. His unnecessary death was a tragic debacle. When he suffered a profuse nose bleed, his one poorly functioning kidney packed up, the local hospital declined to dialyse him and I was uncontactable in Japan, so he joined Jim across the great divide. I was certain that he and his artificial heart could have lived beyond ten years, a landmark a couple of my subsequent patients in other countries have now achieved.

  Merlot and morphine brought these tragic episodes back to me and, although the hallucinations were self-terminating, as usual I endured a long, restless night staring at the ceiling, unable to move, encumbered by the rhythmically pulsating anti-thrombosis leggings, transfixed by the irrigation system up my penis and tethered by the drip like a dog on a lead. Night nurse came in periodically to measure my blood pressure and for a while I thought she was part of the flashback. She looked at me strangely in the morning, so I wondered what I might have said to her. She’d been the only one without a wire cable emerging from her skull.

  By Sunday morning the fluid coming out of my bladder was almost clear, and following the previous day’s fasting I was ravenously hungry. Now rational, I guessed that low blood sugar was the third element of the trio that had fuelled my hallucinations – the two M’s, with added hypoglycaemia. Could that be reproduced, I wondered? Could I summon them all back for another phantom outpatient clinic? It was fascinating being deranged, and I could see why some people took drugs regularly.

  I demolished the private hospital’s full English breakfast, and sheepishly asked for kippers and toast as an encore. Then the nursing sister in charge that morning came in at the beginning of her shift, presumably having been told that I was delirious – or hilarious, perhaps. I told her I wanted this stiff pipe out of my prick as soon as possible, and emphasised the fact by extracting my own intravenous cannula and handing it to her. Off she went to call Professor Cranston. The morning sun shone through the curtains and I decided I’d had quite enough of being a patient. I knew the score. Bleeding stopped, catheter out, make sure I could piss, then home to my private nurse. Bugger three more days of paying for a haunted room and being treated like a recidivist.

  I was working out how to dispense with the bladder catheter when sister came back.

  ‘Professor Cranston says I can remove it if the washout is clear,’ she said.

  ‘Good. Let’s get on with it.’ I added that if I was still bleeding twenty-four hours after the surgery, I wanted my money back.

  ‘But don’t you even think about going home,’ she said. ‘It’s far too soon for that.’

  Being treated like a naughty child made up my contrary mind. Tomorrow the hospital would be full of people I’d once worked with, and I didn’t want the whole of Oxford tuning in to my private parts.

  Sister scrubbed her hands and slipped on rubber gloves with a determination that I found quite sinister – and suggestive. She aspirated water from the retaining balloon inside my bladder, then dragged the catheter out of me with a degree of mischief she could barely conceal, as if to say, ‘Take some of that!’ Blood clots that looked like purple seaweed and the odd fragment of prostate slid out with the balloon, followed by a dribble of fresh blood. This left me wondering, what if I went into retention now? How easy would it be to negotiate a catheter back through that raw space? I drank every drop of liquid in the room to build up a head of pressure before attempting the inaugural piss through my replumbed urinary tract. Then I paced the corridors in my spanking-new dressing gown and slippers, waiting for the urge to come.

  At that point Oliver D
yar made his customary post-operative visit, a civilised and welcome gesture, which served to divert attention from my ragged urethra. More to the point, he was perturbed to hear of my intention to leave. Minutes later, David received a text message: ‘OMG, he is going to go home.’

  When the urge did finally arrive, I returned to my private facilities with an uncharacteristic sense of trepidation. Frankly, I expected it to hurt like hell the first time. And so it did, but the discomfort was surpassed by the sheer delight of pissing like a horse. So much so that I overshot considerably and had to mop it up. By the time the professor arrived at midday I was packed and ready to leave, quite possibly a record early discharge for a surgical prostatectomy. But I wouldn’t contemplate another sleepless night in the hospital at considerable expense.

  David was relaxed about it, like he is about most things as he heads for retirement. We live in close proximity, so he could always nip round if I got into trouble. I did continue to pass blood and clots for a couple of days, but this was trivial compared with the dramatic relief of obstruction and the salvage job for my kidneys. I just wished that I’d had it done years earlier.

  Illness is as frightening for surgeons as it is for anyone else. Perhaps more so, given what we know. To quote one notable newspaper article, ‘The only black mark against the NHS is its poor record in keeping people alive.’ The main problem is that the service was launched as a nationalised industry designed to equalise access but not to maximise efficiency. I don’t mind that myself, and my family has never received any preferential treatment – as occurs in other industries – but I do care when we can’t get any treatment at all. The misery surrounding the seventieth anniversary of the NHS finally dispensed with that crass political deception: ‘Our system is the envy of the world.’ It simply isn’t.

  We lag behind other good healthcare systems in everything except economic stringency. We begin with higher infant mortality rates and continue through to poor outcomes for cancer and heart attacks. The most comprehensive report on cancer survival ever produced was published by The Lancet in 2018. This showed the NHS to be forty-seventh out of fifty-six countries for pancreatic cancer survival, forty-sixth for stomach cancer and forty-fifth for ovarian cancer, and that we lagged behind Latvia, Romania, Turkey and Argentina. Estimates suggest that 10,000 cancer deaths could be prevented each year if we were only average.

  All this is not because our surgeons, doctors or nurses are poor. Quite the opposite. In general, they are talented, hardworking and care about the people they treat. Cut out the bureaucracy and regulatory crap, and they might be more productive. In better-functioning healthcare systems there are many more doctors, higher nurse–patient ratios and vastly shorter delays to assessment and treatment. There are more scanners, and lifesaving drugs and equipment are introduced in a timely fashion whatever their cost. Moreover, such systems are not subject to political ping-pong.

  I have experienced all this myself in hospitals throughout Europe and the United States. My own doctor nephews have been working happily in Australia, while we offer Australian doctors golden handshakes to come here. But they don’t. Only doctors from poor countries want to work in the NHS, and it shows. We are busy trying to attract medical and nursing staff from Asia and Africa, but these countries need them at home. The time has come for a radical rethink.

  Better healthcare systems are not managed by the state, which regards more patients, procedures and technology as a burden. When emphasis remains on patient care not cost containment, other countries don’t have to pay out £5 billion each year to settle medical negligence claims nor choose to ration treatment for osteoarthritis, hernias or varicose veins just because they are not life-threatening. Better healthcare systems don’t have to discontinue all of their elective surgery for a month because of so-called seasonal pressures, as if winter were an unexpected event. What the NHS offered me, still a busy doctor with decades of service, was a one-year wait for surgery, during which time I’d have needed a urinary catheter and a plastic bag full of urine with me perpetually. No small wonder that Britain is the third-worst of eighteen Western countries in preventing avoidable deaths.

  Yet no one has the guts to dismantle or reform this tarnished treasure for fear of being cast into political oblivion. You would have thought the serial horror stories and scandals that emerge daily – even from our best hospitals – would plant a red flag in the field. Labour hopes that the Conservatives will propose European or Australian funding models, just so they can attack them for deviating towards privatisation, while for that same reason the Tories studiously avoid any meaningful reform and simply sing the same tired old song. We are putting in billions of pounds to transform the NHS, but no one ever notices where this money goes or what it achieves. So we – the workers within the system – remain disillusioned. Neil Moat, the great cardiac surgeon who took stock of Sarah’s labour when I was operating, retired prematurely from the Brompton to become medical director of a large pharmaceutical company in California. When I unexpectedly bumped into him in a café, he said, ‘I just couldn’t take any more of the NHS.’

  The sad thing is that those of us at the sharp end did want the NHS to be the best. I had absolutely no interest in private practice throughout my whole career. I did original research, wrote scientific papers and published numerous textbooks, all to fly the flag for the NHS on the global stage. Surgeons gravitated to Oxford simply to learn how we could be so productive with so few resources. But the system couldn’t give a toss. At sixty-eight I was threatened by the medical director with being ‘sent off’ because my Personal Development Plan for ‘Revalidation’ was not up to scratch. Reflect on that, General Medical Council. What was there to foster my ‘emotional health’ that the Royal College of Surgeons seem so keen on?

  My truncated admission to the private sector made me think about what I most valued in a healthcare system. My first concern, whether in England or Africa, has to be access to treatment. Access is allegedly free in the NHS, but remember that we all – or most of us – pay for it in taxes. When we are sick we have four choices. First, an average wait of two weeks for an appointment with a GP. Next, a demoralising struggle through a questionnaire with the barefoot doctors on the 111 help line that’s strictly focused on ‘Do you need an ambulance soon, in four hours, or perhaps never?’ Alternatively, you can go to a pharmacy for that critical opinion on your sick baby. And finally, you join the long queue of walking wounded in an A&E department, only to be dismissed as a time-waster and directed back to that GP’s waiting list again. I’ve tried all of this for my family. Being pushed from pillar to post, the only thing that worked was to turn up at a hospital and join the queue. The primary care system has abrogated all responsibility for out-of-hours care, and clearly the hospital emergency services can’t cope with the day-to-day service that the public demands. No surprises there then.

  For myself, when I became far too worried to go through any of this, I phoned a friend – but the British public don’t have that luxury. Should they be diagnosed with cancer, they have to endure a statutory and terrifying waiting time for treatment that’s decided by politicians, not doctors. When I trained in America, anyone who needed heart surgery or an operation for cancer would have it that same week, as long as they had insured themselves, but when I went to Oxford many poor souls waited for more than a year for their operation – and some died on the waiting list. We called that ‘cost containment’.

  This leads nicely on to the subject of timely intervention – getting on with the investigations so that everyone knows what needs to be done, then receiving the prescribed treatment. Take a patient referred with anginal chest pain and a positive exercise test. Everyone knows that they have coronary artery disease, but they first wait months to see a cardiologist in the outpatient department, then there’s another protracted delay for the coronary angiogram that dictates the appropriate treatment, then another hold-up to consult a cardiac surgeon, only to b
e told about an endless surgical waiting list. All of this while suffering from persistent symptoms, perpetual anxiety and the risk of premature death. How can the British public tolerate this? It amounts to clinical negligence by the State.

  In my last few years as a surgeon, many patients were subject to multiple cancellations before admission to hospital or even on the day of their operation, often because there were no available ward beds. Similarly, operated patients could not leave the intensive care unit through lack of ward beds – a vicious cycle of lousy management. Some of my patients were even discharged home directly from intensive care. Many of the elderly or sicker patients could not be discharged home because there was no one to look after them. Germany has 1,500 specialist rehabilitation hospitals, some with several hundred beds, so the same issues simply cannot occur. The NHS has none. Our patients are left to languish in their acute hospital beds, with serious adverse effects. Surgical patients and those recovering from stroke, head injury or heart attack lose up to 10 per cent of their leg muscle mass after ten days of inactivity, which in itself is equivalent to ten years of the aging process. So I am now working to build a ‘state of the art’ rehabilitation hospital in Oxford to maximise activity in the pressurised acute beds.

  As patients we all need confidence in those designated to treat us. So how do the repeated hospital scandals, fuelled by the government and relished by the media, help us with all that? Bristol, Stafford, Gosport – names that linger in the memory, but the bureaucrats bear the responsibility, not those working at the coal face. At the root of these scandals, systems were at fault, not individuals. When I had my operation I wanted doctors with skill, experience and honesty to look after me – and I favour lucky surgeons that can get away with the unpredictable. While I value privacy and confidentiality, had I been having a more serious operation I really wouldn’t have wanted to be invisible in a single room. Even with continuous remote monitoring, there needs to be someone watching – and usually there isn’t. Nurses are far too busy to sit and watch monitor screens, so having staff and other patients in view is reassuring.