The Knife's Edge

by Stephen Westaby

  So where do empathy and compassion come into it? For me, they simply didn’t matter. What I needed was to feel safe. And as we well know, our business-like NHS staff honestly don’t have the time for the touchy-feely stuff. Some prostate surgery for cancer is done with robots. Surprisingly, robots don’t manifest sympathy or compassion, although they could be programmed to say, ‘I feel your pain, I feel your pain,’ over and over again while digging out the bad bits.

  Yet there are times and situations when kindness helps. Back to the British Medical Journal, which recently published an article entitled ‘The difference that compassionate care makes’. The following were the thoughts of a lady professor in Denmark whose baby suffered then died from an inherited genetic disorder. She wrote:

  Empathetic care can support patients’ and relatives’ attempts to understand and cope with the inexplicable – be it the death of a child, the diagnosis of an illness, or one of the many other experiences that bring us into contact with healthcare systems.

  The author described meeting ‘incredibly caring doctors’, but also ‘hurried and disengaged doctors who appeared unable to truly see the patient – my son – and myself’.

  I would argue that such differentiation is false. The strong likelihood is that the doctors she saw were all caring people, but the impression they left depended upon their workload at the time. NHS GPs have eight minutes to greet, diagnose and treat their patients, then write the records. How does that work for those with mental health issues? They may see fifty people in one day. Given such taxing circumstances, their focus has to remain on not making a mistake. It’s the same story on the wards, in the A&E department and in the operating theatre – pressure-cooker environments with shortages of staff in every discipline, except management. Maybe the NHS should appoint ‘compassion and empathy’ managers, because time-pressured clinical staff have to maintain their objectivity, and cannot possibly delve into the hopes and fears of their patients, as perhaps they did in the good old days.

  What I regret most about the economic expediency of the NHS is that clinical efficiency and productivity detract from aspects of the doctor–patient relationship, and that needs to be recognised. It takes a particular mindset to deal with the spectre of death on a daily basis, which is why those psychological surveys demonstrate a surprising preponderance of psychopathic tendencies in surgeons, children’s cancer doctors and psychiatrists. I rarely lost a child, but when I did I had to walk away from it. I couldn’t keep putting myself in the parents’ shoes, otherwise I wouldn’t come to work the following day. That is what burnout is all about. It was the difference between John Gibbon, the inventor of the heart–lung machine, and John Kirklin, who made that incredibly daunting equipment work for patients. When Gibbon lost a series of children, he gave up. Kirklin didn’t, nor did Lord Brock. I had the great privilege of following in their pioneering footsteps. Sadly, no one else will have that freedom now.

  So, if I may, please let me conclude with a quote from George Orwell:

  Autobiography is only to be trusted when it reveals something disgraceful. A man who gives a good account of himself is probably lying, since any life when viewed from the inside is simply a series of defeats.

  I understand just what he meant by that.

  acknowledgements

  Such was my fascination with the quest to operate meaningfully within the heart that I wrote a comprehensive textbook on the subject called Landmarks in Cardiac Surgery (1997). While researching the intrepid pioneers I made contact with many of them, who in their twilight years were keen to record their memories. These were great characters from both sides of the Atlantic who risked, and often experienced, a death every operating day. As I gradually came to meet them all in person they proved to be a great inspiration for me. Their advice? Always search for a better way. Our specialty still has a long way to go.

  My own career began in some of Britain’s finest institutions, which included the Royal Brompton Hospital, Addenbrooke’s Hospital in Cambridge, then the Hammersmith Hospital and Royal Postgraduate Medical School, and the Hospital for Sick Children at Great Ormond Street. Following training in Britain and the United States, I spent the rest of my career amid the dreaming spires of Oxford. Irrespective of the moans, groans and frustration expressed in this book, I unreservedly rank the Oxford University Hospitals and their dedicated staff as among the finest in Europe. Those who ‘toil at the coal face’ define a hospital, not the buildings, politicians or the NHS itself. So I would like to extend my boundless gratitude to all the colleagues who supported my patients and me in the office, on the wards, in the operating theatres and the intensive care unit, during good times and bad, joyful and sad. Together we achieved world firsts, spectacular saves and notable changes to the way cardiac surgery is practised globally. Innovation was born of necessity – or lack of funds, to be brutally honest. Of course, the NHS turned a blind eye to our achievements, but high honours from the United States, Russia and Japan more than compensated for that. Forgive the boasting – and a few swear words in the text, which I use for emphasis but blame on the head injury! I seldom swore at work.

  Cardiac surgery relies upon finely honed team work and round-the-clock care, which would have been impossible without the fine international fellows who trained with me in Oxford, then returned to be eminent surgeons in their own countries. Training is what we should be doing, not poaching overseas staff to fill spaces made by the deficiencies in what many claim to be a first world healthcare system. While we clinicians rarely acknowledge the fact, I also appreciated the efforts of some dedicated hospital managers who went out of their way to help rather than hinder us. In short, these great hospitals and professional relationships defined my career in a way that can never be repeated, thanks to ‘modernisation’. To use a well-worn phrase, ‘They don’t make them like that anymore.’

  Born within weeks of its inception in 1948, my whole working life was spent supporting our precious NHS. But should it once more aspire to provide first-rate treatment, it must invest more in staff and equipment and less in bureaucracy and committees to promote cost containment. Contemporary medicine and surgery are inordinately expensive. As an ‘off-the-shelf’ alternative to a heart transplant, the implantable rotary heart pumps I pioneered cost more than a Ferrari. Other European countries use them, so Britain needs to learn from more successful healthcare systems right now before it is too late.

  I would like to express my thanks to the doctors, named patients and their relatives who were happy, enthusiastic even, for me to write about them. Others, from early in my career, are sadly no longer with us and their circumstances have been adjusted sufficiently for them not to be recognisable.

  Finally, what I valued most in life was the unwavering love and support from my family. It is an understatement to explain that I was never easy to live with. I left the house before dawn, worked late, travelled too much, then was knackered when I returned home. After leaning over an operating table all day I would tell the wife, ‘Sorry I’m so tired. My back’s bad and the front’s not so good either.’ But everyone appreciated my efforts to save lives. That is why I wrote both Fragile Lives and The Knife’s Edge, so that they may eventually understand who I was, and what I tried to achieve during those years. Special people, my family.

  glossary

  acute heart failure: the left ventricle fails rapidly and cannot sustain sufficient blood flow to the body. The lungs then fill with fluid. Usually caused by myocardial infarction or viral myocarditis and has a high mortality rate. See also shock.

  angina: crushing pain in the chest, neck and left arm due to limitation of blood flow to heart muscle in coronary artery disease. Typically comes on during exercise. If it comes on at rest it may warn of a heart attack.

  angiogram: cardiological investigation where a long catheter is passed through the blood vessels into the heart. This allows blood pressure to be measured in the cardiac chambers and dye t
o be injected to visualise the coronary arteries or aorta.

  aorta: large, thick-walled artery that leaves the left ventricle then branches to supply the whole body. The first small branches are the coronary arteries, which supply blood to the heart itself.

  aortic stenosis: narrowing of the aortic valve at the outlet of the left ventricle, restricting blood flow around the body. Can be caused by a congenital anomaly or degeneration in old age.

  arteries: the blood vessels that convey blood to the organs and muscles of the body.

  atrioventricular canal: congenital heart defect where there is a continuous hole between the collecting (atria) and pumping (ventricles) chambers, and the mitral and tricuspid valves fail to form properly.

  blood pressure: pressure within the large arteries. Normally measured by a cuff and stethoscope or a cannula inserted into an artery. Normal blood pressure is around 120/80 mm Hg. The higher figure is when the left ventricle contracts; the lower, when it relaxes.

  bridge to recovery: the process whereby a ventricular assist device is used to sustain the circulation and rest an acutely failing heart pending recovery from a reversible condition. If the heart does not recover, a limited-duration pump can be replaced by a long-term implanted device.

  bridge to transplant: the process whereby a ventricular assist device is used to prevent death from heart failure until a donor heart can be found. At the time of transplant the pump and diseased heart are both removed.

  cannula: a plastic tube inserted into the heart or a blood vessel to carry blood or fluid.

  cardiac tamponade: a condition that occurs when blood or fluid accumulates within the pericardial sac under pressure, preventing the heart from filling.

  cardioplegia: a cold (4°C) clear or blood-based solution infused into the coronary arteries to stop and protect the heart in a flaccid state during surgery with the heart–lung machine. Usually contains a high concentration of potassium. At the end of the repair the heart is re-animated by restoring normal coronary blood flow.

  cardiopulmonary bypass (CPB): process whereby the patient’s blood is diverted away from the heart and lungs for the duration of the surgical repair. Contact of the patient’s blood with the synthetic surfaces in the pump-oxygenator system elicits an inflammatory response. This limits the safe duration of blood–foreign surface interaction. The longer the procedure, the more damaging is the whole-body inflammatory response.

  congenital heart disease: heart deformity that the patient is born with (e.g. atrial septal defect, ventricular septal defect, dextrocardia).

  coronary artery disease: gradual narrowing of the coronary arteries by atheroma. These fatty, cholesterol-based plaques are prone to rupture when they suddenly occlude the vessel, which then clots (coronary thrombosis).

  crash call: call for a resuscitation team of doctors and nurses.

  CT scan: X-ray-based three-dimensional imaging of the chest and heart. By adding contrast medium, the coronary arteries can be shown in detail.

  Dacron: a woven fabric used to make vascular tube grafts and heart patches.

  defibrillate: electric shock of between 10 and 20 joules used to restore normal heart rhythm during the disordered rhythm of ventricular fibrillation.

  deoxygenated blood: bluish blood leaving the tissues and returning to the right heart, now low in oxygen and carrying carbon dioxide to be expelled by the lungs. See also oxygenated blood.

  diastole: relaxation and filling phase of the ventricles.

  direct vision: to see within the heart in order to conduct a surgical repair.

  distal anastomosis: join between a coronary bypass graft and the target coronary artery.

  echocardiogram: non-invasive ultrasound examination of the heart chambers.

  electrocautery: the electrical instrument used to cut through tissues and simultaneously coagulate blood vessels to stop bleeding.

  endocarditis: bacterial infection that can destroy the heart valves.

  endotracheal tube: tube in the windpipe through which to ventilate a patient.

  exsanguinate: bleed to death.

  heart–lung machine: circuit outside the body to keep the patient alive while the heart is stopped for repair. Contains a mechanical blood pump and a short-term (lasting hours) complex gas exchange mechanism known as the oxygenator (artificial lung). Other pumps are used for suction of blood into the reservoir and for delivery of cardioplegia fluid to stop the heart.

  HeartMate left ventricular assist device: an obsolete large pulsatile implantable pump widely used for bridge to transplant in the 1990s. The first device to be implanted on a permanent basis. Thoratec went on to produce a successful rotary blood pump for permanent use.

  heart transplant: removal of the patient’s diseased and failing heart, then replacement with an organ from a brain-dead donor.

  heart valve replacement: removal of a diseased heart valve, then replacement with a prosthetic valve. Prosthetic valves can be biological (e.g. pig’s valve) or mechanical (e.g. pyrolytic carbon tilting disc valves).

  homograft bank: department that collects and processes human heart valves and blood vessels donated by the deceased for use in patients.

  iliac fossa: part of the lower abdominal wall beneath the umbilicus.

  inferior vena cava: see vena cava.

  intubation: the process of inserting the endotracheal tube into the patient for ventilation.

  left atrium: collecting chamber for blood returning to the heart from the lungs. The blood then passes through the mitral valve into the left ventricle. See also right atrium.

  left ventricle: powerful, thick-walled conical chamber that pumps blood through the aortic valve and around the body. See also right ventricle.

  left ventricular assist device (LVAD): mechanical blood pump to maintain the circulation and rest the ventricles when the heart fails catastrophically. The cannulas are inserted into the chambers of the heart. There are inexpensive temporary external devices suitable for several weeks of support in acute heart failure (e.g. CentriMag or Berlin Heart). The small, implantable but very expensive high-speed rotary blood pumps (e.g. Jarvik 2000) can be used for as long as ten years in chronic heart failure. As such, the long-term LVADs offer an off-the-shelf alternative to heart transplantation.

  metabolic derangement: consequence of poor tissue blood flow. Arteries to the muscles clamp down and the tissues produce lactic acid and other toxic metabolites.

  mitral stenosis: narrowing of the mitral valve between left atrium and left ventricle caused by rheumatic fever. Flow through the valve is restricted, causing breathlessness and chronic fatigue.

  mitral valve: valve between the left atrium and ventricle. Named after a bishop’s mitre.

  oxygenated blood: bright red blood saturated with oxygen and pumped around the body by the left ventricle. See also deoxygenated blood.

  perfusionist: technician who controls the heart–lung machine and ventricular assist devices.

  pericardium: fibrous sac that surrounds the heart. Can be used as patch material in the heart. Calf pericardium is used to make bioprosthetic heart valves.

  pulmonary artery: large, thin-walled vessel that carries blood from the right ventricle to the lungs.

  reperfusion: the process whereby blood is allowed back into the coronary arteries and heart muscle following cardioplegia and cardiac arrest during surgery. The heart is re-animated and begins to beat again.

  resident: trainee surgeon in the US, so-called because they live in the hospital.

  rheumatic fever: autoimmune condition triggered by a streptococcus bacterial infection that damages the heart valves and joints. Very common cause of rheumatic valve disease in the pre-antibiotic era.

  right atrium: collecting chamber for blood returning to the heart from the body via the veins. The blood then passes through the tricuspid valve into the right ventri
cle. See also left atrium.

  right ventricle: crescent-shaped pumping chamber that propels blood through the pulmonary valve and to the lungs. See also left ventricle.

  sharps bin: bin in which to deposit needles and scalpel blades after contact with blood.

  shock: condition when the heart cannot continue to supply sufficient blood and oxygen to the tissues. Cardiogenic shock occurs after a heart attack. Haemorrhagic shock follows profuse bleeding of two litres or more.

  tricuspid valve: valve between the right atrium and right ventricle.

  valvotomy: surgical manoeuvre to dilate the narrowed orifice of an aortic or mitral valve.

  veins: thinner-walled vessels that return blood to the heart.

  vena cava: large vein entering the right atrium. The superior vena cava drains the upper part of the body; the inferior vena cava drains the lower half.

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