CHAPTER TWELVE
A MATTER OF LIFE AND DEATH
The University of Minnesota was the center of the cardiac surgery universe in the States. In Europe it was the Brompton Hospital in London. Founded during the reign of Queen Victoria, the Brompton was first hospital in the world to specialize in diseases of the chest—in those days mainly tuberculosis, the most common cause of death then. Tuberculosis afflicted people without regard to social status, though poor nutrition put people at greater risk. One in two hundred people developed the disease, and half of those died within five years. Originally called the Hospital for Consumption and Diseases of the Chest, it eventually became the Brompton, named after the part of Chelsea where it was located. Its long wards were named for British royalty.
In the early days, the Brompton was run by physicians, not surgeons, since there was no surgical treatment for tuberculosis except in the late stages of the disease. When I first went to the Brompton in 1973, the buildings were much as they had been for 130 years. But the surgeons had come into their own.
In February 1935, a Brompton surgeon named Arthur Tudor Edwards did the first complete removal of a lung in Europe, a pneumonectomy. Another chest surgeon, Clement Price-Thomas, later joined Arthur Tudor Edwards at the Brompton. On September 23, 1951, Price-Thomas removed the left lung of King George VI, Queen Elizabeth’s father. A heavy smoker, as most people were in those days, the king had been ailing for some time. The king did not go to the hospital; the hospital went to the king. The operation was done at Buckingham Palace. I later learned from someone who assisted on the operation that when Price-Thomas went out to tell the queen about the surgery, she asked if she could see the king. “Not now, Your Majesty,” was the reply, “my assistants are still closing his chest.”
Winston Churchill, who was a confidant of the king and was to become prime minister again the following month, was present. He asked, somewhat indignantly, “Mr. Price-Thomas, you do not close the king’s chest yourself?”
“Mr. Churchill,” Price-Thomas said calmly, “I haven’t closed a chest in twenty years and do not intend to start practicing on the king!”
Clement Price-Thomas received a knighthood for operating upon King George VI, becoming Sir Clement. Apparently, nobody ever told His Majesty that he had cancer, as he was puzzled until he died as to why he was not improving. Price-Thomas, having chain-smoked throughout his life, even while seeing patients, eventually got lung cancer himself.
I joined the staff at the Brompton as a senior house officer, an SHO. In most hospitals, an SHO would not have to have the Fellowship of the Royal College of Surgeons to be appointed, but competition at the Brompton for these jobs was so fierce that generally this was required. Even an SHO would generally be a Mister. I did not yet have the fellowship but thought I would apply anyway. At my interview, I sat down before Mr. Matt Paneth, one of the Brompton’s senior surgeons. He only asked me one question.
“Are you married, Jamieson?”
“No, sir,” I said.
I got the job.
I was assigned to spend the next three months with Chris Lincoln and Stuart Lennox, consultant surgeons who worked with Paneth. Though he was in his forties, Lincoln had only just been made a consultant. He did all types of adult pulmonary and cardiac surgery but specialized in pediatrics. On my first bewildering day, I was introduced to one of the registrars, Ibrahim Mustafa. Mustafa was from Nigeria and had a gentle disposition. The only cardiac surgery I’d done until then had been in rats. I couldn’t wait to get started.
Mustafa took me around to see the patients. Among them were many small babies who had had heart surgery. Just twenty years after Lewis and Lillehei performed the first open-heart surgeries in the world, operations to repair complex defects were done every day at the Brompton. I was fascinated by the machines, monitors, and chest tubes coming out of the patients connected to bottles by the bedside to drain blood after the operation. Catheters in the bladder collected urine to monitor kidney output—a good measure of how a patient is doing. When the cardiac function drops, blood flow to the kidneys slows, and urine production decreases as a result. It’s one symptom of the body’s protective response to a lower cardiac output, as it prioritizes blood flow to vital organs such as the brain. This makes the hands and feet cold to the touch. I was fascinated to see a standard thermometer taped to the big toe of the babies. The temperature was recorded at ten-minute intervals. One of the first signs of impending trouble was to see a downward trend in the toe temperature. There was a saying that a patient was doing well if he or she was awake, warm, and pissing.
At eight a.m., after rounds, I went with Mustafa down to the operating room. We scrubbed in. On the operating table was a little baby, covered in blue towels and ready for surgery. Mustafa made the first incision, and blood welled up from the sternum. He took a small bone saw to cut through the sternum and expose the heart. As soon as he did, the baby’s heart fibrillated and stopped pumping. Mustafa quickly opened the sac of the heart, the pericardium, and started to massage the little heart, which was about the size of a hen’s egg. Someone alerted Mr. Lincoln in the surgeon’s waiting room. He burst through the operating room doors in his street clothes, and, cursing, pushed Mustafa aside. He asked for the defibrillating paddles and got the heart restarted almost immediately. I’d had my first important lesson—heart surgery is a matter of life and death.
Lincoln went out, scrubbed in, and came back into the OR. I stood silently at Mustafa’s side for the four-hour surgery. The scrub nurse was opposite me, and to her left was Lincoln. I did not speak, and I was not spoken to. After we came off bypass, the little heart beat steadily. The baby was now pink instead of blue. Lincoln went out to the surgeon’s room to have coffee, chat with the other surgeons, and dictate some notes. Mustafa changed sides, taking Lincoln’s place, and I stood opposite Mustafa to help close the chest. The next baby was already being put to sleep. As soon as we had put the final sutures in, the dressings were put on and the baby was wheeled out. The next baby was wheeled in. We started again.
As we worked, we got word that the first baby had started to bleed in the intensive care unit. Sometimes when the body warms up again after bypass, small vessels that had been dry start bleeding. Possibly one of the many suture lines had come loose, or a needle hole was leaking. We finished, and the first baby was brought back in. Lincoln also came in. We reopened the incision. A small artery on the breastbone was causing the trouble. It was easily cauterized. Lincoln left, and once more Mustafa and I closed.
When we were done, it was seven p.m. It had been a long day, with nothing to eat or drink. Though I really hadn’t done anything, I had learned a lot. After taking the baby back to the intensive care unit, I ran into Lincoln, who was sitting in the surgeon’s room with his feet on the table. He put his tea down and gave me a careful look.
“What did you say your name was?” he said finally.
“Jamieson, sir,” I stammered.
“Well, Jamieson, you didn’t have a very good first day, did you?”
I wondered if my career in heart surgery had ended before it began.
Every day was an adventure, like going into the African bush with a chance of encountering almost anything. Lung surgery had been well worked out at the Brompton, which had done more of it than any other hospital in the world. The lung surgeons there were masters. But when I started, only six hundred coronary-bypass operations were done during the year in the whole of England. The senior surgeons at the Brompton had had to learn coronary surgery late in their careers. One big difference was the extremely fine suturing required in coronary surgery.
I got into a routine. Lincoln remained irritable, unpredictable, and hard to please. The days were not without mishap. Nothing was ever Lincoln’s fault. There was always someone else to blame. We learned to live with it. One of the registrars told me that Lincoln had a special instrument that he kept locked away and that only he could use. “It’s called the Lincoln retrospecto
scope,” the registrar said. “Lincoln uses it when something has gone wrong. He looks through it like a telescope to identify the guilty party. However, it’s missing an important attachment. A mirror.”
I did not work directly for Paneth, but when I could, I assisted at his surgeries and covered his patients on nights and weekends. He was not like Lincoln. Tall and always expensively dressed, Paneth had a patrician air. He drove a Porsche. More interesting to me was that he had studied at the University of Minnesota under Walt Lillehei, alongside Norman Shumway and Christiaan Barnard.
Paneth was reserved outside the OR—and a supreme ruler inside it. It was not unusual for him to throw an instrument in frustration, and his nurses were sometimes reduced to tears. But his technical skills were breathtaking. I never saw a better lung surgeon. He also had his own way of working on heart valves, especially the mitral valve, which regulates blood flow between the left chambers of the heart. Most surgeons then would simply replace a bad mitral valve with an artificial one. But Paneth repaired the valve, using plastic-surgery methods.
CHAPTER THIRTEEN
MR. LENNOX WOULD LIKE TO KNOW WHAT THE PROBLEM IS
Three years passed. In 1974, five years after I first attended a meeting of the Transplantation Society with the money from the Rothschild prize, I went again. This time the meeting was in Jerusalem. Evelyn Rothschild made some calls on my behalf, and although I was an anonymous surgical resident, I was treated like a VIP. I was invited to lunch by the dean of Hadassah hospital and medical school, where I renewed my acquaintance with Tom Starzl. I had met Dr. Starzl—the liver-transplant pioneer—when I first worked in Ken Porter’s lab. He was a giant in the field of transplantation.
I was impressed by how energetic and full of life everyone in Israel seemed to be. The country was between wars. A former Miss Israel, who was about my age, served as my escort. She was beautiful and fun. We had a marvelous time together, and I was sorry to leave.
At Christmastime in 1976, I made my last visit to Ascott. Paneth knew that I was close to Mrs. Rothschild and made sure I could get away. I think he was amused that one of the richest people in the world took such an interest in me. When I arrived Mrs. Rothschild was seriously ill. Over the holiday I think we both realized the end was coming. When I left on New Year’s Eve, Yvonne hugged me. “Happy New Year,” she said, “and goodbye, darling.” I went back to the Brompton and threw myself into work. One day Paneth called me into his office. This was never a good thing, and I wondered what I could have done wrong.
“You’d better sit down, Jamieson,” he said. “Mrs. Rothschild has died.”
I was brokenhearted. Although I kept clothing and books at Ascott—it really had become my second home—I could not bear to retrieve them. Instead, I did the only thing that relieved the pain: I worked. It was now 1977. I had been a doctor for six years and finished all the requirements for general surgery. I was a fellow of the Royal College of Surgeons, Mr. Jamieson. I was appointed a senior registrar, to work mainly with Paneth.
Patients still died all the time, though nobody was keeping score back then. Today you’re in trouble if you lose a patient doing heart-valve surgery. But back then surgery was often bloody, the outcome uncertain. If we did a valve and lost the patient in the OR, or later on in the night, we’d take the valve out, clean it up and sterilize it, and put it in somebody else the next day.
Paneth was always the lead surgeon on valve operations. The registrar assisted. I’d only been working for him for a few days when a complicated case appeared on the schedule. It was a young guy from Wales, only in his twenties. He needed an aortic-valve replacement. I wanted to do it. So I went to see Paneth.
“Mr. Paneth, I’d like to do this case,” I said. Paneth was indignant. I might as well have asked if I could borrow the Porsche to take his daughter out.
“Look here, Jamieson, just who in the hell do you think you are?” he said.
“Sir, I think I’m the best registrar you’ll ever have,” I said.
Paneth stared at me. This was a make-or-break moment. I knew that I was either in or about to be fired.
“All right,” he said finally.
I was in.
Paneth assisted on the operation, the first time he’d ever done that for a registrar. The operation went well. When it was finished, I went out to the waiting area to talk with the man’s young wife, who had never been in London before. I was feeling like the king of the world. I told her that everything had gone perfectly and reassured her that her husband would be fine. Relieved, she went off to the pub. While she was there, the provisional Irish Republican Army detonated a bomb directly outside. When her husband woke up the next morning, I had to tell him that he was doing well but that his wife had lost a leg overnight.
After that, Paneth let me do a number of cases. And eventually he let me operate on my own. He’d be in the next room, maybe having a cup of coffee, but he was there if I needed him. I spent the year doing heart surgery as Paneth’s apprentice. I rarely went home and often worked through the night and into the next day. When Paneth operated I opened and closed, looked after the patients, and dealt with the nurses and hospital staff. But when Paneth was away, I stepped into his shoes. This would not have been easy even with an experienced team backing me up. But that wasn’t usually the case. The Brompton wasn’t a teaching hospital. I had to learn a lot of things on my own. When I operated I was given the most junior anesthetists and scrub nurses when I really needed the most senior.
I worked with a surgeon named Silvio, whom I didn’t like. He was careless and always making a joke at the wrong moment. We would do three or four cases a day, moving between ORs. I often opened or closed a case while Silvio helped Paneth. Occasionally Silvio would be allowed to close a case if it seemed simple enough. Closing is more than just sewing up the incision. You have to make sure nothing is bleeding and stop anything that is. And you have to be sure nothing has been overlooked and all surgical equipment is accounted for.
One day we operated on a private case, an English lord with lung cancer. When Paneth and I finished the surgery, Paneth moved to another room to do a heart case. Silvio went with him. Paneth sent for me ten minutes later—he didn’t say why, but I could guess Silvio wasn’t up to it. I swapped places with Silvio, who closed the lord’s chest. When we reviewed the X-rays later that day, I saw what looked like a sponge in the lord’s chest. I phoned Paneth at home.
“Where is it?” he asked. I told him it was at the base of the lungs, at the back.
“Where it always is,” he said. “Well, we’ll take it out in the morning.”
I squared the situation with the patient and his family. They took it well. The next morning, Paneth and I operated and fished out the sponge. Silvio, standing idly at the head of the table asked, “Is that what you would call a spongioma?” He was joking that it was a type of sponge tumor. I wanted to choke him. Paneth was seething.
“No, Silvio, this is a sponge,” he said coldly.
Silvio had left the sponge in, but I had been in charge. It was my responsibility. Silvio showed no remorse and declined to admit that he had done it. After we were out of the OR, Paneth pulled me aside.
“You closed the chest?” he asked. He knew I hadn’t.
“Yes,” I said.
“Swab count reported as correct?”
“Yes, sir.”
“You’re a member of the Medical Defense Council?” he said, referring to our malpractice insurance.
“Yes,” I said. I realized suddenly that he was pulling my leg. Even so, I was shaken. I felt I had let Paneth down.
He thought things over for a minute.
“I don’t want you to be depressed about it,” he said at last. “Nobody will say you leave swabs behind.”
A few days later, seeing that I was still upset, Paneth talked to me again, this time to tell me a story about Russell Brock. Lord Brock had been a legendary surgeon, the first at the Brompton to use the heart-lung machine. Paneth h
ad been his senior registrar.
“We were going through a very bad time,” Paneth recalled. “Everybody we did died, and it was demoralizing for the whole unit. One day I said to Brock, ‘How do you manage, sir, all these people dying all over the place?’ He said, ‘Well, when I get up in the morning, I look in the mirror and I say to myself, Brock, who are you going to kill today?’
“Well, that’s it. You can’t be flippant about it, but you do your best and don’t let it get you down. You can do no more.”
But I never forgave Silvio. The last straw came when Paneth had done a coronary bypass, grafting a vein from the leg to restore blood supply to the heart. Although none could match his expertise in lung surgery, and few could match him in valve surgery, Paneth had learned coronary-artery surgery later in life. The delicate suturing was a challenge for him, and his stitches sometimes leaked. On this occasion I was with the patient in the intensive care unit after Paneth had left for the evening when the patient started to bleed. I monitored the situation for a while before deciding the bleeding wasn’t going to stop on its own. We needed to go back to the operating room. Paneth was in the middle of dinner when I phoned. “You can take care of it, Jamieson, can’t you?” he said. Certainly, I said.
I called in the operating room staff and the anesthetist, a young South African with whom I got on well. All was ready about a half hour later. The patient’s blood pressure was now going down. I was hanging blood, trying to replace what he was losing. When the anesthetist arrived, we wheeled the patient into the elevator. The intensive care unit was on the fourth floor, the operating rooms on the first. The patient’s blood pressure fell precipitously in the elevator, and the anesthetist gave him a shot of adrenaline. This made the pressure shoot up. But it also worsened his bleeding, which was really going now.
We rushed into the OR, and I opened the chest immediately. It was full of blood and blood clot. Silvio began removing the clot with a suction hose. He wasn’t careful enough. Suddenly the graft was sucked into the tube and broke free from the aorta and the heart, ending up in the vacuum canister on the wall twelve feet away. I was horrified. Incredibly, Silvio thought it was funny and started laughing. I knew we needed Paneth and called him again. While he hurried to the hospital, I retrieved another segment of vein from the patient’s leg. When Paneth got there, we sewed the graft back on. Of course, I again took full responsibility. It was a miracle that I wasn’t fired.
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