Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table. Stephen Westaby

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СКАЧАТЬ heart were virtually insurmountable. So would the boy be better off if he were operated on by a more experienced surgeon in the States? I couldn’t see why, because his combination of pathologies was probably unique. No one else would have greater experience, even if they did have a better team. I had a good enough team and great equipment, the best that money could buy. So I was the man for the job, wasn’t I?

      It was then that I had my eureka moment, while staring up at the Milky Way. I suddenly knew the obvious way to get at the tumour. It might have been an outrageous idea, but I had a plan.

      On Saturday I brought the anaesthetic and surgical teams together to discuss the case, and showed them the novel pictures of the unusual anatomy. Then, unusually – as much of what happens in an operating theatre remains impersonal, which is perhaps best when operating on those who may not survive – I told them the heart-rending story of the mother and boy. Everyone agreed that the boy was doomed if we made no effort but voiced justifiable concerns that the tumour was inoperable in dextrocardia. I said that we’d only know that through trying, although I kept the operating plan to myself.

      I spent a hot, restless night in the apartment, my mind racing, disturbed by irrational thoughts. Would I have risked this back in England? And was I doing it for the patient or for the mother – or even for myself, so I could publish a paper about it? If I succeeded, who would care for this slave girl and her illegitimate child? The boy was an inconvenience. In Yemen he would be left out under a bush for the wolves to eat. It was the mother they wanted.

      The early-morning call to prayer put an end to my discomfort. It was already 28°C as I walked from the apartment to the hospital. Mother and boy came down to the operating theatre complex and anaesthetic room at 7 am. She’d stayed awake until morning with her child in her arms, and all through the night the nurses had been concerned that she might capitulate and run away. She didn’t, but they were still worried whether she would hand the boy over.

      Despite premedication he was screaming and thrashing around when they tried to put him asleep. Dreadful for the mother – and difficult for the anaesthetic staff – this was pretty much routine in paediatric surgery. Gas through the face mask eventually subdued him sufficiently to insert a cannula into a vein and stun him into unconsciousness. His mother still wanted to follow him into the operating theatre, so the ward nurses eventually dragged her away. Finally raw emotion had broken through the mask – whatever she had suffered physically, this was worse for her. Yet there were still no words.

      I sat, dispassionate, in the coffee room until the mayhem abated, enjoying thick Turkish coffee and dates for breakfast. The caffeine hit was good for my ADHD but racked up my sense of responsibility. What if the boy dies? Then she has nothing. Nobody in the world.

      One of the Australian scrub nurses came through to ask that I check the equipment, the extra bits I’d requested for the radical plan conceived under the dark desert sky. I’d yet to share it with my team.

      Uncovered on the shiny black vinyl of an operating table, this emaciated little body was a pathetic sight, with none of the puppy fat that every infant deserves. Instead his skinny legs were swollen with fluid. The heart failure paradox – the muscle is replaced by water but the weight stays the same. His prominent, skinny ribs rose and fell with the ventilator, as he was no longer struggling for breath on his own. Now everyone understood why the mother was so fiercely protective. We could see the heart beating away in the wrong side of the chest and the outline of his swollen liver in the contrary side of the bulging abdomen. Everything was the wrong way round, all a source of fascination for the onlookers and presenting a daunting challenge for me. I’d seen one operation on dextrocardia in the US and another at Great Ormond Street. This would be the first I’d attempted myself.

      There were still streaks of dried salt down his cheeks from the traumatic separation from his mother. What was it I used to say when asked if I was ever anxious about undertaking an operation? ‘No. It’s not me on the table!’ But although I don’t do anxiety, I was now in tiger country with an untested procedure in an unfamiliar environment and could feel sweat trickling down my back. It all felt a very long way from Oxford.

      Everyone was happier when that fragile little body was covered in blue drapes, leaving just a rectangular window of dark skin exposed over the breastbone. He was now no longer a child, just a surgical challenge. That is until we heard his tormented mother banging on the operating theatre doors. She’d given her minders the slip and rushed back, and after a brief struggle they allowed her to sit in the corridor just outside. Her day had been traumatic enough without being dragged away for a second time.

      Back inside the operating theatre the scalpel blade slid left to right along the length of the boy’s sternum until a trickle of bright red blood skidded over the plastic drape. The electrocautery soon put a stop to that as it sizzled down onto white bone, reminding me of that line from Apocalypse Now – ‘I love the smell of napalm in the morning.’ The whiff of white smoke told me that the diathermy had too much power and I reminded the orderly that we were operating on a child, not electing a pope, so would he please turn down the voltage.

      Heart failure fluid was pushing up the diaphragm. I made a small hole in the boy’s abdominal cavity and straw-coloured fluid poured out like piss into the wound. The noisy sucker removed almost a pint into the drainage bottle and his belly flattened out. A very quick way to lose weight. The saw zipped up the sternum, spraying beads of bone marrow onto the plastic. It breached the right chest cavity, releasing a knuckle of stiff, pink, waterlogged lung. Yet more fluid spilled out, so the sucker bottle had to be changed. It left no one in any doubt that this kid was seriously unwell.

      Impatient to view the congenitally distorted heart, I dissected away the redundant thymus gland and sliced open the pericardium – the fibrous sac that encases the heart – with the same excitement and anticipation as unwrapping a surprise parcel at Christmas.

      Everyone wanted to get a good look at the dextrocardia heart before I started, so I took a step back and relaxed for a minute. The plan was to open up the narrowed channel below the aortic valve by coring out as much solid tumour as possible, then close the hole in the atrial septum. I gave the order to go onto the heart–lung machine and proceeded to stop the empty heart with cardioplegia fluid. It lay cold, still and flaccid in the bottom of the pericardial sac. I gently pressed the muscle and could feel the rubbery tumour through the heart wall. By now I was sure that I couldn’t reach it all with a conventional approach and that there was little point cutting into the ventricle that his circulation depended upon purely on an exploratory basis. So I told myself, ‘Just do it.’ Plan B. The eureka option, one that had probably never been done before. The perfusionist began to cool the whole body down from 37°C to 28°C. The boy was likely to be on the bypass machine for at least two hours.

      At that point I had no option but to share Plan B with the rest of the team. I would chop out the boy’s heart from his chest and, with it lying on a kidney dish full of ice to keep it cool, operate on it on the bench. Then I could twist and turn the thing as much as I needed to do a good job. I considered it to be a brilliant idea, but I had to work fast.

      The process was equivalent to removing a donor heart for transplant then sewing it back into the same patient. Back in my research days I’d transplanted tiny rat hearts. This boy’s heart should be no problem, even if the anatomy was unusual, so I transected the aorta just beyond the origin of the coronary arteries, then the main pulmonary artery. By pulling these vessels towards me, the roof of the left atrium was exposed at the back of his heart. I cut through the atria, leaving all the large veins from the body and lungs in place, then, lifting the ventricles out, I left most of the atria in situ. It was then, as you’d do with a donor heart, that I placed the cold, floppy muscle onto the ice.

      Now I could see the tumour within the outflow part of the left ventricle. I started to dissect it out, cutting a channel through it so that СКАЧАТЬ