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

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СКАЧАТЬ I lifted the saw again and asked Sister to move her hands. Through a deluge of blood I ran the saw through the remaining intact bone – the thickest part of the sternum, just below the neck. Then we pressed on the bleeding again while more transfusion restored some blood pressure.

      As pressure drops the rate of bleeding slows. This gave me a window of opportunity to dissect the heart sufficiently away from the back of the breastbone to insert the metal sternal retractor and wedge open the chest. Now I could see the lacerated right ventricle spewing its contents into the wound. When everything is stuck together like this, spreading the bone edges can tear the heart muscle wide open, sometimes irretrievably. But I’d been lucky and her heart was still in one piece. Just about.

      By now my own pulse was galloping. I could see that the problem was a ragged slit 5 cm long in the free wall of the right ventricle, comfortably distant from the main coronary arteries. Sister instinctively put her fist directly on it as I wound the retractor open, and this at last stemmed the bleeding. Dr English squeezed a second unit of blood in through the drips, bringing the old lady’s blood pressure back up to 80 mm Hg, and the back-up scrub nurse divided the long plastic tubes to the heart–lung machine so that we could use it when ready. But as yet not enough of the heart had been exposed for that. First I needed to stitch up the bloody hole. As a surgical houseman I’d stitched skin, blood vessels and guts – never a heart.

      Sister told me what stitch to use, and that it was best to stitch over and over rather than using individual stitches. This was quicker and would provide a better seal. ‘Don’t tie the knots too tight,’ she added, ‘or the stitches will cut through the muscle. She’s fragile. Get started and you might finish before Paneth gets here and chews your head off.’

      The difficult part was to stitch accurately as blood poured out of the ventricle with every beat. By now my gloves were dripping with blood on the outside and sweat on the inside, and sewing was all but impossible.

      Dr English saw this and shouted, ‘Use the fibrillator! Stop the heart beating for a couple of minutes.’

      The fibrillator is an electrical device that causes what we’d normally never want to see – ventricular fibrillation, where the heart doesn’t pump but quivers, stopping blood flow to the brain at normal body temperature. In four minutes brain damage begins.

      Dr English was reassuring. ‘Just defibrillate it after two minutes. If you haven’t closed it by then we can wait a couple of minutes, then fibrillate again.’

      I felt like a puppet with the experienced players pulling the strings. That was fine by me, so I put the fibrillating electrodes on the surface of what muscle I could see and Dr English threw the switch. The heart stopped beating and started quivering, and I began to sew at top speed. Just then Mr Paneth appeared at the operating theatre door. He could see ventricular fibrillation on the monitor and feared the worst. But I didn’t look up and just kept on stitching. By the time Dr English announced the two-minute cut-off I’d almost finished bringing the muscle edges together. I carried on to three minutes. Then the hole was closed, with just the knot to tie.

      Putting the defibrillating paddles as close to the heart as possible I said, ‘Defibrillate.’ Nothing happened. The leads to the paddles hadn’t been plugged into the machine, a minor detail. Seconds ticked by. Then came the ‘zap’ I’d been waiting for. The heart briefly stood still then fibrillated again.

      Paneth strode across from the door in his smart suit and outdoor shoes. No hat, no mask. He looked over the drapes at the quivering muscle and said the obvious. ‘More volts.’ Another zap. The heart defibrillated and started to beat vigorously.

      Paneth grinned, then asked, ‘Anything you’d like to tell me, Westaby? The mitral valve isn’t in the right ventricle, you know. I thought you were bright.’ He winked at Sister, announced that he was going for tea and meanwhile not to let Westaby do anything stupid.

      I scraped my nerves from the ceiling, took stock and tied that last knot. The heart seemed to be working fine, despite my assault. There was blood all down my gown, on Lord Brock’s boots and in a pool on the marble floor, but the blood pressure was back to normal. Today’s battle had been won.

      I looked at Sister, who was just a pair of cool blue eyes above the mask, and reached for her blood-stained rubber glove to say thanks for saving both of us. By the time Mr Paneth took over it was as if nothing had happened, apart from jokes about the extra needlework on the front of the heart. I felt like screaming at him, ‘Why didn’t you tell me she was a fucking re-do?’, then realised that he probably had no recollection of that as it was many months since he’d talked to her in Outpatients.

      The rest of the operation went smoothly. Dr English and the perfusionist continued their chess game, I held the sucker and Paneth chopped out the deformed valve, replacing it with a ‘ball in cage’ prosthesis. Then lots of stitching-up.

      There was no end to the day for surgical residents. That night I sat in the intensive care unit waiting for the old lady to wake up, desperately hoping that she wasn’t brain damaged and wondering how I’d have felt had she bled to her death on the operating theatre floor. Would I have had the grit to continue? Or would my surgical career have ended that day? There was such a very fine line between hero and zero, but I’d survived. I just wanted her to wake up now.

      Her husband and daughter were keeping vigil by her bedside. Her husband asked whether the operation had gone well. I just glibly said, ‘Yes, very well. Mr Paneth did a great job,’ avoiding any implication that I’d fucked up.

      As if to order, she opened her eyes. A wave of relief flowed over me. Husband and daughter jumped to their feet, making sure that she could see them as she stared up at the ceiling, still transfixed by the breathing tube. They reached out for her hand. At that point I realised something – heart surgery might become an everyday occurrence for me, but for the patient and their relatives it is once in a lifetime, and absolutely terrifying. Treat them kindly.

      Cardiac surgery is like quicksand. Once in it you’re sucked deeper and deeper, and I struggled to leave the hospital in case something remarkable happened and I missed it. I spent endless hours sitting beside the cots of Mr Lincoln’s babies, listening to the bip, bip, bip of the monitors, watching the blood pressure sag and trying to get it up again, hoping that blood would stop dripping into the drains.

      The next débâcle followed quite quickly. One Saturday evening before Christmas, a group of residents were in the pub following dinner in the mess. Because there was no casualty department at the Brompton it was highly unusual for emergency operations to be held at night, particularly over the weekend. With a couple of pints of beer on board we were alerted by the switchboard that an American Air Force jet had taken off from Iceland carrying a young man injured in a road-traffic accident. He had a tear in the wall of the aorta and Mr Paneth was coming in to operate. Bad problem, both the injury and the beer. Not so much the amount of alcohol – we were used to that – more the volume of urine to pass during a four-hour operation. Nor could I avoid being involved, as Paneth would need two assistants. Although there was no way I could maintain concentration with a bursting bladder, I didn’t want to lose face by asking to leave, like a whimpering schoolboy with his hand up in class.

      As the senior registrar went off to make arrangements with the operating theatres I pondered the possibilities. What about a urinary catheter and drainage bag for the duration of the procedure? I didn’t really relish the idea of passing the catheter myself. Nor the discomfort of standing with the bag of urine strapped to my leg. And then it dawned on me. Lord Brock’s operating theatre boots! One of them would hold a couple of pints, and with a length of Paul’s tubing – thin-walled rubber tubing that was once used for incontinent males – there would be less risk of a bladder infection than if I inserted my own urinary СКАЧАТЬ