The Knife’s Edge. Stephen Westaby

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СКАЧАТЬ department, just three heart surgeons would perform 1,500 heart operations each year and we’d cover the chest surgery between us. Now in the same modest facilities we had five heart surgeons performing half that number of cases, alongside another three chest surgeons operating on the lungs. This was the price of progress – twice as many highly trained professionals doing much less work amid a disintegrating infrastructure. But hey. A hospital delegation was trying to recruit nurses in the Philippines that very week, so all would be well one day.

8 am – and my early-morning optimism was already punctured. I left the cacophony of life support, pulsating balloon pumps, hissing ventilators and screeching alarms. I heard weeping relatives, suggesting that a bed might soon be vacated. Knife to skin should be at 8.30, and I expected the baby to be anaesthetised by now. I assiduously avoided watching parents part from their children at the operating theatre doors. It was traumatic enough for me when my son had his tonsils out. Heart operations were a cut above. When I told parents that their child had a 95 per cent chance of survival, all that registered was the 5 per cent possibility of death. Statistics don’t help when it’s your child that doesn’t make it. So I told them what they wanted to hear, then hoped it would be true.

      But the anaesthetic room was empty. The anaesthetist was sitting in the coffee room eating breakfast.

      ‘Have we sent yet?’ I asked with an air of resignation.

      She shook her head. We had to wait for the paediatric intensive care ward round to decide whether they could give us a bed. No bed, third cancellation. It couldn’t be allowed to happen, yet the round hadn’t even started. It was an 8.30 start at the other end of the corridor, so I went there directly. With rising blood pressure, I still tried to remain polite. The staff had desperately sick children to care for and my little patient was just another anonymous name in the diary, followed by the words ‘atrioventricular canal’. The whole centre of her heart was missing and her lungs were flooded. With every day that passed, her chances of survival decreased.

The trouble was that I loved the children’s intensive care unit. That little enclave of rooms was my escape from the rest of the hospital, a place that always put life – and my own troubles – in perspective. Only special people could survive the heartache in that place. The nurses liked to work with my heart surgery cases because the vast majority got better, a welcome relief from the ravages of children’s cancer, septicaemia or road-traffic accidents that they also had to deal with. The worst things in the world happened there, but everyone came back the next day to start all over again.

      Every one of the cots had a little body in it, with fretful family groups gathered around. My eyes fixed on a pair of gangrenous arms – the meningococcal meningitis child I’d watched for weeks, hanging on to life. The mother knew me well enough by now, seeing my babies come and go with happy parents. I always asked her how things were going, she always smiled. Today they were going to amputate those black, mummified limbs. No more little hands or tiny fingers. They would just drop off, with a little help to tidy things up.

      I asked whether there was any chance of a bed by lunchtime, so that we could at least send for the baby. Sister really didn’t want to let me down. One of her day-shift nurses was already in the radiology department with a head-trauma victim who’d been hit by a speeding car on the way to school. Should the injuries prove as severe as feared, ventilatory support would be withdrawn. Then my case could go to theatre. I enquired whether the organ donor phrase had been mentioned.

‘Do you want the bed or don’t you?’ she replied. ‘That route could take us well into tomorrow.’

      For comfort I picked up a bacon sandwich, then wandered off in my theatre gear through the hordes who arrived for work at nine o’clock. These were normal people who didn’t have to split breast-bones, stop hearts or give desolate parents bad news, such as ‘Your child’s operation is cancelled again.’ Now the dilemma. Should I give up on the little girl, then send for the VIP and her mitral repair? The lady wouldn’t have been starved long enough or had a pre-med, but at least I could take off to Cambridge to see my daughter afterwards without the worry of leaving a newly operated infant when I wasn’t on call. Or should I hold out for the possibility of a bed for her parents’ sake?

Turning away from blank faces and the tacit acceptance of dysfunctionality, I diverted to radiology. They knew me well enough at the CT scanner and seemed relieved to discover that I was not attempting to take over their next slot. The images of the child’s battered brain emerged slice by slice. The skull had been cracked open like the top of a boiled egg. Where there should have been clear lakes of cerebrospinal fluid, there was nothing. The brain surgeon and intensive care doctors shook their heads in dismay. Nothing would be gained by operating. The cerebral cortex was pulp and the brain stem had herniated through the base of the skull. I was relieved that I couldn’t see that poor broken body concealed within the scanner. She had toddled off happily to the village school; now she hovered between earth and heaven, her brain already gone. So I had my intensive care bed. Relief for one set of parents, complete and utter desolation for another.

      Striding purposefully back to the operating theatres, I requested that they send directly for my first case. The agency anaesthetic nurse hadn’t the faintest idea who I was and confronted me with the usual crap, saying that they hadn’t heard if there was a bed yet.

      Uncharacteristically, and because I didn’t know the woman, I lost the plot and shouted, ‘I’m telling you there’s a fucking bed. Now send for the child.’

      The anaesthetist stood in the doorway and gave me a long, hard stare. The nurse picked up the phone and called the paediatric intensive care unit sister. At that moment, I worried that others had not been informed that the trauma case was not for ventilation. But I got lucky. The response confirmed my outburst. Yes, we could send for the cardiac case.

      To put the baby asleep and insert cannulas into her tiny blood vessels would take an hour, so to avoid the transmitted anxiety from the parents’ tearful separation from their baby girl, I slipped into the anaesthetic room of the thoracic theatre, carrying a plastic cup of ghastly grey coffee. This time I was warmly greeted by an old friend, whom I asked to measure my blood pressure. It was 180/100 – far too high, despite the daily blood pressure medication I had been taking for ten years.

As the fearful parents shuffled past the door I heard one of them say, ‘Please tell Professor Westaby we are grateful for this chance.’ I suspected they still didn’t believe that their baby would make it. Perhaps they were worried that we wouldn’t try as hard as we could because of the Down’s syndrome.

      Would a concert pianist prepare for an important recital by first enduring three hours of intense frustration? Would a watchmaker have to face a blazing row before assembling a complicated Rolex movement? My job was to reconfigure a deformed heart the size of a walnut, yet I enjoyed zero consideration for my state of mind from those around me. I wouldn’t so much as get on a bus if the driver was subject to that much irritation. The first time I stood as the operating surgeon looking into the void at the centre of an atrioventricular canal defect, I thought, ‘Shit, what the hell do I do with this?’ Yet I always succeeded in separating the left and right sides of the heart with patches, then creating new mitral and tricuspid valves from the rudimentary valve tissue. It’s complex work, but I never lost one on the operating table.

I finally ran the stainless-steel blade through the baby’s skin at 11 am. As the first drops of blood skidded over the plastic drape, I remembered that I had not made contact with my daughter. That thought hit me just as the oscillating saw bisected the baby’s sternum, but there was nothing I could do about it now. I needed complete focus to reconfigure that tiny deformed heart and give the baby a lifetime without breathlessness or pain. So what did I need to consider? The new mitral valve must not leak, although it wouldn’t be too bad if there was a whiff of regurgitation through the tricuspid valve on the low-pressure side of the circulation. And we had to be careful not to damage СКАЧАТЬ