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

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       lord brock’s boots

      He has been a doctor a year now and has had two patients. No, three, I think. Yes, three. I attended their funerals.

      Mark Twain

      The best way to prepare for the exams to become a Fellow of the Royal College of Surgeons was to work as an anatomy demonstrator in the dissection room of the medical school, teaching anatomy to the new students in minute detail and helping them to dismantle their cadaver sliver by sliver – skin, fat, muscle, sinew and then the organs. They were given greasy embalmed corpses on a tin trolley, and there were six new and impressionable students to each one. They’d march in with their starched white coats and brand new dissection kits – scalpel, scissors, forceps and hooks in a linen roll – all as green as grass. Just like me when I started.

      I moved from group to group to maintain their momentum. A few couldn’t hack it. Spending untold hours picking away at a corpse was not part of their medical dream, so I gave the best advice I could to help them through it: wear strong perfume, don’t skip breakfast and try to think about something else – football, shopping, sex, anything. Just learn enough to pass the tests and don’t let the stiffs drive you out. This worked with some. Others had nightmares, their dissected corpses visiting them at night.

      For my first surgery exam I had to master anatomy, physiology and pathology – nothing to do with being able to operate. There were courses in London that just hammered home the facts, taught by past examiners who presented the information in the way that the college wanted it. Pay up and pass was the message, unless you were an idiot. Yet two-thirds of candidates still failed come exam time, including myself on the first occasion.

      In the midst of this academic monotony the Royal Brompton Hospital advertised for ‘Resident Surgical Officers’, with Fellowship of the Royal College of Surgeons being ‘desirable but not obligatory’. Could I aspire to this? I’d only just passed the first part. It would be a minimum of three years before I could sit the final exam, but there would be nothing lost by trying for the post.

      Despite the odds I succeeded in securing the job and started in the position just a few weeks later. I was allocated to work for Mr Matthias Paneth, an imposing six-foot, six-inch German, and Mr Christopher Lincoln, the newly appointed children’s heart surgeon of similar height. Two very different personalities, but both scary in their own way until I knew them better. In my massively busy junior resident jobs at Charing Cross I learned that the only way to keep up was to write everything down. Record every order or request as it was verbalised. To forget was to be in deep shit, so I always carried a clipboard. This was a source of great amusement to Mr Paneth, who took to saying, ‘Did you get that, Westaby? Did you get that, Westaby?’

      My surgical logbook opened in spectacular fashion. The Paneth team had a case scheduled after the outpatient’s clinic, a little old lady from Wales for mitral valve replacement. The boss invited me to go and start while he saw a couple more private patients. I proudly changed into the blue scrubs. Not only that, I found a pair of white rubber surgeon’s boots in an open locker. They were well worn and dirty. I could have had new clogs but coveted these discarded second-hand boots. Why? Because down the strip at the back was written ‘Brock’. I was about to inherit Lord Brock’s boots.

      By now Baron Brock of Wimbledon was seventy and had stopped operating, Paneth alluding to his having ‘perpetual disappointment at the unattainability of universal perfection’. He was President of the Royal College of Surgeons when I was at medical school and stayed on as Director of the Department of Surgical Sciences, and now I’d be following in his footsteps. Literally. I strode out of the surgeons’ changing room straight into the operating theatre to introduce myself.

      The old lady was on the operating table. The scrub sister, who had already prepared her with antiseptic iodine solution and covered her naked body in faded green linen drapes, was now impatiently tapping her theatre clogs on the marble floor, and the long-suffering anaesthetist Dr English and the chief perfusionist were playing chess by the anaesthetic machine. I sensed that everyone had been waiting for some time. I pulled on my face mask and quickly scrubbed up, relishing this first opportunity to showcase my skills.

      I carefully located the landmarks, the sternal notch at the base of the neck and the tongue of cartilage at the lower end of the breastbone. The scalpel incision – a perfectly straight line cut from top to bottom – would carefully join the two. The old lady was thin and emaciated with heart failure, and there was little fat between skin and bone to cleave with the electrocautery. At this point there was still no sign of the other assistant surgeon, but I pressed on regardless, seeking to impress the nurses.

      I took the oscillating bone saw and tested it. Bzzzz. That was fierce enough. So I bravely started to run it up the bone towards the neck. Then, disaster. After the light spattering of bloody bone marrow there was a sudden whoosh of dark red blood pouring from the middle of the incision. Oh shit! Instantly I started to sweat, but Sister knew the score, swiftly moving around to the first assistant’s position. I grabbed the sucker but she was giving the orders. ‘Press hard on the bleeding.’

      Dr English belatedly looked up from the chess board, unfazed by the frenetic activity. ‘Get me a unit of blood,’ he calmly instructed the anaesthetic nurse. ‘Then give Mr Paneth a call in Outpatients.’

      I knew what the problem was. The saw had lacerated the right ventricle. But how? There should have been a tissue space behind the sternum and fluid in the sac around the heart. Sister was reading my mind, something she would do many times over the next six months. ‘You do know that this is a reoperation.’ A statement that was really a question.

      ‘No, absolutely not,’ I replied frantically. ‘Where’s the bloody scar?’

      ‘It was a closed mitral valvotomy. The scar’s around the side of the chest. You can just see it under her breast. Didn’t Mr Paneth tell you it was a re-do?’

      By this point I’d decided to keep my mouth shut. It was time for action, not recrimination.

      In reoperations the heart and surrounding tissues are stuck together by inflammatory adhesions, and there’s no space between the heart and the fibrous sac around it. In this case the right ventricle had stuck to the underside of the breastbone and everything was matted together. Worse still, the right ventricle was dilated because the pressure in the pulmonary artery was high, the rheumatic mitral valve having narrowed considerably. We were there to replace the diseased valve but I’d buggered it up right from the start. Great.

      Pressing hadn’t controlled the bleeding. Blood still poured through the bone and the sternum wasn’t completely open yet. The patient’s blood pressure began to sag and, as she was a small lady, she didn’t have that much blood to lose. Dr English started to transfuse donor blood but that wasn’t the answer, like pouring water into a drainpipe. In one end, straight out the other. I was the surgeon, it was my job to stop the haemorrhage – and for that I needed to see the hole.

      My own perspiration dripped into the wound and trickled down my legs into Lord Brock’s boots. The old lady’s blood flowed off the drapes onto the faded СКАЧАТЬ