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First published by HarperCollinsPublishers 2017

FIRST EDITION

© Stephen Westaby 2017

Cover design by Claire Ward © HarperCollinsPublishers Ltd 2017

Cover photograph © Shutterstock.com

Text illustrations © Dee McLean

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Source ISBN: 9780008196783

Ebook edition: February 2017 ISBN: 9780008196776

Version: 2017-12-02

dedication

This book is dedicated to my wonderful children Gemma and Mark, and to my granddaughters Alice and Chloe.

contents

Cover

Title Page

Copyright

Dedication

Foreword

1 The Ether Dome

2 Humble Beginnings

3 Lord Brock’s Boots

4 Township Boy

5 The Girl with No Name

6 The Man with Two Hearts

7 Saving Julie’s Heart

8 The Black Banana

9 Domino Heart

10 Life on a Battery

11 Anna’s Story

12 Mr Clarke

13 Adrenaline Rush

14 Despair

15 Double Jeopardy

16 Your Life in Their Hands

Afterword

Acknowledgements

Glossary

About the Publisher

foreword

Woody Allen famously said, ‘The brain is my second favourite organ.’ I had the same affinity with the heart. I liked to watch it, stop it, repair it and start it up again, like a mechanic tinkering with an engine beneath the bonnet of a car. When I finally understood how it worked, the rest just followed on. After all, in my younger days I’d been an artist. I simply shifted from brush on canvas to scalpel through human flesh. More hobby than job, and more pleasure than chore, it was simply something I was good at.

My career followed a curiously erratic course, from self-effacing schoolboy to wildly extrovert medical student, from ruthlessly ambitious young doctor to introverted surgical pioneer and teacher. Throughout this journey I was repeatedly asked what I found so compelling about cardiac surgery. I hope the following pages will make that clear.

But before launching into the action let me share with you some facts about this vibrant organ. Every heart is different. Some are fat, some are lean. Some are thick, some are thin. Some are fast, some are slow. Just never the same. Most of the 12,000 that I’ve worked on have been desperately sick, causing misery, crushing chest pain, interminable fatigue and terrifying breathlessness.

What’s so fascinating about the human heart is its movement – the rhythm and efficiency of the thing. The facts are staggering. The heart beats more than 60 times per minute to pump five litres of blood. This adds up to 3,600 beats an hour and 86,400 in 24 hours. It beats more than 31 million times in a year and 2.5 billion times in 80 years. The left and right sides of the heart eject more than 6,000 litres of blood daily to the body and lungs. A truly incredible workload that requires huge amounts of energy. So when the heart fails there are dire consequences. And given this astounding performance how could one conceive of replacing the human heart with a mechanical device? Or even with a dead person’s heart?

My school biology classes taught me that the heart sits in the centre of the chest and has four parts – two collecting chambers, the left and right atria; and two pumping chambers, the left and right ventricles. Textbook diagrams show them side by side, like a house with two bedrooms situated above a sitting room and a kitchen. The spongy, expansible lungs surrounding the heart resemble the roof of a Swiss chalet, and they constantly replenish blood oxygen levels and expel carbon dioxide into the atmosphere. (Most of us also know that other chemicals can be discharged in the breath, notably alcohol when blood levels exceed the liver’s capacity to metabolise it.)

Well-oxygenated blood leaves the lungs to enter the left atrium through four separate veins, two from each side. During the heart’s filling phase, or diastole, blood flows through the mitral valve – named after its likeness to a bishop’s mitre – and into the powerful left ventricle. During ventricular contraction, or systole, the mitral valve closes. The contents of the left ventricle are ejected onwards through the aortic valve into the aorta and around the arteries to the body.

Intriguingly, the right ventricle works in an entirely different way. It’s crescentic in shape and applied to the side of the left ventricle, the part known as the ventricular septum. With this ‘new moon’ shape the right ventricle pumps like bellows. So the ventricles depend on each other. It was that rhythm of the heart that I found captivating, like watching a pianist’s hands or a dancer’s feet.

But is it all really that simple? My mother used to buy sheep hearts from the butcher; inexpensive and tasty enough, and great for dissecting. It was while cutting these up that I discovered that real hearts are more complex and difficult to understand than in textbook diagrams, as the shape and muscular architecture of the two ventricles are completely different. Nor are they left and right – more front and back. The thicker left ventricle is conical in shape and has circular muscle bands that constrict and rotate the chamber. Now we can visualise how the left ventricle really works. As the powerful muscle contracts and thickens, its cavity narrows and shortens. During relaxation – the diastolic phase – the left ventricle recoils and the aortic valve closes. The recoiling cavity widens and lengthens, sucking blood from the atrium into the ventricle through the mitral valve. Thus every coordinated cycle of contraction and relaxation involves narrowing, twisting and shortening, followed by widening, uncoiling and lengthening. A veritable Argentine tango … but with two important differences: the whole process takes less than one second and the dance goes on forever.

Every cell in the body needs ‘life blood’ and oxygen; in the absence of these the tissues die at different rates, brain first, bone last. It all depends upon how much oxygen each cell needs. When the heart stops, the brain and nervous system are damaged in less than five minutes. Brain death ensues.

Now you are a cardiologist. You know about the heart and circulation. But you will still need a surgeon to help your patient.

1

the ether dome

For this relief much thanks; ’tis bitter cold and I am sick at heart.

William Shakespeare, Hamlet, Act I, Scene i

The finest of margins separates life from death, triumph from defeat, hope from despair – a few more dead muscle cells, a fraction more lactic acid in the blood, a little extra swelling of the brain. Grim Reaper perches on every surgeon’s shoulder and death is always definitive. There are no second chances.

November 1966. I’m eighteen and a week into my first term as a student at the Charing Cross Hospital Medical School in the centre of London, just across from the hospital itself. I wanted to see a vibrant, beating heart, not a slimy piece of lifeless meat on the dissection table. I was told by a hall porter at the school that heart surgery was done over the road in the hospital on Wednesdays and that I should look for the ether dome. Find the green door on the very top floor under the eaves where nobody goes. But don’t get caught, he warned me. Pre-clinical students are not allowed up there.

It was late in the afternoon, already dark, and drizzle was falling on the Strand when I set out to find the ether dome, which turned out to be an antiquated leaden glass dome above the operating theatre in the old Charing Cross Hospital. Not since my entrance interview had I entered the hallowed portals of the hospital itself. We students had to earn that privilege by passing exams in anatomy, physiology and biochemistry. So I didn’t enter by the Grecian portico of the main entrance, but sneaked in through Casualty under the blue light and found a lift, a rickety old cage used to take equipment and bodies from the wards to the basement.

I worried that I would be too late, that the operation would be finished – and that the green door would be locked. But it wasn’t. Behind the green door was a dark, dusty corridor, a depository for obsolete anaesthetic machines and discarded surgical instruments. Ten yards away I could see the glow of the operating lights beneath the dome itself. It was an old operating theatre viewing gallery respectfully separated by glass from the drama on the operating table no more than ten feet below, with a hand rail and curved wooden benches worn smooth by the restless backsides of would-be surgeons.

I sat clutching the hand rail, just me and Grim Reaper, and peered through glass hazy with condensation. It was a heart operation and the chest was still open. I moved to find the best view, settling for a position directly above the surgeon’s head. He was well known, at least in our medical school, a tall man, slim and imposing, with very long fingers. In the 1960s heart surgery was still new and exciting, its practitioners few and far between, and not many had been properly trained in the specialty. Often they were skilled general surgeons who had visited one of the pioneering centres and then volunteered to start a new programme. They were on a steep learning curve, with the cost measured in human lives.

The two surgical assistants and the scrub nurse were huddled together over the gaping wound, frantically shuttling instruments between them. And there it was, the focus of their attention and of my fascination. A beating human heart. In fact it was squirming more than beating, and was still attached by cannulas and tubing to the heart–lung machine. Cylindrical discs were spinning through a trough of blood bathed in oxygen and a crude roller pump squeezed the tubes, accelerating this life blood back to the body. I peered closer but could only see the heart as the patient was completely covered by green drapes, gratifyingly anonymous to all concerned.

The surgeon restlessly shifted his weight from foot to foot, wearing the big, white operating boots that surgeons once used to keep blood off their socks. The team had replaced the patient’s mitral valve but the heart was struggling to separate from the bypass machine. This was the first time I’d seen a beating human heart, and even to me it looked feeble, blown up like a balloon, pulsating but not pumping. On the wall behind me was a box marked ‘Intercom’. I threw the switch and the drama now had a soundtrack.

Against the din of amplified background noise I heard the surgeon say, ‘Let’s give it one last go. Increase the adrenaline. Ventilate and let’s try to come off.’

There was silence as everyone watched the desperate organ fight for its life.

‘There’s air in the right coronary,’ the first assistant said. ‘Give me an air needle.’ He shoved the needle into the aorta, frothy blood fizzed into the wound, then the patient’s blood pressure started to improve.

Sensing a window of opportunity, the surgeon turned to the perfusionist. ‘Come off now! This is our last chance.’

‘Off bypass,’ came the reply, said more as a blunt matter of fact than with any great confidence.

The heart–lung machine was switched off and the heart was now free-standing, with the left ventricle pumping blood to the body, the right ventricle to the lungs. Both were struggling. The anaesthetist stared hopefully at the screen, watching the blood pressure and heart rate. Knowing that this was their last attempt, the surgeons silently withdrew the cannulas from the heart and sewed up the holes, each one of them willing it to get stronger. For a while it fluttered feebly but then the pressure slowly drifted down. There was bleeding from somewhere – not torrential but persistent. Somewhere at the back. Somewhere inaccessible.

Lifting the heart caused it to fibrillate. It was now squirming again, wriggling like a bag of worms, but not contracting, fed by uncoordinated electrical activity. Wasted energy. It took the anaesthetist a while to spot this on his screen. ‘VF,’ he shouted. I’d soon learn that this meant ventricular fibrillation. ‘Shock it.’

The surgeon was expecting this and was holding the defibrillating paddles hard against the heart. ‘Thirty joules.’ Zap! No change. ‘Give it sixty.’

Zap! This time it defibrillated, but then just sat there stunned and devoid of electrical activity, like a wet brown paper bag. Asystole, as we call it.

Blood continued to fill the chest and the surgeon poked the heart with his finger. The ventricles responded by contracting. He poked it again and the rhythm returned. ‘Too slow. Give me a syringe of adrenaline.’ The needle was shoved unceremoniously through the right ventricle into the left, and a clear liquid squirted in. Then he massaged the heart with his long fingers to push the powerful stimulant into the coronary arteries.

The grateful heart muscle responded rapidly. Straight out of the textbook, the heart rate accelerated and the blood pressure soared, up and up, dangerously testing the stitches. Then, as if in slow motion, the cannula site in the aorta gave way. Whoosh! Like a geyser erupting, a crimson fountain hit the operating lights, spraying the surgeons and soaking the green drapes. Someone murmured, ‘Oh, shit.’ An understatement. The battle was lost.

Before a finger could plug the hole the heart was empty. Blood dripped from the lights and red rivulets streamed across the marble floor. Rubber soles stuck to it. The anaesthetist frantically squeezed bags of blood into the veins, but to no avail. Life was fast ebbing away. As the injected slug of adrenaline wore off, the turgid heart simply blew up like a balloon and stopped. Stopped forever.

The surgeons stood silently in despair, as they did week after week. The senior surgeon then walked away out of my view and the anaesthetist turned off the ventilator, waiting for the electrocardiogram to flatline. He removed the tube from the patient’s windpipe, then he too disappeared from view. The brain was already dead.

Just yards away mist descended on the Strand. Commuters rushed into Charing Cross Station to get out of the rain, late lunches were finishing at Simpson’s and Rules, cocktails were being shaken in the Waldorf and the Savoy. That was life, this was death. A lonely death on the operating table. No more pain, no more breathlessness, no more love, no more hate. No more anything.

The perfusionist wheeled his machine out of theatre, and it would take hours to disassemble, clean, restore and sterilise it for the next patient. Only the scrub nurse lingered. Then she was joined by the anaesthetic nurse who had comforted the patient in the anteroom. They took off their masks and stood silently for a while, unconcerned by the sticky blood that covered every surface and by the chest still splinted open. The anaesthetic nurse searched for the patient’s hand beneath the drapes and held it. The scrub nurse pulled away the blood-soaked covering from the face and stroked it. I could see the patient was a young woman.

They were oblivious to the fact that I was upstairs in the ether dome. No one had seen me there. Only Grim Reaper – and he’d already departed with the soul. I gingerly shifted along the bench to look at the woman’s face. Her eyes were wide open, staring up into the dome. She was ashen white but still beautiful, with her fine cheek bones and jet black hair.

Like the nurses I couldn’t leave. I needed to know what happened next. They peeled back the bloodied drapes from her naked body. I was silently screaming for them to take out that hideous retractor cranking open her breastbone and let her poor heart go back to where it belonged. When they did the ribs recoiled and the poor lifeless organ was covered again. It lay flat, empty and defeated in its own space, with just a fearsome, deep gash separating her swollen breasts.

The intercom was still switched on and the nurses started to talk.

‘What’ll happen to her baby?’

‘Adopted, I guess. She wasn’t married. Her parents were killed in the Blitz.’

‘Where did she live?’

‘Whitechapel, but I’m not sure the London do heart surgery yet. She got really sick during the pregnancy. Rheumatic fever. She nearly died during the delivery. Might’ve been for the best.’

‘Where’s the baby now?’

‘On the ward, I think. Matron’ll have to deal with it.’

‘Does she know?’

‘Not yet. You go and find her. I’ll get some help to finish off.’

It was all so matter of fact. A young woman had died, her baby left without a relative in the world. No more love, no more warmth, lost amid that tangled, blood-soaked technology in the operating theatre. Was I ready for this? Was this what I aspired to?

Two student nurses came to wash the body. I recognised them as respectful public schoolgirls from the Friday-night freshers’ dance. They’d brought a bucket of soapy water with sponges and set about scrubbing her clean. They removed the vascular cannulas and the bladder catheter but were visibly upset by the wound and what lay beneath. Blood kept slopping out of it.

‘What did she have done?’ asked the girl I’d danced with.

‘Heart operation, obviously,’ came the reply. ‘Valve replacement, I guess. Poor kid. She’s only our age. Bet her mum’s upset.’

They covered the wound with gauze to soak the blood, then taped it up. The scrub nurse returned and thanked the girls for a job well done. She called back the surgical registrar to close over the wound, ready to move the body to the mortuary, as all deaths on the operating table are referred to the coroner for autopsy. The young woman would be sliced open again from neck to pubis, so there was no point closing the breastbone or bringing together the different layers of the chest wall. He took a big needle and some thick braid, and sewed her up like a mail bag. The wound edges still gaped and oozed serum. Mail bags were much neater.

It was now around 6.30 in the evening and I was meant to be in the pub down the road getting pissed with the rugby team. But I still couldn’t leave. I was attached to this empty shell, this skinny corpse I’d never met but now felt I knew well. I’d been with her at the single most important part of her life.

The three nurses manhandled her into a starched white shroud with a ruff around the neck, tied it up at the back then secured her ankles with a bandage. She was beginning to stiffen with rigor mortis. The students had done their job with kindness and respect. I knew that I would meet them again. Maybe I’d ask them how they felt.

Now there were just the two of us left, the corpse and me. The operating lights still shone on her face and she was staring straight up at me. Why hadn’t they closed her eyelids like they did in the movies? I could see through those dilated pupils to the pain etched on her brain.

From fragments of conversation I’d overheard and with just a little medical knowledge I could sketch her life story. She was in her twenties. Born in the East End. She could only have been a small child when her parents were killed in the bombing. As a child she carried the scars of those sights and sounds, the fear of being alone as her world disintegrated. Brought up in poverty, she develops rheumatic fever, a simple streptococcal sore throat that triggers a devastating inflammatory process. Rheumatic fever was common in areas of deprivation and overcrowding. Perhaps she had painful, swollen joints for a few weeks. What she doesn’t know is that the same inflammation is in her heart valves. There was no diagnostic test in those days.

She develops chronic rheumatic heart disease and is known as a sickly child. Perhaps she develops rheumatic chorea – involuntary, jerky movements, unsteady gait and emotional turmoil. She gets pregnant, an occupational hazard. But this makes things worse as her sick heart must work much harder. She becomes breathless and swollen but makes it through to term. Maybe the London Hospital delivers her safely but recognises heart failure. A murmur. A leaking mitral valve. They prescribe the heart drug digoxin to make it beat stronger, but she doesn’t take it as it makes her nauseous. Soon she’s too tired and breathless to look after the baby, and she cannot lie flat. With worsening heart failure her outlook is grim. They send her to the city to see a surgeon, a real gentleman in a morning suit with pinstriped trousers. He’s kind and sympathetic, and says that only surgery on her mitral valve can help. But it doesn’t. It terminates her sad life and leaves another orphan in the East End.

When the porters came for her the operating lights had long been switched off. The mortuary trolley – a tin coffin on wheels – was drawn up alongside the operating table. By now her limbs were rigid. The body was unceremoniously dragged into this human sardine can, her head bouncing with a sickening thud, but nothing could hurt her any more. I was relieved to lose eye contact. A green woollen blanket was folded over the top to make it look like an ordinary trolley, and then off they went to slot her into the fridge. Her baby would never see her again, would never have a mother again.

Welcome to cardiac surgery.

I sat there, arms on the rail, chin on my hands, staring down from the ether dome at the black rubber surface of the empty operating table, as generations of would-be surgeons had done before me. The ether dome was a gladiatorial amphitheatre, people coming here to gaze down on a spectacle of life or death. Perhaps if others had been there it might have seemed less brutal, others with whom to share the shock of this poor girl’s death, the misery awaiting her child.

Auxiliary nurses came with mops and buckets to erase the last traces of her – her blood now dry on the floor around the operating table, the bloody footprints heading towards the door, the blood on the anaesthetic machine, the blood on the operating lights. Blood everywhere – now meticulously wiped up. A slip of a girl reaching up to clean the operating light saw me in the dome, my pale face and staring eyes against the gloom. I frightened her, and so it was my cue to leave. But one spot of blood remained on top of the light where no one could see. Adherent and black, it said part of me is still here. Remember me.

The green door closed behind me and I walked away to the shuddering lift where her body had been taken down to lie in a cold fridge in the mortuary.

Notice of autopsies were posted on a board in the entrance hall of the medical school. Usually the patients were elderly. The young ones were either drug addicts, road-traffic accidents, suicides from the underground system or cardiac surgery patients. I found her on the list for Friday morning. She was called Beth. Not Elizabeth, just Beth. She was twenty-six years old. It had to be her. On the day of the autopsy the bodies were brought from the hospital mortuary in the basement, then dragged under the road to the medical school in a tin box on rails by a pulley system and up the lift to the autopsy room. Should I go? Should I watch her guts and brain be cut out, watch her dead heart be carved into slices, tell them how she really died in that crimson fountain?

No, I couldn’t do it.

Beth taught me a very important lesson that day in the ether dome. Never get involved. Walk away as her surgeons did and try again tomorrow. Sir Russell Brock, the most renowned heart surgeon of the era, was known for his bluntness about losing patients – ‘I have three patients on my operating list today. I wonder which one will survive.’ This may seem insensitive, even callous, but to dwell on death was a dreadful mistake then, and it still is now. We must learn from failure and try to do better the next time. But to indulge in sorrow or regret brings unsustainable misery.

I grappled with this later in my career when my interests veered towards the sharp end: heart surgery for complex congenital anomalies in babies and young children. Some came toddling happily into the hospital, teddy bear in one hand, Mummy holding the other. Blue lips, little chest heaving, blood as thick as treacle. They’d never known a different life and I strived to provide that for them. To make them pink and energetic, liberate them from impending doom. I did this in good faith, yet sometimes without success. So what should I do? Sit with the weeping parents in a dark mortuary holding a cold, lifeless hand, blaming myself for taking that risk?

All heart surgery is a risk. Those of us who make it as surgeons don’t look back. We move on to the next patient, always expecting the outcome to be better, never doubting it.

2

humble beginnings

Courage is doing what you’re afraid to do. There can be no courage unless you’re scared.

Edward V. Rickenbacker, The New York Times Magazine, 24 November 1963

It was at the very start of the post-war baby boom that I arrived into the world in the maternity department of Scunthorpe War Memorial Hospital on 27 July 1948, star sign Leo. Good old Scunthorpe, my childhood home for eighteen years, a steel town and the long-suffering butt of music-hall jokes.

My dear mother, exhausted after a long and painful labour but happy with her first child, brought me safely back home from the carnage of the delivery suite. I was a pink, robust son, wailing from the depths of his newly expanded lungs.

My mother was an intelligent woman, caring, gentle and well liked. During the war she’d managed a small high-street bank, and with other tills empty the old folks would still queue to tell her their troubles. My father joined the RAF at sixteen to fight the Germans, and after the war he got a job in the local Co-operative grocery department and worked hard to improve our circumstances. Life wasn’t easy.

We were church-mice poor in a grimy council estate. House number 13, no pictures allowed on the walls in case the plaster crumbled, with a corrugated tin air-raid shelter in the back garden that housed geese and chickens – and the outside toilet.

My maternal grandparents lived directly across the street. Grandmother was kindly and protective of me, but frail. Grandfather worked at the steelworks and during the war had been the local air-raid warden. On pay day I’d go with him to the works to collect his wages. There I was intrigued by the spectacle of white-hot molten metal being poured into ingots, bare-chested, sweaty men in flat caps stoking the furnaces, steam trains belching fire, clanking up and down between the rolling mills and the slag heaps, and sparks flying everywhere.

Grandfather patiently taught me how to draw and paint. He’d sit over me, puffing away on Woodbines as I painted red night skies over the chimneys, street lamps and railway trains. Grandfather smoked twenty a day and spent his whole life working in smoke at the steelworks. Not the best recipe.

In 1955 we got our first television set, a 10-inch-square box with a grainy black-and-white picture and just one channel, the BBC. Television dramatically widened my awareness of the outside world. That year two Cambridge scientists, Crick and Watson, described the molecular structure of DNA. In Oxford the physician Richard Doll linked smoking with lung cancer. Then came exciting news on a programme called Your Life in Their Hands that would shape the rest of my life. Surgeons in the United States had closed a hole in the heart with a new machine. They called it the heart–lung machine, because it did the job of both organs. The television doctors wore long white coats down to the floor, the nurses had fine, starched uniforms and white caps and rarely spoke, and the patients sat stiffly to attention with their bed sheets folded back.

The show talked about heart operations and how surgeons at the Hammersmith Hospital would attempt one soon. They too would close holes in the heart. This seven-year-old street kid was captivated. Quite mesmerised. Right then I decided that I would be a heart surgeon.

At ten I passed the tests for entry to the local grammar school, and by then I was quiet, compliant and self-conscious. As one of the ‘promising’ set I was forced to work hard. I was a natural in art, although I had to stop those classes in favour of academic subjects. But one thing was clear. I was good with my hands, and my fingertips connected with my brain.

One afternoon after school I was out walking with Grandfather and his Highland terrier Whisky on the outskirts of town when he stopped dead on a hill, clutching the collar of his cloth shirt. His head bowed, his skin turned ashen grey and, sweating and breathless, he sank to the ground like a felled tree. He couldn’t speak and I saw the fear in his eyes. I wanted to run and fetch the doctor but Grandfather wouldn’t let me. He couldn’t risk being off work, even at the age of fifty-eight. I just held his head until the pain abated. It lasted thirty minutes, and once he’d recovered we slowly made for home.

His ill health wasn’t news to my mother. She told me that he’d been getting a lot of ‘indigestion’ while cycling to work. Reluctantly, Grandfather agreed to get off the bike, but it didn’t do much good. The episodes became more frequent, even at rest, and especially when he climbed the stairs. Cold was bad for his chest, so the old iron bed was brought down in front of the fire and the commode was carried inside to save a journey outdoors.

His ankles and calves were so swollen with fluid that he needed bigger shoes. It was a gargantuan effort just to tie his shoelaces, and from then on he didn’t get out much, mostly just moving from the bed to a chair in front of the fire. I’d sit and draw for him to take his mind off his rotten symptoms.

I remember that dismal wet afternoon in November, the day before President Kennedy was assassinated in Dallas. I came home from school to find a black Austin-Healey outside my grandparents’ house. It was the doctor’s car and I knew what that meant. I stared through the condensation on the front window but the curtains were drawn, so I went around the back of the house and walked in quietly through the kitchen door. I could hear sobbing and my heart sank.

The living-room door was ajar and inside it was dimly lit. I peered in. The doctor was standing by the bed with a syringe in his hand, and my mother and grandmother were at the end of the bed, clasping each other tightly. Grandfather looked leaden, with a heaving chest and his head tipped back, and frothy pink fluid was dripping from his blue lips and purple nose. He coughed agonally, spraying bloody foam over the sheets. Then his head fell to one side, wide eyes staring at the wall, fixed on the placard proclaiming ‘Bless This House’. The doctor felt for a pulse at his wrist, then whispered, ‘He’s gone.’ A sense of peace and relief descended on the room. The suffering was at an end.

The certificate would say ‘Death from heart failure’. I slipped out unnoticed to sit with the chickens in the air-raid shelter, and quietly disintegrated.

Soon afterwards my grandmother was diagnosed with thyroid cancer, which started to close off her windpipe. ‘Stridor’ is the medical term to describe the sound of strangulation as the ribs and diaphragm struggle to force air through the narrowed airway, and that’s what we heard. She went to Lincoln, forty miles away, for radiotherapy, but it burned her skin and made swallowing more difficult. We were given some hope of relief by an attempted surgical tracheostomy, but when the surgeon tried to do it he couldn’t position the hole low enough in the windpipe below the narrowing. Our hopes were dashed and she was doomed to suffer until she died. It would have been better if they’d allowed her to go under anaesthetic. Every evening I sat with her after school and did what I could to make her comfortable. Soon opiate drugs and carbon dioxide narcosis clouded her consciousness, and one night she slipped away peacefully with a large brain haemorrhage. At sixty-three she was the longest-lived of my grandparents.

When I reached sixteen I took a job at the steelworks in the school holidays, but after a collision between a dumper truck and a diesel train hauling molten iron they dispensed with my services. I spotted a temporary portering job at the hospital and negotiated the role of operating theatre porter. There were disparate groups to please. The patients – fasted, fearful and lacking dignity in their theatre gowns – required kindness, reassurance and handling with respect. Junior nurses were friendly and fun, the nursing sisters were self-important, bossy and business-like, and needed me to shut up and do what they told me, and the anaesthetists didn’t want to be kept waiting. The surgeons were simply arrogant and just ignored me – at first.

One of my jobs was to help transfer anaesthetised patients from their trolleys onto the operating table. I knew what sort of surgery was planned for each one, having read the operating list, and I helped out by adjusting the overhead lights, focusing them on the site of the incision (as an artist I was intrigued by anatomy and had some knowledge of what lay where). Gradually the surgeons began to take notice, some even asking me about my interest. I told them that I’d be a heart surgeon one day, and soon enough I was allowed to watch the operations.

Working nights was great because of the emergencies: broken bones, ruptured guts and bleeding aneurysms. Most of those with aneurysms died, the nurses cleaning up the corpses and putting on the shrouds, me hauling them from the operating table and onto the tin mortuary trolley, always with a dull thud. Then I’d wheel them off to the mortuary and stack the bodies in the cold store. I soon got used to it.

Inevitably my first mortuary visit took place in the dead of night. The windowless grey brick building was set apart from the main hospital and I was frankly terrified of what I’d find in there. I turned the key in the heavy wooden door that led directly into the autopsy room but when I reached inside I couldn’t find the light switch. I’d been given a torch and its beam danced around as I plucked up the courage to go in.

Green plastic aprons, sharp instruments and shiny marble sparkled in the gloom. The room smelt of death, or what I expected death to smell like. Eventually the torch beam settled on a light switch and I turned on the overhead neons. They didn’t make me feel any better. There were stacks of square metal doors from floor to ceiling – the cold store. I needed to find a fridge but wasn’t sure which ones were empty.

Some doors had a piece of cardboard slotted into them with a name on it, and I figured that they must be occupied. I turned the handle on one without a name, but there was a naked old woman under a white linen sheet. An anonymous corpse. Shit. Try again on the second tier. This time I was lucky, and I pulled out the sliding tin tray and pushed the creaking mechanical hoist towards my stiff. How to make this thing work without dropping the body on the floor? Straps, crank handles and manhandling. I just got on with it and slid the tray back into the fridge.

The mortuary door was still wide open – I didn’t want to be shut in there alone. I sped out and pushed the squeaking mortuary trolley back to the main hospital ready for the next customer. I wondered how pathologists could spend half of their career in that environment, carving entrails from the dead on marble slabs.

Eventually I charmed an elderly female pathologist into letting me watch the autopsies. Even after witnessing some disfiguring operations and terrible trauma cases this took some getting used to, young and old sliced open from throat to pubis, eviscerated, scalp incised from ear to ear and pulled forward over the face like orange peel. An oscillating saw removes the cranium, as if taking the top off a boiled egg, and then the whole human brain lies in front of me. How does this soft, grey, convoluted mass govern our whole lives? And how on earth could surgeons possibly operate on this, a wobbly jelly?

I learned so much in that dingy, desolate autopsy room: the complexity of human anatomy, the very fine line between life and death, the psychology of detachment. There was no room for sentiment in pathology. An ounce of compassion there may be, but affinity with the cadaver? No. Yet personally I felt sad for the young who came here. Babies, children and teenagers with cancer or deformed hearts, those whose lives were destined to be short and miserable or had been terminated by a tragic accident. Forget the heart as the source of love and devotion, or the brain as the seat of the soul. Just get on and slice them up.

Soon I could identify a coronary thrombosis, a myocardial infarction, a rheumatic heart valve and a dissected aorta, or cancer spread to the liver or lungs. The common stuff. Charred or decomposed bodies smelt bad, so Vicks ointment stuffed up the nostrils spared your olfactory nerves. I found suicides to be terribly sad, but when I verbalised this I was told to ‘Get over it if you want to be a surgeon’ and that it would all be easier when I was old enough to drink. I sensed that alcohol was high on the list of surgeons’ recreational activities, and this seemed more obvious when they were called in at night. But who was I to judge?

I began to wonder whether I could really get in to medical school. I was no great academic, and I struggled with maths and physics. For me these subjects were the real barometer of intelligence. But I excelled in biology and could get by in chemistry, and in the end I passed a lot of exams, stuff I would never need like Latin and French literature, additional maths and religious studies. These I saw as a function of effort, not intelligence, but hard work bought me my ticket out of the council estate. In addition, the time spent in the hospital had made me worldly. I’d never been out of Scunthorpe, yet I knew about life and death.

I started to search for a place at medical school, and returned to the hospital during every school holiday. I progressed to working as an ‘operating department assistant’, becoming an expert in cleaning up blood, vomit, bone dust and shit. Humble beginnings.

I was surprised to be called for an interview at a magnificent Cambridge college. Someone must have put in a good word but I never learned who it was. The streets bustled with lively young students in their gowns chatting loudly with public school accents, all seeming much smarter than me. Erudite, bespectacled professors cycled down cobbled streets in their mortarboards off to college dinners for wine, then port. My mind flashed back to the grimy steelworkers silently making their way home in flat caps and mufflers through the smog for bread and potatoes, and then maybe a glass of stout. My spirits started to sink. I didn’t belong here.

The interview was conducted by two distinguished fellows in an oak-panelled study overlooking the main college quadrangle. We sat in well-worn leather armchairs. It was meant to be a relaxed atmosphere, and nothing was said about my background. The anticipated question, ‘Why do you want to study medicine?’ never came. Wasted interview practice. Instead I was asked why the Americans had just invaded Vietnam and whether I had heard of any tropical diseases their soldiers might be exposed to. I didn’t know whether there was malaria in Vietnam so I said, ‘Syphilis.’

That broke the ice, particularly when I suggested that this might be less of a health problem than napalm and bullets. Next I was asked whether smoking cigars may have contributed to Winston Churchill’s demise (he’d only recently died). Smoking was one of the key words I was waiting for. My mouth fired off in automatic mode: cancer, bronchitis, coronary artery disease, myocardial infarction, heart failure, how the corpses of smokers looked in the autopsy room. ‘Had I seen an autopsy?’ ‘Many.’ And cleared up the brains, guts and bodily fluids afterwards. ‘Thank you. We’ll let you know in a few weeks.’

Next I was called down to Charing Cross Hospital, between Trafalgar Square and Covent Garden on the Strand. The original hospital was built to serve the poor of Central London and had a distinguished war history. Although I arrived early I was always last alphabetically, so I twiddled my thumbs anxiously to while away what seemed like hours. A kindly matron received the candidates with tea and cakes, and I made polite conversation with her about what had happened to the hospital during the war.

The interview took place in the hospital board room. Across the other side of the boardroom table from me was the chief interviewer – a distinguished Harley Street surgeon wearing a morning suit – together with the famously irascible Scottish professor of anatomy upon whom the Doctor in the House films were based. I sat straight-backed to attention on an upright wooden chair – no slouching here. I was first asked what I knew about the hospital. Thank you, God. Or Matron. Or both. Next I was asked about my cricketing record and whether I could play rugby. And that was all, the interview was over. I was the last of the day, they’d had enough and they’d let me know.

I wandered out into Covent Garden past the colourful market stalls and bristling public houses. All life was there: tramps, tarts, buskers and bankers, the Charing Cross Hospital clientele, and the black cabs and scarlet London buses that drove up and down the Strand. Meandering between the crowds and the traffic I came to the grand entrance of the Savoy Hotel. I wondered whether I dared go in. Surely I looked smart enough in my interview suit and Brylcreemed hair. But the decision was swiftly made for me when the immaculate doorman pushed the swing doors open and ushered me through with a ‘Welcome, sir.’ The seal of approval. From Scunthorpe to the Savoy.

I strode purposefully through the atrium, past the Savoy Grill, hesitating only to scrutinise the menu in its gilt frame. The prices! I didn’t stop. A sign pointed to the American Bar. The hall was lined with signed cartoons, photographs and paintings of West End stars, and when I reached it there was no queue as it was only 5 pm. Perched on a high stool I furtively devoured free canapés and perused the cocktail menu. Devoid of insight – this was my first alcoholic drink – I was pushed to make a decision. ‘Singapore Sling, please.’ Like flipping a switch, my life had changed. Had I ordered a second I’d never have found King’s Cross station.

Within the week a letter arrived from Charing Cross Hospital Medical School. Opening it surrounded by my anxious parents felt like defusing a bomb. There was the offer of a place. The conditions? Just pass my biology, chemistry and physics exams, no grades specified. Charing Cross was a small medical school with an intake of only fifty students each year, but I’d be following in the footsteps of distinguished alumni such as Thomas Huxley the zoologist and David Livingstone the explorer. I was the first in my family to go to university, the first to attempt to become a doctor and, hopefully, the first heart surgeon.

3

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 white rubber. By now one of the circulating nurses had scrubbed up and joined us at the operating table. Not so brave now, 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 catheter.

I went to the wards in search of the tubing. This came in a roll to be cut to the appropriate length, in my case that of my inside leg. Once I’d found a supply, off I went to the surgeons’ changing room as I was keen to be in theatre all ready to go – with my clipboard and white boots as usual, tubing attached with sticky tape – when the boss arrived. And I was just in time, the ambulance screeching in from Heathrow much sooner than we’d anticipated. Those jets were fast.

We were opening through the ribs of the left side of the chest by midnight and soon encountered bleeding. Paneth was in an irascible mood, having been called out of a Christmas party. As I predicted the beer soon began to make its effects tell and my registrar colleague became restless, shifting from foot to foot and losing concentration. Eventually he had to excuse himself, so I moved into the first assistant position, coughing loudly to disguise the unusual squelching sound. I stayed in his position after he returned as I had no discomfort, despite the fact that my right Wellington boot was slowly filling. After another twenty minutes the registrar had to go out again.

By now the patient was safe, but Paneth was cross. ‘What’s wrong with him? He’s been in the pub, hasn’t he? He’s been drinking.’

‘I really don’t know about that, Mr Paneth. I’ve been studying in the library all evening,’ I replied, waiting to be struck down by a thunderbolt. But it never came.

‘Well done, Westaby,’ he said instead. ‘You get on and close the chest. He can assist you for a change. See you on Monday.’

I disposed of the evidence and accompanied the young man back to intensive care. No one ever knew.

Now beyond sleep, I sat drinking coffee in the paediatric intensive care unit. I talked with the nurses while watching tiny people struggle for life at Christmas in their cosy incubators. As surgical trainees we were all chronically sleep deprived, but there was little excitement in sleep. Sleep was something for the odd weekend off. We were adrenaline junkies living on a continuous high, craving action. From bleeding patients to cardiac arrests. From theatre to intensive care. From pub to party.

Sleep deprivation underpins the psychopathy of the surgical mind – immunity to stress, an ability to take risks, the loss of empathy. Bit by bit I was joining that exclusive club.

4

township boy

Genius is one per cent inspiration, ninety-nine per cent perspiration.

Thomas Edison

October 1979. I was Senior Registrar with the thoracic surgery team at Harefield Hospital in north London. Everyone training in heart surgery had to learn to operate on the lungs and gullet as well, and this meant working with cancer, which I found deeply depressing. Too often it had already spread to other parts of the body, and for most patients the prognosis was grim, so they were depressed too. Moreover, there was an element of monotony about it. The choices were stark: between taking out half a lung or the whole lung, on the right or on the left, or removing the upper part of the gullet or the lower half. After doing each one of these procedures a hundred times it was no longer very stimulating.

Every so often a more challenging case would present itself. Mario was a forty-two-year-old Italian engineer working on a restoration project in Saudi Arabia. A jovial family man, he’d gone to the kingdom hoping to earn enough money to buy a house, which meant toiling hours on end at a large industrial complex outside Jeddah in the searing desert heat. Then catastrophe. Without warning, while he was working in an enclosed area, a huge boiler exploded, filling the air with steam. Steam under high pressure. It scalded his face and burnt the lining of his windpipe and bronchial tubes.

The shock almost killed him immediately. The scalded tissues were dead and whole sheets of necrotic membrane sloughed off from the lining of his bronchial tubes. This obstructive debris had to be removed through an old-fashioned rigid bronchoscope, a long brass tube with a light on its end passed through the back of his throat and voice box then down into his airways.

Mario needed this done regularly, almost daily, to prevent asphyxiation, and pushing the bronchoscope back and forth through his larynx became more and more difficult. Soon it became so scarred that the bronchoscope would not pass and he needed a tracheostomy – a surgical hole in the neck to enable him to breathe. But the dead bronchial lining was quickly replaced by inflammatory tissue and masses of cells started to fill the airways like calcium blocking water pipes. He became unable to breathe, and his condition took a relentless downhill course.

I took the call from Jeddah. The burns doctor looking after him explained the dire situation and wondered whether we had any advice. My only suggestion was that they airlift him to Heathrow and we’d see if anything could be done, so the building company paid for the medical evacuation and he arrived the following day. At the time my boss was in the twilight of his career and was happy for me to take on as much as I felt confident to do. Which was everything. I had no fear. But this was a disaster in a middle-aged man. I asked that we should take a look down his windpipe together and then try to come up with a plan.

Mario was a sorry sight. He was gasping for breath, with the infected froth pouring from his tracheostomy tube making a dreadful, gurgling sound. His scarlet face was badly burnt, its crusted, dead skin peeling away and weeping serum. Burnt on the outside and burnt on the inside, the fragile and bloody tissue that occluded the whole of his windpipe was going to asphyxiate him. It was a great relief for him to be put to sleep.

As he lapsed into unconsciousness I sucked blood-stained sticky secretions from the hole in his neck, then attached the tubing from the ventilator to the tracheostomy tube and squeezed the black rubber bag. The lungs were difficult to inflate against the resistance. I decided that we should attempt to pass the rigid bronchoscope by the normal route directly through the vocal cords and larynx. This is akin to sword swallowing, but down the airways rather than the gullet.

We needed a view of the whole windpipe and both right and left main bronchial tubes. For this the head needs to be tipped at the correct angle so the vocal cords at the back of the throat can be seen. We do try hard not to knock out any teeth. This technique used to be performed on conscious individuals after lung surgery, when I’d have to hoover the patients out because there were never enough physiotherapists. Rough at the time but better than drowning.

I manoeuvred the rigid telescope over the teeth and along the back of the tongue, then peered down to locate the snippet of cartilage – the epiglottis – that protects the opening of the voice box during swallowing. If you lift its tip with the bronchoscope you should be able to find the glistening white vocal cords, with a vertical slit between the two. This is the way into the windpipe and I’d done the procedure hundreds of times to biopsy lung cancer. Or remove peanuts. But here, with the voice box burned and the vocal cords like sausages, inflamed and angry looking, there was no way through. Mario was entirely reliant on the tracheostomy.

Standing aside, I tried to show the boss by keeping the bronchoscope still, propped on the teeth. He grunted and shook his head. ‘Try pushing it harder. Nothing to lose, I suspect.’

Taking aim again, I pushed the beak of the scope where the slit should be and shoved. The swollen vocal cords parted and the instrument crashed against the tracheostomy tube. We attached the ventilating apparatus to the side of the bronchoscope and pulled out the tube. Normally we’d see the full length of the windpipe to where it divides into the main bronchi. In this case, not a chance. The airways had been virtually obliterated by the proliferating cells, so I eased the rigid implement onward using the sucker to aspirate blood and detached tissue, at the same time pushing in oxygen through the bronchoscope tip. I was hoping to see an end to the burns, and we finally encountered normal airway lining halfway down each main bronchial tube. But now the traumatised lining was oozing blood.

Mario’s bright red face had turned purple and was getting bluer by the minute, so the boss took over, peering down the tube, occasionally inserting the long telescope for a better view. It was a precarious situation without an obvious solution. If you can’t breathe you die. Fortunately with time the bleeding died down and the airway was better than it had been once some gunk had been removed. We reinserted the tracheostomy tube and put him back on the ventilator. Both sides of the chest still moved and both lungs were inflated. This was a triumph in itself, but it was doubtful there was any way forward. We both concluded that his prospects were bleak.

Two days later Mario’s left lung collapsed and we went through the same process again. It was just as bad. The tissue just kept on growing, and he remained fully conscious on the ventilator but very distressed.

Asphyxiation is the most miserable way to die. I remembered my grandmother, strangulated by cancer of the thyroid gland. She’d been told she needed a tracheostomy, only to have the procedure aborted, so she sat propped up in bed day and night gasping for breath. I recalled trying to work out ways to help. Why wasn’t it possible to put a tube further down, past the obstruction? Why couldn’t tracheostomy tubes be made longer? A simple concept but I was repeatedly told it wasn’t possible.

From what I could see through the bronchoscope, the situation with Mario was nearly identical. He needed something to bypass his whole trachea and both main bronchi, otherwise he’d be dead in days. We couldn’t keep opening the airways with a bronchoscope. Not forever. Grim Reaper was winning this battle and was about to swing his scythe.

Ever the optimist, I questioned whether there was anything else we could do. Could we make a branched tube to bypass the damaged airways? The boss thought not, because it would clog with secretions. Surely someone else would have done it before for cancer. Then something else occurred to me – a company called Hood Laboratories in Boston, Massachusetts made a silicone rubber tube with a tracheostomy side limb, called a Montgomery T-tube after its ear, nose and throat surgeon inventor. Maybe I should talk to them and explain the problem.

When I bronchoscoped Mario later that afternoon I took measurements to calculate how long the tube needed to be to reach down each main bronchus, and in the evening I rang Hood. A small family firm who were most helpful, they confirmed that no one had tried such an approach but agreed to make me the bifurcated tube to fit the whole of Mario’s trachea and main bronchial tubes. I said we needed it urgently. They delivered in less than one week, with no invoice, pleased to help with this unique case. Now I had to work out how to get it in.

I’d need to railroad the branched end of the tube into the separate bronchi simultaneously over guide wires. But wires were too sharp and dangerous for the delicate silicone rubber, and I needed something blunt and harmless to do the job. We used to dilate strictures of the gullet with gum elastic bougies. Two of the narrowest bougies would fit down the T-Y tube, and down each limb of the Y branches. I could insert the bougies through the damaged trachea and into one bronchus at a time, then railroad the tube into place over them. I drew the technique step by step and showed it to the other thoracic surgeons. The consensus was that we had absolutely nothing to lose. Without some crazy new approach Mario was definitely going to die.

The following day we took him to theatre, removed the tracheostomy tube and inserted the rigid bronchoscope through his burnt larynx. I tried to create as little bleeding as possible this time. We surgically enlarged the tracheostomy hole through which the T-Y tube would be introduced, then the bougies were inserted into the right and left main bronchi under direct vision through the scope, vigorously ventilating with 100 per cent oxygen between each step. So far so good. I lubricated the silicone rubber with K-Y jelly and shoved the tube forcefully downward. The bronchial limbs spread out at the branching point until there was resistance to any further pushing. It was in. Better than sex. The boss took a leap of faith and withdrew the bronchoscope into the larynx.

Ever the Irishman he exclaimed, ‘Crikey, look at this! You’re a bloody genius, Westaby.’ The horribly disintegrating trachea had been replaced by a clean white silicone tube, the Y limbs sitting in perfect position. There was no kinking or compression, and clean healthy airways lay beyond.

Meanwhile Mario was blue and hypoxic. We were all so excited that we had stopped ventilating him, so we needed to blow in oxygen furiously. But he was now easy to inflate through the wide rubber airways. It was a complete revelation. Whether it would last we didn’t know, and only time would tell. It depended entirely upon whether Mario was strong enough to cough secretions out through the tubes, and on our ability to suck them out and ventilate him through the side limb. When the swelling in his larynx and vocal cords subsided we’d keep this closed with the rubber bung. Then he could breathe and speak through his own larynx if it ever recovered. There were many unknowns, but for now Mario was safe. He could breathe. Fifteen minutes later he woke up with fantastic symptomatic relief.

I should have been thrilled that the concept had worked but I wasn’t. I was in a difficult head space. I had a beautiful baby daughter – Gemma – whom I didn’t live with. I lived at the hospital. This was grinding away at me in the background, so I compensated by operating fanatically on everything that I could lay my hands on. I was always available but was possessed by a disquieting restlessness.

In the meantime Mario recovered well, though life was difficult without a voice. He could cough secretions through the tube and keep it clear – something that everyone else had regarded as impossible – and was sent home to his family in Italy. Gratifyingly Hood started to manufacture the T-Y stent and called it the ‘Westaby tube’. We used it often for patients in whom lung cancer was threatening to occlude their lower airways, relieving the dreadful strangulation that my grandmother was forced to endure. Why could no one have done it when she needed help and I was so miserable?

I never knew how many Westaby tubes were manufactured but it stayed in Hood’s product list for many years. My original drawings were published in a chest surgery journal and served as the guide for others. While I still performed thoracic surgery I continued to use it for complex airways problems, often on a temporary basis until radiotherapy or cancer drugs caused the tumour to shrink. It was my grandmother’s legacy. Then came the rare opportunity to use the artificial airways alongside my expertise with the heart–lung machine.

In 1992 I was invited to Cape Town for a conference to celebrate the twenty-fifth anniversary of the world’s first heart transplant by Christiaan Barnard. At that meeting the distinguished children’s heart surgeon Susan Vosloo asked me to see a sick two-year-old who’d been a patient at the Red Cross Children’s Hospital for several weeks. Little Oslin lived in a sprawling Cape Town ghetto situated between the airport and the city, acre upon acre of tin shacks, wooden sheds and tents with brackish water and little sanitation. Nevertheless he was a cheerful little chap whose toys were oil drums, tin cans and pieces of wood. He knew no other life.

One day his family’s faulty gas cylinder exploded in the shack, setting fire to the walls and roof. The blast killed Oslin’s father outright, while Oslin sustained severe burns to his face and chest. Worse still, he inhaled hot gas from the blast, much like Mario. The accident department at Red Cross saved his life, intubating and ventilating him before he asphyxiated, then treating his burns with intravenous fluids and antibiotics. The little lad could survive the external burns, but his burnt-out trachea and main bronchi were life threatening, and without repeated bronchoscopies to clear slough and secretions he was destined to asphyxiate. On top of this his face was badly disfigured, he was almost blind and he couldn’t swallow food, just his own saliva. So he was fed with liquids through a tube directly into the stomach.

It so happened that Susan had read a journal article about Mario and the tube I’d designed, and, although Oslin was much smaller, she wondered whether we could do anything to help him. When I first met the lad he was wearing a bright red shirt, had tight, curly black hair, and was pushing himself around the ward on a kiddies’ bicycle with his back to me. Susan called to him and he turned around. The sight of his face took my breath away. There was no hair on the front of his scalp and no eyelids, just white sclera and a severely burned nose and lips. His neck was webbed from contracting scars with a tracheostomy tube in the middle. And the noise coming from him was heart-rending, a kind of rattling with thick mucus secretions made up by a long, noisy in-drawing of breath then a high-pitched wheeze as he forcibly exhaled. It was worse than a horror movie and tragic beyond belief. My first thought was, ‘Poor kid, he should have died with his dad. It would have been much kinder.’

Strangely enough he was happy, as he’d never had a bicycle before the explosion. I kneeled on the floor to talk with him. He looked straight at me but I couldn’t tell whether he could see my face as his corneas were opaque, so I took his little hand. There would be no objectivity in this discussion. I needed to help him, even if I wasn’t sure how it could be done. We could work that out.

By this point I was chief of cardiac surgery in Oxford and I had to get back there to operate. In any case there was no Westaby tube in Cape Town, and if there had been it wouldn’t have fitted anyway since the adult size was too big. Could I persuade Hood over in Boston to make a smaller tube? Probably, but not within the time frame that we’d been presented with; if he developed pneumonia in the next couple of weeks he’d surely die.

My return flight to Heathrow was the following day, so instead of going for lunch in the harbour I asked Susan whether she’d take me to see Oslin’s township. Cape Town was my favourite city in the world but this was an aspect I’d never seen before, the sort of place that warranted an armed escort through its thousands of acres of misery and depravity. I’d come back in a couple of weeks when I had the tube, and a surgical strategy – that’s what flying time was for. I quickly had it clear in my mind and before the plane touched down in Heathrow I’d drawn up the operation in detail.

I was back at the Children’s Hospital in three weeks. There had already been a fund-raising drive to help Oslin and they expected to pay my expenses. But none of that mattered. I was driven to help the boy as no kid on earth deserved that. I guess thousands of Vietnamese children suffered the same with napalm, but I hadn’t met them. I did know Oslin and I cared about him. So did the doctors and nurses at Red Cross. Perhaps the whole of Cape Town cared. As the airport taxi reached the city I saw the newspaper billboards emblazoned with ‘UK Doc flies in to save dying Township boy’ stuck on lamp-post after lamp-post. No pressure then.

At the hospital I met Oslin’s mother for the first time. She’d been at work when the gas cylinder exploded and was now clearly depressed. She said virtually nothing, but signed the consent form for an operation that even I didn’t understand.

We operated the following morning. I’d needed to trim the adult tube by shortening both bronchial limbs, the tracheostomy T-piece and the top part that would sit below his vocal cords, but even this shortened adult tube wouldn’t fit inside the two-year-old’s scarred windpipe. My objective was to rebuild his major airways around the tube. If it worked he’d have even wider airways than before the accident.

Clearly he wouldn’t be able to breathe or be ventilated during the reconstructive surgery, so we’d do it with him supported on the heart–lung machine. This meant we’d open his sternum as we would in a heart operation. The tricky part was to gain access to the whole length of the trachea and main bronchial tubes from an incision in the front of his chest, these structures being situated directly behind the heart and large blood vessels.

I’d already worked it all out on a cadaver in the dissecting room in Oxford. When a sling was placed around the aorta and the adjacent vena cava they could be pulled apart to expose the back of the pericardial sac, like opening a pair of curtains and looking out onto a tree. Then a vertical incision between the two served to expose the lower trachea and both main bronchi.

My plan was to fillet these damaged tubes then lay in the modified T-Y stent. Next we’d repair the front of the opened airways and cover the tube with a patch of Oslin’s own pericardium. It would be just like sewing an elbow patch onto a worn jacket sleeve. Simple. It should all heal up around the tube and we could maybe remove the prosthesis in time, after the tissues had healed and moulded around the silicone. That was my plan, in any case. Maybe ‘fantasy’ would have been a more realistic term, but no one else had a better solution.

The skin incision started in Oslin’s neck just below his voice box and extended all the way down to the cartilage at the lower end of his breastbone. Since he was emaciated, unable to eat, there was no fat, so the electrocautery cut straight through to the bone, which we then sawed through. I cut out his fleshy, redundant thymus gland and dissected down onto the upper part of his inflammed trachea, all while he was ventilated through his tracheostomy tube. We needed to go on bypass before removing this and exposing the rest of his airways. The metal retractor stretched open his scarred little chest, exposing more of the fibrous pericardium. The front of this was removed for the tracheal patch and I saw that his little heart was beating away happily. Rarely do I see a normal child’s heart, as most are deformed and struggling.

When I was ready to open the windpipe we started the bypass machine. This rendered the lungs redundant so we could remove the contaminated tracheostomy tube from the clean surgical field. Through the hole the devastation was clear to see. Poor Oslin had been breathing through a sewer. I cut down the length of it with the electrocautery and continued the incision into each main bronchus until I could see normal respiratory lining just at the limits of our access. Copious thick secretions poured out of the obstructed airways, then we scraped tissue off the walls, which caused all-too-predicable bleeding.

But the electrocautery eventually stopped the haemorrhaging, so we inserted the shiny white T-Y tube and covered it with a patch of Oslin’s own pericardium. I adjusted the length of the rubber cylinder for the last time to get it just right, then sewed the patch into place to seal the implant. It needed to be airtight, otherwise the ventilator would push air into the tissues of the neck and chest, making him blow up like the Michelin man. With the shiny new breathing tubes attached to the ventilator we blew air into his little lungs. There was no leak. Both inflated then deflated normally. A sense of excitement permeated the room. The high-risk strategy was working.

Oslin’s heart bounced off the bypass machine and his lungs moved freely, needing much lower pressure from the ventilator. Our anaesthetist murmured, ‘Unbelievable. I’d never have believed it possible.’ I covered the repair by closing the back wall of the pericardium, then asked that the registrar put in the drains and close.

Through the theatre window we could see Oslin’s mother sitting in the waiting room, still expressionless and rigid with fear. I anticipated a blunt response to our news. But she was too emotionally drained to register relief, simply holding out her hand and squeezing mine. She whispered, ‘God bless you,’ then a tear zigzagged down her pockmarked cheek. I wished her a better life in the future, one way or another.

The intensive care unit was pleased to have him back. Most of their patients were township kids having heart surgery, and some of the nurses lived in that same environment. They’d cared for Oslin and his depressed mum for weeks, watching them both deteriorate. So ‘UK Doc’ had flown in to save ‘Township boy’ and succeeded. I was proud of that. Now it was time to ride off into the sunset.

Oslin recovered and could breathe freely through the white rubber tube in his neck. He couldn’t speak but went on to have his corneal transplants. Being able to breathe and see at the same time was as much as he could have hoped for. The little family were relocated to better social housing on the outskirts of the city – crude but clean, and safer. A chest infection could still kill him, so for the first few months following the operation I contacted Cape Town frequently. Oslin was doing fine and Mum was faring better on anti-depressives. Then I stopped calling.

Eighteen months passed, and then a letter arrived from the Red Cross Hospital. Oslin had been found dead at home and no one really knew why. Sometimes life is shit.

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