The Knife’s Edge

There followed hugs, kisses and expressions of relief, then the usual request – ‘Can we see him now?’ I had to explain that Steve was still on the table with his chest wide open being rewarmed on the bypass machine and that while he was not entirely out of the woods, things had gone according to plan. I added that it was likely to be another couple of hours before we controlled the bleeding and closed him up. With that I left, intending to apologise to the sister in charge for springing this upon them. But it transpired that in fact there had been enough nurses – the last heart attack patient brought up from the catheter laboratory had ruptured his left ventricle and could not be resuscitated. The conveyor belt rumbled on.

I wandered wearily back to theatre and sat down with the two anaesthetists beside Steve’s head. Amir was happy enough to remain in charge. Steve’s temperature was back at 37°C and although still empty, his heart looked cheerful enough. I asked Brian to leave some blood in it, so any residual air would be ejected into the graft. I could hear Steve’s artificial aortic valve clicking away reassuringly, and from the echo probe behind the heart we could see tiny bubbles flashing through it like a snow storm. I didn’t have to ask. Amir already had the air needle in place. Bubbles fizzed out intermittently, then stopped. Now we were ready to come off the machine. I asked Dave to start ventilating the lungs and soon afterwards heard Brian say that he was ‘off bypass’. Amir and the locum registrar stood like spectators at a football match, as I dispatched instructions from the stool. I was scrutinising the inside of the heart and aorta on the monitor screen while they watched it from the outside.

‘How does it look?’ I asked Amir. ‘Any bleeding?’

‘Looks great. Just some oozing from around the graft. Nothing serious.’

‘What are you going to do now then?’

No answer. He was tired.

‘Give the protamine,’ I told Dave. Protamine extracted from salmon sperm reverses the anticoagulant effect of heparin, which comes from digested cow’s guts. So my noble profession relied on cows and fish, a sobering thought at this time in the morning.

Amir gently packed gauze swabs around the heart to encourage the oozing blood to clot on them. Next he set about putting in the chest drains and stainless-steel wires to close up. The clock on the wall read 4.30. Dave flicked through a motorcycle magazine and Brian asked whether he could remove his equipment, get it ready for the morning and go home. No stamina, some people. Ayrin and her runner nurse were wilting too. I suggested they took turns to take a break while we transfused blood and clotting factors. For the first time a sense of calm filled the room. Job done.

Behind the operating theatre block was a car park, and beyond this lay Old Headington graveyard, thinly shielded by an unkempt hedge of privet and conifers. I walked out into the night past the Mercedes that never got to Cambridge, with Gemma’s birthday present still concealed in the well of the passenger seat. I drifted on through the ornate metal gate to the brow of a hill overlooking the Oxfordshire countryside. There I lay silently on the grass by the grave of a baby girl and stared up into the night sky. The tombstone read, ‘Taken too soon’. She’d been taken by me twenty years earlier, something I hadn’t forgotten. She would have been Gemma’s age now, had God not given her that twisted, convoluted heart that I failed to fix. So I sat with her from time to time when I was feeling bad, just to remind myself that I wouldn’t always succeed. Difficult day today. Or was it yesterday?

6 am. Daylight broke the horizon and the sparrows chirped. Headlights sprinted around the Oxford ring road below, the early-bird London commuters and shift workers at the Cowley car plant. Sue would already be on her way into the office, so I ambled back to Theatre 5, now empty except for Ayrin. She was scrubbing blood and urine from the floor, ready for the morning’s operating list. Steve was already settled in intensive care, surrounded by his extended family, perfectly stable.

Cheerful Amir said, ‘Great case. So pleased you called me.’

The locum registrar was nowhere to be seen. Gone to collect his pot of gold, I thought.

I looked bad and smelled bad, so I went to the changing rooms, took a shower and stepped into clean theatre blues. The ritual signified the end of yesterday and the beginning of today. First, I made tea for Sue in the office, taking a dose of Ritalin with mine. Oxford students used the stimulant to aid concentration and inflate their exam grades; I used it for a boost when I was buggered or with added melatonin for jet lag. All in the patients’ best interest, of course.

At 7.30 I joined the intensive care ward round. I related Steve’s case story and asked whether his pupils were still small and reacting to light. Had anyone looked? Not yet, but they would. Had he shown any signs of waking up yet? No, but I was happy about that because I wanted him kept sedated and didn’t want the tube in his windpipe to make him cough. Coughing would shoot his intra-cranial pressure through the roof and his brain was already too swollen in there. By explaining that to the juniors in front of Hilary, I assumed that they would get the message. At least I hoped they would.

I celebrated Steve’s recovery with a sausage and egg sandwich, and, with the Ritalin kicking in, I felt better too. I had a floppy mitral valve to fix, and happily for me there was no bed for a second case. But the tone of day soon changed. As I emerged from theatre in the late morning, Steve partially woke from the sedation and started to struggle in his bed. With his brain swelling, he was disorientated, confused and agitated, then he started coughing vigorously against the tracheal tube and strained against the ventilator. He was a big man and not easy to control.

A debate ensued about whether to let him wake up fully and remove the endotracheal tube or re-sedate and paralyse him. In the midst of this, his left pupil dilated widely. Understanding its dire significance, John, our anaesthetist friend who had stayed by Steve’s bedside, hurried off to find me in my office. We returned to check the pupils again. Steve’s nurse thought that his right pupil was larger too. My spirits plummeted. I had hoped that cooling and barbiturates would limit the swelling around the stroke.

Did Hilary know of this sinister development? She had been given a relatives’ room and gone there to rest after the stressful night. Perhaps it was best to leave the family alone until we gained a clear picture of what had happened. That meant an urgent brain CT scan, which was not easy for a post-operative patient connected to all the paraphernalia. Drips, drains, pacing wires and monitors had to be wheeled through the hospital corridors to the radiology department, then his paralysed body moved from his bed into the scanner. But without the pictures, we couldn’t know how to help. So I walked round there myself and grovelled to my friend the chief radiographer to fit him in as a dire emergency.

As the scans emerged it was obvious that the whole brain was swollen. The parts damaged during the original stroke had haemorrhaged, probably as a result of the obligatory anticoagulant given during surgery. The injured brain had expanded like a sponge soaking up water yet confined in a rigid box. The skull has one hole at its base, through which the spinal cord enters its bony canal. When pressure rises, the brain stem can be forced down into the spinal canal with fatal consequences. This is called coning, and a blown pupil heralds that catastrophe. So I needed a brain surgeon to look at the scans with me.

It was not an easy conversation. Richard Kerr was the chief. He had seen it all, done it all, and was destined to be President of the British Association of Neurosurgeons. I asked him to decompress Steve’s brain by removing the top of his skull. A craniectomy is like taking off the top of a boiled egg, except the bone is kept in a fridge and put back again should the patient survive. Richard was a man of few words. Before he even spoke, I knew he believed it to be a lost cause. I pleaded the family’s case for them. Richard said that even if he survived, he would never be a GP again, indeed he might not even wake again. The delay in re-perfusing the stroke with the surgery had already destroyed his chance of survival. But that was now history. We couldn’t turn the clock back.

So I played my last card. Steve was an old friend, I said, and I had spent all night and lots of money trying to save him. Richard groaned and went back through the scans.

‘OK, you win. He has nothing to lose, but it has to be quick. I’ll put off my next case.’

Within thirty minutes Steve was on a neurosurgery operating table at the far end of the hospital. I pushed the bed there myself.

2 pm. Steve’s scalp was peeled back and the bone saw removed the top of his cranium, revealing a tense, swollen brain without pulsation. We were watching a dying brain. Richard inserted an intracranial pressure monitor into the pulp and closed the scalp skin loosely over the top. Then we took him back to cardiac intensive care, whose expertise he needed most.

Hilary and her children were still napping on a single bed and an armchair in their room. Consumed by my own misery and her husband’s impending doom, I tentatively knocked on the door. Hilary read my gaunt expression and realised that this was not a social call.

‘He’s dead, isn’t he?’

I hesitated to say no, since Steve’s chances of survival were negligible. I just told her the truth. That he had a dilated pupil and the brain scan looked bad, that I’d immediately persuaded the finest neurosurgeon in the country to help, but we were both doubtful that Steve could recover now. It was a waiting game. More of our medical school friends arrived, hoping for better news. I heard that old chestnut – ‘If anyone can save him, Westaby can.’ But he couldn’t. Great dissection repair, pity about the outcome. Soon afterwards, the second pupil dilated. Neither reacted to light. Despite the decompression, his brain was not going to recover. Hilary and the children had lost him.

Unbeknown to me, both Hilary and her eldest son had congenital polycystic kidneys, and the lad was teetering on the edge of needing renal dialysis. With remarkable composure, she asked whether he could be given his father’s functioning kidney. An organ from his dad would provide the best possible chance of immune compatibility – same blood group, same genes, no rejection. For a brief moment I thought I could generate something positive out of this disaster. At the same time as the intensive care doctors carried out tests for brain stem death, I called the director of the transplant service.

What I learned was barely believable. While Steve was conscious he could have voluntarily donated a kidney to his son. Now that he was functionally dead, the family could request that he become an organ donor. But now the body blow. Whatever was still transplantable must go to the national donor pool. Those were the rules. The transplant authorities would not allow Steve’s kidney to be used for his son, nor given to Hilary, who was close to needing a transplant herself. That was the law, so the Oxford transplant team couldn’t get involved. I was dumbstruck, then apoplectic about it. Fucking bureaucracy.

Steve’s ventilator was switched off at lunchtime. He died peacefully, surrounded by his family, with many of my medical school year grieving in the hospital corridors. I was alone in my office when his proud heart fibrillated, when the metallic click of his prosthetic valve finally came to a stop. Twelve hours earlier I had watched it beating vigorously and I had been confident that I’d saved him. Now it was forever still. All his organs died with him, except the corneas from his eyes. Despite my protestations, the transplant authorities had their way.

When Sue went home she left a note on my desk – ‘The medical director wants to see you.’

‘One day,’ I said to myself, and drove home with Gemma’s present still tucked away in the passenger seat.

Next day I was back in the car park by 6.10 am, another three cases on the operating list, beginning with a newborn infant whose right ventricle was missing. The car park lies between the graveyard and the mortuary at the back of the hospital. I always attended the autopsies of my own patients, so the morticians knew me well enough. This morning was a social call. I wanted to let Steve know that we had done our best for him. He was cold, pale and peaceful now. It was the only time I’d known him to be speechless. Had he still been able to talk, he would have said, ‘You bastard. You were meant to get me out of this mess!’ My instinct was to remove the drips and drains left in his lifeless body, but I was not allowed to. Those who die soon after surgery are the coroner’s property, and the pathologists must satisfy themselves as to the cause of death. Not difficult in this case, but it was an autopsy I wouldn’t be returning to watch. So I said my goodbyes to a great character.

There were many sad moments in my professional career, but this one stayed with me. Steve had devoted his life to the NHS but was caught up in the pass the parcel lottery that was out-of-hours surgery for aortic dissection. Eventually a decree was issued by the Society for Cardiothoracic Surgery that each regional centre must take responsibility for patients in their area. Special aortic dissection rotas were established in London and specific experienced surgeons designated to operate on the cases. That brought the mortality rate down. After UK Transplant prevented us taking a kidney for Steve’s son, the issue of organ donation was not discussed further. A healthy liver and two lungs could have gone in to the pool, had that single functioning kidney been used in Oxford.

Later that year Steve’s son Tom received a kidney donated by his wife. Steve’s daughter Kate was given one of her husband’s kidneys in 2015. Hilary was fortunate enough to meet a new partner and received one of his kidneys in 2011. They are all well.

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