Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table. Stephen Westaby
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.
5
Dream that my little baby came to life again, that it had only been cold, and that we rubbed it before the fire and it had lived. Awake and find no baby.
Mary Shelley, author of Frankenstein
The girl was hauntingly beautiful, with eyes that burned like lasers – as if the blistering desert heat were not enough (50°C during the day). When she fixed those eyes on mine she delivered a message – eye to eye, pupil to pupil, retina to retina – straight into my cerebral cortex. As she stood there holding her bundle of rags I understood perfectly what she was saying: ‘Please save my child.’ But she never spoke. Not to any of us. Ever. And we never even knew her name.
The Kingdom of Saudi Arabia, 1987. I was young and fearless, seemingly invincible and massively overconfident, and had just been appointed as a consultant in Oxford. So why was I in the desert? Heart operations cost money. We’d worked hard to build Oxford’s new cardiac centre and clear a backlog of sick hearts, but the annual budget was gone in five months so the management closed us down. Bugger the patients. The cardiologists were told to send them to London again.
On the day before I was locked out of the operating theatre I took a call from a prestigious Saudi cardiac centre that served the whole Arab world. Their lead surgeon needed three months sick leave, and they were looking for a locum who could tackle both congenital and adult heart surgery, an extremely rare species. At the time I wasn’t interested but the following day I was, and three days later I jumped on the plane.
It was Jumada al-thani, the ‘second month of dryness’ in the Middle East, and I’d never felt heat like it, blistering, unremitting heat with the hot shamal wind blowing sand into the city. But it was a great cardiac centre. My medical colleagues were an eclectic mix of Saudi men who had trained overseas, Americans rotating from the major centres for experience, then the band of mercenaries from Europe and Australasia.
Nursing was very different. Saudi women did not nurse, as the profession was regarded with suspicion and disrespect, and was culturally taboo because it required mixing with the opposite sex. So all female nurses were foreign, most with contracts for just one or two years. Their accommodation was free, they paid no tax and stayed just long enough to save for that elusive mortgage back home. In turn they were not allowed to drive, had to travel in the rear of buses and be completely covered in public.
I was intrigued by my new environment: the repetitive calls to prayer from the minarets, the tantalising aromas of sandalwood, incense and amber around the hospital, Arabian coffee roasting on the frying pan or boiling with cardamom. It was a very different life and important not to step out of line – their culture, their rules, harsh penalties.
This presented a unique opportunity for me as I could operate on every conceivable congenital anomaly. There were innumerable young patients with rheumatic heart disease sent from remote towns and villages, mostly without access to anticoagulant therapy or drugs that we take for granted in the West. The rural health care was out of the Middle Ages, and we had to innovate and improvise to repair their heart valves rather than replace them with prosthetic materials. I remember thinking that every cardiac surgeon should train here.
One morning a bright young paediatric cardiologist from the Mayo Clinic, the world-famous medical centre in Minnesota, came to find me in the operating theatre. His opening gambit was, ‘Can I show you something really interesting? Bet you haven’t seen anything like this before,’ swiftly followed by, ‘Sadly, I doubt you can do anything about it.’ I was determined to prove him wrong even before I’d seen the case because for surgeons the unusual is always a challenge.
He thrust the X-ray onto a light box. On a plain chest X-ray the heart is simply a grey shadow, but to the educated eye it can still tell the story. The message was clear. This was a small child with an enlarged heart in the wrong side of the chest, a rare anomaly called dextrocardia. Normal hearts lie to the left. In addition there was fluid on the lungs. But dextrocardia alone does not cause heart failure. There had to be another problem.
The enthusiastic Mayo cardiologist was testing me. He had already catheterised the eighteen-month-old boy and knew the answer. I offered an insightful guess to show off – ‘In this part of the world it could be Lutembacher’s syndrome.’ This is a dextrocardia heart with a large hole between the right and left atrium, together with rheumatic fever that narrows the mitral valve, a rare combination which floods the lungs with blood, leaving the rest of the body short. The Mayo man was impressed.