Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table. Stephen Westaby
echocardiograms, the ultrasound examination of his heart chambers.
By now the trauma patient was dying. He had a torn tricuspid valve, a rare, high-speed deceleration injury we never see with our mandatory seatbelt law. The right ventricle was pulverised as the sternum fractured and had been driven back against the spine, the rapid increase in pressure causing the valve to burst. Now, when the heart contracted, as much blood went backwards as forwards, little was passing through the lungs and the heart couldn’t fill adequately because of blood in the pericardium. Cardiac tamponade, we call it.
Once I’d seen the pictures I didn’t waste time visiting the patient. I just needed to crack that chest, relieve the tamponade and if possible repair the tricuspid valve. We had to get him onto the heart–lung machine quickly to restore blood flow to the brain and correct his dire metabolic state. Then someone behind me whispered, ‘Don’t rush. He’s a madman. He killed the other driver.’ I said nothing. That wasn’t my business. Striding purposefully back to the operating theatre I encountered the little entourage in transit to paediatric intensive care. The fast, regular beeping of the heart rate monitor was reassuring. Without diverting her gaze the mother held out her hand as we crossed over, and I did the same. Contact.
I should have been with the boy in intensive care, at least for the first couple of hours until I was confident that he was stable. But now I couldn’t be. Soon the trauma patient was on the operating table being resuscitated. He had disfiguring facial injuries and extensive bruising over the chest wall, and the edges of the fractured sternum were overlapped with a step deformity. But it was nothing we couldn’t fix with pins and wires.
Within minutes I had the chest open and was scooping clumps of blood clot into a kidney dish. This improved his blood pressure, but his right ventricle looked like tenderised steak – and it didn’t contract any better than a steak – and his right atrium looked like it would burst. So I put the pipes directly into the major veins. As we started cardiopulmonary bypass, his struggling heart emptied out and flapped around at the bottom of the pericardial sac like a wet fish. He was safe – and just in time!
With an incision directly into the right atrium the ruptured valve was there in front of me. It was torn like a curtain, but when I stitched it like torn cloth it was easily repaired. I tested it by filling the right ventricle through a bulb syringe. No leak. So I closed the atrium and removed the snares to fill it again. The job was done. The tenderised meat functioned better than anticipated and eased itself off the bypass machine. By then I’d had enough. I left my assistants to repair the fractured sternum and close the chest. No doubt he’d survive to go to prison.
The sun was setting on a hot and difficult day. For a while I felt content, satisfied after two ‘out on the edge’ operations, difficult cases that few heart surgeons would ever encounter in their whole career. I needed a beer, many beers, but there was no chance of that. I wondered whether the mother was happier now. She’d achieved what she set out for – treatment for her dying child.
Having heard nothing from intensive care I assumed that the boy was doing fine. Wrong. They were already in trouble. For some reason the doctors had tampered with the temporary pacing box and the electric stimulus from the generator had coincided with the heart’s natural beat, fibrillating it and instantaneously inducing that uncoordinated, squirming rhythm, a herald of imminent death.
To counteract this they’d used external cardiac massage until a defibrillator was brought to his bedside. The vigorous chest compressions he’d been given had displaced the pacing wire from the atrium and, although the heart defibrillated at the first shock, the sequential pacing of atrium then ventricle no longer worked. Now only the ventricles could be paced. As a result there was a precipitous drop in cardiac output and his kidneys had stopped producing urine. The boy was deteriorating but no one had told me because I was in the middle of another big case. Shit.
Throughout this débâcle the poor mother had stayed by the cot where she’d watched them pounding on her little boy’s chest, then witnessed the electrical shock that caused his little body to spring from the bed and convulse. At least he only needed one shot at defibrillation. The resulting beep, beep, beep was of little comfort to her, however, and like her child she was spiralling down.
I found her clasping his tiny hand, tears running down her cheeks. She’d been so happy as she escorted him from the operating theatre. Now she was desolate and I was too. It was clear that these intensive care doctors didn’t understand cardiac transplant physiology.
And why should they? They’d never been involved with heart transplants so they failed to grasp that taking the heart out of the body cut off its normal nerve supply. They were pacing the heart at 100 beats per minute with an insufficient volume of blood while simultaneously flogging it with high doses of adrenaline to raise the blood pressure. This constricted the arteries to his muscles and organs, substituting blood pressure for flow and once again producing metabolic mayhem.
The nurse looking after the boy on the intensive care ward seemed anxious and was pleased to see me. A very capable New Zealander, she clearly did not rate the critical care registrar. Her opening remark was, ‘He’s not passing urine and they’re not doing anything about it,’ followed more directly with, ‘If you’re not careful they’re going to fuck up your good work!’
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