The Knife’s Edge. Stephen Westaby
brain was cooling too. Then I asked the enthusiastic registrar to scrub up and babysit the bypass circuit so I could duck out for coffee and a piss. What I really wanted to do was to phone Gemma, but when I did there was no answer. She was still in a seminar. Although time was passing relentlessly, I remained hopeful that I would be in Cambridge by the evening.
At 18°C I was too impatient to wait any longer. Gowned and gloved for the third time that day, I told the perfusionist to stop the pump and empty the lady’s circulation into the blood reservoir. Nick could finally withdraw his cold, stiff arms from her chest after having had them in there for more than an hour, while I took the first operator’s position. In turn, Nick moved the registrar out of the way, eager to get a look at the damage for himself.
With no blood flowing around the body, we were working against the clock. The infected tissues had the consistency of wet blotting paper and the stench of rotten cabbage. We could not repair the damaged oesophagus, and Nick agreed it had to go. I chopped through the precious muscular tube above and below the abscess, and dissected it away from the aorta. Nick passed a wide-bore suction tube down into the stomach to prevent it from spewing acid and bile over my aortic repair.
Now we had a clear view of the ragged hole, which really should have been a fatal problem. I reluctantly decided to replace the whole infected segment of aorta with the homograft tube rather than risk just a patch. No time to debate this. I trimmed the donor tube to the correct length, then sewed at top speed using blue polyester thread on a fine stainless-steel needle, held in a long titanium needle holder; deep bites into healthy tissue – aesthetically pleasing, bordering on the erotic. Throwing the final knot left-handed, I told Richard the perfusionist to ‘go back on’ and rewarm. Cold blood from the machine expanded the flaccid graft and air fizzed through the needle holes. It needed a couple of extra stitches to make the whole repair blood tight, but we restored blood flow to the brain after thirty-two minutes. Happy days. Though not so happy in my own case.
I really didn’t have time to loiter and admire my needlework. Between us we agreed that Nick would divert the upper end of the oesophagus out of the left side of the poor lady’s neck to drain saliva and enable her to swallow liquids for comfort. The lower end would then be closed off and an entrance to the stomach fashioned through the abdominal wall through which she would now be fed. We call this a gastrostomy. Months down the line Nick would restore her swallowing with a new gullet made by transposing a length of large bowel between her neck and stomach. But for now she was safe. In life, and for that matter death, timing is everything. Heart surgeon close at hand. Heart–lung machine and perfusionist available between cases. Spare parts on the shelf. Otherwise she was dead, killed by a fish.
Nick’s gastro team were happy to close the chest, put in the drains and finish off. Stepping backwards from the table into a pool of slippery blood clot, I skidded gracelessly onto my backside, hard down on the tiled floor with a crack – retribution perhaps for leaving Nick for so long with his cold hands in the chest. Now with a soggy red patch on my trousers and the suspense of a near-death drama lifted, it gave the nurses something to laugh at. Some proffered concern for the integrity of my coccyx. But, pain apart, I was content to have dispelled the gloom.
The levity was short-lived as no fewer than four messages with my name attached were taped to the door. First, the lady waiting for the mitral repair on the ward was agitated and wanted to see me. Predictable. Second, would I go to the paediatric intensive care unit where the baby was losing a little too much blood into the drains? Shit. Next, a lady doctor in the accident department of the Norfolk and Norwich Hospital was trying to get hold of me. Why on earth would that be? It was many miles away. And last, the medical director would like to see me in his office with the director of nursing at 4 pm.
Bugger that. It was already 4.10, and I was in no doubt what the chat would be about – swearing at the unhelpful agency nurse, quite inappropriate conduct for a consultant surgeon. Another ticking off. Nor was I in the mood for an acrimonious discussion with the cancelled mitral lady. After 5 pm there were only sufficient nurses to staff one emergency theatre. The nurses would never allow me to begin an elective operation at this time of day. So my only concern was for the baby. Was it significant surgical bleeding or just oozing through compromised blood clotting after being on the bypass machine? Still hoping to leave town, I went directly to the unit to find out.
The afternoon ward round was congregated around the cot. On either side crouched an anxious parent holding a cool, sweaty little hand. Suspended from the drip stand was a tell-tale bag of donor blood dripping briskly through the jugular vein cannula in the baby’s neck. Without reading the levels I could see that there was too much blood in the drains. The precious red stuff was dripping in one end and straight out the other. What’s more, they had checked the clotting profile and it was virtually normal.
With that one glance my plans for the evening were dashed. Cambridge might as well have been on a different planet. I had to take the baby back to theatre and stop the bloody bleeding. Abject despair turned to anger. I should have closed the chest myself – but then fishbone lady would be dead now. Acrimoniously I rang my so-called ‘helper’, telling him to lay claim to the emergency operating theatre and that I would push the cot around myself. Five minutes later Mr Putty Fingers called back to say that they couldn’t staff an emergency theatre because the chest surgeons were running late with a lung cancer operation. We would have to wait for them to finish. Until then, no room for emergencies, so keep squeezing in the blood. In the meantime, any remaining chance of seeing my daughter on her birthday had gone. More of the same. Useless absentee father ridden with guilt, and made worse by the fact that I had still not made contact. I was a sorry sight with my bloody trousers and sore bum.
There was no point in trying to rush the chest surgeons. They operate slowly through small holes with telescopes and invariably overestimate what they can squeeze in to an operating list. Yet no access for emergency surgery spells trouble. I was now glued to the cot side, with the fretting parents wanting me to stop the bleeding. I deployed that old chestnut: ‘It was alright when I left. It can’t be bleeding from the heart.’
Sure enough, over the next thirty minutes the bleeding slowed to a trickle. I fantasised that blood clotting had finally sealed the needle holes, which would allow me to escape the hospital without reopening the chest. Except the jugular veins were distending as the blood loss slowed. Perhaps there was too much transfusion. More likely, the chest drains had blocked off and blood was now accumulating under pressure in the closed space within the pericardium so the right atrium couldn’t fill properly – what we call cardiac tamponade. Should the blood pressure begin to fall, we would be in real trouble.
The baby’s blood pressure drifted down. We couldn’t wait any longer for an operating theatre. Now I needed to reopen the chest right there in the cot and scoop out the blood clot. Sister carried the heavy pre-sterilised thoracotomy kit to the cot side and dumped it on a trolley. Still wearing theatre blues, I hastily scrubbed up at the sink while calling for the registrar who had left me in this mess. He had already gone home, so we tried to find the on-call registrar. It was a locum, who was already scrubbed up in the thoracic theatre.
So I got on and did it without help – it was a very small chest, after all – getting the baby prepared, draped and her sternum wide open in less than two minutes. The suction tubing was not connected yet, so I scooped out the clots with my index finger, then packed the pericardial cavity with virginal white swabs. An expanding bright red spot soon showed me the bleeding point, a continuous trickle from the temporary pacing wire site in the muscle of the right ventricle, ostensibly trivial but life-threatening. That’s the way with cardiac surgery. It has to be perfect every time or patients die needlessly.
The cardiac rhythm was normal, so I pulled out the wire and stemmed the dribble with a single mattress stitch. Sure enough the drains were blocked. I changed them for clean ones and closed up. The whole process took ten minutes, but it had been a completely avoidable charade. It transpired that the trainee surgeon lacked the confidence to put a stitch into the baby’s twitching ventricle, simply hoping that the oozing would stop. He would not make it in this specialty.
7 pm. I was intrigued by that message from Norwich A&E. Were