Fragile Lives Page 11

  The blade went straight through hard onto the bone at one stroke. Forget the electrocautery – we didn’t need it. By now there was no circulation – so no bleeding from skin or fat – and Julie’s heart rate was agonisingly slow. I ran the saw up the sternum. Again, no oozing from the bone marrow. We wedged in the retractor and swiftly slit open the pericardium with scissors. Mike pointed out that the ECG was slowing to a stop but I didn’t need him to tell me that as I was watching Julie’s swollen, virus-ridden heart. It just squirmed in a pathetic sort of way, like one of those toys whose battery is almost flat, the tin soldier beating his drum slower and slower till his arm finally stops in the air. Spent.

  But while the heart was stopping, I kept moving. I stitched purse-string sutures in the aorta and the right atrium to hold the bypass tubes in place. The aorta was soft, with no pressure, the right atrium tense to bursting point. Every stitch hole pissed out dark blue blood carrying no oxygen. There was barely any blood flow to her lungs and by this stage I wondered whether she was retrievable.

  Working like clockwork and saying nothing, we shoved in the cannulas to connect the bypass machine. Between each critical step I took Julie’s buggered little ventricles into my fist and hand-pumped hard and rhythmically, like squeezing juice out of a grapefruit, a form of internal cardiac massage to maintain a semblance of blood flow to her brain and coronary arteries. That was all that mattered. Forget the guts and offal, just keep the brain and heart alive with whatever oxygen remained in the sticky blood.

  Katsumata, a man of few words, murmured, ‘Don’t mention the war.’ I told Brian to go onto bypass even before the venous drainage pipe was connected to the circuit, and almost black blood drained sluggishly into the tubing. In our haste we had an air lock in the drainage pipe from the right atrium, but this was no big deal. Lifting the tubing, air floated to the top, then, after the tube was dropped down onto the table, the air whizzed off into the reservoir.

  Peace suddenly descended on the operating theatre as the once empty heart started to beat steadily, now that it was receiving blood from the machine. Julie’s blood oxygen levels increased rapidly and her black blood turned red again, lactic acid filtering away. She was safe, as long as her brain was not damaged. A just-in-time job.

  I turned to Richard. ‘How do we implant this thing?’ It seemed straightforward. There was an inflow tube, which I felt to be unreasonably rigid. This would be inserted into the left atrium to drain well-oxygenated blood from the lungs into the centrifugal pump. The pump would become her new left ventricle. There was a vascular graft to return blood to her aorta, which would then be circulated around the body. Simple. The device itself would sit in the right side of her chest between lung and heart. With the left side of the heart effectively bypassed, her brain and body would be safe. So let’s get on with it.

  Richard handed over the sterilised equipment to Sister Linda. I considered how best to insert the stiff inflow tube into the small, thin-walled chamber of the atrium. The entry point had to stay blood-tight for a long time so I thought we should sew a tube of human aorta to the left atrium. This would provide a degree of flexibility to the cannula entry site and make it safer to remove, without leaving a sizeable hole in the heart itself. This simple trick could make the difference between success and failure, life or death.

  We kept donated human heart valves and bits of blood vessel in an operating theatre fridge for emergencies, and I had a special team whose job it was to arrange donations and rescue scraps from the autopsy room. These spare parts, pickled and preserved, were invaluable for congenital heart surgery, where we have to rebuild children’s hearts.

  Dawn found a suitable tube of donor aorta in a sterile bottle in the fridge. I carefully sewed this to an accessible part of Julie’s left atrium and slid in the inflow cannula. It was all a bit Heath Robinson, making it up as we went along. Then, with careful, blood-tight stitching, I sewed the outflow graft of the AB-180 to the aorta using a side clamp. There was one last thing to do. The combined power cable and lubrication port needed to be passed out through a stab wound in the upper abdominal wall, making it look like we were wiring an android. I passed it to Richard and he connected it to the power supply.

  By now, with the steady blood flow from the bypass machine, Julie’s own heart was beating again. But it was still feeble. I decided that we should support her for another thirty minutes before attempting to switch from cardiopulmonary bypass to the AB-180 because, although the pump would take over from the inflamed and swollen left ventricle, the right ventricle had to look after itself. With this better blood flow the cut tissues started to bleed. What’s more, she’d cooled as she was dying, and with the heat exchanger in the bypass machine her body temperature started to rise again.

  I grew tired and a little impatient. I asked Mike to ventilate the lungs and Brian to leave some blood in the heart. We needed to fill Julie’s own heart before switching on the AB-180, otherwise it would suck the heart empty and obstruct. We needed to slide imperceptibly from one to the other. But how? I told Brian to simply stop the bypass machine. He turned it off, and this confirmed that Julie’s own heart was useless.

  Then I told Richard to switch on the AB-180 and steadily turn up the flow to five litres per minute, equivalent to normal heart output. In a state of great excitement, he flipped the switch and turned it on. Immediately, the pump came to life. Julie now had bright red blood coursing around her body.

  On the monitor there was no blood pressure trace – no systole or diastole – just flatline, continuous flow from the centrifugal blood pump. Would it work? We’d find out in the next few days. Until this point there had been a 100 per cent mortality rate in humans. But we could tell from the blood samples that it was looking good. Julie had pretty normal biochemistry. What’s more, the homograft tube was working well. There was no bleeding around that crazy inflow tube, which had been a major problem in the three American patients. The turbine was spinning at 4,000 rpm, with a flow exceeding normal cardiac output, and the pump itself was perched comfortably on Julie’s right diaphragm.

  We’d succeeded in keeping her alive.

  Somewhat perturbed by the flatline pressure trace, Mike asked Brian to switch the balloon pump on again. This produced a feeble pulse wave on the trace but absolutely no difference in blood flow to the body. But the pulse wave was much less important than blood flow. Every cell of the body needs well-oxygenated blood containing glucose, protein, fat, minerals and vitamins, and it really didn’t matter whether the blood had a pulse or no pulse in it. Flow was the key.

  This was a complete revelation at the time. Systole and diastole had always been considered so important, and you had to continually measure them. If blood pressure was low you had to get it up. But this was not the case with a continuous-flow pump. Low blood pressure actually provided less resistance for the pump to work against. When pressure went up pump flow went down. Counterintuitive physiology. We had to get used to it.

  It was almost 8 am and the sun shone brightly on the dreaming spires. I left Katsumata to close the chest and went to warn the intensive care unit about the impending arrival. It would be something completely different for them. I told them that for the next twelve hours – Julie’s critical period – she’d have no pulse, and that an average blood pressure of 70 mm Hg was fine. Her kidneys had packed up, so she’d need dialysis for a few days. And she was a little yellow, as her liver was suffering as well. In fact, when she’d arrived in the ambulance from London by most criteria she’d been dead. But we hoped she wouldn’t be dead now. Good or what?

  Desiree Robson, our chief nurse, asked whether I’d talked to the family. They were sitting in the relatives’ room – Mum, Dad and little sister, totally exhausted after their night-time chase around the south of England – awash with tea and sympathy, but still expecting bad news.

  ‘Go and tell them what’s going on,’ Sister ordered. ‘Celebrate later.’

  At that point I was unsure what I could t
ell them. Try this – ‘Your precious daughter arrived too late. We all thought she was dead despite the ventilator and balloon pump, but we implanted an unlicensed, previously completely unsuccessful machine from the States. And now we have resurrected her from the dead. As long as her brain still works, that is.’ This was the harsh truth of it all.

  I walked into the miserable relatives’ room, where the clock was still stuck on 5. Three heads were bowed, hands wrung in laps. They all looked up at once, and I could tell right then that even though they’d no idea who I was they just knew I was there to tell them the worst. Then they read my expression. With mask dangling down and blood on my theatre shoes, I looked pleased, and not with the sycophantic, forced look of sympathy doctors put on when giving bad news. Julie was still alive, a miracle of science.

  I didn’t explain that it was new, untested technology that had never before succeeded. The nurse allocated to Julie’s ITU bed slipped in behind me, quite appropriately, to hear what I would tell them. But nurses hate it when I suggest that everything will be fine. They want me to look grave and talk about a critical period just in case something goes wrong. They don’t want me to put the unit under too much pressure. Pressure to get things right.

  All I could tell them was that the pump we’d used was keeping her alive and we’d been very lucky. It had only arrived from the States two days before, and we’d unpacked it with Julie already on the heart–lung machine.

  ‘What are her chances now?’ Julie’s mother asked.

  I told her that we hoped it would keep her alive until we could arrange a transplant. We weren’t a transplant centre but I would talk to one and make it happen. It wasn’t the time to mention that I was scheduled to be in Japan in three days’ time.

  I left the relatives there in the room. I was told that Mike and Katsumata were bringing Julie around, and that her mum and dad would be able to see her soon. Although it might be distressing for them – there were many tubes and lots of equipment attached to her diminutive body – it was better than visiting her on a slab in the morgue, with ashen white face and waxy cold hands, lips bruised from the tracheal tube. I knew well from experience that anything was preferable to that.

  Sister Desiree was there to sort things out – unravel the drips, plug in the machines, calibrate the monitors. Get it all absolutely right. Desiree and Katsumata would be experts on the AB-180 by the end of the morning. For now they had to get used to looking after the girl with no pulse. This team didn’t need me, which was just as well. My mobile phone rang. The signal was poor but the message was just discernible – the medical director wanted me to come to his office.

  I was expecting this, and knew that I wasn’t being invited round for coffee. Medical directors are the Stasi from a hospital doctor’s standpoint. Put simply, they are there to ensure that no one does anything new or interesting. Anything that might generate bad press for the hospital. As they say in court, I had previous form. A loose cannon.

  His face was like thunder. How dare I use an unregulated device? Who knew about this? Were the ethics committee involved? What on earth was I trying to do, keeping this young girl alive? He didn’t say any of this, but that’s how it came across.

  I didn’t respond, but just sat there in my blood-stained theatre gear thinking, ‘Get a life.’ It was time to play the obvious card. I said I didn’t have time for this and needed to get back to the patient. His parting comment was, ‘If you do anything like this again you’ll be out.’ This reminded me of repeated threats to send me to a bad boys’ boarding school as a child. They never worked.

  I went straight back to the ITU. Julie’s family were now by the bedside and Desiree was explaining the paraphernalia keeping her alive – breathing machine, balloon pump driver, AB-180 console, infusion pumps, warming blanket. All quite simple, really. And they were bringing in the dialysis machine for her kidneys. By now the operating theatres were waiting to start the day’s planned cases. I told them I was ready and that they should send for the first patient, a premature baby with a big hole in the heart whose parents were getting anxious.

  Between operations I kept going back to Julie. I couldn’t see the bed for doctors. One of my cardiology colleagues was trying to get good ultrasound pictures of Julie’s heart without interference from the adjacent pump, and these were provoking great interest. The ventricular muscle was completely offloaded and doing no work, well and truly rested, and only a slight twitch remained to show that electrical activity continued. The flat line on the monitor unnerved some of the medical staff.

  By early evening everything was stable and the crowds had melted away. With an empty left ventricle and low blood pressure, the balloon pump was superfluous. Not only that, it was partly blocking Julie’s leg artery and was just another route for bacteria to gain entry to her system. I insisted they remove it. Katsumata lived in the hospital complex, Desiree just a couple of streets away. They said they’d keep a close eye on her, so I set off home for the night, away from the madhouse.

  By early morning Julie was awake. With the breathing tube down her throat she was frightened and agitated. She had no idea of her whereabouts or why she had apparatus emerging from every orifice of her body. And she was clearly in pain, so we needed to sedate her again. Just enough, because too much would drop her blood pressure. An injection of barbiturate into the drip and she drifted away again into oblivion, the best place to be in these circumstances.

  I put a stethoscope over her sternum and heard the loud, continuous whirring sound of the magnetically suspended turbine – still set at 4,000 rpm – pumping five litres per minute, the same volume pumped by a normal heart. Few of the people at her bedside, on the ITU, in the hospital, in Oxford – or even in the country as a whole – realised the significance of this one, single case. Pulseless flow was causing Julie’s organs to recover – brain, kidneys, then liver. The pioneers of artificial heart technology had denied that this was possible, claiming that pulsatile pumps were essential and blaming the three previous failures with the AB-180 on this fact.

  So what was the significance of this finding and why was I starting to get excited? If pulseless flow worked this well temporarily, then the new Jarvik Heart should be successful in the longer term.

  At 7 am I was called to the phone at the nurse’s station. Someone with an American accent wanted to speak to me – they didn’t get the name. It was George Magovern, the man who’d initiated the AB-180 project, calling from Pittsburgh well after midnight local time. Richard had called him but he wanted to thank me personally. His engineering team were still out celebrating and they wished Julie luck, hoping that we could keep her going till a donor heart became available. I said we’d try. This was just the boost I needed right then, something to put the sceptics in perspective. And the medical director.

  The next day we took her off the ventilator and removed the tracheal tube. Miraculously her brain seemed fine. She could talk to her parents and there was more urine in the bag. I watched the flat line on the monitor screen. Then I noticed something. Her regular heart rhythm had changed to irregular atrial fibrillation. This was not unusual in itself, but when there was a long pause after irregular beats a definite blip appeared on the arterial trace – her own heart was starting to eject blood when allowed to fill for long enough.

  I didn’t say anything but wondered whether her heart was beginning to get better. Most cases of viral myocarditis improve with medical treatment before they ever reach the shock stage. So why would we want to give Julie a transplant if her own heart was recovering? It was simply the conventional thing to do with severe heart failure. I suggested that we give her a dose of steroids to help decrease the swelling in the muscle. Witchcraft, but if nothing else it would make her feel less lousy.

  I now had a very difficult decision to make. Today was Wednesday. Through some curious oversight I was scheduled to talk at a conference in Japan on Friday and another in South Africa on Saturday. Unbelievable planning. Clearly the dates ha
d been written in the diary as if they were London and Birmingham, yet it was just about doable. The question I asked myself was whether I should go at all. With the time differences I even had difficulty working out how long I’d be away. But no one’s indispensable, I had a great team and Julie was stable. So I decided to go.

  Before I set off we had a team meeting – Katsumata, Richard, Desiree and the intensive care doctors – as we needed a plan for the time I’d be away. The signs were good: Julie’s kidneys and liver were already recovering, there were regular blips on the arterial pressure trace and echocardiogram pictures showed improvements in her heart muscle contractility. The pump was doing its job. The plan was to keep her stable and just let her recover slowly. This required a steady nerve.

  A few days later I received the sort of message I dread. When I switched on my mobile phone in Johannesburg airport on Saturday there was a worrying text from Katsumata. They thought Julie was bleeding into her stomach, a common stress response but made worse by anticoagulation for the pump. But. The big but. Her own heart was much better on the echo pictures. With the pump turned down the left ventricle generated virtually normal blood pressure. I wondered whether the steroids had helped the heart but caused the gastric bleed. I needed to talk around the situation.

  I sent Katsumata a text. ‘Now in South Africa. Ring me.’

  His call followed soon afterwards. ‘How was Japan?’ he asked.

  ‘Great,’ I replied. ‘Just don’t mention the war.’ Then my punchline – ‘Don’t stop the anticoagulation yet. Turn the pump down to 1,000 rpm for an hour. If the heart still performs well, take the pump out.’