Fragile Lives Read online

  The first Mr Clarke had to take over their care. When I heard about what had happened I was desperately sad yet at the same time relieved that I didn’t have to face that family. With age, my objectivity was fading and empathy was taking over. I was suffering for my profession.

  13

  adrenaline rush

  We are but tenants. Shortly the Great Landlord will give us notice that our lease has expired.

  Epitaph on the tomb of Joseph Jefferson, Sandwich, Cape Cod

  Allied fighter pilots during the Battle of Britain thrived on adrenaline, the hormone secreted by the adrenal gland in response to stress. One minute they were relaxing in deckchairs in the sunshine, the next scrambling for their planes and soaring up into the sky, anticipating the conflict ahead, then risking sudden death.

  Medical students are taught that adrenaline is the ‘fight or flight’ hormone, flight as in escape – not flying a Spitfire. But there are times when I have to scramble like those fighter pilots, times when every minute counts, even seconds. The call comes through that a patient with a penetrating chest injury is on their way to the accident department by helicopter or by ambulance. The entry wound is close to the heart, their blood pressure low and they need a cardiac surgeon as soon as possible. Scramble!

  Sometimes simple, frustrating issues spell the difference between life and death – a set of traffic lights, a police car in front, no space in the hospital car park. I cannot speed like an ambulance and there’s no blue flashing light on my car. So I drive fast and get into trouble. As a senior registrar travelling between London hospitals I was pulled over so many times that the police came up with an offer.

  When you need to move fast, call 999. Explain to the operator and we will take you where you need to go. They did this on several occasions, but it wouldn’t happen these days. Now they flag me down and I throw a fit. I tell them to check out the incident with the ambulance service, then escort me to the hospital. This conflict pumps up the adrenaline even more, so when I get there I’m ready to explode into action, to wield that knife.

  My mobile rings at 11 pm, number ‘unknown’. ‘Unknown’ is always the hospital. The operator says, ‘I will just connect you with the Accident Department,’ and I’m all ears, pissed off at being disturbed late at night but listening intently. The doctor says an ambulance is on its way from Stoke Mandeville Hospital. The patient has a high-velocity gunshot wound to the left chest and is in shock. The doctors at Stoke Mandeville had put up a drip and said, ‘Take him directly to Oxford.’

  I asked what turned out to be an Air Force medic how he knew it was high-velocity. Because it was a hunting rifle. Was there an exit wound? No. This had important implications for the damage inside. I knew about gunshot wounds. I’d done a stint at the Washington Hospital Trauma Center, then another at the Baragwanath Hospital in Soweto, Johannesburg, and I’d written the chapter on ‘Ballistic Injuries of the Chest’ for the British military’s textbook of emergency medicine. I loved operating on penetrating chest wounds as they’re unpredictable, each one is different and they’re always a challenge.

  ‘OK, I’m coming. Could you call my registrar? Ask him to call the theatre team in.’

  I had a high-powered Jaguar in those days, before I wrote it off, and the roads were dark and empty. I could let loose on the accelerator, all the while keeping a cautious eye out for deer or foxes on the road. My mind sifted through the sparse information I’d been given. How on earth did this guy get shot late in the evening with a high-velocity rifle?

  High-velocity bullets follow a predictable course when they hit the chest but they spin rapidly, transferring energy-gouging holes into the lung and generating secondary missiles – fragments of metal, shards of rib, bits of cartilage. They’re usually fatal. Had he been shot at shorter range the bullet would have gone straight out the back of his chest with a large exit wound.

  This unfortunate gentleman lived on the edge of a woodland shooting estate. Having just switched off the television before going to bed he heard what sounded like gunshots. Was it poachers? Despite it being a cold night with a full moon and coming up to Halloween, with patches of eerie mist lingering in the hollows, he walked down the lane to the edge of the woods and out into the fields to find out.

  Suddenly a crashing blow to the chest knocked him off his feet, even before the sound wave reached him – the crack of rifle fire. There was an agonising sharp pain above his left nipple that took his breath away and he immediately felt faint, but he had the presence of mind to pull out his mobile phone and dial 999. He told the operator he thought he’d been shot and gave his location, then collapsed in mental and physical shock. Staring up at the dim stars on this moonlit night, he fully expected to die.

  The assailant was in big trouble. He’d been poaching deer on his own patch and had mistaken the glint of moonlight in the victim’s spectacles as a pair of bright eyes. Dropping the rifle sights down to a broader target and aiming at what he expected to be the deer’s chest, he pulled the trigger. It certainly was a chest – but not of an animal, and he missed the heart by an inch. This was exceptionally lucky for both of them, as no one survives a high-velocity rifle bullet through the heart.

  Years earlier, at the Middlesex Hospital, I’d saved the life of a young man shot by the police in east London. The difference then was that it was a pistol bullet – this had passed straight through his heart but a blood clot in the pericardium plugged the holes, which is what happens when the pressure in the heart falls after blood loss. But with high-velocity bullets it’s a totally different story. They tear the heart to pieces, so I knew our patient didn’t have a cardiac injury and was confident that I could fix the rest.

  I arrived before the patient. The accident department was otherwise quiet, so a horde of medical and nursing staff were on hand, waiting to pounce. But I needed just one – an anaesthetist to insert the tube in his windpipe and secure his breathing. What I didn’t want was aggressive fluid infusion to replace the blood loss. Clear fluid simply raises the blood pressure, promotes bleeding and impairs the blood’s ability to clot, risking catastrophic haemorrhage.

  Back then the Advanced Trauma Life Support guidelines were poor if not dangerous in this respect. Research from Washington, DC, even showed that patients with penetrating chest wounds had better survival rates when brought to hospital by private car rather than by paramedics who spent time putting up drips and pushing in cold fluid.

  The ambulance sounded its siren on approach, and by now the patient’s blood pressure was less than 60 mm Hg with a heart rate of 130. He was cold, pale, sweating profusely and losing consciousness, and the paramedics knew that time was running out. They reversed towards the entrance and threw the ambulance’s rear doors open. Down came the ramp and the patient was rushed into the resuscitation area. I asked him his name but he didn’t respond.

  He was still wearing a sweaty, blood-stained shirt with a ragged bullet hole in the front. Beneath was the small skin-entrance wound, surrounded by a ring of black blood under his pale white skin, and now plugged by swollen muscle and clotted blood. What’s more, I could feel air in the tissues under the skin, a sure sign that his major airways had been damaged. I needed to predict the injuries inside from the site of the entry wound, and it was not reassuring. The wound was close to the root of his lung – the major clockwork – and over the blood vessels. Luckily it lay a little distance away from the heart.

  There were far too many cooks about to spoil the broth. I wanted him put to sleep and ventilated quickly so I could cut open his chest and get to the bleeding. He needed a couple of wide-bore venous cannulas in the veins, but there was no time for X-rays or scans. He needed treatment not investigation. As the anaesthetist put the tube down his trachea I asked the nurses to give me a gown and gloves, then get the chest-opening instruments ready.

  Panic spread with the realisation that I was about to open him up right there on the trolley. The anaesthetic drugs had stolen away what remained of
his blood pressure and he was about to arrest. I had to find the bleeding, stop it, then get some donor blood into him. Clear fluid doesn’t carry oxygen – only red cells do that, and he was short of them. I reckoned he had three litres or more of blood spilled into his chest cavity and a completely collapsed left lung. My registrar scrubbed up to join me. I had the nurses roll him onto his side, left side up, then cut away the wet, bloody shirt with scissors. We rapidly painted his skin with iodine antiseptic and wiped away the sticky mess.

  Curiously, I spotted the bullet lying under the skin just beneath his left shoulder blade. It must have been deflected by the scapula bone at the back of his chest then travelled downwards to rest in the centre of a bruise. I remember thinking that we should fish the bullet out and keep it for ballistic evidence to link it with the rifle that was fired.

  With a scalpel I sliced open his chest between the ribs, from the edge of the sternum all the way round to the shoulder blade, where the bullet popped out. I kept cutting with the blade, down through the thick, pale muscle layers. In a live patient these would normally hose blood – but he had no blood pressure and there was in any case little left to bleed. As I breached his chest cavity, great hunks of clotted blood like liver slithered out and plopped onto the floor, followed by fresh liquid blood. I grabbed the large rib retractor and cranked open the chest cavity, trying to expose his injuries and spot the bleeding point.

  By now one of my own theatre nurses had arrived with a powerful sucker, and I could see blood welling up from the depths. As I’d anticipated, the pulmonary artery was lacerated and air was blowing out of the main bronchial tube, so I needed to apply a large clamp across the root of the lung to control both of them. The operating theatre nurse scrabbled around trying to find me one, and once she’d done so and it was safely in place I told the anaesthetist to transfuse him rapidly.

  The patient’s heart was slowing down, grinding to a halt in fact. I could see it right in front of my nose through the thin pericardial sac, so I stuck my fist around it and pumped hard for a few cycles to give it some help. It felt empty. I asked for a syringe of adrenaline and stuck the needle directly into the apex of the left ventricle. A couple of millilitres would cheer it up. We needed to get the pressure up and neutralise the lactic acid in his blood with sodium bicarbonate. The adrenaline shot the blood pressure up to acceptable levels and the heart rate soared up to 140 beats per minute. A fit man, he would bounce back now we had things under control.

  To finish the job properly I needed him under the bright lights of the operating theatre, together with proper sterile drapes and accurate monitoring of his bloods and vital signs. By now it was 2 am and the theatre was ready, the hospital corridors long since deserted. We’d just wheel him along with his chest wide open, clamp in place and a drape over the top to keep the wound clean, then lift him onto the operating table.

  Throwing off my gown and rubber gloves, I retrieved the bullet from the floor. Things like that had a habit of disappearing, becoming desirable if macabre souvenirs. But this projectile had great forensic importance and I wanted to give it to the police, who were accumulating in great numbers.

  I walked ahead of the bizarre cortège to scrub up again in theatre, where the nurses were waiting with the operating lights switched on. Now I could see. I gently removed the clamp and was met with a gush of dark blue blood from the pulmonary artery. The chest wound edges were oozing bright red blood and air was blowing out of a lacerated bronchial tube, but otherwise there was no problem.

  In order to get a better view of the damage I pulled on the airless lung. It was what you’d expect from a high-velocity round, as if a dog had chewed at the vital structures. My hopes of conserving the lung rapidly disappeared. It simply had to come out, the whole thing. We needed to make him safe, not attempt some heroic repair job. If he died his family would be devastated – and the gamekeeper, as the culprit would turn out to be, left facing a murder charge.

  I encircled the pulmonary artery with a thick silk ligature and tied it off. No more dark blue bleeding. Two large veins enter the heart from the lung; I tied them both off as well, then cut through all three large blood vessels with scissors. This just left his injured bronchus blowing out blood and froth. I stapled it, chopped through the tube and lifted out the redundant lung. It missed the receptacle and fell to the floor. He’d be just fine with the one, and the right lung is larger than the left. We washed out the empty space with warm salt solution and the powerful antibiotic gentamicin, infection now his biggest risk as the bullet had sucked fragments of jacket and shirt into his chest.

  I sat and wrote up my notes while the registrar and house officer stopped bleeding from the wound edges and sewed him up. Documentation is vital in criminal cases, even at three in the morning. Driving home through the dark lanes I saw a fox on the grass verge, then a deer in the headlights, eyes sparkling. I was relaxed and content, another battle won, my adrenaline dissipated.

  Our patient recovered without complications. The bullet matched the gamekeeper’s rifle. He was arrested, then released on bail, having avoided a murder or manslaughter charge by a whisker – just minutes. It was a unique case for sleepy Oxford, one for Inspector Morse.

  Nothing sets off an adrenaline rush like a stab wound to the heart. I still remember the first one I had to deal with as a young man, way back in 1975. I was a casualty officer in the accident department of King’s College Hospital in south London, right on the edge of the war zone that was Brixton, London’s equivalent to Harlem in New York, where I’d encountered many stab wounds. Having cut my teeth on chests at the Brompton, I was in my ‘invincible’ phase, a coiled spring ready to launch into action.

  First a tutorial to set the scene. After my brief internship in Harlem I knew that most cardiac stab-wound victims died at the scene of the incident or on the way to hospital. Those who arrive alive sit on the edge of a precipice. The stakes are high, but most can survive with appropriate treatment, which is immediate surgery.

  Most assailants attack face to face and stab the front of the right ventricle. A few wounds involve both right and left ventricles. Stab wounds to the left ventricle usually enter from the flank or back – the ‘domestic incident’ route. The thin-walled right atrium is protected by the breastbone, while the left atrium lies further back in the chest. Only rarely are the atria involved in knife wounds.

  Rule number one. If the knife – or occasionally screwdriver – is still in place, do not remove it, and if it’s bobbing about with every beat the blade or shaft is very likely plugging a hole in the heart muscle. Such patients are usually suicide attempts, as assailants rarely leave their knives and fingerprints as evidence.

  When a knife is withdrawn, blood under pressure sprays out into the fibrous pericardial sac, the confined space that houses the heart. If there’s free escape of blood out of the pericardium into the expansive chest cavity this will most likely result in exsanguination – bleeding to death. When blood accumulates within the pericardial space because the entry wound is small, we call that cardiac tamponade. As blood compresses the heart itself, the patient’s blood pressure falls until a balance is reached and the bleeding stops. The circulation is maintained with lower blood pressure. These patients tend to survive. They’re brought in pale, cold and restless with a fast heart rate and distended neck veins, but are perfectly able to live for a short period of time as long as their blood pressure is kept down.

  Rule number two. Those admitted fully conscious usually have cardiac tamponade, and many need immediate chest opening for resuscitation. Holes in the heart are not amenable to standard resuscitation techniques, because if a patient is given intravenous fluids they will bleed more, often terminally. So it’s important to control the bleeding point first. Once the cardiac tamponade is relieved the patient may not need any fluid. I’ve operated on tamponade patients to whom so much fluid has been given that their poor hearts were fit to burst. Before sewing the wound I’d have to open it up and discard c
opious amounts of diluted blood into the sucker. Only then would the heart look sufficiently comfortable for me to stitch the laceration.

  Some patients arrive still warm but showing no other signs of life. But emergency surgery should only be undertaken if their pupils react to light. With vigorous cardiac massage and adrenaline it’s possible to restart any heart, whether the brain is dead or not. That’s why it’s important to scrutinise the pupils first. No coroner will allow a murder victim to be kept alive just to be an organ donor.

  I was still a junior doctor at King’s, not a heart surgeon, and at two in the morning the department was full of drug addicts, drunks, vagrants and the walking wounded. Not that we didn’t care for them. We did. The nurses were saints but constantly needed protection. It was a volatile environment.

  This particular patient had been dumped in the entrance hall by fellow gang members. His shirt was covered in blood, and he was deathly pale and already unconscious. The porters brought him through to a resuscitation bay and the sister in charge called the resuscitation team. He still had a faint pulse and his pupils reacted to light.

  As the nurses removed his shirt I could see the stab wound directly over his heart, about 1 cm wide. Blood trickled from the edges of the wound but his heart wasn’t pumping, and his jugular veins stood out like tree trunks in his skinny neck because of raised pressure within the pericardial sac. This was an obvious case of cardiac tamponade.

  The anaesthetist had already inserted the endotracheal tube and was frantically ventilating the lungs, but we still needed a large-bore cannula in his jugular vein for transfusion. A nurse took over squeezing the gas bag while the anaesthetist did the deed. He couldn’t miss. Dark blue blood shot out the end at high pressure.