Fragile Lives Page 22

  In those days there were no consultants in Casualty at night and there were certainly no cardiac surgeons in the hospital. The sister knew I’d worked at the Brompton. She just looked at me and said, ‘Open him up. I’ll help you.’

  My brain said, ‘Oh shit,’ but my mouth said, ‘Let’s get on with it then – it’s now or never.’

  The anaesthetist was a senior registrar, and he nodded in approval, well aware that the kid would die if we did nothing. External cardiac massage is futile when the heart is compressed and cannot fill. There wasn’t even time to scrub up as he had no pulse or blood pressure. The assembled crowd rolled him over left side up while I pulled on a gown and gloves, Sister following suit. I stood behind him, Sister in front, and with my own adrenaline pumping I carved his chest open with a scalpel, then spread his ribs with a metal retractor stored ready for such an eventuality but rarely used.

  There was no blood or air in the patient’s chest cavity as the stiletto knife had gone directly through into the pericardium and right ventricle. All I could see was the tense, blue, bulging pericardial sac. I knew what I had to do, assuming I could stop my own perspiration from clouding my eyes and dripping into the incision.

  I opened the stretched membrane with a scalpel, and blood and blood clot spewed out. His heart was still beating but empty, and the ventricles filled as the pericardium emptied. His blood pressure started to come up and the stab wound began to squirt blood out again, although this was no longer an issue.

  I put my index finger over the gash and said, ‘Transfuse him while I stitch the ventricle.’

  ‘What stitch do you want?’ Sister asked.

  I didn’t have any idea and just said, ‘Give me anything you’ve got on a curved needle.’

  The first needle was much too big, the next much too small, but the third was just right – a blue-coloured, braided suture that knotted well. Perfect. I swapped fingers with Sister, who’d never touched a heart before, and she was squirted with blood.

  Now the tricky bit. I mounted the curved needle on the needle holder and edged into the best position to throw the stitch. I knew that as soon as Sister moved her finger blood would be pissing out. Not only that. The young heart was now bounding away, a rapidly moving target and not easy to stitch accurately. Deep breath. Just get on and do it.

  I drove the needle straight through the middle of the laceration from one side to the other, with deep bites. Sister cut the needle from the suture material and, to avoid tearing through the muscle and making the hole bigger, I tied the knot very gently. It worked, but to make him safe I needed further stitches on either side – three in total. It was nerve-racking for an amateur, as each time the needle penetrated the muscle it triggered a run of fast, uncontrolled rhythm. I guess in all the three stitches took me ten minutes, very different from now.

  Sister looked straight at me over her mask. I knew what the eyes were saying. She was impressed. Actually so was I – the hero of the moment. The patient’s blood pressure and heart rate were soon back to normal, and just when we no longer needed him the cardiothoracic registrar had been called in. By now I was happy to leave him to it. Sister and I retired to the coffee room, very sweaty but elated. With his chest closed up, they rolled the patient onto his back on the trolley.

  There was blood everywhere – on the stretcher canvas, in his hair, soaking his clothes and drying in a pool on the floor, all testament to our struggle. They needed to get him to intensive care for a clean-up. By now there were scores of other patients in the department, all getting restless with the wait.

  Then the lad suddenly woke up, uncontrollably agitated following his near-death experience. He sat bolt upright and began tugging at the drips. The jugular vein cannula in the neck disconnected. As he took a deep breath in, negative pressure in his chest sucked air into the circulation and he collapsed, pulseless again for a different reason. At the time no one realised why it had happened. They started external cardiac massage but couldn’t revive him. My first solo heart operation had proved fatal, and I’d gone from hero to zero in the space of a few minutes. Shit and derision.

  Suddenly the night had turned into a nightmare and paranoia set in. I was concerned that I’d be blamed for the death and be accused of recklessness, but I needn’t have worried. Sister and the anaesthetist made the situation clear; that without my intervention he’d have been dead sooner. The case went to the coroner’s court. The verdict? Unlawful killing. The cause of death? Air embolism after a cardiac stab wound.

  Not only was the operation my début emergency thoracotomy, it was also my first encounter with this fatal complication – air reaching the vessels of the brain. Sadly, it would not be the last. I was destined to operate on many more cardiac stab wounds throughout my career. Most were simple; a few were complex, involving the heart valves or coronary arteries. But none of the patients died.

  Knives and bullets are not the only source of penetrating chest wounds. Some of the most horrific injuries occur during road-traffic accidents.

  One quiet Saturday afternoon in the autumn of 2005 I was waiting for my son’s rugby match to start when my mobile suddenly rang and I was required to scramble again. It was an immediately life-threatening injury in a young woman. Mark’s school was just ten minutes from the hospital, and I was waiting in the hospital before the unfortunate victim arrived.

  Input from the paramedics en route suggested that a car had veered off the A40 dual carriageway at speed, shattering a wooden fence. A sharp shard of wood the length of a spear had penetrated the windscreen and transfixed the driver’s neck. The fire brigade had extricated her from the wreck, but she was blowing air from the wound and had difficulty in breathing. Her blood pressure was low, so they suspected internal bleeding.

  While I waited with the trauma team in the resuscitation area warning lights were flashing in my brain – it sounded as if her windpipe had been cut in two. If this were the case, then blind attempts to pass the breathing tube through could push the ends apart and completely obstruct her airway. So I wanted an experienced cardiothoracic anaesthetist to join us and the cardiac operating theatre team to stand by.

  I called Dr Mike Sinclair myself, asking him to come at top speed, which he did. As we waited I politely requested that the resuscitation team should hold fire until I had the chance to examine the woman. It was already more than an hour since the crash, and if she was still alive it meant that she’d reached some degree of equilibrium. A couple of minutes to work out the likely injuries would be time well spent.

  Tension rose palpably as the woman was wheeled in. She was awake but deathly pale, rigid with fear and her lips blue. All eyes were immediately drawn to the gash in the root of her neck on the right side, where bare sternomastoid muscle was exposed while air raised the torn skin as she exhaled. It sounded as if she were farting through the wound with every breath, while simultaneously spraying out an aerosol of blood. I was in no doubt about the cause. Equally, I was incredulous that the transfixion hadn’t ripped out at least one of her two carotid arteries. If it had she’d have died at the scene.

  The woman feebly raised her right arm, inviting me to take her sweaty hand. I was pleased to do that. We needed to connect as we’d be spending the afternoon together. Instinctively, I told her she’d be fine – not that I knew that, but she could use some comfort, to be treated like a person not an object of curiosity.

  She was in shock, not just mental distress, and had clearly lost litres of blood internally. My guess was that the stake had passed downwards through her neck and into the left side of her chest, taking out a significant blood vessel. A good old-fashioned stethoscope would tell me that. Physical examination was quick and still important in this era of fancy scans. Air was filling her right lung but there was no sound of breathing on the left. When I tapped her ribs the left chest was ‘dull to percussion’, a traditional physical sign of fluid surrounding the lung. So she had blood in the chest and barely recordable blood pressure, with her hea
rt rate 110 beats per minute.

  Now we faced a stern surgical test – a severe injury to the root of the neck together with bleeding into the left chest. A tricky combination. Yet the basic principles remained the same. First establish a safe and reliable airway. Next take control of the breathing. Then support the circulation, in this case by stopping the bleeding and blood transfusion. The ‘ABC’ of resuscitation.

  I needed Mike to put her to sleep. The only reliable way to secure her airway was with a rigid bronchoscope – a long, narrow brass tube with a light at the end. We had done hundreds of bronchoscopies together, whether to investigate lung cancer or remove inhaled peanuts from children.

  By now the resus team had put a couple of drips in the woman’s arms and were giving her clear fluids. I didn’t want too much of that. She was critical but stable, the same old story. The blood pressure drops and a blood clot plugs the hole – nature’s own rescue strategy. Clear fluid pushes the pressure up and makes the patient bleed again. ‘Treating the numbers,’ I call it, ‘not the patient’. Then Mike walked in and we agreed to push her directly round to the operating theatres. There I had complete control surrounded by my own team, away from the circus.

  Sister Linda had the bronchoscope waiting in the anaesthetic room, but first Mike needed to anaesthetise and paralyse her. Then I could slip the tube down the back of her throat, through her vocal cords and into the injured trachea, just like sword swallowing but down the windpipe. High-pressure ventilation through the scope sprayed blood out of her neck and there was blood everywhere, but I could soon see the injury. Two-thirds of the circumference of her trachea had been lacerated, leaving only the muscular back wall intact.

  I pushed a long gum-elastic probe down the bronchoscope and through the site of injury. After vigorously blowing in air to raise her oxygen levels the bronchoscope was withdrawn. Mike could then railroad his breathing tube safely over this guide. ‘A’ and ‘B’ were sorted. We could ventilate the lungs safely.

  Now I had to get on with ‘C’ and stop the life-threatening bleeding. They wheeled the woman through into the operating theatre and turned her left side up. Dawn was already scrubbed up, with the thoracotomy instruments laid out on sterile linen. I didn’t have to say a word. It all just happened around me like clockwork. Mike was ready with two units of donor blood and now had arterial blood pressure monitoring on the screen via a cannula in the wrist.

  A range of thoughts went through my mind at the scrub sink. First, I was relieved for the poor woman that she was unconscious and far distant from her terrifying ordeal. Then I was apprehensive. What would I find in the apex of the chest? I feared laceration of the large subclavian artery to her arm, although she still had a pulse at the left wrist. Hopefully it was just low-pressure venous bleeding, which would be easier to control. I was cognizant of the fact that the nerves to the arm were close by and I needed to avoid damaging them with the electrocautery.

  Two litres of blood spilled out of her chest, splashing over my trousers and clogs and onto the floor. Warm and wet, but wasted. It was meant to be good for the garden. With compression relieved, her left lung expanded like a kid’s balloon. It was virginal pink, not like the mottled grey lungs of smokers. We scooped and sucked blood from the depths of her chest until the ragged hole came into view. Mercifully there was no brisk, bright red arterial haemorrhage, just dark red bleeding from the main arm vein. I set about stopping the bleeding. If I tied off the vein her arm would swell, so I repaired it with a patch from a less important vein to preserve the flow.

  Now I was content that she was safe, we washed the chest cavity out with antiseptic solution. All the other main arteries and nerves were clearly visible in the roof of her chest. The stake had simply pushed them aside, generously limiting its destruction to the least important structures. The luck of the woman was barely believable. ‘C’ for circulation was now sorted.

  We were left with one other major injury to sort out – the transected trachea, a big tube containing air and much less intimidating than what we’d so far done. We closed up her chest, leaving a drain to remove residual air and blood, and I injected a generous volume of long-acting local anaesthetic into the nerves under the ribs to dull the pain. She had suffered enough.

  It was time for a cup of tea while they rolled her onto her back, ready to explore the neck wound. I liked to operate in the neck. Hers was slender with no fat, making everything easier. The horrendous gash, just above the joint between the sternum and clavicle, was 8 cm long. It gaped widely to reveal bare muscle, like grinning lips exposing teeth. The simplest approach was to excise the ragged edges then extend the incision into a thyroid gland incision.

  Her lacerated trachea was right in front of me, with the thyroid gland above and the rigid plastic breathing tube passing through the gap. With the benefit of full resuscitation the wound edges oozed bright red blood. This was easy to stop, but because the rural fence post was inevitably covered with bacteria I excised the contaminated edges of the trachea, then joined the clean ends with multiple separate sutures.

  It had been an intimidating problem but easy surgery. I managed a solid, airtight repair and finished by checking the nerves to the vocal cords. Again these were spared what might have been. God must have been with her in the car. Or sitting on my shoulder. Maybe both. Mike gave her a slug of heavy-duty antibiotics for good measure, then we closed the skin and subcutaneous layers with metal clips. A job well done.

  The family were huddled anxiously in the intensive care unit. They’d come in through the accident department, been injected with a dose of pessimism then dispatched for the long wait. Waiting to be told the outcome of emergency surgery is a truly miserable experience, particularly when it’s your own kid and they tell you that a fence post has nearly taken her head off. Alive or dead? Disabled or intact? Disfigured or still beautiful? It’s difficult to concentrate on the football results.

  I told them what I’d told her when I squeezed her hand as life ebbed away – that everything would be OK. Then I rode off into the sunset. Well, as far as the pub, that is, for time with my own little family, to hear about my son’s rugby and my daughter’s golf match. The fights. The cuts and the bruises. And that was just the ladies’ golf.

  As for the woman, she recovered quickly. Mike and I came in on Sunday morning to find her wide awake, so we took the bull by the horns and bravely pulled out the tracheal tube. Inevitably, after such an accident she felt like she’d been hit by a truck. Her throat and chest were sore, but her breathing was fine and she could speak. Everything was intact and she went home in a week.

  Thankfully, with age, my adrenaline addiction and testosterone are wearing off, yet the excitement of the unexpected persists. For the unfortunate patient, any prospect of survival depends upon having an experienced trauma surgeon at hand. Few are offered that privilege.

  14

  despair

  Strength does not come from winning. Your struggles develop your strengths. When you go through hardships and decide not to surrender, that is strength.

  Arnold Schwarzenegger

  Oxford Brookes University lies within a mile of my hospital and is full of vibrant, happy students. One of these, a twenty-year-old girl studying Japanese, had complained of fainting attacks. A series of preliminary investigations, including an ECG and echocardiogram, indicated that her heart was normal, but one evening she was talking with friends on the campus when she suddenly collapsed to the floor.

  This happened only a few days after the very public resuscitation of a Premier League footballer on the pitch in north London, which had been widely reported in the media. He survived through effective bystander resuscitation by a cardiologist in the ground, then rapid transport to a frontline cardiac centre. As a result, cardiopulmonary resuscitation was very much in the public awareness.

  The girl’s friends began cardiac massage and called the emergency services. A paramedic ambulance was despatched from the nearby headquarters and reached h
er in less than four minutes. Their cardiac monitor showed ventricular fibrillation – random electrical activity, with the heart squirming aimlessly and not pumping. These days, paramedic vehicles carry a defibrillator. As the girls continued chest compressions the paramedics set up to defibrillate, putting electrodes on the front and side of her chest. Ninety joules. Zap!

  This usually works in heart attack patients, but after a brief period of flatline it fibrillated again. Although the hospital was only two minutes away from the campus, and full of specialist doctors, they didn’t bring her in. Instead they inserted a tube into her windpipe and persisted with on-site resuscitation. At least she was getting oxygen. The ambulance was carrying a new toy – a ‘Lucas’ chest compression machine. Manual cardiac massage is tiring but this machine doesn’t tire, rhythmically pushing down on the lower half of the breastbone, forcing blood out of the heart and around the body.

  When more shocks failed they fitted the machine around her chest. Now her heart was squeezed between the sternum and spine and continuously pounded like a meat tenderiser. Time passed, and it was more than thirty minutes after the cardiac arrest that she was wheeled in to the accident department, lifeless but replete with medical equipment, the Lucas machine still bashing away. Her pupils still reacted to light – they’d kept her brain alive – yet her poor heart was still squirming, battered and bruised.

  Fabrice Muamba, the Bolton Wanderers footballer, had been lucky as there was an experienced cardiologist right there in the ground. What this young woman needed was treatment targeted towards the underlying problem, but what she got was the Standard Advanced Life Support approach: first, defibrillation with high electrical charge – 150 joules then 200 joules on multiple occasions using the original electrodes – then, after repeated failure with this and persistent fibrillation, continuous cardiac compression by the machine and adrenaline injected into a vein. The adrenaline would have been potentially useful had the heart been contracting, but it worsens muscle irritability and predisposes the patient to more ventricular fibrillation.