Fragile Lives Page 26

  They were justifiably nervous but eager to proceed, suitably impressed with the technology. Moreover, Jim was a great character, perfect for television. He shuffled down the corridors, head bowed, panting for breath, his nose and lips blue, and although he could barely speak he’d still joke for the camera. ‘It’s great to be down in London with these Ferrari mechanics, not like the Ford Escort boys up north,’ he’d say. That resonated with me.

  It was good to be back at the Brompton. As most of the original intensive care team in Oxford had now moved on, I asked Philip if we could do the implant in London, which pleased him enormously. First I needed to engage with the senior surgeon, Professor John Pepper. He was happy to help out, so we planned the implant for the following week. Rob Jarvik agreed to fly the pump across from New York at short notice and my Oxford colleague Andrew Freeland would come to help with the skull pedestal.

  Now we had the patient, the pump and a top team – the producer’s dream. All we needed was a successful implant with the cameras rolling, and Jim must survive. But as the Brompton anaesthetists emphasised, he wasn’t fit for an anaesthetic. Nevertheless, the hospital remained keen and supportive, and we didn’t have to fight the management to do it. They’d never implanted a left ventricular assist device before and would have been disappointed if we hadn’t gone ahead.

  Five thirty in the morning, dark and cold. The film crew picked me up by taxi and we headed into Oxford to find Andrew. He was wandering down the Woodstock Road carrying instruments to screw the plug into Jim’s skull. We headed down the M40 doing an interview in the car.

  ‘How do you feel about operating in a different hospital?’

  ‘Excited. I’ve operated everywhere from Tehran to Toronto. An operating theatre is an operating theatre and I’ve a good team. As Baldrick would say in Blackadder, “We have a cunning plan!”’

  ‘And how do you feel about the fact that he could easily die? Are you nervous?’

  ‘Absolutely not. Jim will be dead in days if we don’t try. No one else is going to help.’

  ‘Do you think that the NHS should pay for these pumps?’

  I answered that with a question of my own. ‘Should a First World health-care system use modern technology to prolong life? Or should it let young heart failure patients die miserably, like in the Third World?’

  The BBC liked that answer, but they didn’t broadcast it in the programme. Too controversial and intimidating.

  We reached the Brompton at 7 am, and I took Andrew and the crew directly to its deserted canteen. Little had changed since my day. They still did a good breakfast, so I helped myself to the healthy option: sausage, bacon, black pudding, fried egg and fried bread. Andrew followed suit. As we sat together the cameras started rolling. It was what the producer was waiting for. Heart doctor eats huge pile of fried food – wall-to-wall cholesterol.

  Me: ‘This is great. I never get this at home.’

  Andrew: ‘What would your wife say about that?’

  Me: ‘Don’t care!’

  This encounter turned out to be what everyone remembered about the programme. When my brain surgeon friend Henry Marsh did his episode they filmed him cycling to work through the streets of London – without a crash helmet! When asked he simply stated, ‘Never wear one. It wouldn’t save me!’ The BBC wanted characters and they got characters.

  John Pepper came down to meet us. Under the circumstances we were a very relaxed group, perhaps not what you might expect but good for Jim. Stressed surgeons do not function well, as numerous studies have shown. Stress impairs judgement and makes the hands shake. In fact stress is killing my profession.

  We went to the ward to see Jim and Mary before they brought him down. Jim was excited, Mary petrified. Was this her last goodbye, the end of their journey together? And would it be the high road or the low road back to Scotland? I did what I always do at such moments – reassured them that everything would be fine. Not that I knew that. I just wanted them to go into the operation with confidence. With the cameras rolling we were all in this together.

  There was an air of busy excitement in the operating theatre – nurses setting up trays of glistening instruments, perfusionists assembling their heart–lung machine, technicians jealously guarding the artificial heart, only to be revealed at the crucial time. But no Lord Brock’s boots this time. I was my own man.

  Now uncovered, poor Jim was obviously emaciated with the heart failure. The left side of his head was shaved, ready for the skull pedestal and power line. He was about to become battery-powered. Beginning with needle and guidewire then small stab wounds, John inserted the pipes for the cardiopulmonary bypass machine into the main artery and vein of Jim’s left leg. This was more sophisticated equipment than mine. I was learning something.

  Once Jim’s chest had been prepared with iodine and draped with adhesive film, Andrew exposed the surface of his skull while I sliced open the ribs, the camera panning from one site to the other. About a litre of straw-coloured fluid poured out of Jim’s chest – heart failure juice. I could then see the hugely dilated left ventricle through the pericardial sac.

  I started to tunnel the pump’s electric driveline out through the apex of the chest and into the neck, avoiding the perilous blood vessels and nerves to the left arm. Having penetrated through the neck I delivered the miniature plug on the end to Andrew. He passed this through the middle of the titanium skull pedestal, then screwed the titanium onto the skull behind the ear. Rigid fixation, it was called, so that the external power line could be plugged in securely. It all looked fascinating on television, but we still hadn’t reached the tricky bit.

  As I opened the pericardium clear fluid spilled out. The pale, distended left ventricle just twitched – you couldn’t dignify it with the word ‘contraction’. I urged the cameraman to focus in on it as I was about to sew on the pump’s restraining cuff. Each time the needle pierced the muscle the heart twitched and threatened to fibrillate. Irritating, because I was trying to do the implant without starting the heart–lung machine. This would reduce the risk of bleeding at the end of the operation. But Jim was too unstable. Before the cuff was secure the heart did fibrillate. No blood pressure but no problem. We just started the bypass machine and emptied the heart.

  Now came the exciting sequence for the film – carving the hole in the apex of the heart to insert the Jarvik 2000. First I made the cruciate scalpel incision, during which blood always spurts out. Next we cored out a circle of muscle with a cork bore device, causing blood to pour into the pericardium. This was halted when we inserted the titanium pump into the heart, and with a professor of surgery assisting me it all went smoothly. Andrew connected the external power cable to the skull pedestal and we switched Jim on, slowly at first until blood expelled the air from the Dacron graft.

  As usual air came fizzing and frothing out of the needle, red bubbles forming on the white tube. Visually it was extremely satisfying. I instructed the perfusionist to cut back on flow so we could fill the heart before turning up the Jarvik 2000 impeller speed. The last few air bubbles spluttered out from the highest part of the ventricle, apex uppermost. It was simple physics and done without thinking. There was lots of chemistry going on at the same time – optimising the potassium level and neutralising the lactic acid with sodium bicarbonate – as well as biology, with the electrical defibrillation of the quivering muscle to provide a stable heart rhythm. My three school examination subjects were not wasted.

  For many viewers it was the engineering that proved the most exciting part: an electric plug in the head and a turbine in the heart, spinning at 12,000 rpm without damaging the blood cells, and no pulse in the circulation. I maintained a continuous commentary for the television while throwing out instructions to the anaesthetist and perfusionists. ‘Start ventilating the lungs. Reduce your flow. Turn up the Jarvik.’ Detailed coordination by a guy who wouldn’t lift a car bonnet and couldn’t use a computer. No one quite believed how well it had all gone.

 
Were we pleased for Jim or focused on making great television? The honest answer is both. Naïvely, I thought that if the public could see his miraculous recovery there would be pressure to treat patients with these techniques on the NHS. We couldn’t sustain a charitably funded programme any longer – it was second-hand-shop health care. Poole-Wilson had this in mind too.

  We wanted to do a proper clinical trial by randomly allocating dying heart failure patients to a ventricular assist device or continuing medical treatment. We knew what the outcome would be: symptom-free extended life versus inexorable deterioration and death. We didn’t consider that fair to those who didn’t get a pump, but the devices would never be approved for NHS use without a trial. Only the British Heart Foundation had enough money to support this endeavour and they turned us down. At the time it couldn’t be done in the States, either. They were waiting to see the long-term outcome of pulseless patients before agreeing to it, so all eyes were on us.

  Jim separated easily from the bypass machine. This was the most taxing part for the Brompton anaesthetists. It was the first time they’d managed a patient with continuous blood flow. An average flatline blood pressure of 80 mm Hg was optimum, although for any other heart patient this would be regarded as unreasonably low. Vasoconstrictor drugs would normally be used to raise it beyond 100 mg Hg, but Jim needed a counterintuitive approach.

  We gave him vasodilator drugs to reduce blood pressure. The lower the vascular resistance, the greater volume of blood the Jarvik 2000 would pump. His organs needed sufficient perfusion pressure, but 70 mm Hg to 90 mm Hg was just fine. The kidneys, liver and brain work normally at this level, tiny capillaries supplying the tissues – there’s no pulse in capillaries even when the arteries are pulsatile. We learned all this through trial and error. It worked in the laboratory, so it should be fine on the wards, albeit a source of fascination for the Brompton team and the film crew.

  Andrew closed the scalp and neck incisions, then took off for Oxford. He had a busy clinic that afternoon – snotty noses and wax-filled ears, not artificial hearts. John removed the pipes from Jim’s groin, and I inserted the chest drains and started to close the chest wound, meticulously cauterising all the bleeding points. His scalp was still oozing, so I put a couple of extra stitches to the skin, then cleaned the blood off the skull pedestal. Today cosmetics mattered. We needed clean white dressings and empty drains, every single spot of blood cleaned away.

  Nostalgically, I remembered my first heart operation in this very same operating theatre. I’d been wearing Lord Brock’s boots, and I recalled that when I pushed the saw through the poor lady’s sternum and into her heart Matthias Paneth strolled through the theatre doors in his pinstriped suit and exclaimed, ‘Westaby, what have you done this time?’ Now it was me in charge.

  The cameras kept rolling as Jim was wheeled off to intensive care. I glanced back into that operating theatre for the last time. There were pools of blood under the table, glistening bright red under the lights, and a puddle of urine where the catheter bag had leaked. The perfusionists were folding their redundant tubes into a yellow plastic container, bloodied green drapes were stuffed into clear plastic bags and the nurses in their theatre blues were disposing of the redundant white swabs – all the colours of the rainbow, an artist’s dream.

  It had been a historic day. The backstreet kid from Scunthorpe had implanted an artificial heart at the Brompton for the television programme that took him there in the first place, fifty years before.

  Once Jim was safely connected to the ventilator and monitors we went to find Mary and her daughter, cameras in tow. There was no escape. Drama they were after and drama they were determined to find. We took the family to see him. The surroundings in critical care are always intimidating, this time particularly so. Jim’s scalp was shaved and a black power cable dangled from his head, life dependent on a battery.

  We explained everything to them but they already knew most of it from Peter Houghton, who was now on his way to the hospital. But they couldn’t see the electric plug under Peter’s hair. It was rather more alarming when they confronted it head on. I handed Jim’s daughter a stethoscope and placed the listening end over his heart. A look of surprise lit her face. She could hear the continuous whine of the spinning impeller that would keep her dad alive. I pointed to the cardiac output monitor. The implanted device was pumping four litres of blood per minute and consuming seven watts of power via the controller and battery. I could turn Jim’s blood flow up or down. It was easy – just one single knob. The producer loved it. This was much more exciting than brain surgery. Drilling small holes in the head and sucking out bits of tumour? That needs a different personality type altogether.

  Jim stayed incredibly, boringly stable. He didn’t bleed, whereas Peter and others had lost gallons. John, Philip and I wistfully discussed other potential patients. Where could we get the money? I could raise enough for a few more pumps but not a full-scale trial. The discussions ended up where they needed to, in the pub, cameras and all.

  When I wandered back to intensive care Peter Houghton was with the family, beaming like the Cheshire Cat. It was important for him to have what he called ‘cyborg companions’ – battery-driven people making a new life for themselves, Dr Frankenstein’s monsters with a metal bolt sticking out their skull. For me this was a happy scene and I felt that one day all life would be this way. On that curious note of fantasy, I decided to go home to Woodstock. The longer I stayed at the Brompton, the more I wished I still worked there. It was a ‘can do’ environment – a famous old hospital wanting to do new things, not seeking reasons not to do them.

  I operated in Oxford the following day, then headed back to London. Jim had been taken off the ventilator, the tube was out of his windpipe and he was chatting to Mary, back in the land of the living. He looked completely different, animated and radiating joy, his nose and ears pink not blue. The pump was pushing out five litres of blood per minute with absolutely no pulse on the arterial pressure trace. And there was a litre of urine in the bag, this liquid gold, meaning that his kidneys were happy.

  By now the camera team were in the pub. I asked the intensive care doctor whether he’d prescribed warfarin yet. It was all done and there was nothing for me to add. This dead-end heart failure patient was recovering rapidly, with no immunosuppression or any of the other poisons that a heart transplant patient needs. What’s more, Jim’s own right ventricle was coping well with the extra blood flow. So when I returned to Woodstock it was with a sense of deep satisfaction.

  I saw Jim several times before he returned to Scotland. Philip greatly reduced his heart failure drugs, in particular the water tablets that make every patient’s life difficult, and the family had no problem getting used to the pump, changing the batteries regularly and plugging it into the mains overnight. Jim’s ankles slimmed down, he was no longer breathless and he could lie flat for the first time in months.

  Weeks later he was there when his daughter graduated, with a glass of champagne in his hand. Then the BBC filmed him walking along a Scottish beach with Mary at sunset – a happy man, breathing easily, reflecting on his journey – and this poignant scene was used to close the programme. The Your Life in Their Hands series won a prestigious award for Best Television Documentary, and I was proud to have played my part in that. It was a high point in my career.

  Only rarely did Jim return to the Brompton for a check-up. The local hospital and his GP became familiar with the technology and were happy to look after him. But then came dismal news from Scotland, shortly before Christmas. Jim had gone to visit a friend without taking a spare battery with him. He was enjoying life and his mind was on other things. The ‘low power’ alarm went off on the controller, meaning that he had twenty minutes to change the battery before the power went off altogether.

  Jim didn’t make it home. His own heart had not recovered sufficiently to see him through. When the battery expired Jim died too, his lungs filled with fluid. It was desperately sad af
ter three years of good-quality extra life. For me this catastrophe illustrated just how effective these devices can be. It was a tragic loss.

  Time passes. Before I knew it, it was 2016. By now I’d had a lifetime in cardiac surgery. How much longer did I want to spend doing this? The trouble was that I remained good at it, a compulsive operator who would take on the difficult stuff and, after thirty-five years, vastly experienced in a way new surgeons could never be. Did I owe it to the patients to stay? Or to my family to quit, to move to an easier job?

  My personality and retirement were not in the least bit compatible, but my right hand had become deformed. The fascia in my palm – where the scrub nurse slapped the metal instruments – was contracting and I was developing a claw hand, known as Dupuytren’s contracture. Now I couldn’t even greet people properly, as my hand was warped into the position in which I held the scissors, the needle holder, the sternal saw. It was a true occupational adaptation, and one that would ultimately force a decision. Then, as for many ageing surgeons, bending over an operating table for hours on end eventually took its toll on my spine. As I used to instruct my registrars, ‘Please take over – my back’s bad and the front’s not so good either.’ Yet no physical ailment was as debilitating as hospital bureaucracy, not being able to operate, no beds, not enough nurses, junior doctors on strike. In addition, there was the ‘statutory and mandatory’ training, where I had to sit in a classroom while a paramedic taught me how to resuscitate, or taking a quiz on how to prescribe insulin or cancer drugs – things that I never ever have to do – or writing my personal development plan at the age of sixty-eight. It was all time wasted, when I really should have been up to my elbows in someone’s chest, doing some good.

  The fire alarm went off in the operating theatres recently, right in the middle of a valve operation while the patient was still on the bypass machine, their heart cold and flaccid, the prosthetic valve half sewn in. An administrator poked her head round the door and said, ‘The fire alarm has just gone off. We don’t think there’s a fire but we have to evacuate.’