Fragile Lives Read online

  I just said, ‘Right then, I’m off.’ The look on her face was priceless. I followed up with, ‘You rush off then. Save yourself. But please leave us a bucket. We’ll piss in it and put the fire out!’ One can only tolerate so much. My whole profession had lost direction.

  afterword

  Don’t cry because it’s over. Smile because it happened.

  Theodor Seuss Geisel (Dr. Seuss)

  After I qualified in medicine in 1972, the old Charing Cross Hospital closed down and relocated. When the last patient left the famous landmark on the Strand, many of us students walked around the empty shell to reminisce about our training. I went back to that rickety old lift and up into the eaves, and for one last time I opened the green door into the Ether Dome. The electric lights still worked but all the dusty antiquated equipment had gone. I walked tentatively across the boards to gaze down into the operating theatre, just as I’d done six years before. Sure enough, that last spot of Beth’s blood was there on top of the operating light – black, ingrained and inaccessible. They never did succeed in washing her away.

  Beth continued to come to me in the dead of night, particularly during the bad times, of which there were many. The baby was now in her arms, behind it the brutal metal retractor embedded in her frail chest, her dead heart empty and still. She’d walk towards me, ashen white, with her piercing eyes wide open and staring at me, exactly as they were on that day. Beth wanted me to be a cardiac surgeon and I didn’t disappoint her. I was good at it. Yet despite my best efforts some patients took the fast track to Heaven. How many, I really don’t know. Like a bomber pilot I didn’t dwell on death. It was more than three hundred, fewer than four hundred, I guess. But Beth was my only ghost.

  June 2016. It was an astonishing fifty years after I tentatively passed through the doors of the dissecting room as a nervous young student to start cutting on a wizened, greasy and embalmed human body. Now I was standing on the podium in the Royal College of Surgeons, holding court at a meeting for heart surgeons in training. The organisers were parading me as a role model – a pioneering heart surgeon who had survived the course without being sued or suspended. An increasingly rare species. My talk was about the illustrious history of the heart–lung machine and circulatory support technology, celebrating the great men and daring deeds that I grew up with, not to mention those I did myself.

  As the next lecture began I attempted to slip out unnoticed. But there was a flurry of activity behind, a scramble of eager young men who wanted their picture taken with me. I found that flattering. We posed in front of the marble statue of John Hunter – legendary surgeon, anatomist and bodysnatcher – in the entrance hall. I always felt uneasy at that particular spot. It was where I learned that I’d failed my exams – on more than one occasion – when my name wasn’t read out. When many of us walked away in shame.

  Even my eventual triumph was painful. It was the time I took the oral examinations with a badly fractured jaw that kept me quiet. On a grim winter’s afternoon in Cambridge I’d been sitting in the Addenbrooke’s accident department covered in mud following a misjudged rugby tackle. Still in my rugby kit, I was waiting to see the orthodontic surgeon when an ambulance brought in a young motorcycle-accident victim who was bleeding to death into his left chest. There was no time to call the cardiac surgeons from Papworth Hospital, so the casualty officer and nursing sister, who both knew I’d worked there, asked me to intervene before it was too late. I opened him up wearing grubby shorts with muddy knees, spitting out my own blood into the scrub sink.

  This bizarre story went viral and there were Cambridge surgeons at the examinations. Maybe it even helped. Yet ultimate success hadn’t dimmed those memories. I detested the cardboard elitism, with the examiners dressed in bright red gowns sweeping around the pillars – ‘Flash Gordon outfits’, I used to call them. Now the Royal College had become an institution that tacitly supported the ‘name and shame’ culture, that endorsed the public release of named surgeons’ death rates, that tipped its hat to the politicians who ruled health care in preference to defending its members.

  How things had changed since my day. Despite the hardships, when we made it into heart surgery we felt ten feet tall – proud, bullish, like fighting cocks. The world was our oyster, we’d reached the top and people respected us. By contrast, these trainees were downtrodden, defensive, uncertain of themselves. The mood in the College was sombre.

  One earnest young man from the Middle East wanted to talk. His hospital was under investigation for borderline results, his mentors – whom he respected – were being chastised in the newspapers and as a result he wondered whether he should continue. Was it worth the struggle, or should he give up and go home to his family? I told him that I’d once operated on a sick blue baby in Iran, the child of a politician back in the bad old days after the Revolution. At the time, although I was really concerned for my own safety had the child not survived, I stuck my neck out because the patient had no other option. So my first piece of advice to him was, ‘We’re here for the patients, not for ourselves. We may suffer for that but we’ll rarely regret it.’

  We left the gloom of that historic building and walked down to the Strand in the sun. I asked him why he’d chosen heart surgery in the first place and he told me it was because his sister had died from a congenital heart defect. He wanted to operate on children but this already seemed a ‘bridge too far’.

  As we passed the Savoy I explained my own background, about losing my grandfather to heart failure and wanting to find a solution. If a backstreet kid from Scunthorpe could do it, so could he. Then I told him about Winston Churchill, whom I often talked with in the graveyard at Bladon. How in the dark days of the Second World War and during his ‘black dog’ hours he never gave up, and how I didn’t give up after the débâcle of my own first heart operation. So my second piece of advice was, ‘Follow your star. Do it for your sister.’

  We turned off from the Strand and went past Rules restaurant in Covent Garden. As an impecunious student I’d seek to impress potential girlfriends there, then starve for the rest of the month. I told him not to be afraid to take risks. Sometimes they pay off handsomely. We walked for another couple of hundred yards and there was the entrance portal of the old Charing Cross Hospital, my glorious medical school now turned into a police station. I described to him the Ether Dome and the operation that haunted me, a catastrophe that could have changed my life. But it didn’t. It made me more determined to press on against the odds. So perhaps one last thought for him: ‘The past is the past. Put it behind you. It’s tomorrow that matters.’

  The young man was grateful. Taking the time to talk made a difference to him. Perhaps he felt as I did in America when Dr Kirklin told me to take the difficult route and operate on children, or when Dr Cooley first showed me an artificial heart. As he turned to go back to the conference he went to shake my hand. From his quizzical look I could tell he was surprised that the hand was badly deformed. Until recently it hadn’t interfered with my operating. I’d been advised to have surgery long before but typically had ignored it, concerned that it would end my surgical career. Now it had gone too far. I could no longer grasp the instruments without dropping some of them and I couldn’t shake hands without people thinking I was a member of some secret society.

  At that point I conceded that my operating days were over. I’d never get back to complex surgery. Instead my focus would be on our new stem cell research and the ventricular assist device we were developing – plenty to engage with but different, research with the potential to change millions of lives. Just a few weeks later I quietly disappeared from the hospital and had my right hand operated on. Normally my plastic surgery colleagues would have done it using a regional nerve block with me awake, but they didn’t want the interference. Frankly, I was pleased to be asleep as I really didn’t enjoy being on the other side of the fence. And for me it wasn’t just an operation. It was the end of an era.

  acknowledgements


  My mentor in the United States was the great Dr John Kirklin, who launched open heart surgery with the heart–lung machine. Towards the end of his distinguished career he wrote:

  After many years of cardiac surgery, with many tests and challenges, and after many deaths that could not then be prevented, we tend gradually to become a little weary and, in some sense, infinitely sad because of life’s inevitabilities.

  I wrote this book because I’ve reached that same point in a career spanning the rise and fall of the NHS. Hence my acknowledgements are as emotionally charged as the rest of the text.

  Heart surgery has been in turn a difficult road and a lonely destination. In the 1970s and 80s we really did work constantly. In the States it was 5 am ward rounds, call the boss at 6 am, operate all day, go to the laboratory in the evenings, capped by night-time vigils beside the intensive care bed. It was not so different at the Brompton or Hammersmith hospitals in London.

  The pioneering early days were highly competitive, and junior heart surgeons were the thrusting young blades of the medical world. I was lucky. I succeeded because early in my training I learned from the great men: Roy Calne, John Kirklin, Denton Cooley, Donald Ross, Bud Frazier and many more. I understood what was necessary to move the specialty forward. For me it took relentless effort and lateral thinking, then sheer guts to go with the blood.

  This ruined any aspiration towards a normal family life. We were not normal people. Most rational young men would be paralysed by fear at the thought of carving open someone’s chest, then stopping, opening and repairing their heart. But I did this day after day. We were fuelled with testosterone, driven by adrenaline. Few of us stayed married in our youth, and many of us subsequently harboured deep regrets.

  I was always sorry for the distress caused to my first wife Jane and eternally grateful for my talented daughter Gemma, now a Cambridge-educated human resources lawyer. While I spent many hours striving to save other people’s children, I never spent enough time with my own. This book goes some way to explaining why I was so preoccupied. It also gives me the opportunity to emphasise that nothing ever mattered more to me than them – and the rest of my precious family. My only sibling David attended the same grammar school in Scunthorpe but did go to Cambridge. He read medicine at Christ’s College, then followed me to Charing Cross and became an eminent gastroenterologist in London.

  Inevitably, I met my soulmate over an open chest in the accident department, blood everywhere, drowning in sheer desperation. Sarah was the kindest accident and emergency sister I ever met. The daughter of a Battle of Britain Spitfire pilot, she was never flustered, nothing was too much effort. The lad died, and when I couldn’t face telling the family she dealt with it. She did the same for others, time and time again. A free spirit from Africa, she made no distinction between tramps and politicians – they were all valued people to be treated with respect. I ruined her relationship and she suffered considerably for it. But she went on to give me unquestioning and unfailing love and support for the past thirty-five years, particularly through those difficult times. Mark came along ten years after Gemma, a sportsman and adventurer who took himself off to South Africa to train as a game ranger.

  It was a struggle to build the Oxford programme. The hard work was done by a handful of dedicated personnel who took the cardiac centre from fewer than one hundred operations a year in 1986 to more than 1,600 in 2000. Our productivity was allied to innovation, and the team was replete with skilled surgeons and cardiologists, supportive anaesthetists and perfusionists, and superb nurses – too many to name, but I’m grateful to all of them.

  We could never have started the paediatric and artificial heart programmes without the support of one visionary hospital chief executive, Nigel Crisp, who went on to run the whole NHS and now deservedly sits in the House of Lords. Much of the artificial heart work was undertaken with charitable funding. In that context certain individuals and organisations were very generous. These include Heart Research UK, Sir Kirby Laing, Jim Marshall of Marshall Amplifiers (to whom I was introduced by my patient, the entertainer Frankie Vaughan), Christos Lazari, and the TI Group courtesy of Sir Christopher Lewinton and David Lillycrop. I would also like to pay tribute to Professor Philip Poole-Wilson, past president at the European Society of Cardiology, who helped us greatly with the Jarvik 2000 Heart Programme. Philip sadly passed away suddenly on his way to work at the Royal Brompton Hospital.

  Eventually, when I was the only remaining paediatric surgeon, we lost children’s heart surgery. Then I had to move the artificial heart research away from Oxford.

  I’m grateful to my friend Professor Marc Clement, head of both the Institute of Life Sciences and the Business School at the University of Swansea for providing us with a laboratory and an engineering team. We met serendipitously through my famous artificial heart patient Peter Houghton, who, with Nicki King, worked tirelessly to raise charitable research funding. Under the corporate banner ‘Calon CardioTechnology’ we now have an implantable British ventricular assist device to compete with the American pumps, all of which cost the same as a Ferrari! Stuart McConchie, past chief executive of the HeartWare Company and Jarvik Heart, came to help us with that.

  The Welsh connection put me in contact with the Nobel Prize-winner Professor Sir Martin Evans of Cardiff University, who first isolated foetal stem cells. With his colleague Ajan Reginald and the company Celixir he has worked on a heart-specific cell for regenerative medicine. With pumps and cells we aim to create a definitive alternative to heart transplantation.

  Despite a degree in biochemistry and a PhD in the bioengineering of mechanical hearts I’m a computer-illiterate technophobe who’s unable to perform the simplest repair on a car. So I’ve relied on good old-fashioned secretaries. For the past ten years Sue Francis has kept me afloat. We’d both be in the office before 6.30 am. Our Portakabin window looked directly onto the noisy twisted pipes of an air-conditioning plant, like an apocalyptic scene from Banksy’s Dismaland. In summer, flying ants ate through the window frames, then in the winter the cold rain seeped through the holes. I spent long, restless nights there, scrunched up on a small sofa, afraid to go home in case my patient deteriorated. Besides my patients, world-famous people visited that office – Christiaan Barnard, Denton Cooley, Robert Jarvik, even David Cameron, our last prime minister. All were bewildered by the modesty of an NHS heart surgeon’s headquarters. But between us Sue and I achieved great things; she took home and typed hundreds of publications, not to mention this book.

  In that context I’d like to thank John Harrison, who published some of my surgical textbooks. John encouraged me to write for the public and introduced me to my agent Julian Alexander, who made this book happen. It was also a pleasure to work with the expertise of Jack Fogg, Emily Arbis, Mark Bolland and the team at HarperCollins. I would also like to thank my medical artist, colleague and friend, Dee McLean, for her superb illustrations.

  So what happened to heart surgery in the UK? After multiple hospital scandals the NHS in England decided to publish individual surgeons’ death rates. Now no one wants to be a heart surgeon. And who would, with the long, taxing operations, the anxious relatives, and the nights and weekends on-call? It’s a system entrenched in nonsensical bureaucracy, with the reward of public exposure for a run of bad luck. Already 60 per cent of the UK’s children’s heart surgeons are overseas graduates.

  Ultimately the stars of this book are my patients, but I fear that few of the dramatic cases would now reach an operating theatre in the UK. In the final analysis a profession that dwells upon death is unlikely to prosper, undertakers and the military apart. As Dr Kirklin emphasised, death in cardiac surgery is inevitable. When a surgeon remains focused on helping as many patients as his ability will allow, some will die. But we should no longer accept substandard facilities, teams or equipment. Otherwise patients will die needlessly. The comedian Hugh Dennis is not noted for his empathy. On the satirical BBC programme Mock the Week he offered an alternative o
de to Dr Kirklin’s thoughtful statement:

  Roses are red, Violets are blue.

  Sorry you’re dead, What can I do?

  The answer? Bury the blame-and-shame culture and give us the tools to do the job!

  glossary

  AB180 ventricular assist device: a temporary centrifugal blood pump that was originally implanted into the chest. Now known as the Tandem Heart, an external blood pump used in cardiogenic shock.

  acute heart failure: the left ventricle fails rapidly and cannot sustain sufficient blood flow to the body. The lungs then fill with fluid. Usually caused by myocardial infarction or viral myocarditis and has a high mortality rate. See also shock.

  angina: crushing pain in the chest, neck and left arm due to limitation of blood flow to heart muscle in coronary artery disease. Typically comes on during exercise. If it comes on at rest it may warn of a heart attack.

  angiogram: cardiological investigation where a long catheter is passed through the blood vessels into the heart. This allows blood pressure to be measured in the cardiac chambers and dye to be injected to visualise the coronary arteries or aorta.

  aorta: large, thick-walled artery that leaves the left ventricle then branches to supply the whole body. The first small branches are the coronary arteries, which supply blood to the heart itself.

  aortic stenosis: narrowing of the aortic valve at the outlet of the left ventricle, restricting blood flow around the body. Can be caused by a congenital anomaly or degeneration in old age.

  arteries: the blood vessels that convey blood to the organs and muscles of the body.

  blood pressure: pressure within the large arteries. Normally measured by a cuff and stethoscope or a cannula inserted into an artery. Normal blood pressure is around 120/80 mm Hg. The higher figure is when the left ventricle contracts; the lower, when it relaxes.