Fragile Lives Page 4

  The rest of the operation went smoothly. Dr English and the perfusionist continued their chess game, I held the sucker and Paneth chopped out the deformed valve, replacing it with a ‘ball in cage’ prosthesis. Then lots of stitching-up.

  There was no end to the day for surgical residents. That night I sat in the intensive care unit waiting for the old lady to wake up, desperately hoping that she wasn’t brain damaged and wondering how I’d have felt had she bled to her death on the operating theatre floor. Would I have had the grit to continue? Or would my surgical career have ended that day? There was such a very fine line between hero and zero, but I’d survived. I just wanted her to wake up now.

  Her husband and daughter were keeping vigil by her bedside. Her husband asked whether the operation had gone well. I just glibly said, ‘Yes, very well. Mr Paneth did a great job,’ avoiding any implication that I’d fucked up.

  As if to order, she opened her eyes. A wave of relief flowed over me. Husband and daughter jumped to their feet, making sure that she could see them as she stared up at the ceiling, still transfixed by the breathing tube. They reached out for her hand. At that point I realised something – heart surgery might become an everyday occurrence for me, but for the patient and their relatives it is once in a lifetime, and absolutely terrifying. Treat them kindly.

  Cardiac surgery is like quicksand. Once in it you’re sucked deeper and deeper, and I struggled to leave the hospital in case something remarkable happened and I missed it. I spent endless hours sitting beside the cots of Mr Lincoln’s babies, listening to the bip, bip, bip of the monitors, watching the blood pressure sag and trying to get it up again, hoping that blood would stop dripping into the drains.

  The next débâcle followed quite quickly. One Saturday evening before Christmas, a group of residents were in the pub following dinner in the mess. Because there was no casualty department at the Brompton it was highly unusual for emergency operations to be held at night, particularly over the weekend. With a couple of pints of beer on board we were alerted by the switchboard that an American Air Force jet had taken off from Iceland carrying a young man injured in a road-traffic accident. He had a tear in the wall of the aorta and Mr Paneth was coming in to operate. Bad problem, both the injury and the beer. Not so much the amount of alcohol – we were used to that – more the volume of urine to pass during a four-hour operation. Nor could I avoid being involved, as Paneth would need two assistants. Although there was no way I could maintain concentration with a bursting bladder, I didn’t want to lose face by asking to leave, like a whimpering schoolboy with his hand up in class.

  As the senior registrar went off to make arrangements with the operating theatres I pondered the possibilities. What about a urinary catheter and drainage bag for the duration of the procedure? I didn’t really relish the idea of passing the catheter myself. Nor the discomfort of standing with the bag of urine strapped to my leg. And then it dawned on me. Lord Brock’s operating theatre boots! One of them would hold a couple of pints, and with a length of Paul’s tubing – thin-walled rubber tubing that was once used for incontinent males – there would be less risk of a bladder infection than if I inserted my own urinary catheter.

  I went to the wards in search of the tubing. This came in a roll to be cut to the appropriate length, in my case that of my inside leg. Once I’d found a supply, off I went to the surgeons’ changing room as I was keen to be in theatre all ready to go – with my clipboard and white boots as usual, tubing attached with sticky tape – when the boss arrived. And I was just in time, the ambulance screeching in from Heathrow much sooner than we’d anticipated. Those jets were fast.

  We were opening through the ribs of the left side of the chest by midnight and soon encountered bleeding. Paneth was in an irascible mood, having been called out of a Christmas party. As I predicted the beer soon began to make its effects tell and my registrar colleague became restless, shifting from foot to foot and losing concentration. Eventually he had to excuse himself, so I moved into the first assistant position, coughing loudly to disguise the unusual squelching sound. I stayed in his position after he returned as I had no discomfort, despite the fact that my right Wellington boot was slowly filling. After another twenty minutes the registrar had to go out again.

  By now the patient was safe, but Paneth was cross. ‘What’s wrong with him? He’s been in the pub, hasn’t he? He’s been drinking.’

  ‘I really don’t know about that, Mr Paneth. I’ve been studying in the library all evening,’ I replied, waiting to be struck down by a thunderbolt. But it never came.

  ‘Well done, Westaby,’ he said instead. ‘You get on and close the chest. He can assist you for a change. See you on Monday.’

  I disposed of the evidence and accompanied the young man back to intensive care. No one ever knew.

  Now beyond sleep, I sat drinking coffee in the paediatric intensive care unit. I talked with the nurses while watching tiny people struggle for life at Christmas in their cosy incubators. As surgical trainees we were all chronically sleep deprived, but there was little excitement in sleep. Sleep was something for the odd weekend off. We were adrenaline junkies living on a continuous high, craving action. From bleeding patients to cardiac arrests. From theatre to intensive care. From pub to party.

  Sleep deprivation underpins the psychopathy of the surgical mind – immunity to stress, an ability to take risks, the loss of empathy. Bit by bit I was joining that exclusive club.

  4

  township boy

  Genius is one per cent inspiration, ninety-nine per cent perspiration.

  Thomas Edison

  October 1979. I was Senior Registrar with the thoracic surgery team at Harefield Hospital in north London. Everyone training in heart surgery had to learn to operate on the lungs and gullet as well, and this meant working with cancer, which I found deeply depressing. Too often it had already spread to other parts of the body, and for most patients the prognosis was grim, so they were depressed too. Moreover, there was an element of monotony about it. The choices were stark: between taking out half a lung or the whole lung, on the right or on the left, or removing the upper part of the gullet or the lower half. After doing each one of these procedures a hundred times it was no longer very stimulating.

  Every so often a more challenging case would present itself. Mario was a forty-two-year-old Italian engineer working on a restoration project in Saudi Arabia. A jovial family man, he’d gone to the kingdom hoping to earn enough money to buy a house, which meant toiling hours on end at a large industrial complex outside Jeddah in the searing desert heat. Then catastrophe. Without warning, while he was working in an enclosed area, a huge boiler exploded, filling the air with steam. Steam under high pressure. It scalded his face and burnt the lining of his windpipe and bronchial tubes.

  The shock almost killed him immediately. The scalded tissues were dead and whole sheets of necrotic membrane sloughed off from the lining of his bronchial tubes. This obstructive debris had to be removed through an old-fashioned rigid bronchoscope, a long brass tube with a light on its end passed through the back of his throat and voice box then down into his airways.

  Mario needed this done regularly, almost daily, to prevent asphyxiation, and pushing the bronchoscope back and forth through his larynx became more and more difficult. Soon it became so scarred that the bronchoscope would not pass and he needed a tracheostomy – a surgical hole in the neck to enable him to breathe. But the dead bronchial lining was quickly replaced by inflammatory tissue and masses of cells started to fill the airways like calcium blocking water pipes. He became unable to breathe, and his condition took a relentless downhill course.

  I took the call from Jeddah. The burns doctor looking after him explained the dire situation and wondered whether we had any advice. My only suggestion was that they airlift him to Heathrow and we’d see if anything could be done, so the building company paid for the medical evacuation and he arrived the following day. At the time my boss was in the t
wilight of his career and was happy for me to take on as much as I felt confident to do. Which was everything. I had no fear. But this was a disaster in a middle-aged man. I asked that we should take a look down his windpipe together and then try to come up with a plan.

  Mario was a sorry sight. He was gasping for breath, with the infected froth pouring from his tracheostomy tube making a dreadful, gurgling sound. His scarlet face was badly burnt, its crusted, dead skin peeling away and weeping serum. Burnt on the outside and burnt on the inside, the fragile and bloody tissue that occluded the whole of his windpipe was going to asphyxiate him. It was a great relief for him to be put to sleep.

  As he lapsed into unconsciousness I sucked blood-stained sticky secretions from the hole in his neck, then attached the tubing from the ventilator to the tracheostomy tube and squeezed the black rubber bag. The lungs were difficult to inflate against the resistance. I decided that we should attempt to pass the rigid bronchoscope by the normal route directly through the vocal cords and larynx. This is akin to sword swallowing, but down the airways rather than the gullet.

  We needed a view of the whole windpipe and both right and left main bronchial tubes. For this the head needs to be tipped at the correct angle so the vocal cords at the back of the throat can be seen. We do try hard not to knock out any teeth. This technique used to be performed on conscious individuals after lung surgery, when I’d have to hoover the patients out because there were never enough physiotherapists. Rough at the time but better than drowning.

  I manoeuvred the rigid telescope over the teeth and along the back of the tongue, then peered down to locate the snippet of cartilage – the epiglottis – that protects the opening of the voice box during swallowing. If you lift its tip with the bronchoscope you should be able to find the glistening white vocal cords, with a vertical slit between the two. This is the way into the windpipe and I’d done the procedure hundreds of times to biopsy lung cancer. Or remove peanuts. But here, with the voice box burned and the vocal cords like sausages, inflamed and angry looking, there was no way through. Mario was entirely reliant on the tracheostomy.

  Standing aside, I tried to show the boss by keeping the bronchoscope still, propped on the teeth. He grunted and shook his head. ‘Try pushing it harder. Nothing to lose, I suspect.’

  Taking aim again, I pushed the beak of the scope where the slit should be and shoved. The swollen vocal cords parted and the instrument crashed against the tracheostomy tube. We attached the ventilating apparatus to the side of the bronchoscope and pulled out the tube. Normally we’d see the full length of the windpipe to where it divides into the main bronchi. In this case, not a chance. The airways had been virtually obliterated by the proliferating cells, so I eased the rigid implement onward using the sucker to aspirate blood and detached tissue, at the same time pushing in oxygen through the bronchoscope tip. I was hoping to see an end to the burns, and we finally encountered normal airway lining halfway down each main bronchial tube. But now the traumatised lining was oozing blood.

  Mario’s bright red face had turned purple and was getting bluer by the minute, so the boss took over, peering down the tube, occasionally inserting the long telescope for a better view. It was a precarious situation without an obvious solution. If you can’t breathe you die. Fortunately with time the bleeding died down and the airway was better than it had been once some gunk had been removed. We reinserted the tracheostomy tube and put him back on the ventilator. Both sides of the chest still moved and both lungs were inflated. This was a triumph in itself, but it was doubtful there was any way forward. We both concluded that his prospects were bleak.

  Two days later Mario’s left lung collapsed and we went through the same process again. It was just as bad. The tissue just kept on growing, and he remained fully conscious on the ventilator but very distressed.

  Asphyxiation is the most miserable way to die. I remembered my grandmother, strangulated by cancer of the thyroid gland. She’d been told she needed a tracheostomy, only to have the procedure aborted, so she sat propped up in bed day and night gasping for breath. I recalled trying to work out ways to help. Why wasn’t it possible to put a tube further down, past the obstruction? Why couldn’t tracheostomy tubes be made longer? A simple concept but I was repeatedly told it wasn’t possible.

  From what I could see through the bronchoscope, the situation with Mario was nearly identical. He needed something to bypass his whole trachea and both main bronchi, otherwise he’d be dead in days. We couldn’t keep opening the airways with a bronchoscope. Not forever. Grim Reaper was winning this battle and was about to swing his scythe.

  Ever the optimist, I questioned whether there was anything else we could do. Could we make a branched tube to bypass the damaged airways? The boss thought not, because it would clog with secretions. Surely someone else would have done it before for cancer. Then something else occurred to me – a company called Hood Laboratories in Boston, Massachusetts made a silicone rubber tube with a tracheostomy side limb, called a Montgomery T-tube after its ear, nose and throat surgeon inventor. Maybe I should talk to them and explain the problem.

  When I bronchoscoped Mario later that afternoon I took measurements to calculate how long the tube needed to be to reach down each main bronchus, and in the evening I rang Hood. A small family firm who were most helpful, they confirmed that no one had tried such an approach but agreed to make me the bifurcated tube to fit the whole of Mario’s trachea and main bronchial tubes. I said we needed it urgently. They delivered in less than one week, with no invoice, pleased to help with this unique case. Now I had to work out how to get it in.

  I’d need to railroad the branched end of the tube into the separate bronchi simultaneously over guide wires. But wires were too sharp and dangerous for the delicate silicone rubber, and I needed something blunt and harmless to do the job. We used to dilate strictures of the gullet with gum elastic bougies. Two of the narrowest bougies would fit down the T-Y tube, and down each limb of the Y branches. I could insert the bougies through the damaged trachea and into one bronchus at a time, then railroad the tube into place over them. I drew the technique step by step and showed it to the other thoracic surgeons. The consensus was that we had absolutely nothing to lose. Without some crazy new approach Mario was definitely going to die.

  The following day we took him to theatre, removed the tracheostomy tube and inserted the rigid bronchoscope through his burnt larynx. I tried to create as little bleeding as possible this time. We surgically enlarged the tracheostomy hole through which the T-Y tube would be introduced, then the bougies were inserted into the right and left main bronchi under direct vision through the scope, vigorously ventilating with 100 per cent oxygen between each step. So far so good. I lubricated the silicone rubber with K-Y jelly and shoved the tube forcefully downward. The bronchial limbs spread out at the branching point until there was resistance to any further pushing. It was in. Better than sex. The boss took a leap of faith and withdrew the bronchoscope into the larynx.

  Ever the Irishman he exclaimed, ‘Crikey, look at this! You’re a bloody genius, Westaby.’ The horribly disintegrating trachea had been replaced by a clean white silicone tube, the Y limbs sitting in perfect position. There was no kinking or compression, and clean healthy airways lay beyond.

  Meanwhile Mario was blue and hypoxic. We were all so excited that we had stopped ventilating him, so we needed to blow in oxygen furiously. But he was now easy to inflate through the wide rubber airways. It was a complete revelation. Whether it would last we didn’t know, and only time would tell. It depended entirely upon whether Mario was strong enough to cough secretions out through the tubes, and on our ability to suck them out and ventilate him through the side limb. When the swelling in his larynx and vocal cords subsided we’d keep this closed with the rubber bung. Then he could breathe and speak through his own larynx if it ever recovered. There were many unknowns, but for now Mario was safe. He could breathe. Fifteen minutes later he woke up with fantastic symptomatic
relief.

  I should have been thrilled that the concept had worked but I wasn’t. I was in a difficult head space. I had a beautiful baby daughter – Gemma – whom I didn’t live with. I lived at the hospital. This was grinding away at me in the background, so I compensated by operating fanatically on everything that I could lay my hands on. I was always available but was possessed by a disquieting restlessness.

  In the meantime Mario recovered well, though life was difficult without a voice. He could cough secretions through the tube and keep it clear – something that everyone else had regarded as impossible – and was sent home to his family in Italy. Gratifyingly Hood started to manufacture the T-Y stent and called it the ‘Westaby tube’. We used it often for patients in whom lung cancer was threatening to occlude their lower airways, relieving the dreadful strangulation that my grandmother was forced to endure. Why could no one have done it when she needed help and I was so miserable?

  I never knew how many Westaby tubes were manufactured but it stayed in Hood’s product list for many years. My original drawings were published in a chest surgery journal and served as the guide for others. While I still performed thoracic surgery I continued to use it for complex airways problems, often on a temporary basis until radiotherapy or cancer drugs caused the tumour to shrink. It was my grandmother’s legacy. Then came the rare opportunity to use the artificial airways alongside my expertise with the heart–lung machine.

  In 1992 I was invited to Cape Town for a conference to celebrate the twenty-fifth anniversary of the world’s first heart transplant by Christiaan Barnard. At that meeting the distinguished children’s heart surgeon Susan Vosloo asked me to see a sick two-year-old who’d been a patient at the Red Cross Children’s Hospital for several weeks. Little Oslin lived in a sprawling Cape Town ghetto situated between the airport and the city, acre upon acre of tin shacks, wooden sheds and tents with brackish water and little sanitation. Nevertheless he was a cheerful little chap whose toys were oil drums, tin cans and pieces of wood. He knew no other life.