Fragile Lives Page 5

  One day his family’s faulty gas cylinder exploded in the shack, setting fire to the walls and roof. The blast killed Oslin’s father outright, while Oslin sustained severe burns to his face and chest. Worse still, he inhaled hot gas from the blast, much like Mario. The accident department at Red Cross saved his life, intubating and ventilating him before he asphyxiated, then treating his burns with intravenous fluids and antibiotics. The little lad could survive the external burns, but his burnt-out trachea and main bronchi were life threatening, and without repeated bronchoscopies to clear slough and secretions he was destined to asphyxiate. On top of this his face was badly disfigured, he was almost blind and he couldn’t swallow food, just his own saliva. So he was fed with liquids through a tube directly into the stomach.

  It so happened that Susan had read a journal article about Mario and the tube I’d designed, and, although Oslin was much smaller, she wondered whether we could do anything to help him. When I first met the lad he was wearing a bright red shirt, had tight, curly black hair, and was pushing himself around the ward on a kiddies’ bicycle with his back to me. Susan called to him and he turned around. The sight of his face took my breath away. There was no hair on the front of his scalp and no eyelids, just white sclera and a severely burned nose and lips. His neck was webbed from contracting scars with a tracheostomy tube in the middle. And the noise coming from him was heart-rending, a kind of rattling with thick mucus secretions made up by a long, noisy in-drawing of breath then a high-pitched wheeze as he forcibly exhaled. It was worse than a horror movie and tragic beyond belief. My first thought was, ‘Poor kid, he should have died with his dad. It would have been much kinder.’

  Strangely enough he was happy, as he’d never had a bicycle before the explosion. I kneeled on the floor to talk with him. He looked straight at me but I couldn’t tell whether he could see my face as his corneas were opaque, so I took his little hand. There would be no objectivity in this discussion. I needed to help him, even if I wasn’t sure how it could be done. We could work that out.

  By this point I was chief of cardiac surgery in Oxford and I had to get back there to operate. In any case there was no Westaby tube in Cape Town, and if there had been it wouldn’t have fitted anyway since the adult size was too big. Could I persuade Hood over in Boston to make a smaller tube? Probably, but not within the time frame that we’d been presented with; if he developed pneumonia in the next couple of weeks he’d surely die.

  My return flight to Heathrow was the following day, so instead of going for lunch in the harbour I asked Susan whether she’d take me to see Oslin’s township. Cape Town was my favourite city in the world but this was an aspect I’d never seen before, the sort of place that warranted an armed escort through its thousands of acres of misery and depravity. I’d come back in a couple of weeks when I had the tube, and a surgical strategy – that’s what flying time was for. I quickly had it clear in my mind and before the plane touched down in Heathrow I’d drawn up the operation in detail.

  I was back at the Children’s Hospital in three weeks. There had already been a fund-raising drive to help Oslin and they expected to pay my expenses. But none of that mattered. I was driven to help the boy as no kid on earth deserved that. I guess thousands of Vietnamese children suffered the same with napalm, but I hadn’t met them. I did know Oslin and I cared about him. So did the doctors and nurses at Red Cross. Perhaps the whole of Cape Town cared. As the airport taxi reached the city I saw the newspaper billboards emblazoned with ‘UK Doc flies in to save dying Township boy’ stuck on lamp-post after lamp-post. No pressure then.

  At the hospital I met Oslin’s mother for the first time. She’d been at work when the gas cylinder exploded and was now clearly depressed. She said virtually nothing, but signed the consent form for an operation that even I didn’t understand.

  We operated the following morning. I’d needed to trim the adult tube by shortening both bronchial limbs, the tracheostomy T-piece and the top part that would sit below his vocal cords, but even this shortened adult tube wouldn’t fit inside the two-year-old’s scarred windpipe. My objective was to rebuild his major airways around the tube. If it worked he’d have even wider airways than before the accident.

  Clearly he wouldn’t be able to breathe or be ventilated during the reconstructive surgery, so we’d do it with him supported on the heart–lung machine. This meant we’d open his sternum as we would in a heart operation. The tricky part was to gain access to the whole length of the trachea and main bronchial tubes from an incision in the front of his chest, these structures being situated directly behind the heart and large blood vessels.

  I’d already worked it all out on a cadaver in the dissecting room in Oxford. When a sling was placed around the aorta and the adjacent vena cava they could be pulled apart to expose the back of the pericardial sac, like opening a pair of curtains and looking out onto a tree. Then a vertical incision between the two served to expose the lower trachea and both main bronchi.

  My plan was to fillet these damaged tubes then lay in the modified T-Y stent. Next we’d repair the front of the opened airways and cover the tube with a patch of Oslin’s own pericardium. It would be just like sewing an elbow patch onto a worn jacket sleeve. Simple. It should all heal up around the tube and we could maybe remove the prosthesis in time, after the tissues had healed and moulded around the silicone. That was my plan, in any case. Maybe ‘fantasy’ would have been a more realistic term, but no one else had a better solution.

  The skin incision started in Oslin’s neck just below his voice box and extended all the way down to the cartilage at the lower end of his breastbone. Since he was emaciated, unable to eat, there was no fat, so the electrocautery cut straight through to the bone, which we then sawed through. I cut out his fleshy, redundant thymus gland and dissected down onto the upper part of his inflammed trachea, all while he was ventilated through his tracheostomy tube. We needed to go on bypass before removing this and exposing the rest of his airways. The metal retractor stretched open his scarred little chest, exposing more of the fibrous pericardium. The front of this was removed for the tracheal patch and I saw that his little heart was beating away happily. Rarely do I see a normal child’s heart, as most are deformed and struggling.

  When I was ready to open the windpipe we started the bypass machine. This rendered the lungs redundant so we could remove the contaminated tracheostomy tube from the clean surgical field. Through the hole the devastation was clear to see. Poor Oslin had been breathing through a sewer. I cut down the length of it with the electrocautery and continued the incision into each main bronchus until I could see normal respiratory lining just at the limits of our access. Copious thick secretions poured out of the obstructed airways, then we scraped tissue off the walls, which caused all-too-predicable bleeding.

  But the electrocautery eventually stopped the haemorrhaging, so we inserted the shiny white T-Y tube and covered it with a patch of Oslin’s own pericardium. I adjusted the length of the rubber cylinder for the last time to get it just right, then sewed the patch into place to seal the implant. It needed to be airtight, otherwise the ventilator would push air into the tissues of the neck and chest, making him blow up like the Michelin man. With the shiny new breathing tubes attached to the ventilator we blew air into his little lungs. There was no leak. Both inflated then deflated normally. A sense of excitement permeated the room. The high-risk strategy was working.

  Oslin’s heart bounced off the bypass machine and his lungs moved freely, needing much lower pressure from the ventilator. Our anaesthetist murmured, ‘Unbelievable. I’d never have believed it possible.’ I covered the repair by closing the back wall of the pericardium, then asked that the registrar put in the drains and close.

  Through the theatre window we could see Oslin’s mother sitting in the waiting room, still expressionless and rigid with fear. I anticipated a blunt response to our news. But she was too emotionally drained to register relief, simply holding out her hand and squ
eezing mine. She whispered, ‘God bless you,’ then a tear zigzagged down her pockmarked cheek. I wished her a better life in the future, one way or another.

  The intensive care unit was pleased to have him back. Most of their patients were township kids having heart surgery, and some of the nurses lived in that same environment. They’d cared for Oslin and his depressed mum for weeks, watching them both deteriorate. So ‘UK Doc’ had flown in to save ‘Township boy’ and succeeded. I was proud of that. Now it was time to ride off into the sunset.

  Oslin recovered and could breathe freely through the white rubber tube in his neck. He couldn’t speak but went on to have his corneal transplants. Being able to breathe and see at the same time was as much as he could have hoped for. The little family were relocated to better social housing on the outskirts of the city – crude but clean, and safer. A chest infection could still kill him, so for the first few months following the operation I contacted Cape Town frequently. Oslin was doing fine and Mum was faring better on anti-depressives. Then I stopped calling.

  Eighteen months passed, and then a letter arrived from the Red Cross Hospital. Oslin had been found dead at home and no one really knew why. Sometimes life is shit.

  5

  the girl with no name

  Dream that my little baby came to life again, that it had only been cold, and that we rubbed it before the fire and it had lived. Awake and find no baby.

  Mary Shelley, author of Frankenstein

  The girl was hauntingly beautiful, with eyes that burned like lasers – as if the blistering desert heat were not enough (50°C during the day). When she fixed those eyes on mine she delivered a message – eye to eye, pupil to pupil, retina to retina – straight into my cerebral cortex. As she stood there holding her bundle of rags I understood perfectly what she was saying: ‘Please save my child.’ But she never spoke. Not to any of us. Ever. And we never even knew her name.

  The Kingdom of Saudi Arabia, 1987. I was young and fearless, seemingly invincible and massively overconfident, and had just been appointed as a consultant in Oxford. So why was I in the desert? Heart operations cost money. We’d worked hard to build Oxford’s new cardiac centre and clear a backlog of sick hearts, but the annual budget was gone in five months so the management closed us down. Bugger the patients. The cardiologists were told to send them to London again.

  On the day before I was locked out of the operating theatre I took a call from a prestigious Saudi cardiac centre that served the whole Arab world. Their lead surgeon needed three months sick leave, and they were looking for a locum who could tackle both congenital and adult heart surgery, an extremely rare species. At the time I wasn’t interested but the following day I was, and three days later I jumped on the plane.

  It was Jumada al-thani, the ‘second month of dryness’ in the Middle East, and I’d never felt heat like it, blistering, unremitting heat with the hot shamal wind blowing sand into the city. But it was a great cardiac centre. My medical colleagues were an eclectic mix of Saudi men who had trained overseas, Americans rotating from the major centres for experience, then the band of mercenaries from Europe and Australasia.

  Nursing was very different. Saudi women did not nurse, as the profession was regarded with suspicion and disrespect, and was culturally taboo because it required mixing with the opposite sex. So all female nurses were foreign, most with contracts for just one or two years. Their accommodation was free, they paid no tax and stayed just long enough to save for that elusive mortgage back home. In turn they were not allowed to drive, had to travel in the rear of buses and be completely covered in public.

  I was intrigued by my new environment: the repetitive calls to prayer from the minarets, the tantalising aromas of sandalwood, incense and amber around the hospital, Arabian coffee roasting on the frying pan or boiling with cardamom. It was a very different life and important not to step out of line – their culture, their rules, harsh penalties.

  This presented a unique opportunity for me as I could operate on every conceivable congenital anomaly. There were innumerable young patients with rheumatic heart disease sent from remote towns and villages, mostly without access to anticoagulant therapy or drugs that we take for granted in the West. The rural health care was out of the Middle Ages, and we had to innovate and improvise to repair their heart valves rather than replace them with prosthetic materials. I remember thinking that every cardiac surgeon should train here.

  One morning a bright young paediatric cardiologist from the Mayo Clinic, the world-famous medical centre in Minnesota, came to find me in the operating theatre. His opening gambit was, ‘Can I show you something really interesting? Bet you haven’t seen anything like this before,’ swiftly followed by, ‘Sadly, I doubt you can do anything about it.’ I was determined to prove him wrong even before I’d seen the case because for surgeons the unusual is always a challenge.

  He thrust the X-ray onto a light box. On a plain chest X-ray the heart is simply a grey shadow, but to the educated eye it can still tell the story. The message was clear. This was a small child with an enlarged heart in the wrong side of the chest, a rare anomaly called dextrocardia. Normal hearts lie to the left. In addition there was fluid on the lungs. But dextrocardia alone does not cause heart failure. There had to be another problem.

  The enthusiastic Mayo cardiologist was testing me. He had already catheterised the eighteen-month-old boy and knew the answer. I offered an insightful guess to show off – ‘In this part of the world it could be Lutembacher’s syndrome.’ This is a dextrocardia heart with a large hole between the right and left atrium, together with rheumatic fever that narrows the mitral valve, a rare combination which floods the lungs with blood, leaving the rest of the body short. The Mayo man was impressed. But no cigar!

  He then wanted to take me to the catheterisation laboratory to see the angiogram (moving X-ray pictures with dye shot into the circulation to clarify the anatomy). By now I’d become fed up with the quiz but I still went along with him. There was a huge, sinister mass within the cavity of the left ventricle below the aortic valve, almost cutting off the flow of blood around the body. I could see this was a tumour, and whether benign or malignant the infant could not survive for much longer. So could I remove it?

  I’d never seen surgery on a dextrocardia heart before. Few young surgeons had and most never would, but I did know about heart tumours in children. Indeed I’d published a paper on the subject in the United States that the paediatric cardiologist had read, making me the expert on the subject in Saudi Arabia.

  The most common tumour in babies is a benign mass of abnormal heart muscle and fibrous tissue called rhabdomyoma. This is often associated with a brain abnormality that causes epileptic fits. No one knew whether the poor boy had suffered fits, but he was certainly dying from an obstructed heart. I asked the boy’s age and whether his parents understood the desperate nature of the condition. Then his tragic story began to unfold.

  It happened that the boy and his young mother were close to death when the Red Cross found them on the border between Oman and South Yemen. In the searing heat both were emaciated, dehydrated and in a state of collapse. Apparently she’d carried her son through the desert and mountains of Yemen, frantically seeking medical help. They were airlifted to the Military Hospital in Muscat in Oman, where they’d found that she was still trying to breastfeed. She’d nothing else to feed her son but her milk had dried up. When the boy was rehydrated with fluids into a vein he became breathless and was diagnosed with heart failure. In turn the mother had severe abdominal pain and a high temperature from a pelvic infection.

  Yemen was a lawless place. She’d been raped, abused and mutilated. Not only that, she was African, not an Arab. The Red Cross suspected that she’d been kidnapped from Somalia and taken across the Gulf of Aden to be sold as a slave. But for one curious reason they couldn’t be sure. She never spoke. Not a word. And she barely showed any emotion, even in response to pain.

  When the Omanis saw the boy�
��s chest X-ray and diagnosed dextrocardia and heart failure they transferred him to our hospital. Now, the Mayo man wondered whether I could conjure up a miracle. I knew that the Mayo Clinic had a great children’s heart surgeon so I tentatively asked my colleague what Dr Danielson would do.

  ‘Operate, I guess,’ he said. ‘Not a lot to lose, as it’s all downhill from here.’ That’s what I expected him to say.

  ‘Right then, I’ll do what I can,’ I said. ‘At least we’ll know what kind of tumour it is.’

  What else did I need to know about the boy? Not only was his heart in the wrong side of the chest, but the abdominal organs were switched over too. What we call situs inversus. So the liver was in the left upper quadrant of the belly with the stomach and the spleen on the right. The bigger problem was that there was a large hole between the left atrium and right atrium, so blood returning from both the body and the veins of the lungs mixed freely. This meant that the level of oxygen in the arteries to his body was lower than it should be. Had his skin not been black he may have been recognised as a blue baby, where blood in the veins streams across into the arteries. Complicated stuff, even for doctors.

  Money was no object here. We had state-of-the-art echocardiography, which in those days was new and exciting. It employed the same ultrasound waves that were used to detect submarines underwater, and an accomplished operator could provide sharp pictures of the inside of the heart and measure pressure gradients across areas of obstruction. I saw a clear image of the tumour in the small left ventricle, smooth and round, like a bantam’s egg, and felt confident that it was benign. If only I could relieve him of it, the tumour would not grow back.