Fragile Lives Page 8

  Like an archaeological dig, the vital clues emerged. Above the left ear she had a healed skull fracture with damage to the dural membranes and brain beneath. This involved Broca’s area, the zone of the cerebral cortex responsible for speech. When the Scotsman carved her soft brain into slices the scar became more apparent, extending deeply and slicing through the nerves to her tongue. These were injuries she was lucky to survive during her abduction in Somalia and the reason she never spoke – why she understood but couldn’t respond.

  I’d seen enough. I didn’t want to watch her eviscerated, her life blood spilt out onto the mortuary slab, or witness her ruptured liver and fractured spine. She died from internal bleeding but I remember thinking that a fatal head injury would have been kinder for her and that she’d have been better off dying in Somalia, sparing her the misery of her life in South Yemen. With that I thanked the Scotsman for his cooperation and headed back to the operating theatre where I belonged, hoping for a better day, desperate to do some good.

  6

  the man with two hearts

  A successful cardiac surgeon is a man who, when asked to identify the three best surgeons in the world, has difficulty in naming the other two.

  Denton Cooley

  It was quite by chance that I ever met Robert Jarvik. I’d travelled to San Antonio in Texas for the 1995 meeting of the US Society of Thoracic Surgeons and it was there, while wandering around the Alamo, that an executive in the cardiovascular industry asked me to give an opinion on a new product. He took me back to a corporate meeting with an engineer whose name I was well familiar with – Robert Jarvik.

  The device under consideration was a small turbine pump designed to boost blood flow down the legs of patients with severe peripheral arterial disease. When the company men moved off to their dinner with clients, Jarvik turned to me and said, ‘Come up to my hotel room. I have something interesting to show you.’ I’m always wary of such invitations from men, but on this occasion I was intrigued.

  First he filled the sink in the bathroom, then he took out a small plastic container from his briefcase. It looked like a sandwich box, and inside was a thumb-size titanium cylinder with an attached vascular tube graft and a silicone-covered electric power cable. He put the titanium cylinder in the water, attached the cable to a telephone-sized controller and switched it on. Whoosh!

  This small, continuous-flow pump shifted around five litres of water a minute, redirecting it through the graft back into the sink without noise or vibration. Jarvik had been working on the concept of a left ventricular booster pump for many years, one designed to be ‘functional but forgettable’ for the patient.

  I then said something stupid. ‘This is a great pump for water but if you put it into the bloodstream it will clot or chew up the red cells,’ as if Jarvik had neither thought about these issues nor addressed them. Then I said something sensible. ‘But I’d love to work with you to test it, away from the Food and Drugs Administration [FDA]. If it looks good we could use it in the UK long before you’ll get permission over here.’

  This was a punt in the dark, so I continued by asking if he was already working with a centre in the US. He said that he was testing the product with Bud Frazier, the head of the transplant service at the Texas Heart Institute. Bud was America’s foremost advocate of mechanical circulatory support devices. Jarvik told me that he was at the meeting and asked whether I’d like to be introduced. So off we went to find him.

  Bud was 100 per cent Texan, wearing a Stetson and cowboy boots with a smart suit. Both charming and understated, as well as being a surgeon he was a collector of antiquarian books. He expressed confidence in the new pump, which was currently known as the Jarvik 2000, the year 2000 being the projected date for human implants if the laboratory research work went well. He asked if I’d like to see the calves implanted with the pump at the Texas Heart Institute. The Texas Heart animal laboratories were considerably more impressive than my facilities for humans and were filled with sophisticated, modern equipment that I could never get for my patients.

  When I visited I found the calves happily munching away at hay in the stalls. The monitors showed the impeller to be spinning at 10,000 rpm, pumping around six litres of blood per minute, more than what was needed by a patient at rest. Bud handed me a stethoscope so that I could listen to the faint, continuous whine of the turbine in the bloodstream.

  I’d been wrong. It didn’t damage the blood cells and, irrespective of the lack of blood-thinning therapy, it didn’t clot either. This was a complete revelation. Could the device be a monumental step forward for patients dying from heart failure? It was certainly right in front of my nose with an opportunity to get involved. I took the chance and offered to test the Jarvik 2000 in sheep back in Oxford.

  As a result of these fortuitous meetings I returned to Oxford thinking that an immense international project would soon be underway: Houston, Jarvik Heart from New York … and Oxford. Indeed I felt as though I could fly back to London without the aeroplane. But after I’d reflected on it a little longer I was no longer so positive. After all, I had no research funds and no access to a large animal laboratory. All I possessed was grim determination and the will to succeed.

  Within months I had raised sufficient funds from philanthropists to begin the project. Now Cambridge had their pig-heart transplant programme and Oxford had miniature artificial hearts – a veritable Varsity match. Soon we confirmed what Houston had suspected: continuous blood flow without pulse pressure was safe and effective. This changed the whole philosophy of blood-pump design, eliminating the need to replicate the pulsatile function of the normal human heart.

  Against the background of this thriving research programme I felt justified in beginning a surgical heart-failure service in Oxford. There were many thousands of terminally ill heart-failure patients in Britain, but fewer than two hundred heart transplants each year. Most patients with deteriorating kidney and liver function were considered too sick to be accepted onto a waiting list. Their lives would be terminated by drugs in the name of palliative care. My vision was that these desperately symptomatic patients should be helped by ‘lifetime’ blood-pump support – an ‘off the shelf’ mechanical solution that didn’t need a dead person or frantic donor-heart retrieval by helicopter in the middle of the night. My megalomania told me to establish Oxford as a national centre for mechanical-circulatory support.

  In Houston, Bud was already implanting a more conventional pulsatile ventricular-assist device to keep patients alive until a donor heart could be found. A so-called ‘bridge to transplant’, the ThermoCardiosystems HeartMate pump was intended to replace the diseased left ventricle by filling and ejecting blood rhythmically. It was shaped like a round chocolate box and too large to fit in the chest, so it was implanted into a pocket in the abdominal wall. Out of this emerged a stiff electrical cable to the external batteries and controller. This ‘life line’ also incorporated an air vent that hissed continuously in time with the pumping mechanism and was audible from across the street.

  The prolonged hospital confinement – as the average wait for a donor heart for patients with the HeartMate assist device was 245 days, and much longer for those with blood group O – was massively expensive and psychologically damaging. But with increased experience, the Houston team gained confidence that the patients should be released from hospital. Not only that – they considered that this mechanical blood pump could be used as an alternative to heart transplantation.

  Bud knew that the FDA would not consider it as a permanent treatment at the time. He phoned me in Oxford and said that, since we were working together on the Jarvik 2000, might we be able to test the ‘Lifetime Support’ concept in NHS patients with the HeartMate. ThermoCardiosystems would provide the pumps free of charge, and this would offer a lifeline for terminally ill patients who’d already been turned down by the transplant centres, who were breathless on minimal exertion, swollen with fluid and housebound. In other words the walking dead, thoug
h rarely walking!

  This was the opportunity I’d been waiting for. I flew to Houston to watch an implant and meet the transplant candidates who were living with the device in the hospital. When asked whether I’d like to assist with an operation I jumped at the chance. The patient was a Mid-Western college football player who’d caught a virus – virile to viral, athlete to asthenic. The poor lad was wasted and waterlogged, his life ebbing away inexplicably. His girlfriend sat by the bedside beside him and it seemed that she didn’t know what to say. What do you say to someone who needs an artificial heart?

  She was a football cheerleader, very pretty, but with nothing to cheer about now as her hero was dying. She’d watched him deteriorate, lose his place in the team and drop out of college. But it had taken too long to realise that he was sick and that it wasn’t recreational drugs, as some had suspected. And what should she do now? Leave him and get back to her studies, or stick by the lad whose best chance would be a heart transplant? Life is a bugger sometimes and we seldom stop to think how it is on the other side. For good reason, I guess, as it rarely helps.

  In the operating room the nurses helped the surgeon to gown and glove, then painted and draped the patient, leaving the entire chest and upper abdomen exposed. Once he rippled with biceps, pecs, abs – the lot. Now he was just skin and bone, with distended liver bulging beneath his ribs. Heart failure is shit. The creeps who declined to fund our research should come and stand here at the operating table.

  Bud made the incision from the lad’s neck down into his belly as the HeartMate pump needed a sizeable pocket in the abdominal wall, making it look like an alarm clock beneath the skin when in place. The dilated heart was huge and the left ventricle barely moved, the usual yellow fluid spilling out of the pericardial sac and filling the new pump pocket until it disappeared down the sucker.

  While I was despairing at the utter decline of this great athlete, Bud was concentrating on where to bring the stiff electric driveline through the skin, looking for a position that didn’t interfere with his belt and trousers, and where he could keep it clean, with as little motion as possible. He made a stab wound with the scalpel and we hauled the line through. More than a centimetre thick – and stiff enough to prevent kinking of the air vent – this wasn’t a domestic electric light cable. It was his lifeline, as vital as the placenta to an unborn child. Then we carefully stitched the pump outflow graft to the ascending aorta as it left the heart, ensuring it was precise, otherwise it would bleed profusely under pressure.

  All that remained was to sew a restraining cuff to the apex of the heart and use a circular coring knife to make a dollar-sized hole for the pump inflow cannula. Now blood returning to the heart from the lungs would pass straight through the mitral valve and into the machine, his own buggered ventricle completely redundant. But I was thinking about Jarvik’s new device, which was barely larger than this pump’s inflow cannula. The titanium shell of the HeartMate’s pulsatile pumping chamber was huge in comparison.

  Before switching on the HeartMate pump it must be filled with blood to expel air. ‘Air in the brain, life down the drain,’ I quipped. Poetic, perhaps, but by then I was jet lagged, sleep deprived and a touch manic. The technical team had made the connections, we were ready for the big switch on, and, as the pusher plate mechanism started to shift in the pump housing, air hissed to and fro in the vent like a steam train setting off. The chamber filled, then ejected blood into the aorta, any residual air fizzing and frothing through needle holes in the graft, gratefully making its exit. His own useless muscle was sucked down, no longer tense and quivering in an attempt to keep him alive. He had a new heart. Just temporary but I hoped it would serve him well.

  I wondered how his girlfriend would react to this pulsating, hissing monster inside him and to the stiff new appendage emerging from his belly. How long would she stay with him now? These were thoughts that I’d never normally entertain, this lack of empathy stemming from continuous stress and fatigue. If I ever saw her again I resolved to be really supportive and tell her how well it had gone. That he would now get better and stronger. Soon someone would have their brains blown out in Houston. Then – if he was lucky – he could have their heart.

  It took a while to stop the bleeding and the general oozing from the poorly functioning liver and bone marrow in common heart failure patients. Bleeding, excessive blood transfusion, then bad lungs and kidneys were a common scenario in such surgery. Now I needed to go to the airport for another twelve-hour flight back to a completely different world where none of this would have happened, where he’d have been left to die. But I wanted to see his girlfriend first. The young man’s parents had just joined her, all of them anxious as hell together.

  As she looked up and recognised me I told her quickly that the operation had gone well, something that always triggers waves of relief, five words that cut straight through the tension. The coiled spring was released, her sweet face lit up with joy and she started to cry. So she really did care about him, not just that he was a football star. I felt like a miserable shit for doubting that. His parents hugged and thanked me. ‘For what?’ I thought. I just assisted Bud. But with good news, gratitude goes out to all. I wished them all the best and a donor heart soon. With all the misery that would bring for another family.

  With the help of Professor Philip Poole-Wilson at the Royal Brompton Hospital we soon identified potential candidates for the HeartMate pump in London. Sadly, the first and youngest died before we could help. The next, however, seemed ideal. He was sixty-four, tall and slim, and had already been turned down for a transplant. Like the American football player, he had dilated cardiomyopathy, possibly genetically linked, but more likely the result of a virus or an autoimmune disease. An intelligent Jewish man, Abel Goodman had a huge heart and was virtually bedridden.

  On the plus side, his coronary arteries were free from disease and he still had reasonable kidney and liver function. Hopefully that would make the post-operative care less of a battle – and less expensive. His breathlessness was worsening, so he was propped up in the bed with pillows as he was unable to lie flat with his swollen legs and abdomen. Philip needed to admit him to the Brompton for medical stabilisation so I went to see him there. I always loved returning to that hospital, this time as my own man, more proper heart surgeon than music-hall joke.

  Abel sat bolt upright in bed, with laboured breathing, sweat beading on his brow and the fear in his eyes that says, ‘I’m not long for this earth.’ He was too distressed to talk. Too sick for a haircut, as we say. Ready to meet his maker but secretly hoping his saviour had come instead. I shook his limp hand. It was cold and slippery, his blood not reaching that far. I explained that the HeartMate pump I’d seen in action in Houston would take away his terrible symptoms and that he was the first patient in the world to be offered this technology on a ‘lifetime’ basis. Normally it was only used for transplant candidates. How long was a ‘lifetime’? I didn’t know, but without it he’d probably die within weeks. At most. (I thought he could ‘go’ during the conversation.)

  His head tipped back and his eyes rolled as he digested the information. There wasn’t much blood reaching his brain either, but he managed to raise his head from the pillow and murmur, ‘Let’s get on with it, then.’ I think he hoped it would be that day. Enough was enough.

  It was 3 pm in London, six hours ahead of Houston. I called Bud to explain the tight timeline and that we’d only be given permission to use the pump in a dying patient on ‘humanitarian grounds’. We had the dying patient, so could we do it next week? The line went quiet for what seemed like minutes. Then one word: ‘Yep.’

  I felt a surge of adrenaline and excitement. We’d implant a mechanical heart in Oxford. But who was I excited for: Abel or myself? I was an ambitious bastard and we all wanted to do something special, to take risks – not just for the patients but for ourselves, knowing that it would create headlines, as well as extreme animosity from the transplant lobby, flying in the
face of that curious attitude that it’s better to let patients die than attempt something new.

  The Houston team arrived in Oxford on 22 October. That evening the anaesthetists, perfusionists and nursing teams gathered in the conference room. We needed to talk through the procedure and get acquainted with the equipment, not to mention my Texas friends and their dress code – cowboy boots and Oxford colleges rarely come together.

  Abel had survived the transfer out of London and was now bemused by the cosmopolitan medical team, yet too breathless to care. The nurses told him to think positively and the ward orderly took his order for supper the next evening. He didn’t want the gammon. The rabbi came to prepare him for death.

  Bud had never been to Oxford. With his interest in antiquarian books I wanted to show him the Bodleian library and the ancient colleges in the centre of town, as if on a different planet from Houston. We drank beer in the Eagle and Child tavern where Tolkien and C. S. Lewis met regularly on Thursday evenings in the 1930s. I listened to his stories about the Vietnam War, how he’d been a helicopter medic in the middle of the action and would sit on his helmet to avoid getting his testicles blown off. Several of his surgical colleagues didn’t make it. Bud kept his balls – and it showed. He’d done more heart transplants than anyone else and more ventricular assist devices. He reminisced about the agony and the ecstasy of those days, all when I was still at medical school.