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.
My plan was to clear the obstruction and close the hole in the heart, an ambitious attempt to restore normal physiology. This was straightforward in principle yet taxing in a back-to-front heart in the wrong side of the chest, and I didn’t want any surprises. So I did what I always do in difficult circumstances – set about to draw the anatomy in detail.
Was the surgery possible? I didn’t know, but we had to try. Even if we failed to remove the tumour completely it would still help him, although should it prove to be a rare malignancy his outlook would be bleak. But between us we were convinced that it was a rhabdomyoma.
It was time to meet the boy and his mother. Mayo man took me to the paediatric high-dependency unit where he was still being fed via a tube through his nose, which he disliked intensely. His mother was sitting cross-legged on a mat on the floor beside the cot and she never left his side, day or night.
As we approached she rose up. She was not at all what I’d expected – stunningly beautiful, with a striking resemblance to the model Iman, the widow of David Bowie. Her jet black hair was straight and long, her skinny arms folded across her chest. The Red Cross had established that she was Somali, and as she was a Christian her head was not covered.
Her long delicate fingers were clutching the bundle in which she held her son, precious rags that had shielded him from the hot sun then kept him warm in the cold desert nights. An umbilical cord of drip tubing emerged from these swaddling clothes and stretched to the drip pole and a bottle of feed, which was a milky-white solution replete with glucose, amino acids, vitamins and minerals to put meat back on his little bones.
Her eyes turned towards the stranger, the English heart surgeon whom she had heard about. Head gently tilted backwards in an attempt to remain detached, a bead of sweat appeared in the root of her neck and slithered down over the sternal notch. She was becoming anxious and her adrenaline was flowing.
I tried to engage with her in Arabic. ‘Sabah al-khair, aysh ismuk?’ (Good morning, what’s your name?). She said nothing and looked at the floor. Showing off, I continued, ‘Terref arabi?’ (Do you know Arabic?), then, ‘Inta min weyn?’ (Where are you from?). Still no response. Finally in desperation I asked, ‘Titakellem ingleezi?’ (Do you speak English?). ‘Ana min ingliterra’ (I’m from England).
Then she looked up, wide eyed, and I knew that she understood. Her lips parted but still no words. She was mute. Mayo man was speechless too, stunned by my linguistic skills, which unbeknownst to him had almost been exhausted. She appeared to appreciate my efforts and her shoulders dropped. She relaxed. I wanted to show her kindness, to take her hand, but I couldn’t in this environment.
I indicated that I’d like to examine the boy, which was fine as long as she could continue to hold him. But I was shocked as she pulled back his linen covering. The lad was emaciated, with all his skinny ribs protruding. There was virtually no fat on him and I could see his bizarre heart pounding against his chest wall. He was breathing rapidly to overcome the stiffness in his lungs, his protuberant belly full of fluid and his enlarged liver clearly visible on the opposite side to normal. From the different skin tone to his mother I assumed that his father was an Arab. A curious rash covered his dark olive skin and I thought I saw fear in his eyes.
His mother pulled the linens back over his face, protectively. He was all she had in the world, this boy and a few rags and rings, and I couldn’t help the upwelling of pity I felt for both of them. Surgery was my business but I was sucked into this whirlpool of despair, my objectivity gone.
In those days I had a red stethoscope and I placed it on the infant’s chest, trying to look professional. There was a harsh murmur as blood squeezed past the tumour and out through the aortic valve, then the crackling sounds of wet lungs, even the gurgling and bubbling of empty guts. The cacophony of the human body.
Next I said, ‘Mumken asaduq?’ (‘Will you let me help you’?). For a second I thought she responded. Her lips moved and those eyes fixed on mine. I sensed that she’d murmured, ‘Naam’ (Yes). I tried to explain that I needed to operate on the boy’s heart to make him well so they could both have a better life. When tears appeared in her eyes I knew that she understood.
But how could I persuade her to sign a consent form? We sent for a Somali interpreter who repeated my words, yet still we