We had kept the interpersonal rapport to a minimum. Surgery has to be dispassionate, anonymous even. It was less of a problem because Steve couldn’t speak and I simply couldn’t verbalise the real risks to a friend who faced certain death if no one was prepared to operate. He was a doctor and knew the score. I didn’t need to render him any more anxious in his last conscious moments.
I sat in the coffee room until the lily-white body had been painted brown with iodine and covered with drapes. I didn’t want to see his flabby torso. I preferred to remember him the way he once was, that fine physical specimen striding out onto the pitch on a winter’s afternoon, adrenaline pumping, ready for the scrap. Closely aligned in those days, we were very different characters now. Steve would sit in an office chatting affably to patients and dishing out pills. A proper doctor. There I was at midnight, ready to wield the knife and drive an oscillating saw through his chest, all after an endless day of disappointment, conflict and misery. But adrenaline dissipates the tiredness, wipes out time as the contest begins.
After the previous surgery, Steve had no pericardium or thymus gland between the back of the breast-bone and the front of his heart. So with an expanded, tissue-paper-thin aorta immediately beneath, chest re-entry with an oscillating saw was extremely hazardous. I reduced the risk of catastrophic bleeding by exposing the main artery and vein of the leg, and connecting them to the heart–lung machine. Should the saw lacerate the heart or aorta, I could go rapidly onto cardiopulmonary bypass, take pressure out of the circulation, then suck away blood from the bleeding site. Mostly that works. Sometimes it doesn’t. If heart surgery were easy, everybody would be doing it.
Fixing Steve was like replumbing a Victorian house. All the main pipes were buggered and those coming out of the boiler needed to be replaced as they were rusty and might fall to bits at any moment, so I couldn’t do it with hot water flowing through them. I needed the same conditions as fishbone lady – a cold brain and all the blood drained off into the machine. Dave put electroencephalogram leads onto the scalp to monitor the brain waves, which gradually disappeared as Steve’s temperature fell but were already grossly abnormal after his stroke. Amir began by cutting the skin straight down the line of the scar from the previous operation, then used the electrocautery to sizzle through fat onto bone. He snipped through the old stainless-steel bone sutures with a wire cutter, then ripped them out. I was always going to open the sternum myself. Getting the depth of the oscillating saw just right is a matter of fine judgement. You must gently feel it pass through the back of the sternum, then pull back in case the posterior table of the bone and the muscle of the right ventricle are adherent.
The dissected aorta had the intimidating appearance of a tense aubergine, purple and angry, and I could see blood swirling beneath its perilously thin outer layer. Dave had positioned an echo probe in the oesophagus, directly behind the heart. This showed the original tear in the wall around 1 cm beyond the origin of the coronary arteries, the vital branches that supply the heart muscle itself. My job was to replace the torn part and redirect blood flow back to where nature intended, in the hope that this would restore flow to Steve’s blocked brain and kidney arteries. The compromised kidney would undoubtedly survive, but the injured brain was unlikely to. It had been starved of blood and oxygen for too long, although barbiturates and cooling might help.
I told Brian the perfusionist to go onto bypass and cool to 18°C. Draining the whole living body of blood is a curious thing to do. Only vampires and the few heart surgeons who operate on congenital heart defects and extensive aortic aneurysms ever do it. I specialised in both, so I emptied people out on a regular basis. I once gave a spoof lecture about halal humans at Dracula’s castle in Romania. I felt at home there. The Count and I had much in common.
I was normally relaxed about working against the clock, even when the brain had no blood flow. I didn’t stand there contemplating the nerve cells as they died, nor did I rush the job. At 1.30 in the morning I told Brian to come off bypass and drain, the second time I had done that in twenty-four hours. Steve’s cold, anticoagulated blood emptied into a reservoir and would sit there like a jug of Ribena until we pumped it all back again. I chopped away at the empty disintegrating aorta until I could see the inside of those vital branches coursing up into the head and arms.
The first step was to reapproximate the dissected layers of the filleted vessel with tissue glue. I was one of the first surgeons in the world to use the glue and it undoubtedly contributed to my gratifying survival rate. Then, with care bordering on obsession, I sewed in the vascular tube graft buttressed with strips of Teflon felt to prevent the stitches from cutting through the fragile tissue. Every patient’s survival relied upon the connections between my cerebral cortex and fingertips, but this was especially the case in aortic dissections. Amir’s eyes fixed on my every movement. He wanted to learn all the nuances of technique, which is why he willingly came in. Amir would definitely make it one day.
The repair to the aorta and inserting the graft without blood flow took thirty-four minutes. This lay within the window of safety for a normal brain, but Steve’s brain was not normal. We carefully refilled the vascular tree with blood and evacuated air from the head vessels. Once back on cardiopulmonary bypass, blood oozed through the needle holes. These would continue to bleed until we reversed the anticoagulation that prevented blood from clotting on the foreign surfaces of the circuit. So many detailed steps to recall, but the whole sequence was ingrained in my neural circuits, with everything done on autopilot, even in the early hours of the morning.
It was now time to re-warm to normal body temperature. With warm blood coursing through his coronary arteries, Steve’s heart muscle came to life again, first wriggling in what we call ventricular fibrillation, followed by spontaneous defibrillation and then the slow, lazy contractions that sped up as his temperature rose. Soon brain waves reappeared on the electroencephalogram. Dave thought it looked a bit better already.
The only other time that we watched this process of reanimation was when we tried to save children who had fallen through ice and drowned in a frozen pond, and there are rare cases of survival from Canada. Our Oxford trauma doctors pressed us to rewarm these lifeless bodies, and while we succeeded in salvaging hearts, lungs, livers and kidneys, the children were always fatally brain injured. We gave hope to their parents, then snatched it away again.
At 3 am I left Amir in charge at the operating table. Rewarming takes thirty minutes, and I’d been told that Hilary and several visitors were waiting in the intensive care relatives’ room. On the positive side, their arrival broke the ice with our nursing staff and I at least now knew that there was a bed waiting for him. As I appeared in the doorway they all sprang to their feet. This was reflex not reverence. Here was a medical school reunion, such was Steve’s popularity. Stan was a professor of oncology, John a consultant anaesthetist and Mike a GP. All were here to support Hilary and her children.
Before any type of greeting I told them the news they wanted to hear, that Steve’s OK, I’ve repaired the aorta and fixed the blood supply to his brain. The surgery has gone well. This simple sentence scraped them down from the ceiling and untied the knot in their stomachs. News – either good or bad – always dissolves that agonising fear of the unknown. As they stood there, far from home in the middle of the night, their old pal assumed a different persona. I was no longer the boozy buffoon from Scunthorpe.
There followed hugs, kisses and expressions of relief, then the usual request – ‘Can we see him now?’ I had to explain that Steve was still on the table with his chest wide open being rewarmed on the bypass machine and that while he was not entirely out of the woods, things had gone according to plan. I added that it was likely to be another couple of hours before we controlled the bleeding and closed him up. With that I left, intending to apologise to the sister in charge for springing this upon them. But it transpired that in fact there had been enough nurses – the last heart attack patient brought up from the catheter laboratory had ruptured his left ventricle and could not be resuscitated. The conveyor belt rumbled on.