Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table

‘What did she have done?’ asked the girl I’d danced with.

‘Heart operation, obviously,’ came the reply. ‘Valve replacement, I guess. Poor kid. She’s only our age. Bet her mum’s upset.’

They covered the wound with gauze to soak the blood, then taped it up. The scrub nurse returned and thanked the girls for a job well done. She called back the surgical registrar to close over the wound, ready to move the body to the mortuary, as all deaths on the operating table are referred to the coroner for autopsy. The young woman would be sliced open again from neck to pubis, so there was no point closing the breastbone or bringing together the different layers of the chest wall. He took a big needle and some thick braid, and sewed her up like a mail bag. The wound edges still gaped and oozed serum. Mail bags were much neater.

It was now around 6.30 in the evening and I was meant to be in the pub down the road getting pissed with the rugby team. But I still couldn’t leave. I was attached to this empty shell, this skinny corpse I’d never met but now felt I knew well. I’d been with her at the single most important part of her life.

The three nurses manhandled her into a starched white shroud with a ruff around the neck, tied it up at the back then secured her ankles with a bandage. She was beginning to stiffen with rigor mortis. The students had done their job with kindness and respect. I knew that I would meet them again. Maybe I’d ask them how they felt.

Now there were just the two of us left, the corpse and me. The operating lights still shone on her face and she was staring straight up at me. Why hadn’t they closed her eyelids like they did in the movies? I could see through those dilated pupils to the pain etched on her brain.

From fragments of conversation I’d overheard and with just a little medical knowledge I could sketch her life story. She was in her twenties. Born in the East End. She could only have been a small child when her parents were killed in the bombing. As a child she carried the scars of those sights and sounds, the fear of being alone as her world disintegrated. Brought up in poverty, she develops rheumatic fever, a simple streptococcal sore throat that triggers a devastating inflammatory process. Rheumatic fever was common in areas of deprivation and overcrowding. Perhaps she had painful, swollen joints for a few weeks. What she doesn’t know is that the same inflammation is in her heart valves. There was no diagnostic test in those days.

She develops chronic rheumatic heart disease and is known as a sickly child. Perhaps she develops rheumatic chorea – involuntary, jerky movements, unsteady gait and emotional turmoil. She gets pregnant, an occupational hazard. But this makes things worse as her sick heart must work much harder. She becomes breathless and swollen but makes it through to term. Maybe the London Hospital delivers her safely but recognises heart failure. A murmur. A leaking mitral valve. They prescribe the heart drug digoxin to make it beat stronger, but she doesn’t take it as it makes her nauseous. Soon she’s too tired and breathless to look after the baby, and she cannot lie flat. With worsening heart failure her outlook is grim. They send her to the city to see a surgeon, a real gentleman in a morning suit with pinstriped trousers. He’s kind and sympathetic, and says that only surgery on her mitral valve can help. But it doesn’t. It terminates her sad life and leaves another orphan in the East End.

When the porters came for her the operating lights had long been switched off. The mortuary trolley – a tin coffin on wheels – was drawn up alongside the operating table. By now her limbs were rigid. The body was unceremoniously dragged into this human sardine can, her head bouncing with a sickening thud, but nothing could hurt her any more. I was relieved to lose eye contact. A green woollen blanket was folded over the top to make it look like an ordinary trolley, and then off they went to slot her into the fridge. Her baby would never see her again, would never have a mother again.

Welcome to cardiac surgery.

I sat there, arms on the rail, chin on my hands, staring down from the ether dome at the black rubber surface of the empty operating table, as generations of would-be surgeons had done before me. The ether dome was a gladiatorial amphitheatre, people coming here to gaze down on a spectacle of life or death. Perhaps if others had been there it might have seemed less brutal, others with whom to share the shock of this poor girl’s death, the misery awaiting her child.

Auxiliary nurses came with mops and buckets to erase the last traces of her – her blood now dry on the floor around the operating table, the bloody footprints heading towards the door, the blood on the anaesthetic machine, the blood on the operating lights. Blood everywhere – now meticulously wiped up. A slip of a girl reaching up to clean the operating light saw me in the dome, my pale face and staring eyes against the gloom. I frightened her, and so it was my cue to leave. But one spot of blood remained on top of the light where no one could see. Adherent and black, it said part of me is still here. Remember me.

The green door closed behind me and I walked away to the shuddering lift where her body had been taken down to lie in a cold fridge in the mortuary.

Notice of autopsies were posted on a board in the entrance hall of the medical school. Usually the patients were elderly. The young ones were either drug addicts, road-traffic accidents, suicides from the underground system or cardiac surgery patients. I found her on the list for Friday morning. She was called Beth. Not Elizabeth, just Beth. She was twenty-six years old. It had to be her. On the day of the autopsy the bodies were brought from the hospital mortuary in the basement, then dragged under the road to the medical school in a tin box on rails by a pulley system and up the lift to the autopsy room. Should I go? Should I watch her guts and brain be cut out, watch her dead heart be carved into slices, tell them how she really died in that crimson fountain?

No, I couldn’t do it.

Beth taught me a very important lesson that day in the ether dome. Never get involved. Walk away as her surgeons did and try again tomorrow. Sir Russell Brock, the most renowned heart surgeon of the era, was known for his bluntness about losing patients – ‘I have three patients on my operating list today. I wonder which one will survive.’ This may seem insensitive, even callous, but to dwell on death was a dreadful mistake then, and it still is now. We must learn from failure and try to do better the next time. But to indulge in sorrow or regret brings unsustainable misery.

I grappled with this later in my career when my interests veered towards the sharp end: heart surgery for complex congenital anomalies in babies and young children. Some came toddling happily into the hospital, teddy bear in one hand, Mummy holding the other. Blue lips, little chest heaving, blood as thick as treacle. They’d never known a different life and I strived to provide that for them. To make them pink and energetic, liberate them from impending doom. I did this in good faith, yet sometimes without success. So what should I do? Sit with the weeping parents in a dark mortuary holding a cold, lifeless hand, blaming myself for taking that risk?

All heart surgery is a risk. Those of us who make it as surgeons don’t look back. We move on to the next patient, always expecting the outcome to be better, never doubting it.

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humble beginnings (#uf798782c-3c73-51a1-bcb1-d9fe66b548ca)

Courage is doing what you’re afraid to do. There can be no courage unless you’re scared.

Edward V. Rickenbacker, The New York Times Magazine, 24 November 1963

It was at the very start of the post-war baby boom that I arrived into the world in the maternity department of Scunthorpe War Memorial Hospital on 27 July 1948, star sign Leo. Good old Scunthorpe, my childhood home for eighteen years, a steel town and the long-suffering butt of music-hall jokes.

My dear mother, exhausted after a long and painful labour but happy with her first child, brought me safely back home from the carnage of the delivery suite. I was a pink, robust son, wailing from the depths of his newly expanded lungs.

My mother was an intelligent woman, caring, gentle and well liked. During the war she’d managed a small high-street bank, and with other tills empty the old folks would still queue to tell her their troubles. My father joined the RAF at sixteen to fight the Germans, and after the war he got a job in the local Co-operative grocery department and worked hard to improve our circumstances. Life wasn’t easy.

We were church-mice poor in a grimy council estate. House number 13, no pictures allowed on the walls in case the plaster crumbled, with a corrugated tin air-raid shelter in the back garden that housed geese and chickens – and the outside toilet.

My maternal grandparents lived directly across the street. Grandmother was kindly and protective of me, but frail. Grandfather worked at the steelworks and during the war had been the local air-raid warden. On pay day I’d go with him to the works to collect his wages. There I was intrigued by the spectacle of white-hot molten metal being poured into ingots, bare-chested, sweaty men in flat caps stoking the furnaces, steam trains belching fire, clanking up and down between the rolling mills and the slag heaps, and sparks flying everywhere.

Grandfather patiently taught me how to draw and paint. He’d sit over me, puffing away on Woodbines as I painted red night skies over the chimneys, street lamps and railway trains. Grandfather smoked twenty a day and spent his whole life working in smoke at the steelworks. Not the best recipe.

In 1955 we got our first television set, a 10-inch-square box with a grainy black-and-white picture and just one channel, the BBC. Television dramatically widened my awareness of the outside world. That year two Cambridge scientists, Crick and Watson, described the molecular structure of DNA. In Oxford the physician Richard Doll linked smoking with lung cancer. Then came exciting news on a programme called Your Life in Their Hands that would shape the rest of my life. Surgeons in the United States had closed a hole in the heart with a new machine. They called it the heart–lung machine, because it did the job of both organs. The television doctors wore long white coats down to the floor, the nurses had fine, starched uniforms and white caps and rarely spoke, and the patients sat stiffly to attention with their bed sheets folded back.

The show talked about heart operations and how surgeons at the Hammersmith Hospital would attempt one soon. They too would close holes in the heart. This seven-year-old street kid was captivated. Quite mesmerised. Right then I decided that I would be a heart surgeon.

At ten I passed the tests for entry to the local grammar school, and by then I was quiet, compliant and self-conscious. As one of the ‘promising’ set I was forced to work hard. I was a natural in art, although I had to stop those classes in favour of academic subjects. But one thing was clear. I was good with my hands, and my fingertips connected with my brain.

One afternoon after school I was out walking with Grandfather and his Highland terrier Whisky on the outskirts of town when he stopped dead on a hill, clutching the collar of his cloth shirt. His head bowed, his skin turned ashen grey and, sweating and breathless, he sank to the ground like a felled tree. He couldn’t speak and I saw the fear in his eyes. I wanted to run and fetch the doctor but Grandfather wouldn’t let me. He couldn’t risk being off work, even at the age of fifty-eight. I just held his head until the pain abated. It lasted thirty minutes, and once he’d recovered we slowly made for home.

His ill health wasn’t news to my mother. She told me that he’d been getting a lot of ‘indigestion’ while cycling to work. Reluctantly, Grandfather agreed to get off the bike, but it didn’t do much good. The episodes became more frequent, even at rest, and especially when he climbed the stairs. Cold was bad for his chest, so the old iron bed was brought down in front of the fire and the commode was carried inside to save a journey outdoors.

His ankles and calves were so swollen with fluid that he needed bigger shoes. It was a gargantuan effort just to tie his shoelaces, and from then on he didn’t get out much, mostly just moving from the bed to a chair in front of the fire. I’d sit and draw for him to take his mind off his rotten symptoms.

I remember that dismal wet afternoon in November, the day before President Kennedy was assassinated in Dallas. I came home from school to find a black Austin-Healey outside my grandparents’ house. It was the doctor’s car and I knew what that meant. I stared through the condensation on the front window but the curtains were drawn, so I went around the back of the house and walked in quietly through the kitchen door. I could hear sobbing and my heart sank.

The living-room door was ajar and inside it was dimly lit. I peered in. The doctor was standing by the bed with a syringe in his hand, and my mother and grandmother were at the end of the bed, clasping each other tightly. Grandfather looked leaden, with a heaving chest and his head tipped back, and frothy pink fluid was dripping from his blue lips and purple nose. He coughed agonally, spraying bloody foam over the sheets. Then his head fell to one side, wide eyes staring at the wall, fixed on the placard proclaiming ‘Bless This House’. The doctor felt for a pulse at his wrist, then whispered, ‘He’s gone.’ A sense of peace and relief descended on the room. The suffering was at an end.

The certificate would say ‘Death from heart failure’. I slipped out unnoticed to sit with the chickens in the air-raid shelter, and quietly disintegrated.

Soon afterwards my grandmother was diagnosed with thyroid cancer, which started to close off her windpipe. ‘Stridor’ is the medical term to describe the sound of strangulation as the ribs and diaphragm struggle to force air through the narrowed airway, and that’s what we heard. She went to Lincoln, forty miles away, for radiotherapy, but it burned her skin and made swallowing more difficult. We were given some hope of relief by an attempted surgical tracheostomy, but when the surgeon tried to do it he couldn’t position the hole low enough in the windpipe below the narrowing. Our hopes were dashed and she was doomed to suffer until she died. It would have been better if they’d allowed her to go under anaesthetic. Every evening I sat with her after school and did what I could to make her comfortable. Soon opiate drugs and carbon dioxide narcosis clouded her consciousness, and one night she slipped away peacefully with a large brain haemorrhage. At sixty-three she was the longest-lived of my grandparents.

When I reached sixteen I took a job at the steelworks in the school holidays, but after a collision between a dumper truck and a diesel train hauling molten iron they dispensed with my services. I spotted a temporary portering job at the hospital and negotiated the role of operating theatre porter. There were disparate groups to please. The patients – fasted, fearful and lacking dignity in their theatre gowns – required kindness, reassurance and handling with respect. Junior nurses were friendly and fun, the nursing sisters were self-important, bossy and business-like, and needed me to shut up and do what they told me, and the anaesthetists didn’t want to be kept waiting. The surgeons were simply arrogant and just ignored me – at first.

One of my jobs was to help transfer anaesthetised patients from their trolleys onto the operating table. I knew what sort of surgery was planned for each one, having read the operating list, and I helped out by adjusting the overhead lights, focusing them on the site of the incision (as an artist I was intrigued by anatomy and had some knowledge of what lay where). Gradually the surgeons began to take notice, some even asking me about my interest. I told them that I’d be a heart surgeon one day, and soon enough I was allowed to watch the operations.

Working nights was great because of the emergencies: broken bones, ruptured guts and bleeding aneurysms. Most of those with aneurysms died, the nurses cleaning up the corpses and putting on the shrouds, me hauling them from the operating table and onto the tin mortuary trolley, always with a dull thud. Then I’d wheel them off to the mortuary and stack the bodies in the cold store. I soon got used to it.

Inevitably my first mortuary visit took place in the dead of night. The windowless grey brick building was set apart from the main hospital and I was frankly terrified of what I’d find in there. I turned the key in the heavy wooden door that led directly into the autopsy room but when I reached inside I couldn’t find the light switch. I’d been given a torch and its beam danced around as I plucked up the courage to go in.

Green plastic aprons, sharp instruments and shiny marble sparkled in the gloom. The room smelt of death, or what I expected death to smell like. Eventually the torch beam settled on a light switch and I turned on the overhead neons. They didn’t make me feel any better. There were stacks of square metal doors from floor to ceiling – the cold store. I needed to find a fridge but wasn’t sure which ones were empty.

Some doors had a piece of cardboard slotted into them with a name on it, and I figured that they must be occupied. I turned the handle on one without a name, but there was a naked old woman under a white linen sheet. An anonymous corpse. Shit. Try again on the second tier. This time I was lucky, and I pulled out the sliding tin tray and pushed the creaking mechanical hoist towards my stiff. How to make this thing work without dropping the body on the floor? Straps, crank handles and manhandling. I just got on with it and slid the tray back into the fridge.

The mortuary door was still wide open – I didn’t want to be shut in there alone. I sped out and pushed the squeaking mortuary trolley back to the main hospital ready for the next customer. I wondered how pathologists could spend half of their career in that environment, carving entrails from the dead on marble slabs.

Eventually I charmed an elderly female pathologist into letting me watch the autopsies. Even after witnessing some disfiguring operations and terrible trauma cases this took some getting used to, young and old sliced open from throat to pubis, eviscerated, scalp incised from ear to ear and pulled forward over the face like orange peel. An oscillating saw removes the cranium, as if taking the top off a boiled egg, and then the whole human brain lies in front of me. How does this soft, grey, convoluted mass govern our whole lives? And how on earth could surgeons possibly operate on this, a wobbly jelly?

I learned so much in that dingy, desolate autopsy room: the complexity of human anatomy, the very fine line between life and death, the psychology of detachment. There was no room for sentiment in pathology. An ounce of compassion there may be, but affinity with the cadaver? No. Yet personally I felt sad for the young who came here. Babies, children and teenagers with cancer or deformed hearts, those whose lives were destined to be short and miserable or had been terminated by a tragic accident. Forget the heart as the source of love and devotion, or the brain as the seat of the soul. Just get on and slice them up.

Soon I could identify a coronary thrombosis, a myocardial infarction, a rheumatic heart valve and a dissected aorta, or cancer spread to the liver or lungs. The common stuff. Charred or decomposed bodies smelt bad, so Vicks ointment stuffed up the nostrils spared your olfactory nerves. I found suicides to be terribly sad, but when I verbalised this I was told to ‘Get over it if you want to be a surgeon’ and that it would all be easier when I was old enough to drink. I sensed that alcohol was high on the list of surgeons’ recreational activities, and this seemed more obvious when they were called in at night. But who was I to judge?

I began to wonder whether I could really get in to medical school. I was no great academic, and I struggled with maths and physics. For me these subjects were the real barometer of intelligence. But I excelled in biology and could get by in chemistry, and in the end I passed a lot of exams, stuff I would never need like Latin and French literature, additional maths and religious studies. These I saw as a function of effort, not intelligence, but hard work bought me my ticket out of the council estate. In addition, the time spent in the hospital had made me worldly. I’d never been out of Scunthorpe, yet I knew about life and death.

I started to search for a place at medical school, and returned to the hospital during every school holiday. I progressed to working as an ‘operating department assistant’, becoming an expert in cleaning up blood, vomit, bone dust and shit. Humble beginnings.