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

I spent a hot, restless night in the apartment, my mind racing, disturbed by irrational thoughts. Would I have risked this back in England? And was I doing it for the patient or for the mother – or even for myself, so I could publish a paper about it? If I succeeded, who would care for this slave girl and her illegitimate child? The boy was an inconvenience. In Yemen he would be left out under a bush for the wolves to eat. It was the mother they wanted.

The early-morning call to prayer put an end to my discomfort. It was already 28°C as I walked from the apartment to the hospital. Mother and boy came down to the operating theatre complex and anaesthetic room at 7 am. She’d stayed awake until morning with her child in her arms, and all through the night the nurses had been concerned that she might capitulate and run away. She didn’t, but they were still worried whether she would hand the boy over.

Despite premedication he was screaming and thrashing around when they tried to put him asleep. Dreadful for the mother – and difficult for the anaesthetic staff – this was pretty much routine in paediatric surgery. Gas through the face mask eventually subdued him sufficiently to insert a cannula into a vein and stun him into unconsciousness. His mother still wanted to follow him into the operating theatre, so the ward nurses eventually dragged her away. Finally raw emotion had broken through the mask – whatever she had suffered physically, this was worse for her. Yet there were still no words.

I sat, dispassionate, in the coffee room until the mayhem abated, enjoying thick Turkish coffee and dates for breakfast. The caffeine hit was good for my ADHD but racked up my sense of responsibility. What if the boy dies? Then she has nothing. Nobody in the world.

One of the Australian scrub nurses came through to ask that I check the equipment, the extra bits I’d requested for the radical plan conceived under the dark desert sky. I’d yet to share it with my team.

Uncovered on the shiny black vinyl of an operating table, this emaciated little body was a pathetic sight, with none of the puppy fat that every infant deserves. Instead his skinny legs were swollen with fluid. The heart failure paradox – the muscle is replaced by water but the weight stays the same. His prominent, skinny ribs rose and fell with the ventilator, as he was no longer struggling for breath on his own. Now everyone understood why the mother was so fiercely protective. We could see the heart beating away in the wrong side of the chest and the outline of his swollen liver in the contrary side of the bulging abdomen. Everything was the wrong way round, all a source of fascination for the onlookers and presenting a daunting challenge for me. I’d seen one operation on dextrocardia in the US and another at Great Ormond Street. This would be the first I’d attempted myself.

There were still streaks of dried salt down his cheeks from the traumatic separation from his mother. What was it I used to say when asked if I was ever anxious about undertaking an operation? ‘No. It’s not me on the table!’ But although I don’t do anxiety, I was now in tiger country with an untested procedure in an unfamiliar environment and could feel sweat trickling down my back. It all felt a very long way from Oxford.

Everyone was happier when that fragile little body was covered in blue drapes, leaving just a rectangular window of dark skin exposed over the breastbone. He was now no longer a child, just a surgical challenge. That is until we heard his tormented mother banging on the operating theatre doors. She’d given her minders the slip and rushed back, and after a brief struggle they allowed her to sit in the corridor just outside. Her day had been traumatic enough without being dragged away for a second time.

Back inside the operating theatre the scalpel blade slid left to right along the length of the boy’s sternum until a trickle of bright red blood skidded over the plastic drape. The electrocautery soon put a stop to that as it sizzled down onto white bone, reminding me of that line from Apocalypse Now – ‘I love the smell of napalm in the morning.’ The whiff of white smoke told me that the diathermy had too much power and I reminded the orderly that we were operating on a child, not electing a pope, so would he please turn down the voltage.

Heart failure fluid was pushing up the diaphragm. I made a small hole in the boy’s abdominal cavity and straw-coloured fluid poured out like piss into the wound. The noisy sucker removed almost a pint into the drainage bottle and his belly flattened out. A very quick way to lose weight. The saw zipped up the sternum, spraying beads of bone marrow onto the plastic. It breached the right chest cavity, releasing a knuckle of stiff, pink, waterlogged lung. Yet more fluid spilled out, so the sucker bottle had to be changed. It left no one in any doubt that this kid was seriously unwell.

Impatient to view the congenitally distorted heart, I dissected away the redundant thymus gland and sliced open the pericardium – the fibrous sac that encases the heart – with the same excitement and anticipation as unwrapping a surprise parcel at Christmas.

Everyone wanted to get a good look at the dextrocardia heart before I started, so I took a step back and relaxed for a minute. The plan was to open up the narrowed channel below the aortic valve by coring out as much solid tumour as possible, then close the hole in the atrial septum. I gave the order to go onto the heart–lung machine and proceeded to stop the empty heart with cardioplegia fluid. It lay cold, still and flaccid in the bottom of the pericardial sac. I gently pressed the muscle and could feel the rubbery tumour through the heart wall. By now I was sure that I couldn’t reach it all with a conventional approach and that there was little point cutting into the ventricle that his circulation depended upon purely on an exploratory basis. So I told myself, ‘Just do it.’ Plan B. The eureka option, one that had probably never been done before. The perfusionist began to cool the whole body down from 37°C to 28°C. The boy was likely to be on the bypass machine for at least two hours.

At that point I had no option but to share Plan B with the rest of the team. I would chop out the boy’s heart from his chest and, with it lying on a kidney dish full of ice to keep it cool, operate on it on the bench. Then I could twist and turn the thing as much as I needed to do a good job. I considered it to be a brilliant idea, but I had to work fast.

The process was equivalent to removing a donor heart for transplant then sewing it back into the same patient. Back in my research days I’d transplanted tiny rat hearts. This boy’s heart should be no problem, even if the anatomy was unusual, so I transected the aorta just beyond the origin of the coronary arteries, then the main pulmonary artery. By pulling these vessels towards me, the roof of the left atrium was exposed at the back of his heart. I cut through the atria, leaving all the large veins from the body and lungs in place, then, lifting the ventricles out, I left most of the atria in situ. It was then, as you’d do with a donor heart, that I placed the cold, floppy muscle onto the ice.

Now I could see the tumour within the outflow part of the left ventricle. I started to dissect it out, cutting a channel through it so that it would no longer obstruct the heart. The tumour’s rubbery texture was consistent with it being benign, making me optimistic that we had done the right thing. Both my assistants were shocked and mesmerised by the empty chest and were not assisting well. And the longer this heart remained without a blood supply, the more likely that it would fail when I re-implanted it. Frankly, the Australian scrub nurse was much sharper than these trainees, so I asked her to help. She knew instinctively what was required and injected the necessary pace into the procedure.

I was torn between just doing enough or making a radical job of it. But I wanted to tell the boy’s mother that I’d succeeded in removing all of the tumour so I pursued it into the ventricular septum, close to the heart’s electrical wiring system. I knew where this was situated in a normal heart, but its location was less certain in this case. After thirty minutes I infused another dose of cardioplegia solution directly into both coronary arteries to keep the heart really cold and flaccid, and fifteen minutes later the job was done.

I took the boy’s heart back to his body, aligned the ventricles with the atrial cuffs and started to sew it in. I was really quite impressed with myself, the journal article already half-written in my head. The re-implantation process also closed the hole in the heart, so – with luck – he was cured.

This part of the operation had to be fail-safe as these stitch lines would be completely inaccessible in a beating heart. With both atria joined up again it was time to re-join the aorta and let blood back into the coronary arteries. The heart would start beating again and we could warm the boy’s body up. All that was left to do was to reconnect the main pulmonary artery. By then the surgical assistants had also warmed up a bit, on familiar territory once more with the heart back where it belonged.

Usually a child’s heart starts to beat spontaneously and quickly when its blood flow is restored, but this one was too slow. What’s more, I could see that the atria and the ventricles were contracting at different rates. This told me that the conduction system between the two was not working, which is not good as a coordinated heart rhythm is much more efficient. The anaesthetist had already noticed this on the electrocardiogram but said nothing. After cooling, the conduction system often goes to sleep for a while then recovers spontaneously.

Ten minutes later and nothing had changed. I must have cut through the electrical bundle while dissecting out the tumour. Shit and derision. He’d need a pacemaker. This made me more anxious about another issue. A transplanted heart also loses its connection with nerves from the brain, nerves that automatically speed up or slow down the heart during exercise or changes in blood volume. This denervation, together with the disruption of the electrical conduction system, could be a real problem.

My earlier euphoria, optimism and self-congratulation quickly abated, and the young mother drifted back into my thoughts. This wasn’t a good time to lose focus. There was still air within the heart chambers and it had to be let out, so I inserted a hollow needle into the aorta and pulmonary artery. Air fizzed out of both. When air entered the uppermost right coronary artery the right ventricle distended and stopped pumping.

We needed another fifteen minutes on the bypass machine for the effects to wear off. During that time I put temporary pacing electrodes on the right atrium and ventricle. We’d control his heart rate until the cardiologists could implant a permanent pacemaker. Gradually the heart function improved. Obstruction gone, lungs relieved of congestion, his life relieved of heart failure and breathlessness. Or so I hoped.

The boy’s pulse rate was only forty beats per minute, less than half of what it should have been. We increased that to ninety with the external pacemaker, and with this improvement the blood started to well up from behind the heart. I assumed that this was persistent bleeding through my stitching, so I told the perfusionist to turn the bypass machine off and empty the heart while I lifted it up to inspect the join. Nothing. It looked great. No leak.

When we restarted the machine thirty seconds later there was more blood. I inspected the joins of the aorta and pulmonary artery. No leak there, either. Eventually my first assistant spotted oozing from the aorta. The needle used to evacuate air had gone through the back, making a small hole. This would be inconsequential when blood clotting was restored, so we separated the boy from the heart–lung machine and closed the chest.

I didn’t have long to reflect on our success as a message came in from the adult cardiologists. They had just admitted a young male following a high-speed road-traffic accident. He’d not been wearing a seatbelt and his chest had impacted against the steering wheel with great force. He was in shock and his blood pressure could not be restored by fluid resuscitation.

Chest X-rays at the referring hospital had shown a fractured sternum and an enlarged heart shadow, and the veins in his neck were distended, suggesting blood under pressure in the pericardial sac. Not only that. The echocardiogram showed that the tricuspid valve, between his right atrium and ventricle, was leaking badly, hence the persistently low blood pressure and severe shock. The man needed urgent surgery, and could I please come and see him before it was too late?

I was distinctly uneasy about abandoning the boy but there was no choice. Leaving the operating theatre complex I found the mother sitting cross-legged in the corridor, alone and desolate. She’d been waiting there for five hours, and I sensed that she was about to implode mentally, her emotions bottled up for too long owing to her inability to communicate for whatever reason. And finally we’d taken away her bundle of rags. She saw me, sprang to her feet and panicked. Was the operation a success? I didn’t need to speak. Our eyes met again, pupil to pupil, retina to retina. My smile was enough, and with it the message that her son was still alive.

Bugger protocol and the audience of cardiologists. I needed to show her some affection so I held out a sticky hand, wondering whether she’d take it or remain aloof. This act of kindness unlocked the tension. She grasped it and began to shake uncontrollably.

I pulled her in and held her tight, as if to say, ‘You’re safe now, we won’t let anyone harm you any more.’ When I let go, she held on tight and started to weep uncontrollably, waves of emotion discharging onto the hospital corridor and leaving my Saudi colleagues standing in an embarrassed silence. It took a while to calm her, and they were becoming increasingly anxious about their trauma patient.

I told her that her son would shortly leave the operating theatre, that they would bring him out in an intensive care cot attached to drips and drains, and that this might frighten her. She could certainly walk with them but not interfere. Again I sensed that she understood English, but in case she didn’t one of the cardiologists repeated my words in Arabic. Then we left to review the injured man’s echocardiograms, the ultrasound examination of his heart chambers.

By now the trauma patient was dying. He had a torn tricuspid valve, a rare, high-speed deceleration injury we never see with our mandatory seatbelt law. The right ventricle was pulverised as the sternum fractured and had been driven back against the spine, the rapid increase in pressure causing the valve to burst. Now, when the heart contracted, as much blood went backwards as forwards, little was passing through the lungs and the heart couldn’t fill adequately because of blood in the pericardium. Cardiac tamponade, we call it.

Once I’d seen the pictures I didn’t waste time visiting the patient. I just needed to crack that chest, relieve the tamponade and if possible repair the tricuspid valve. We had to get him onto the heart–lung machine quickly to restore blood flow to the brain and correct his dire metabolic state. Then someone behind me whispered, ‘Don’t rush. He’s a madman. He killed the other driver.’ I said nothing. That wasn’t my business. Striding purposefully back to the operating theatre I encountered the little entourage in transit to paediatric intensive care. The fast, regular beeping of the heart rate monitor was reassuring. Without diverting her gaze the mother held out her hand as we crossed over, and I did the same. Contact.

I should have been with the boy in intensive care, at least for the first couple of hours until I was confident that he was stable. But now I couldn’t be. Soon the trauma patient was on the operating table being resuscitated. He had disfiguring facial injuries and extensive bruising over the chest wall, and the edges of the fractured sternum were overlapped with a step deformity. But it was nothing we couldn’t fix with pins and wires.

Within minutes I had the chest open and was scooping clumps of blood clot into a kidney dish. This improved his blood pressure, but his right ventricle looked like tenderised steak – and it didn’t contract any better than a steak – and his right atrium looked like it would burst. So I put the pipes directly into the major veins. As we started cardiopulmonary bypass, his struggling heart emptied out and flapped around at the bottom of the pericardial sac like a wet fish. He was safe – and just in time!

With an incision directly into the right atrium the ruptured valve was there in front of me. It was torn like a curtain, but when I stitched it like torn cloth it was easily repaired. I tested it by filling the right ventricle through a bulb syringe. No leak. So I closed the atrium and removed the snares to fill it again. The job was done. The tenderised meat functioned better than anticipated and eased itself off the bypass machine. By then I’d had enough. I left my assistants to repair the fractured sternum and close the chest. No doubt he’d survive to go to prison.

The sun was setting on a hot and difficult day. For a while I felt content, satisfied after two ‘out on the edge’ operations, difficult cases that few heart surgeons would ever encounter in their whole career. I needed a beer, many beers, but there was no chance of that. I wondered whether the mother was happier now. She’d achieved what she set out for – treatment for her dying child.

Having heard nothing from intensive care I assumed that the boy was doing fine. Wrong. They were already in trouble. For some reason the doctors had tampered with the temporary pacing box and the electric stimulus from the generator had coincided with the heart’s natural beat, fibrillating it and instantaneously inducing that uncoordinated, squirming rhythm, a herald of imminent death.

To counteract this they’d used external cardiac massage until a defibrillator was brought to his bedside. The vigorous chest compressions he’d been given had displaced the pacing wire from the atrium and, although the heart defibrillated at the first shock, the sequential pacing of atrium then ventricle no longer worked. Now only the ventricles could be paced. As a result there was a precipitous drop in cardiac output and his kidneys had stopped producing urine. The boy was deteriorating but no one had told me because I was in the middle of another big case. Shit.

Throughout this débâcle the poor mother had stayed by the cot where she’d watched them pounding on her little boy’s chest, then witnessed the electrical shock that caused his little body to spring from the bed and convulse. At least he only needed one shot at defibrillation. The resulting beep, beep, beep was of little comfort to her, however, and like her child she was spiralling down.

I found her clasping his tiny hand, tears running down her cheeks. She’d been so happy as she escorted him from the operating theatre. Now she was desolate and I was too. It was clear that these intensive care doctors didn’t understand cardiac transplant physiology.

And why should they? They’d never been involved with heart transplants so they failed to grasp that taking the heart out of the body cut off its normal nerve supply. They were pacing the heart at 100 beats per minute with an insufficient volume of blood while simultaneously flogging it with high doses of adrenaline to raise the blood pressure. This constricted the arteries to his muscles and organs, substituting blood pressure for flow and once again producing metabolic mayhem.

The nurse looking after the boy on the intensive care ward seemed anxious and was pleased to see me. A very capable New Zealander, she clearly did not rate the critical care registrar. Her opening remark was, ‘He’s not passing urine and they’re not doing anything about it,’ followed more directly with, ‘If you’re not careful they’re going to fuck up your good work!’