The Knife’s Edge. Stephen Westaby

realised that this was likely to burst the repair.

      The lady night registrar nonchalantly strolled across, clearly uncertain about whom she was about to address.

      ‘Can I help you?’ she enquired in an aloof manner, presuming that this scruffy visitor in theatre blues was a porter or something. My response must have come as a surprise.

      ‘No, but you can help this lady by getting her blood pressure down before she blows her bloody graft off. Paralyse her and keep her asleep until morning.’

The daughters were wide-eyed. The implications of my reply were lost on them, but they sensed an air of tension between the players.

      ‘Give her a bolus of propranolol right now,’ Amir chipped in assertively.

      Registrar lady was now defensive and flustered, verging on shocked. She was not much older than my birthday girl and I immediately regretted being short with her. Maybe we should have done this differently. I could have taken the time to introduce myself and immodestly taken credit for saving the woman’s life, have the relatives fawn around and worship me for the bizarre and heroic rescue. But this was Nick’s case. He had already explained everything to the relatives. I didn’t want to intrude, but I certainly didn’t want to see the repair blown to pieces after all that effort. Having made the point, we wished them all a peaceful night and moved on. Sensitive souls, the intensive care doctors.

10 pm. Amir and I slipped silently into children’s intensive care to check on the morning’s case. Yet I was first drawn to the mother of the meningitis child whose black, gangrenous arms were now gone, replaced with rolls of pristine crepe bandage. Stark contrasts. Was she happy or sad that those mummified little hands had been removed? I wondered whether I would have asked to keep them had it been my child. I set that morbid thought aside and simply asked how the operation had gone. Was she, the mother, OK? Could I help her with anything? Fetch her a coffee? Anything at all to ease her pain? She just looked up at me with tears rolling down her cheeks and said nothing. The nurse knew me well enough and shook her head. It was time to move on to my own little patient.

      The chest drains were dry now, with a steady pulse and blood pressure. Nurse told me that Dr Archer had done an echo and was very pleased – no leak on either valve or across the patches. Fixed for life. The parents had drifted down from the ceiling after the shock of the sudden reoperation and had gone to crash out in their hospital room. They understood the difficulties we faced, which was what really mattered. Not the daily battle for the privilege of bringing a patient to the operating theatre, nor the repeated conflict over intensive care beds. As night fell, we hoped for stable patients, cheerful parents, happy husbands or wives, and a brighter future for them all. While they drifted off to bed, I strolled down a long, dark corridor to the doors of the accident department.

      Out in the fresh air for the first time in sixteen hours, I stared at the night sky and waited for the ambulance to arrive. The operating theatre lay ready, the heart–lung machine was primed, and the team were watching Newsnight in the coffee room, yawning with boredom and resigned to the fact that we were likely to be there all night. My own thoughts drifted back to Gemma and the disappointment I must have caused her once again. But maybe I was wrong. Maybe she had a much better time without me.

11.50 pm. The ambulance with East Anglia Health Authority painted across the side finally arrived, its blue lights flashing. Paramedics threw open the rear doors and the long-off-duty Lucy stepped down the ramp. I just knew it was her. Like a scene from Casablanca, she walked towards the Emergency entrance carrying a stack of medical notes. I thought at that moment how beautiful she was.

      ‘You’re the Prof, aren’t you?’ she said. ‘Mrs Norton told me about you. I trained in Cambridge and they still talk about you there.’ Nothing positive, I expected.

      The trolley bearing Steve’s broken brain and body was being pushed towards us. The last time we met was barely six months before at a medical school reunion. He had delivered a very amusing speech celebrating the fact that all present were still alive despite his open heart surgery. I responded by jesting that things could have been different had he come to me for surgery. Now he was in Oxford in dire straits, not the next reunion we’d all anticipated, with his family still somewhere on the M25. I took his left hand, which firmly gripped mine. The good side that still moved. Then, along with Lucy, we walked in procession through the accident department down the corridor and straight into the operating theatres. A cursory glance at the CT scan confirmed the lethal diagnosis.

We can’t operate without consent, but he was alone and I didn’t want to be too explicit. I just told him that I would repair the dissection and with luck the stroke might recover. He struggled to tell me that he wanted to see Hilary and his children again before being put to sleep. Lucy had a number for Hilary, so I called. They were forty-five minutes away at best. Every extra minute meant less likelihood of neurological recovery, and too many hours had been wasted already. When I promised not to let him die, Steve used his left hand to mark a cross on the form. I counter-signed beneath, then Dave Pigott dispatched him to oblivion with a brain-protective barbiturate.

      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