The Knife’s Edge. Stephen Westaby

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.

I wandered wearily back to theatre and sat down with the two anaesthetists beside Steve’s head. Amir was happy enough to remain in charge. Steve’s temperature was back at 37°C and although still empty, his heart looked cheerful enough. I asked Brian to leave some blood in it, so any residual air would be ejected into the graft. I could hear Steve’s artificial aortic valve clicking away reassuringly, and from the echo probe behind the heart we could see tiny bubbles flashing through it like a snow storm. I didn’t have to ask. Amir already had the air needle in place. Bubbles fizzed out intermittently, then stopped. Now we were ready to come off the machine. I asked Dave to start ventilating the lungs and soon afterwards heard Brian say that he was ‘off bypass’. Amir and the locum registrar stood like spectators at a football match, as I dispatched instructions from the stool. I was scrutinising the inside of the heart and aorta on the monitor screen while they watched it from the outside.

      ‘How does it look?’ I asked Amir. ‘Any bleeding?’

      ‘Looks great. Just some oozing from around the graft. Nothing serious.’

      ‘What are you going to do now then?’

      No answer. He was tired.

      ‘Give the protamine,’ I told Dave. Protamine extracted from salmon sperm reverses the anticoagulant effect of heparin, which comes from digested cow’s guts. So my noble profession relied on cows and fish, a sobering thought at this time in the morning.

      Amir gently packed gauze swabs around the heart to encourage the oozing blood to clot on them. Next he set about putting in the chest drains and stainless-steel wires to close up. The clock on the wall read 4.30. Dave flicked through a motorcycle magazine and Brian asked whether he could remove his equipment, get it ready for the morning and go home. No stamina, some people. Ayrin and her runner nurse were wilting too. I suggested they took turns to take a break while we transfused blood and clotting factors. For the first time a sense of calm filled the room. Job done.

Behind the operating theatre block was a car park, and beyond this lay Old Headington graveyard, thinly shielded by an unkempt hedge of privet and conifers. I walked out into the night past the Mercedes that never got to Cambridge, with Gemma’s birthday present still concealed in the well of the passenger seat. I drifted on through the ornate metal gate to the brow of a hill overlooking the Oxfordshire countryside. There I lay silently on the grass by the grave of a baby girl and stared up into the night sky. The tombstone read, ‘Taken too soon’. She’d been taken by me twenty years earlier, something I hadn’t forgotten. She would have been Gemma’s age now, had God not given her that twisted, convoluted heart that I failed to fix. So I sat with her from time to time when I was feeling bad, just to remind myself that I wouldn’t always succeed. Difficult day today. Or was it yesterday?

      6 am. Daylight broke the horizon and the sparrows chirped. Headlights sprinted around the Oxford ring road below, the early-bird London commuters and shift workers at the Cowley car plant. Sue would already be on her way into the office, so I ambled back to Theatre 5, now empty except for Ayrin. She was scrubbing blood and urine from the floor, ready for the morning’s operating list. Steve was already settled in intensive care, surrounded by his extended family, perfectly stable.

      Cheerful Amir said, ‘Great case. So pleased you called me.’

      The locum