The Knife’s Edge. Stephen Westaby

equivalent, and few people can live with it on a daily basis. During my formative years, to operate within the heart was seen as the last surgical frontier. Direct vision repair was considered as difficult as landing on the moon or splitting the atom. Then the heart–lung machine and the swinging sixties changed everything. Heart transplants and artificial hearts both emerged during my impressionable medical school years. When I embarked on training in the 1970s, heart surgery remained an exclusive and remote club that was exceptionally difficult to join. Yet I was eventually granted the profound privilege of being able to improve thousands of lives.

Each heart is unique in its own way. Although most operations prove straightforward and uneventful, some evolve into an extraordinary battle for survival and a few are quite literally a bloody disaster. As my experience and knowledge increased, I became a last port of call for the cardiologically destitute, a depository for cases that no one else wanted, at home and abroad. Ultimately I lost patients whom I knew could be saved with equipment we were denied in the NHS. The recriminations that accompany death soon followed. An agonising interview with the bereaved, dismal discussions at the ‘Morbidity and Mortality Meeting,’ then a joyless visit to the coroner’s court. I was vehemently outspoken about the system’s deficiencies, and suffered as a result. The NHS doesn’t care for those who do not conform.

      In this book I have set out to describe how it felt to be a heart surgeon as the specialty emerged and what it is like in the current hostile environment. I have depicted the physical and the psychological endeavour, the emotional highs and lows, the triumphs and the disappointments, and how being a surgeon affected me and my loved ones. When I was a young man, as we shall see, a peculiar quirk of fate helped me by dispelling my inhibitions and rendering me immune to fear. It’s not something I would freely recommend and it was a curious launchpad for a career at the sharp end, one that enabled me to embrace challenges that others would wish to avoid.

For someone who is not a professional writer, it takes an inordinate amount of time and effort to write a book for public consumption. You will undoubtedly conclude that I was more the surgeon than the literary genius, yet to my delight my first book, Fragile Lives, became an award-winning bestseller. As the title suggests, the book largely focused on remarkable cases. The Knife’s Edge is darker. It describes my humble beginnings, my struggle to succeed, and my priceless relationships with some of the pioneers and great leaders of the specialty. Because of the huge risks involved and the pile of bodies that ensued, the pioneers all manifested a particular personality type – bold, determined, often flamboyant, with resilience and immunity to grief. Sadly, so taxing is the lifestyle that by the end of my career few UK graduates were prepared to make it their calling and career. The ‘end of an era’, or the ‘end of the beginning’ as some would put it.

      The whole riveting story of modern heart surgery evolved during my lifetime, and I was proud to be part of it.

introduction

      Just weeks after my surgical career came to an end I was invited to present the prizes at a local school speech day. The headmistress urged me to treat the teenagers as adults, and suggested that I convey to them what personal qualities I possessed that enabled me to become a cardiac surgeon. By this stage I had a stock response: ‘To study medicine,’ I said to the assembled schoolchildren, ‘demands an unstinting work ethic and great determination. Then it requires more than a modicum of manual dexterity, together with supreme confidence to train as a surgeon. To aspire to become a heart surgeon and risk a patient’s life every time you operate is a step beyond. For that you need the courage to fail.’

This last phrase wasn’t original – it was regularly used to describe the heart surgery pioneers in the era when more patients died than survived – but the kids didn’t know that. I decided to omit the claim that gender, social class, colour and creed played no part, because I really didn’t believe it myself. Nor did I regard myself as possessing all the qualities I talked about. I was more of an artist. My fingertips and brain were connected.

      After rewarding the school swats, I started nonchalantly answering questions about my achievements in Oxford. With considerable insight, one biology boffin asked how it’s possible to operate inside an organ that pumps five litres of blood every minute and whether the brain dies if the heart stops. Another wanted to know how to get to the heart when it’s surrounded by ribs, breast-bone and spine. Then the art teacher asked what causes blue babies, as if someone paints them blue.

      Coming to the end of the session, a bespectacled little girl with pigtails raised her hand. Standing up like a poppy in a cornfield, she boomed out, ‘Sir, how many of your patients died?’

      So loud was her earnest approach that there was no way I could pretend not to hear. One set of parents tried to disappear under the floorboards while the flustered headmistress began explaining that it was time for the honoured guest to now leave. But I couldn’t ignore this inquisitive individual in front of her friends. I considered the question for a moment, then had to confess: ‘I really don’t know the answer to that. More than most soldiers but fewer than a bomber pilot, I guess.’ At least fewer than Enola Gay over Hiroshima, I thought to myself cynically.

      Quick as a flash, Miss Curiosity probed again. ‘Can you remember them all? Did they make you sad?’

Another brief moment of deliberation. Could I admit to a hall full of parents, teachers and schoolchildren that I had no idea exactly how many patients I had dispatched, let alone recall their names. I could only muster one response: ‘Yes, every death upset me.’ I waited to be struck down with a thunderbolt but mercifully that was the end of our brief dialogue.

      It was only after I stopped being an inadvertent serial killer that I began to remember patients as people, rather than simply recalling mortality statistics and the many times I went along to autopsies or coroner’s courts. And there were deaths that haunted me, not least the young people who succumbed needlessly to heart failure. Those who were not accepted for transplantation but who could have been saved with the new circulatory support devices that our NHS declined to pay for.

In the 1970s one in five of my boss’s cases at the Brompton Hospital died after surgery. As a cocky trainee I would greet each patient, record their medical history, then listen to their fears and expectations about the upcoming operation. Most were severely symptomatic, having waited months to come to the famous hospital in London. It didn’t take long for me to predict the ones who wouldn’t make it, usually the ones with rheumatic valve disease who arrived in a wheelchair and could barely speak on account of their breathlessness. Breathlessness is uniquely terrifying, likened by the patient to drowning or suffocation. They didn’t die because of poor needlework. They simply couldn’t tolerate their time on the heart–lung machine or the poor protection afforded to heart muscle during surgery in those days. We all knew that the slower the surgeon, the more likely the patient was to die. We would take bets on it. ‘If X does the valve replacement he stands a chance. But he’s buggered with Y.’

      That was the way it used to be in the NHS. Treatment was free, so the punters didn’t question what was on offer. Life or death followed from the toss of the dice. But the finality of death was still devastating. The consultants would shield themselves from all the misery by dispatching us juniors to talk with the family.

      I seldom had to speak. The bereaved relatives would recognise the slow walk with dropped shoulders and head down as I approached. They could read my unequivocal ‘bad news’ expression. After the reflex indrawing of breath came shock, my words ‘Sorry’ and ‘Didn’t make it’ triggering emotional disintegration. The sudden relief of suspense and the subsequent crushing grief were often followed by dignified resignation, but sometimes by abject denial or frank meltdown. I’ve had hysterical demands for me to return to theatre and resurrect the corpse, to resume cardiac massage or put the body back on the bypass machine. It was particularly heart-breaking for the parents of young children, little ones who had just developed their own innocent personality. As I saw it, newborn babies just screamed and pooed, but toddlers were well on their way to becoming people. They walked in holding Mummy’s hand