The Knife’s Edge. Stephen Westaby

off with them to the mortuary fridge. Yet the minute I turned and walked away from these families, my sorrow was filed in the out tray. Eventually, when I started to lose my own patients, I became well used to it.

Only once did it strike me that I had murdered someone, and the grim circumstances came as a shocking and bloody reminder that I was not invincible. It was a third-time operation on the mitral valve of a middle-aged patient who had a huge heart on the chest X-ray and excessively high pressures in the right ventricle situated directly below the breast-bone. I always took precautions when reopening the chest after previous surgery, and had started to request a CT scan to determine the gap between bone and heart. This led to me being admonished for adding to the costs of my many reoperations – only committees were allowed to sanction additional expense. The gentleman’s anxious partner accompanied him to the anaesthetic room and I urged her not to worry. I told her I was very experienced and would take good care of him.

      ‘That’s why we came to you,’ she replied, her voice quivering with apprehension. She kissed his forehead and slipped out.

I drew the knife along the old scar and used the electrocautery to singe the outer table of the sternum. The wire cutter snipped the steel wires from the second operation, which I then tore out with heavy grasping forceps. It was just like pulling teeth – should they break, it makes life difficult. The oscillating saw screeched against them as if screaming, ‘I’m not designed to cut steel.’ Then came the tricky bit, which involved edging my way through the full thickness of bone with a powerful saw designed not to lacerate the soft tissues beneath. I had safely reopened the sternum for hundreds of reoperations, but this time there was a great ‘whoosh’. Dark blue blood hosed out through the slit in the bone, poured down my gown, splashed onto my clogs and streamed across the floor.

      I let out a chain of expletives. While I pressed hard over the incision to slow the bleeding, I instructed my jelly-legged assistant to cannulate the blood vessels in the groin so we could get onto the bypass machine. As the anaesthetist frantically squeezed in bags of donor blood through the drips in the neck, it all went dreadfully wrong. The cannula dissected the layers of the main leg artery so we couldn’t establish any flow. With continued profuse haemorrhage, I had no alternative but to prise open the rigid bone edges and attempt to gain access to the bleeding beneath, forcing a small retractor through the bony incision and cranking it open. But there was no gap between the underside of the bone and heart muscle. The cavernous, thin-walled right ventricle had been plastered by inflammatory adhesions to the bone by a previous wound infection. So I found myself ripping the heart asunder and staring at the underside of the tricuspid valve. Both the hand-held suckers, then the heart itself filled with air as I fought for better access. I then found that this tissue-friendly saw had also transected the right coronary artery. My paralysed registrar simply gaped, as if to say, ‘How the fuck are you going to get out of this mess?’

There was nothing I could do in time to save him. Deprived of oxygen, the heart soon fibrillated, so at best – had I persisted – he would have suffered devastating brain injury. So I called time on the gruesome spectacle. The whole shambles had taken less than ten minutes. Apologising to the nurses who had to lay him out and clean the floor, I tossed away my gloves and mask in disgust. The whole bloody catastrophe was straight out of Saw II or Driller Killer. It felt as if I had driven a bayonet into the man’s heart and twisted the blade. Then, just as had been done to me during my formative years, I dispatched the registrar to talk to the man’s wife while I went off to the pub.

      I didn’t see the poor lady again until the inquest, where she sat unaccompanied, listening intently. She bore no malice, nor was the coroner critical in any way. The gruesome fact was that I had unintentionally sawn open that heart and emptied the circulation onto my clogs. In my own mind, I knew that a CT scan would have prompted me to cannulate the man’s leg vessels myself, which could have averted the tragedy and was something that I always did after that. Undeterred, I reopened a sternum for the fifth time in front of television cameras just weeks later.

      Most deaths in surgery are wholly impersonal. The patient is either covered in drapes on the operating table or obscured by the grim paraphernalia of the intensive care unit. As a result, my most haunting experiences of death stemmed from trauma cases. The sudden, unexpected process of injury pitches an unsuspecting individual into their own Dante’s Inferno. Knife and bullet injuries were predictable and easy for me. Cut open the chest, find the haemorrhage, sew up the bleeding points, then refill the circulation with blood – such cases always provoked an adrenaline rush, but usually involved young, healthy tissues to repair.

My own worst nightmare wasn’t caused by a gun or a knife. As a young consultant I was once fast-bleeped to the emergency department to help with an incoming road accident. It was still what was called the ‘swoop, scoop and run’ era, so the patient was being brought in directly without transfusion of cold fluid to screw up the blood clotting. With foresight and sensitivity, the police had already warned reception what to expect, but unfortunately I’d not been party to that. I was outside in the ambulance bays enjoying the sunshine when the vehicle came thundering up the drive, siren blaring and blue lights flashing. When the rear doors were thrown open, the crew wanted a doctor to take a look before they risked moving the patient again.

      I could hear the whimpering before I could see the girl, but I knew from the paramedic’s grim expression that it was something unpleasant. Unusually awful, in fact. The teenage motorcyclist was lying on her left side, covered by a blood-soaked white sheet. This sheet and what I could see of her face were the same colour. The poor girl had been drained of blood. Normally she would have been shunted quickly through to the resuscitation room, but there was every reason not to rush.

The paramedics quietly and deliberately drew back the sheet so I could see that the girl was transfixed by a fence post. A witness had watched her motorcycle swerve to avoid a deer, then she veered off the road, smashing through a fence into a field. She was left skewered like meat on a kebab stick. The fire brigade eventually released her by sawing through the fence and lifting her free. This left the stake protruding from her blood-soaked blouse. The response of the gathering team was to glare incongruously at the gruesome transfixion and ignore that horrified face behind the oxygen mask.

      I took her cold, clammy hand more in clinical assessment than humanity. She was in circulatory shock, not to mention profound mental turmoil. Her pulse rate was around 120 beats per minute, but the fact that I could feel it suggested that her blood pressure was still above 50 mm Hg. Before we moved her I needed to scrutinise the anatomical features of the injury so as to predict what damage we would be confronted with. I had seen several cases of transfixion trauma where the patient survived because the implement narrowly missed or pushed aside all the vital organs. Here the degree of shock indicated otherwise. It was time to get some cannulas in place in a calm and controlled manner, and bring group O negative blood ready to transfuse her. And for pity’s sake, she deserved a slug of morphine to take the edge off the sheer terror of her predicament.

Some things I knew instinctively. Had the stake damaged the heart or aorta she would have bled out at the scene. Traumatised small arteries will go into spasm, clot and stop the bleeding themselves as long as injudicious clear fluid infusion doesn’t raise the blood pressure and blow the clots off. So I surmised that most of the bleeding must be coming from the veins, which do not constrict. I asked the nurses for some scissors to remove her clothing, now stiff with dried blood. It was like cutting through cardboard and opening a window on the grim reality of her situation.

      Her pleading brown eyes remained firmly fixated on the stake. I could make out the jagged ends of ribs protruding through macerated fat and pale, bruised skin. The post had entered directly below her right breast, marginally to the right of the midline, and emerged from her body higher up in her back, suggesting that she had slid feet first after tumbling from her motorcycle. My three-dimensional anatomical knowledge left me in no doubt which structures had been damaged. The post must have taken out her diaphragm and liver, the lower lobe of her right lung and probably the largest vein in the body, the inferior vena cava. The lung wasn’t a problem. But if her liver was pulped and the veins torn off the cava, I knew that we couldn’t fix her. Scrutiny of the post protruding from her back confirmed my