The Knife’s Edge. Stephen Westaby

once deemed blessed with magical powers.’ Perhaps some of us still do have mystical powers. There are few things more intriguing than delivering electricity into a patient’s head through a metal plug screwed into their skull like Dr Frankenstein’s monster or reinventing human circulation with continuous blood flow without a pulse. These innovations may be construed as witchcraft, but they were my own practical solutions to the terrible illness that is heart failure. Sokol went on to say that doctors are in the habit of revealing ‘not the chiselled frame of Apollo … but the wart covered body of Mr Burns, the Simpsons character’. But Burns was the rich factory owner. I’m more of a sensitive intellectual, like Bart Simpson’s father Homer.

As is often the case, the French have a phrase for it: ‘se mettre à nu’, to get naked. So that is what I decided to do, although this was a much more interesting spectacle in my younger years than now. My own insight tells me that the public are happier to learn that their surgeon, even a heart or brain surgeon, is human and subject to the same core emotions as anyone else. But because of a freak sporting accident, some qualities possessed by the vast majority of people were lost to me for a while, which proved an unexpected but substantial boost to a career at the sharp end – life perpetually on the ‘knife’s edge’.

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       family

      When I searched the internet for a contemporary description of the surgical personality, I found this:

      Testosterone-infused swagger, confident, brash, charismatic, commanding. Arrogant, volatile, even bullying and abusive. Aggressive. Cuts first, asks questions later, because to cut is to cure and the best cure is cold steel. Sometimes wrong but never in doubt. Good with his hands but no time to explain. Compassion and communication are for sissies.

      The psychologist author argued that the highly stressful, adrenaline-fuelled environment in which surgeons work attracts a certain personality type. And so it does. Cutting into people, then wallowing in blood, bile, shit, pus or bone dust is such an alien pastime for normal folk that the mere process of operating immediately sets us apart. Those with introspection and self-doubt select themselves out from my specialty.

It is hard to describe how agonisingly difficult it was to gain access to a cardiac surgery training programme in the 1970s, when open heart surgery with the heart–lung machine was only in its second decade. The surgeons of that era were an unashamedly elitist group with the guts, skill and sheer daring to expose a sick heart and attempt to repair it. Methods to protect the muscle when it was starved of blood were frequently inadequate, and prolonged interaction between blood and the foreign surfaces of the bypass machine triggered a damaging inflammatory reaction known as the ‘post-perfusion syndrome’. Heart surgeons therefore needed above all to work against the clock – deaths were a daily occurrence, yet most patients were so sick that this wasn’t considered a catastrophe. While survival and symptomatic relief were gratifying, death put an end to suffering. Consequently, most families were grateful that their loved ones had at least a chance of their condition improving through surgical intervention.

We all had to go through general surgery training first to show that we had what it takes. First, good hands – and you have to be born that way. Most organs just sit there while you cut and sew them, but the heart is a moving target, a bag of blood under pressure that bleeds torrentially if you bugger it up. Just touching it clumsily can provoke disorganised rhythm and sudden cardiac arrest. Second, the right temperament – the ability to explain death to grieving relatives and to bounce back from a bollocking in the operating theatre. Then courage – the bravery to take over from the boss when he’s had enough, the guts to take responsibility for the post-operative care of tiny babies or to address a catastrophe in the trauma room when the nearest consultant is an hour away. Then patience and resilience – being able to stand there as first assistant for six hours without losing concentration, sometimes with a hangover, or to face five days continuously on call in the hospital, day and night without respite. That was surgical training in those days.

A series of infernal exams to become a fellow of the Royal College of Surgeons was an additional burden over and above the clinical work. These covered every aspect of surgery and only a third of the candidates passed each time. It didn’t matter that I wanted to operate in the chest. For the ‘primary’ fellowship we were required to know the anatomy of a human being in minute detail, brain to asshole, teeth to tits – every nerve, artery and vein in the whole body, where they went, what they did, what happened if we damaged them. We had to learn the physiological processes of every organ and the biochemistry of every cell. After some basic operative experience, the ‘final’ fellowship examined us on the pathology of every surgical condition in the book, then the diagnostic and surgical techniques for each specialty. Only after conclusively demonstrating comprehensive knowledge and skills were we allowed to move on and specialise. I failed both the primary and final fellowship on first sitting, an expensive exercise. Most of my associates did too. The whole miserable process was there to sort the wheat from the chaff, and I wasn’t fazed by failure. It was just like rugby, the sport I loved above all others. Some games you won, others you lost.

      The surgical world resembles the army. The consultants are the officers and the gentlemen, the trainees line up in tiers through the ranks: senior house officer is equivalent to corporal, registrar acting as sergeant, senior registrar akin to a non-commissioned officer doing all the work and eventually being promoted to the officer’s mess. That final step was the most competitive of all. For the ruthlessly ambitious it had to be a top teaching hospital. Heart surgeons strove for London hospitals like the Royal Brompton, the Hammersmith, Guy’s or St Thomas’. Appointment to one of these, and you had made it big time. In those days Cambridge had a vibrant cardiothoracic centre in Papworth village out of town. Oxford was doing very little.

      All this took place during our formative years, our late twenties and early thirties, when normal people cement relationships, settle down in one location and start a family. Trainee surgeons lived like gypsies, moving from city to city – wherever the best posts were advertised. Something about being a surgeon elevated us to a different plane. We were the fighting cocks of the doctors’ mess, the flash Harrys who constantly strove to outdo each other and ruthlessly coveted the top jobs; the guys – and at that time, as now, it was almost exclusively guys – who stayed in the hospital night after night seeking every chance to operate, or, if it was quiet, drifting across to the nurses’ quarters, where other exciting action was easy to find.

I was a backstreet kid from Scunthorpe who had married his childhood sweetheart from the local grammar school. Caught up in this whirlwind of ruthless ambition, things changed and marriage became an unintended casualty. I was ashamed of this, but I knew some surgical teams where every member, from junior houseman to consultant, was having an affair in the hospital. Grim in reality, but the stuff of television soaps that glamorise adultery. So widespread was the problem that the Johns Hopkins Hospital in Baltimore carried out a formal study of divorce as an occupational hazard in medicine. The younger their residents were when they married, the higher their divorce rate. Understandably, divorce was commonplace when the spouse did not work in the medical field. Blame it on the communication gap. They had little to talk about because doctors – and especially surgeons – are engrossed in their hospital life.

The Johns Hopkins study showed that more than half of psychiatrists and one in three surgeons divorced. Cardiac surgery had an impressive divorce rate, which I already knew from my colleagues’ experience. Reasons cited were high testosterone levels, long hours and nights in the hospital, and close working relationships with numerous attractive young women, often in stressful and emotional circumstances. Professional bonds are formed, and these evolve into romance. At one stage the Dean of Duke University Medical School saw fit to warn applicants that the institution was experiencing a greater than 100 per cent divorce rate. Why exceeding the maximum? Because students showed up already married, got divorced, then remarried and divorced a second time. They all lived a life in which work was seen to come first, with everything else a distant second.

      Once at a conference