The Knife’s Edge. Stephen Westaby

entitled ‘Why are so many surgeons assholes?’. Obviously it was about prevailing personality types. A scrub nurse friend of the journalist described an incident in the operating theatre where she had passed the sharp scalpel to the surgeon and he lacerated his thumb on the blade. Now furious, he shouted at her, ‘What kind of pass was that. What are we, two kids in the playground with Play-Doh? Ridiculous.’ Then to emphasise his point he threw the scalpel back at her. The nurse was horrified, but as she didn’t know how to react she just kept quiet. No one stood up for her, and no one ever reprimanded the surgeon for being aggressive or throwing the sharp instrument. The inference was that this is how a lot of surgeons behaved and they get away with it all the time.

I have known many surgeons who threw instruments around the room, and although I never aimed one at an assistant I did use to toss faulty instruments onto the floor. It meant that I couldn’t be given them a second time. Having said that, most successful surgeons have certain malign traits in common. These have been summarised in the medical literature as the ‘dark triad’ of psychopathy, Machiavellianism – the callous attitude in which the ends are held to justify the means – and narcissism, which manifests as the excessive self-absorption and sense of superiority that goes with egoism and an extreme need for attention from others. This dark triad emanates from placing personal goals and self-interest above the needs of other people.

      Just in the last few months psychologists at the University of Copenhagen have shown that if a person manifests just one of these dark personality traits, they probably have them all simmering below the surface, including so-called moral disengagement and entitlement, which enables someone to throw surgical instruments with absolutely no conscience at all. This detailed mapping of the dark triad is comparable to Charles Spearman’s demonstration a hundred years ago that people who score highly in one type of intelligence test are likely to perform equally well in other kinds. Perhaps the daunting road to a surgical career inadvertently selects characters with these negative traits. It certainly appears that way, yet I had a very different side to my personality when it came to my own family. Maritally I fell into the same old traps, but I would go to any lengths to make my children happy or my parents proud.

I was not rostered to be in surgery as it was my daughter Gemma’s birthday and I hoped to be free. The phantom father who had let her down so many times in the past, I planned to drive to Cambridge in the afternoon to surprise her. Then I discovered that three of our five surgeons were out of town. Two were committed to outreach clinics at district hospitals trying to bring in ‘customers’, as the NHS now called them, or better still the odd private patient. The third was away at a conference, one of those academically destitute commercial meetings at a glamorous resort paid for by the sponsor, with business-class flights and all the rest. As a gullible young consultant I had enjoyed these trips, but it eventually wears thin – tedious airports, buckets of alcohol and forced comradery with competitive colleagues who would cheerfully drive their scalpel into your back the minute it was all over.

      It was this surgeon’s operating list that lay vacant, and the unit manager had twisted my arm to stand in for him. To let an operating theatre with a full complement of staff lie idle for the day was a criminal waste of resources, so I reluctantly agreed to the request. I had built this unit from nothing to being virtually the largest in the country, not that anyone could give a shit. The management changed so frequently that history was soon forgotten, dispatched to oblivion by the quagmire of financial expediency. So my daughter would have to wait. Again.

When I asked Sue, my secretary, to find two urgent waiting-list patients at short notice, I didn’t mention the birthday. Just two cases should see me on the road by mid-afternoon. I suggested that one should be the infant girl with Down’s syndrome who had been cancelled twice before. She was in danger of becoming inoperable because of excessive blood flow and rising pressure in the artery to the lungs. I bore special affection for these children. When I started out in cardiac surgery, many considered it inappropriate to repair their heart defects. I couldn’t get my head around a policy that discriminated against kids with a particular condition, so ultimately I overcompensated by taking them on as desperately debilitated young adults – trying to turn the clock back, sometimes without success.

      The second case needed to be more straightforward. Sue had repeatedly been pestered by a self-styled VIP who held some snooty position in a neighbouring health authority. When I reviewed this lady in the outpatient clinic, she took exception to my suggesting that weight loss would not only improve her breathlessness but reduce the risks during her mitral valve surgery. I was sternly reminded that she had featured in a recent honours list, presumably for services dedicated to getting her onto an honours list, as is frequently the case in healthcare. I wasn’t in the slightest bit impressed – and she could see that. But she kept insisting on an early date and I couldn’t blame Sue for wanting her out of the way. The titled lady wouldn’t make first slot on the list, however. That was for the baby. A third cancellation was not an option.

6 am. As I set out for work from Woodstock, my home in Oxfordshire, shafts of sunlight burst through the turrets of Blenheim Palace like rays of optimism. I would be seeing Gemma on her birthday. When she was born I was nowhere to be found, and I’d spent twenty years trying to make up for that. Sue, who also suffers from traffic phobia, joined me in the office before 7 am, and we soon dispensed with the paperwork that I had to do before the adult intensive care ward round at 7.30. The day’s operating lists were already displayed on a white board at the main nurse’s station. The male charge nurse knew that my only adult patient was unlikely to reach the unit until mid-afternoon, but still felt obliged to warn me that beds were tight. Glancing towards the row of empty beds surrounded by unplugged ventilators and cardiac monitors, I didn’t need to ask. It was more of the same. ‘Tight on beds’ means not enough nurses. In the NHS, every intensive care bed must have a dedicated nurse. In other countries they double up quite safely to get the work done, but here we just cancel operations as if they were appointments with the hairdresser.

      On this particular morning I didn’t know many of the nurses’ faces – and they didn’t recognise me. This told me that the night shift had relied heavily on agency staff. Two of my three cases from the previous day could leave the unit, but only when ward beds became available. Until then, they would continue to languish in this intimidating environment that never slept, at a cost exceeding £1,000 per day. Sometimes we’d even discharge patients directly home from intensive care when the ward was chronically blocked with the elderly and the destitute.

      This was not how it used to be. >When we fought to build the department, just three heart surgeons would perform 1,500 heart operations each year and we’d cover the chest surgery between us. Now in the same modest facilities we had five heart surgeons performing half that number of cases, alongside another three chest surgeons operating on the lungs. This was the price of progress – twice as many highly trained professionals doing much less work amid a disintegrating infrastructure. But hey. A hospital delegation was trying to recruit nurses in the Philippines that very week, so all would be well one day.

8 am – and my early-morning optimism was already punctured. I left the cacophony of life support, pulsating balloon pumps, hissing ventilators and screeching alarms. I heard weeping relatives, suggesting that a bed might soon be vacated. Knife to skin should be at 8.30, and I expected the baby to be anaesthetised by now. I assiduously avoided watching parents part from their children at the operating theatre doors. It was traumatic enough for me when my son had his tonsils out. Heart operations were a cut above. When I told parents that their child had a 95 per cent chance of survival, all that registered was the 5 per cent possibility of death. Statistics don’t help when it’s your child that doesn’t make it. So I told them what they wanted to hear, then hoped it would be true.

      But the anaesthetic room was empty. The anaesthetist was sitting in the coffee room eating breakfast.

      ‘Have we sent yet?’ I asked with an air of resignation.

      She shook her head. We had to wait for the paediatric intensive care ward round to decide whether they could give us a bed. No bed, third cancellation. It couldn’t be allowed to happen, yet the round hadn’t even started. It was an 8.30 start at the other end of the corridor, so I went there directly.