The Knife’s Edge. Stephen Westaby

my little patient was just another anonymous name in the diary, followed by the words ‘atrioventricular canal’. The whole centre of her heart was missing and her lungs were flooded. With every day that passed, her chances of survival decreased.

The trouble was that I loved the children’s intensive care unit. That little enclave of rooms was my escape from the rest of the hospital, a place that always put life – and my own troubles – in perspective. Only special people could survive the heartache in that place. The nurses liked to work with my heart surgery cases because the vast majority got better, a welcome relief from the ravages of children’s cancer, septicaemia or road-traffic accidents that they also had to deal with. The worst things in the world happened there, but everyone came back the next day to start all over again.

      Every one of the cots had a little body in it, with fretful family groups gathered around. My eyes fixed on a pair of gangrenous arms – the meningococcal meningitis child I’d watched for weeks, hanging on to life. The mother knew me well enough by now, seeing my babies come and go with happy parents. I always asked her how things were going, she always smiled. Today they were going to amputate those black, mummified limbs. No more little hands or tiny fingers. They would just drop off, with a little help to tidy things up.

      I asked whether there was any chance of a bed by lunchtime, so that we could at least send for the baby. Sister really didn’t want to let me down. One of her day-shift nurses was already in the radiology department with a head-trauma victim who’d been hit by a speeding car on the way to school. Should the injuries prove as severe as feared, ventilatory support would be withdrawn. Then my case could go to theatre. I enquired whether the organ donor phrase had been mentioned.

‘Do you want the bed or don’t you?’ she replied. ‘That route could take us well into tomorrow.’

      For comfort I picked up a bacon sandwich, then wandered off in my theatre gear through the hordes who arrived for work at nine o’clock. These were normal people who didn’t have to split breast-bones, stop hearts or give desolate parents bad news, such as ‘Your child’s operation is cancelled again.’ Now the dilemma. Should I give up on the little girl, then send for the VIP and her mitral repair? The lady wouldn’t have been starved long enough or had a pre-med, but at least I could take off to Cambridge to see my daughter afterwards without the worry of leaving a newly operated infant when I wasn’t on call. Or should I hold out for the possibility of a bed for her parents’ sake?

Turning away from blank faces and the tacit acceptance of dysfunctionality, I diverted to radiology. They knew me well enough at the CT scanner and seemed relieved to discover that I was not attempting to take over their next slot. The images of the child’s battered brain emerged slice by slice. The skull had been cracked open like the top of a boiled egg. Where there should have been clear lakes of cerebrospinal fluid, there was nothing. The brain surgeon and intensive care doctors shook their heads in dismay. Nothing would be gained by operating. The cerebral cortex was pulp and the brain stem had herniated through the base of the skull. I was relieved that I couldn’t see that poor broken body concealed within the scanner. She had toddled off happily to the village school; now she hovered between earth and heaven, her brain already gone. So I had my intensive care bed. Relief for one set of parents, complete and utter desolation for another.

      Striding purposefully back to the operating theatres, I requested that they send directly for my first case. The agency anaesthetic nurse hadn’t the faintest idea who I was and confronted me with the usual crap, saying that they hadn’t heard if there was a bed yet.

      Uncharacteristically, and because I didn’t know the woman, I lost the plot and shouted, ‘I’m telling you there’s a fucking bed. Now send for the child.’

      The anaesthetist stood in the doorway and gave me a long, hard stare. The nurse picked up the phone and called the paediatric intensive care unit sister. At that moment, I worried that others had not been informed that the trauma case was not for ventilation. But I got lucky. The response confirmed my outburst. Yes, we could send for the cardiac case.

      To put the baby asleep and insert cannulas into her tiny blood vessels would take an hour, so to avoid the transmitted anxiety from the parents’ tearful separation from their baby girl, I slipped into the anaesthetic room of the thoracic theatre, carrying a plastic cup of ghastly grey coffee. This time I was warmly greeted by an old friend, whom I asked to measure my blood pressure. It was 180/100 – far too high, despite the daily blood pressure medication I had been taking for ten years.

As the fearful parents shuffled past the door I heard one of them say, ‘Please tell Professor Westaby we are grateful for this chance.’ I suspected they still didn’t believe that their baby would make it. Perhaps they were worried that we wouldn’t try as hard as we could because of the Down’s syndrome.

      Would a concert pianist prepare for an important recital by first enduring three hours of intense frustration? Would a watchmaker have to face a blazing row before assembling a complicated Rolex movement? My job was to reconfigure a deformed heart the size of a walnut, yet I enjoyed zero consideration for my state of mind from those around me. I wouldn’t so much as get on a bus if the driver was subject to that much irritation. The first time I stood as the operating surgeon looking into the void at the centre of an atrioventricular canal defect, I thought, ‘Shit, what the hell do I do with this?’ Yet I always succeeded in separating the left and right sides of the heart with patches, then creating new mitral and tricuspid valves from the rudimentary valve tissue. It’s complex work, but I never lost one on the operating table.

I finally ran the stainless-steel blade through the baby’s skin at 11 am. As the first drops of blood skidded over the plastic drape, I remembered that I had not made contact with my daughter. That thought hit me just as the oscillating saw bisected the baby’s sternum, but there was nothing I could do about it now. I needed complete focus to reconfigure that tiny deformed heart and give the baby a lifetime without breathlessness or pain. So what did I need to consider? The new mitral valve must not leak, although it wouldn’t be too bad if there was a whiff of regurgitation through the tricuspid valve on the low-pressure side of the circulation. And we had to be careful not to damage the invisible electrical conduction system that crucially coordinates the heart’s contraction and relaxation. Otherwise she would need a permanent pacemaker. At that point I felt it would have been much easier to be a watchmaker or concert pianist …

      As it turned out, that little heart would be the least of my problems that day. I separated the chambers with obsessively sewn patches of Dacron cloth, then carefully created the new valves upon which the baby’s future depended. It was much the same as operating within an egg cup. When blood was reintroduced into the tiny coronary arteries the little heart took off like an express train. Just as I prepared to separate the baby from the heart–lung machine, a pale and worried face appeared at the theatre door.

      ‘Sorry, Professor,’ the woman said, ‘but we need you right now in Theatre 2. Mr Maynard is in trouble.’

      ‘How much trouble?’ I asked, without diverting my eyes from the baby’s heart.

      ‘The patient is bleeding from a hole in the aorta and he can’t stop it.’ She had a note of desperation in her voice.

      Although the baby seemed fine, I would not normally leave a registrar to remove the bypass cannulas and close up. But it needed a snap decision. On the balance of probabilities, I decided that I should try to help. In haste, I forgot that I was tethered by the electric cable of my powerful head lamp. Standing back from the operating table, I avulsed the bloody thing. Several hundred pounds’ worth of damage in two seconds.

Nick Maynard was a first-rate upper gastrointestinal surgeon who specialised in stomach and oesophageal cancer. He dealt with tubes normally filled with food and air, not blood at high pressure. But this unfortunate patient did not have cancer. Just days before, she had been completely well. While happily eating sea bass in a fancy restaurant she swallowed a fish bone. At first the discomfort abated and she could swallow. Then a dull ache emerged deep in the chest, next a swinging fever with night sweats. Soon just swallowing liquids became difficult and made the