Fragile Lives

2

humble beginnings

Courage is doing what you’re afraid to do. There can be no courage unless you’re scared.

Edward V. Rickenbacker, The New York Times Magazine, 24 November 1963

It was at the very start of the post-war baby boom that I arrived into the world in the maternity department of Scunthorpe War Memorial Hospital on 27 July 1948, star sign Leo. Good old Scunthorpe, my childhood home for eighteen years, a steel town and the long-suffering butt of music-hall jokes.

My dear mother, exhausted after a long and painful labour but happy with her first child, brought me safely back home from the carnage of the delivery suite. I was a pink, robust son, wailing from the depths of his newly expanded lungs.

My mother was an intelligent woman, caring, gentle and well liked. During the war she’d managed a small high-street bank, and with other tills empty the old folks would still queue to tell her their troubles. My father joined the RAF at sixteen to fight the Germans, and after the war he got a job in the local Co-operative grocery department and worked hard to improve our circumstances. Life wasn’t easy.

We were church-mice poor in a grimy council estate. House number 13, no pictures allowed on the walls in case the plaster crumbled, with a corrugated tin air-raid shelter in the back garden that housed geese and chickens – and the outside toilet.

My maternal grandparents lived directly across the street. Grandmother was kindly and protective of me, but frail. Grandfather worked at the steelworks and during the war had been the local air-raid warden. On pay day I’d go with him to the works to collect his wages. There I was intrigued by the spectacle of white-hot molten metal being poured into ingots, bare-chested, sweaty men in flat caps stoking the furnaces, steam trains belching fire, clanking up and down between the rolling mills and the slag heaps, and sparks flying everywhere.

Grandfather patiently taught me how to draw and paint. He’d sit over me, puffing away on Woodbines as I painted red night skies over the chimneys, street lamps and railway trains. Grandfather smoked twenty a day and spent his whole life working in smoke at the steelworks. Not the best recipe.

In 1955 we got our first television set, a 10-inch-square box with a grainy black-and-white picture and just one channel, the BBC. Television dramatically widened my awareness of the outside world. That year two Cambridge scientists, Crick and Watson, described the molecular structure of DNA. In Oxford the physician Richard Doll linked smoking with lung cancer. Then came exciting news on a programme called Your Life in Their Hands that would shape the rest of my life. Surgeons in the United States had closed a hole in the heart with a new machine. They called it the heart–lung machine, because it did the job of both organs. The television doctors wore long white coats down to the floor, the nurses had fine, starched uniforms and white caps and rarely spoke, and the patients sat stiffly to attention with their bed sheets folded back.

The show talked about heart operations and how surgeons at the Hammersmith Hospital would attempt one soon. They too would close holes in the heart. This seven-year-old street kid was captivated. Quite mesmerised. Right then I decided that I would be a heart surgeon.

At ten I passed the tests for entry to the local grammar school, and by then I was quiet, compliant and self-conscious. As one of the ‘promising’ set I was forced to work hard. I was a natural in art, although I had to stop those classes in favour of academic subjects. But one thing was clear. I was good with my hands, and my fingertips connected with my brain.

One afternoon after school I was out walking with Grandfather and his Highland terrier Whisky on the outskirts of town when he stopped dead on a hill, clutching the collar of his cloth shirt. His head bowed, his skin turned ashen grey and, sweating and breathless, he sank to the ground like a felled tree. He couldn’t speak and I saw the fear in his eyes. I wanted to run and fetch the doctor but Grandfather wouldn’t let me. He couldn’t risk being off work, even at the age of fifty-eight. I just held his head until the pain abated. It lasted thirty minutes, and once he’d recovered we slowly made for home.

His ill health wasn’t news to my mother. She told me that he’d been getting a lot of ‘indigestion’ while cycling to work. Reluctantly, Grandfather agreed to get off the bike, but it didn’t do much good. The episodes became more frequent, even at rest, and especially when he climbed the stairs. Cold was bad for his chest, so the old iron bed was brought down in front of the fire and the commode was carried inside to save a journey outdoors.

His ankles and calves were so swollen with fluid that he needed bigger shoes. It was a gargantuan effort just to tie his shoelaces, and from then on he didn’t get out much, mostly just moving from the bed to a chair in front of the fire. I’d sit and draw for him to take his mind off his rotten symptoms.

I remember that dismal wet afternoon in November, the day before President Kennedy was assassinated in Dallas. I came home from school to find a black Austin-Healey outside my grandparents’ house. It was the doctor’s car and I knew what that meant. I stared through the condensation on the front window but the curtains were drawn, so I went around the back of the house and walked in quietly through the kitchen door. I could hear sobbing and my heart sank.

The living-room door was ajar and inside it was dimly lit. I peered in. The doctor was standing by the bed with a syringe in his hand, and my mother and grandmother were at the end of the bed, clasping each other tightly. Grandfather looked leaden, with a heaving chest and his head tipped back, and frothy pink fluid was dripping from his blue lips and purple nose. He coughed agonally, spraying bloody foam over the sheets. Then his head fell to one side, wide eyes staring at the wall, fixed on the placard proclaiming ‘Bless This House’. The doctor felt for a pulse at his wrist, then whispered, ‘He’s gone.’ A sense of peace and relief descended on the room. The suffering was at an end.

The certificate would say ‘Death from heart failure’. I slipped out unnoticed to sit with the chickens in the air-raid shelter, and quietly disintegrated.

Soon afterwards my grandmother was diagnosed with thyroid cancer, which started to close off her windpipe. ‘Stridor’ is the medical term to describe the sound of strangulation as the ribs and diaphragm struggle to force air through the narrowed airway, and that’s what we heard. She went to Lincoln, forty miles away, for radiotherapy, but it burned her skin and made swallowing more difficult. We were given some hope of relief by an attempted surgical tracheostomy, but when the surgeon tried to do it he couldn’t position the hole low enough in the windpipe below the narrowing. Our hopes were dashed and she was doomed to suffer until she died. It would have been better if they’d allowed her to go under anaesthetic. Every evening I sat with her after school and did what I could to make her comfortable. Soon opiate drugs and carbon dioxide narcosis clouded her consciousness, and one night she slipped away peacefully with a large brain haemorrhage. At sixty-three she was the longest-lived of my grandparents.

When I reached sixteen I took a job at the steelworks in the school holidays, but after a collision between a dumper truck and a diesel train hauling molten iron they dispensed with my services. I spotted a temporary portering job at the hospital and negotiated the role of operating theatre porter. There were disparate groups to please. The patients – fasted, fearful and lacking dignity in their theatre gowns – required kindness, reassurance and handling with respect. Junior nurses were friendly and fun, the nursing sisters were self-important, bossy and business-like, and needed me to shut up and do what they told me, and the anaesthetists didn’t want to be kept waiting. The surgeons were simply arrogant and just ignored me – at first.

One of my jobs was to help transfer anaesthetised patients from their trolleys onto the operating table. I knew what sort of surgery was planned for each one, having read the operating list, and I helped out by adjusting the overhead lights, focusing them on the site of the incision (as an artist I was intrigued by anatomy and had some knowledge of what lay where). Gradually the surgeons began to take notice, some even asking me about my interest. I told them that I’d be a heart surgeon one day, and soon enough I was allowed to watch the operations.

Working nights was great because of the emergencies: broken bones, ruptured guts and bleeding aneurysms. Most of those with aneurysms died, the nurses cleaning up the corpses and putting on the shrouds, me hauling them from the operating table and onto the tin mortuary trolley, always with a dull thud. Then I’d wheel them off to the mortuary and stack the bodies in the cold store. I soon got used to it.

Inevitably my first mortuary visit took place in the dead of night. The windowless grey brick building was set apart from the main hospital and I was frankly terrified of what I’d find in there. I turned the key in the heavy wooden door that led directly into the autopsy room but when I reached inside I couldn’t find the light switch. I’d been given a torch and its beam danced around as I plucked up the courage to go in.

Green plastic aprons, sharp instruments and shiny marble sparkled in the gloom. The room smelt of death, or what I expected death to smell like. Eventually the torch beam settled on a light switch and I turned on the overhead neons. They didn’t make me feel any better. There were stacks of square metal doors from floor to ceiling – the cold store. I needed to find a fridge but wasn’t sure which ones were empty.

Some doors had a piece of cardboard slotted into them with a name on it, and I figured that they must be occupied. I turned the handle on one without a name, but there was a naked old woman under a white linen sheet. An anonymous corpse. Shit. Try again on the second tier. This time I was lucky, and I pulled out the sliding tin tray and pushed the creaking mechanical hoist towards my stiff. How to make this thing work without dropping the body on the floor? Straps, crank handles and manhandling. I just got on with it and slid the tray back into the fridge.

The mortuary door was still wide open – I didn’t want to be shut in there alone. I sped out and pushed the squeaking mortuary trolley back to the main hospital ready for the next customer. I wondered how pathologists could spend half of their career in that environment, carving entrails from the dead on marble slabs.

Eventually I charmed an elderly female pathologist into letting me watch the autopsies. Even after witnessing some disfiguring operations and terrible trauma cases this took some getting used to, young and old sliced open from throat to pubis, eviscerated, scalp incised from ear to ear and pulled forward over the face like orange peel. An oscillating saw removes the cranium, as if taking the top off a boiled egg, and then the whole human brain lies in front of me. How does this soft, grey, convoluted mass govern our whole lives? And how on earth could surgeons possibly operate on this, a wobbly jelly?

I learned so much in that dingy, desolate autopsy room: the complexity of human anatomy, the very fine line between life and death, the psychology of detachment. There was no room for sentiment in pathology. An ounce of compassion there may be, but affinity with the cadaver? No. Yet personally I felt sad for the young who came here. Babies, children and teenagers with cancer or deformed hearts, those whose lives were destined to be short and miserable or had been terminated by a tragic accident. Forget the heart as the source of love and devotion, or the brain as the seat of the soul. Just get on and slice them up.

Soon I could identify a coronary thrombosis, a myocardial infarction, a rheumatic heart valve and a dissected aorta, or cancer spread to the liver or lungs. The common stuff. Charred or decomposed bodies smelt bad, so Vicks ointment stuffed up the nostrils spared your olfactory nerves. I found suicides to be terribly sad, but when I verbalised this I was told to ‘Get over it if you want to be a surgeon’ and that it would all be easier when I was old enough to drink. I sensed that alcohol was high on the list of surgeons’ recreational activities, and this seemed more obvious when they were called in at night. But who was I to judge?

I began to wonder whether I could really get in to medical school. I was no great academic, and I struggled with maths and physics. For me these subjects were the real barometer of intelligence. But I excelled in biology and could get by in chemistry, and in the end I passed a lot of exams, stuff I would never need like Latin and French literature, additional maths and religious studies. These I saw as a function of effort, not intelligence, but hard work bought me my ticket out of the council estate. In addition, the time spent in the hospital had made me worldly. I’d never been out of Scunthorpe, yet I knew about life and death.

I started to search for a place at medical school, and returned to the hospital during every school holiday. I progressed to working as an ‘operating department assistant’, becoming an expert in cleaning up blood, vomit, bone dust and shit. Humble beginnings.

I was surprised to be called for an interview at a magnificent Cambridge college. Someone must have put in a good word but I never learned who it was. The streets bustled with lively young students in their gowns chatting loudly with public school accents, all seeming much smarter than me. Erudite, bespectacled professors cycled down cobbled streets in their mortarboards off to college dinners for wine, then port. My mind flashed back to the grimy steelworkers silently making their way home in flat caps and mufflers through the smog for bread and potatoes, and then maybe a glass of stout. My spirits started to sink. I didn’t belong here.

The interview was conducted by two distinguished fellows in an oak-panelled study overlooking the main college quadrangle. We sat in well-worn leather armchairs. It was meant to be a relaxed atmosphere, and nothing was said about my background. The anticipated question, ‘Why do you want to study medicine?’ never came. Wasted interview practice. Instead I was asked why the Americans had just invaded Vietnam and whether I had heard of any tropical diseases their soldiers might be exposed to. I didn’t know whether there was malaria in Vietnam so I said, ‘Syphilis.’

That broke the ice, particularly when I suggested that this might be less of a health problem than napalm and bullets. Next I was asked whether smoking cigars may have contributed to Winston Churchill’s demise (he’d only recently died). Smoking was one of the key words I was waiting for. My mouth fired off in automatic mode: cancer, bronchitis, coronary artery disease, myocardial infarction, heart failure, how the corpses of smokers looked in the autopsy room. ‘Had I seen an autopsy?’ ‘Many.’ And cleared up the brains, guts and bodily fluids afterwards. ‘Thank you. We’ll let you know in a few weeks.’

Next I was called down to Charing Cross Hospital, between Trafalgar Square and Covent Garden on the Strand. The original hospital was built to serve the poor of Central London and had a distinguished war history. Although I arrived early I was always last alphabetically, so I twiddled my thumbs anxiously to while away what seemed like hours. A kindly matron received the candidates with tea and cakes, and I made polite conversation with her about what had happened to the hospital during the war.

The interview took place in the hospital board room. Across the other side of the boardroom table from me was the chief interviewer – a distinguished Harley Street surgeon wearing a morning suit – together with the famously irascible Scottish professor of anatomy upon whom the Doctor in the House films were based. I sat straight-backed to attention on an upright wooden chair – no slouching here. I was first asked what I knew about the hospital. Thank you, God. Or Matron. Or both. Next I was asked about my cricketing record and whether I could play rugby. And that was all, the interview was over. I was the last of the day, they’d had enough and they’d let me know.

I wandered out into Covent Garden past the colourful market stalls and bristling public houses. All life was there: tramps, tarts, buskers and bankers, the Charing Cross Hospital clientele, and the black cabs and scarlet London buses that drove up and down the Strand. Meandering between the crowds and the traffic I came to the grand entrance of the Savoy Hotel. I wondered whether I dared go in. Surely I looked smart enough in my interview suit and Brylcreemed hair. But the decision was swiftly made for me when the immaculate doorman pushed the swing doors open and ushered me through with a ‘Welcome, sir.’ The seal of approval. From Scunthorpe to the Savoy.

I strode purposefully through the atrium, past the Savoy Grill, hesitating only to scrutinise the menu in its gilt frame. The prices! I didn’t stop. A sign pointed to the American Bar. The hall was lined with signed cartoons, photographs and paintings of West End stars, and when I reached it there was no queue as it was only 5 pm. Perched on a high stool I furtively devoured free canapés and perused the cocktail menu. Devoid of insight – this was my first alcoholic drink – I was pushed to make a decision. ‘Singapore Sling, please.’ Like flipping a switch, my life had changed. Had I ordered a second I’d never have found King’s Cross station.

Within the week a letter arrived from Charing Cross Hospital Medical School. Opening it surrounded by my anxious parents felt like defusing a bomb. There was the offer of a place. The conditions? Just pass my biology, chemistry and physics exams, no grades specified. Charing Cross was a small medical school with an intake of only fifty students each year, but I’d be following in the footsteps of distinguished alumni such as Thomas Huxley the zoologist and David Livingstone the explorer. I was the first in my family to go to university, the first to attempt to become a doctor and, hopefully, the first heart surgeon.

3

lord brock’s boots

He has been a doctor a year now and has had two patients. No, three, I think. Yes, three. I attended their funerals.

Mark Twain

The best way to prepare for the exams to become a Fellow of the Royal College of Surgeons was to work as an anatomy demonstrator in the dissection room of the medical school, teaching anatomy to the new students in minute detail and helping them to dismantle their cadaver sliver by sliver – skin, fat, muscle, sinew and then the organs. They were given greasy embalmed corpses on a tin trolley, and there were six new and impressionable students to each one. They’d march in with their starched white coats and brand new dissection kits – scalpel, scissors, forceps and hooks in a linen roll – all as green as grass. Just like me when I started.

I moved from group to group to maintain their momentum. A few couldn’t hack it. Spending untold hours picking away at a corpse was not part of their medical dream, so I gave the best advice I could to help them through it: wear strong perfume, don’t skip breakfast and try to think about something else – football, shopping, sex, anything. Just learn enough to pass the tests and don’t let the stiffs drive you out. This worked with some. Others had nightmares, their dissected corpses visiting them at night.

For my first surgery exam I had to master anatomy, physiology and pathology – nothing to do with being able to operate. There were courses in London that just hammered home the facts, taught by past examiners who presented the information in the way that the college wanted it. Pay up and pass was the message, unless you were an idiot. Yet two-thirds of candidates still failed come exam time, including myself on the first occasion.

In the midst of this academic monotony the Royal Brompton Hospital advertised for ‘Resident Surgical Officers’, with Fellowship of the Royal College of Surgeons being ‘desirable but not obligatory’. Could I aspire to this? I’d only just passed the first part. It would be a minimum of three years before I could sit the final exam, but there would be nothing lost by trying for the post.

Despite the odds I succeeded in securing the job and started in the position just a few weeks later. I was allocated to work for Mr Matthias Paneth, an imposing six-foot, six-inch German, and Mr Christopher Lincoln, the newly appointed children’s heart surgeon of similar height. Two very different personalities, but both scary in their own way until I knew them better. In my massively busy junior resident jobs at Charing Cross I learned that the only way to keep up was to write everything down. Record every order or request as it was verbalised. To forget was to be in deep shit, so I always carried a clipboard. This was a source of great amusement to Mr Paneth, who took to saying, ‘Did you get that, Westaby? Did you get that, Westaby?’

My surgical logbook opened in spectacular fashion. The Paneth team had a case scheduled after the outpatient’s clinic, a little old lady from Wales for mitral valve replacement. The boss invited me to go and start while he saw a couple more private patients. I proudly changed into the blue scrubs. Not only that, I found a pair of white rubber surgeon’s boots in an open locker. They were well worn and dirty. I could have had new clogs but coveted these discarded second-hand boots. Why? Because down the strip at the back was written ‘Brock’. I was about to inherit Lord Brock’s boots.

By now Baron Brock of Wimbledon was seventy and had stopped operating, Paneth alluding to his having ‘perpetual disappointment at the unattainability of universal perfection’. He was President of the Royal College of Surgeons when I was at medical school and stayed on as Director of the Department of Surgical Sciences, and now I’d be following in his footsteps. Literally. I strode out of the surgeons’ changing room straight into the operating theatre to introduce myself.

The old lady was on the operating table. The scrub sister, who had already prepared her with antiseptic iodine solution and covered her naked body in faded green linen drapes, was now impatiently tapping her theatre clogs on the marble floor, and the long-suffering anaesthetist Dr English and the chief perfusionist were playing chess by the anaesthetic machine. I sensed that everyone had been waiting for some time. I pulled on my face mask and quickly scrubbed up, relishing this first opportunity to showcase my skills.

I carefully located the landmarks, the sternal notch at the base of the neck and the tongue of cartilage at the lower end of the breastbone. The scalpel incision – a perfectly straight line cut from top to bottom – would carefully join the two. The old lady was thin and emaciated with heart failure, and there was little fat between skin and bone to cleave with the electrocautery. At this point there was still no sign of the other assistant surgeon, but I pressed on regardless, seeking to impress the nurses.

I took the oscillating bone saw and tested it. Bzzzz. That was fierce enough. So I bravely started to run it up the bone towards the neck. Then, disaster. After the light spattering of bloody bone marrow there was a sudden whoosh of dark red blood pouring from the middle of the incision. Oh shit! Instantly I started to sweat, but Sister knew the score, swiftly moving around to the first assistant’s position. I grabbed the sucker but she was giving the orders. ‘Press hard on the bleeding.’

Dr English belatedly looked up from the chess board, unfazed by the frenetic activity. ‘Get me a unit of blood,’ he calmly instructed the anaesthetic nurse. ‘Then give Mr Paneth a call in Outpatients.’

I knew what the problem was. The saw had lacerated the right ventricle. But how? There should have been a tissue space behind the sternum and fluid in the sac around the heart. Sister was reading my mind, something she would do many times over the next six months. ‘You do know that this is a reoperation.’ A statement that was really a question.

‘No, absolutely not,’ I replied frantically. ‘Where’s the bloody scar?’

‘It was a closed mitral valvotomy. The scar’s around the side of the chest. You can just see it under her breast. Didn’t Mr Paneth tell you it was a re-do?’

By this point I’d decided to keep my mouth shut. It was time for action, not recrimination.

In reoperations the heart and surrounding tissues are stuck together by inflammatory adhesions, and there’s no space between the heart and the fibrous sac around it. In this case the right ventricle had stuck to the underside of the breastbone and everything was matted together. Worse still, the right ventricle was dilated because the pressure in the pulmonary artery was high, the rheumatic mitral valve having narrowed considerably. We were there to replace the diseased valve but I’d buggered it up right from the start. Great.

Pressing hadn’t controlled the bleeding. Blood still poured through the bone and the sternum wasn’t completely open yet. The patient’s blood pressure began to sag and, as she was a small lady, she didn’t have that much blood to lose. Dr English started to transfuse donor blood but that wasn’t the answer, like pouring water into a drainpipe. In one end, straight out the other. I was the surgeon, it was my job to stop the haemorrhage – and for that I needed to see the hole.

My own perspiration dripped into the wound and trickled down my legs into Lord Brock’s boots. The old lady’s blood flowed off the drapes onto the faded white rubber. By now one of the circulating nurses had scrubbed up and joined us at the operating table. Not so brave now, I lifted the saw again and asked Sister to move her hands. Through a deluge of blood I ran the saw through the remaining intact bone – the thickest part of the sternum, just below the neck. Then we pressed on the bleeding again while more transfusion restored some blood pressure.

As pressure drops the rate of bleeding slows. This gave me a window of opportunity to dissect the heart sufficiently away from the back of the breastbone to insert the metal sternal retractor and wedge open the chest. Now I could see the lacerated right ventricle spewing its contents into the wound. When everything is stuck together like this, spreading the bone edges can tear the heart muscle wide open, sometimes irretrievably. But I’d been lucky and her heart was still in one piece. Just about.

By now my own pulse was galloping. I could see that the problem was a ragged slit 5 cm long in the free wall of the right ventricle, comfortably distant from the main coronary arteries. Sister instinctively put her fist directly on it as I wound the retractor open, and this at last stemmed the bleeding. Dr English squeezed a second unit of blood in through the drips, bringing the old lady’s blood pressure back up to 80 mm Hg, and the back-up scrub nurse divided the long plastic tubes to the heart–lung machine so that we could use it when ready. But as yet not enough of the heart had been exposed for that. First I needed to stitch up the bloody hole. As a surgical houseman I’d stitched skin, blood vessels and guts – never a heart.

Sister told me what stitch to use, and that it was best to stitch over and over rather than using individual stitches. This was quicker and would provide a better seal. ‘Don’t tie the knots too tight,’ she added, ‘or the stitches will cut through the muscle. She’s fragile. Get started and you might finish before Paneth gets here and chews your head off.’

The difficult part was to stitch accurately as blood poured out of the ventricle with every beat. By now my gloves were dripping with blood on the outside and sweat on the inside, and sewing was all but impossible.

Dr English saw this and shouted, ‘Use the fibrillator! Stop the heart beating for a couple of minutes.’

The fibrillator is an electrical device that causes what we’d normally never want to see – ventricular fibrillation, where the heart doesn’t pump but quivers, stopping blood flow to the brain at normal body temperature. In four minutes brain damage begins.

Dr English was reassuring. ‘Just defibrillate it after two minutes. If you haven’t closed it by then we can wait a couple of minutes, then fibrillate again.’

I felt like a puppet with the experienced players pulling the strings. That was fine by me, so I put the fibrillating electrodes on the surface of what muscle I could see and Dr English threw the switch. The heart stopped beating and started quivering, and I began to sew at top speed. Just then Mr Paneth appeared at the operating theatre door. He could see ventricular fibrillation on the monitor and feared the worst. But I didn’t look up and just kept on stitching. By the time Dr English announced the two-minute cut-off I’d almost finished bringing the muscle edges together. I carried on to three minutes. Then the hole was closed, with just the knot to tie.

Putting the defibrillating paddles as close to the heart as possible I said, ‘Defibrillate.’ Nothing happened. The leads to the paddles hadn’t been plugged into the machine, a minor detail. Seconds ticked by. Then came the ‘zap’ I’d been waiting for. The heart briefly stood still then fibrillated again.