Stephen Westaby

The Knife’s Edge


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and could move his left side.

      There was one piece of critical information I didn’t have, besides his name, that is. What was his blood pressure? Before committing any patient with dissection to an ambulance or helicopter journey, it was vital that the blood pressure was carefully controlled with intravenous anti-hypertensive drugs because a surge in pressure can easily rupture the damaged vessel. So many patients die during or soon after transfer for that very reason.

      ‘180/100. We can’t seem to get it down.’ An element of panic had now entered her voice.

      What that meant was that all the senior staff had buggered off home and left her to it, and she had never seen such a case before. After a day of conflict and castigation I chose my words carefully.

      ‘Oh shit! You must get that down. Get him on nitroprusside.’

      I pictured the paper-thin tissue expanding to bursting point while the dissection process extended further throughout the vascular tree. Even with emergency surgery, one in four of these patients died.

      This terrified patient had been lying paralysed on a hard hospital trolley for hours, surrounded by his family. He knew his own diagnosis and was fully aware that urgent surgery was his only chance of survival. Worse still, he’d had heart surgery before for an abnormal aortic valve, which is often associated with a weakened aortic wall. Reoperations are much more taxing than virgin surgery, so I summarised the situation in my mind. Physician with the highest-risk acute emergency needs reoperation but has an established stroke and one kidney down. His blood pressure is uncontrolled and he is at least two hours away by road. Could they arrange a helicopter? No, they had already tried. No wonder Papworth weren’t interested!

      Lucy sensed that I was wavering. Hedging my bets, I told her that I had no idea whether we had any intensive care beds available.

      So Lucy played her trump card. ‘The family asked that he be sent to you personally. Apparently you were at medical school together. I think he was a friend of yours.’

      What was that question I never asked? Something we don’t regard as important – the patient’s name. Surgeons are less interested in people. We want problems to fix, but I had already had enough problems for one day.

      I just said, ‘Bugger the beds. Send him across as fast as you can. I appreciate you should be going off duty, Lucy, but someone must come with him to screw that pressure down. And please send the CT scan.’

      With no one to delegate to at this time of the evening, I had to make all the arrangements myself. The on-call nursing team had already worked all day and were just finishing a routine lung cancer operation. They were less than delighted by the prospect of a protracted emergency reoperation, one they expected to take all night. With foot down and blue lights flashing, the ambulance ought to be with us by 11 pm. If Steve survived to see Oxford alive, I would wheel him directly to the anaesthetic room.

      As the sun went down, we waited. I called home and spoke to my long-suffering wife Sarah, who thought I was in Cambridge and was sad for me that I wasn’t. I explained that I was waiting to operate on Steve Norton from medical school and wouldn’t be home tonight. That concerned her. I wasn’t the duty surgeon, and she remembered the heated discussions when I was faced with the prospect of operating on my own father during his heart attack. In the end, my cardiology colleague Oliver spared me the moral issues by curing him with coronary stents.

      Sarah asked tentatively whether I should ask the on-call surgeon to do it. How did I feel about operating on a good friend at such high stakes? Cardiac surgeons are rarely introspective and self-effacing. I answered her question with a question: ‘If you had an aortic dissection, who would you want to do the surgery?’ Response: ‘You.’ Well then, why are you surprised that Steve’s family felt the same?

      Sarah’s next question was whether I’d eaten anything that day. This took some time to think about. I recalled a bacon sandwich at the crack of dawn. I told her that I’d find a bag of crisps from a vending machine before we launched into the night’s work. But food was the least of my concerns at that point. I needed an experienced first assistant, someone who had operated with me on dissections before, not an inexperienced locum brought in to cover a few night shifts. When the shit hits the fan, a coherent team makes a massive difference. Bums on seats is not the same. Amir was not on call, so I picked up the phone and asked him if he was doing anything. One thing he certainly wouldn’t be doing was drinking. He was effusive in his willingness to help, honoured to be dragged in at night to help the boss with a complex case. And I knew that he was capable of standing at the table for hours when I needed someone to stem the bleeding then close up. That was a young man’s game.

      I wandered the silent hospital corridors to pass the time, consciously avoiding a confrontation with cardiac intensive care. I would let Pigott tell them we had an emergency once we were in theatre. Or maybe I’d ask Amir, who joined me in general intensive care, where we visited the fishbone lady. The ‘great save’, whose name I never knew, was beginning to wake up, her bed surrounded by her anxious daughters, arms extended to their mother’s cold hands under the warming blanket. Predictably, she had ‘after-cooled’ down to 34°C following the hypothermic circulatory arrest and was now shivering violently. Shivering, and the vasoconstriction response to cold,