CHAPTER 7

World-class surgery on a shoestring

In 1979 I was attached as a fourth-year medical student to a hospital in New England in the United States. I was on the general medical service, and at the end of the working day it was the duty of our team of physicians to go around and see any ‘consults’, as American doctors called them. That means that patients with medical problems on surgical or other non-medical wards were referred for a specialist medical opinion if they were felt to need the opinion of an expert physician — something that the surgeons looking after them could not provide. Every day a handful of such ‘consults’ needed to be dealt with before the day’s work was done. One day, as part of this ‘consult’ procedure, we all trouped to an orthopaedic ward to see an old woman who had had a hip replacement. Her problem was that she was a bit short of breath and her chest X-ray looked a tad ‘fluffy’. We went to see her, examined her and looked at her X-ray.

‘Chest infection,’ said one of our physicians. ‘Let’s prescribe an antibiotic.’

‘Heart failure,’ said the other. ‘Let’s prescribe a diuretic.’

‘Could be either,’ I thought, but being no more than a lowly visiting medical student observer, I kept my mouth shut.

Back in the NHS, a pragmatic doctor dealing with this relatively minor problem would plump for one or the other, start treating accordingly, and if there was no improvement in a day or so, have a change of heart and switch to the other diagnosis or treatment. If the patient was worryingly ill (which this patient certainly was not), an NHS doctor could cover the bases by treating both. This is an easy, pragmatic, safe and cheap approach. Not so in the grand US of A.

After a seemingly interminable argument about which of the two diagnoses was more likely to be the correct one, I was agog to see that the decision they made was to insert a Swan-Ganz catheter to find out for sure if she was in heart failure. A Swan-Ganz catheter is a thin tube inserted into a large vein in the neck and advanced through the heart to the pulmonary artery, which is the artery leading from the heart to the lungs. Once the catheter is in place, a balloon at its tip is inflated and a pressure monitor located downstream from the balloon measures the filling pressure of the (further downstream) left ventricle: if the pressure is high, it is heart failure. If not, it must be a chest infection by default. All of this is rational and pretty scientific, you may think, but inserting a Swan-Ganz catheter is still quite an invasive procedure, requires admission to the ICU (where the monitoring kits are) and is much, much more expensive than antibiotics and diuretics combined. Still, that was the decision of the experts and — somewhat incredulously — I followed the medical team as they escorted the patient to the ICU for the procedure to be done.

One junior member of the medical team was visibly delighted to be charged with inserting the Swan-Ganz catheter: this was clearly going to be a feather in his cap. He scrubbed, put on gown and gloves, set out his trolley and asked for the patient to be laid down flat. He then prepped the skin, placed surgical drapes around the patient’s neck and upper chest, and inserted the needle just below the collarbone, looking for the right subclavian vein. Subclavian means ‘under the collarbone’ or clavicle, and the right subclavian vein is the large vein that drains blood from the right arm back to the heart, and one that is sometimes used for inserting these catheters.

In and out the needle went, with not a drop of blood coming back through it to indicate that he had struck the vein. He tried again, at different angles and at different points below the collarbone: still no blood. He had one more go and, this time, blood shot up the needle on to the drapes. There was a problem, though: the blood was not blue and sluggish, but bright red and pulsating vigorously. This was not the subclavian vein, but the subclavian artery. This is bad news: like the vein, the artery is tucked behind the collarbone and quite deep. Being an artery, the blood within it is at high pressure. Being behind the collarbone, it is difficult to stop it bleeding, because direct manual pressure on it is impossible. Nevertheless, the doctor tried. He quickly withdrew the needle and applied a big wad of swabs above and below the collarbone, pressed quite hard and waited. The patient complained bitterly about the pressure and was given painkillers. After half an hour or so, the doctor removed the swabs and everyone was relieved to see that there was no further bleeding from the artery. He then went on to look for the vein again and, after a few more punctures, eventually found it. He inserted the Swan-Ganz catheter successfully. The patient, meanwhile, was not at all happy: she was complaining bitterly of a sore right arm and was given even more painkillers.

At the end of the procedure, which had taken nearly two hours, the drapes were removed and the assembled doctors and nurses were greeted by the most unwelcome sight of her right arm: it was white and, when touched, very cold. No wonder she was complaining of pain: her arm had lost its blood supply. Clearly, the interference with the subclavian artery and the pressure applied to it had caused a clot to form. The clot had completely blocked the subclavian artery and she was now being threatened with the loss of her right arm altogether. There was nothing for it but to request an emergency vascular surgery ‘consult’.

The vascular surgeons came, readily agreed with the diagnosis and recommended doing an emergency ‘embolectomy’ — or in plain language, clot removal — in the hope of restoring blood flow to the arm, while it was still viable. She was immediately taken to the operating room and put to sleep. The vascular surgeons then made an incision in the hollow of the arm at the elbow, found the brachial artery (the arm artery that continues from the subclavian artery), put slings around it and opened it. They then threaded another catheter with a deflated balloon at its tip all the way up to reach the subclavian artery. Once they felt they had passed the site of the puncture and the clot, they inflated the balloon and slowly withdrew it, bringing out a sizeable sausage of clot. They closed the hole in the brachial artery and stitched up the wound. When the drapes were removed, the arm, hand and fingers were a healthy pink colour and alive again. After celebrating their success and cleverness, they sent her back to the ICU.

The following morning the ICU doctors switched off her sedation and she began to wake up. To everybody’s horror, it became quickly apparent that she was simply unable to move any part of the left side of her body. She had suffered a massive stroke. What had happened was this: the attempt to withdraw the clot was only partly successful: most of the clot came out as planned, but a fragment of it was pushed back by the manipulations. ‘Back’ from the subclavian artery is the origin of the right carotid artery, which supplies the right side of the brain, and that is where the clot went. The right brain controls the left body, hence the left-sided paralysis. The hapless woman was still in ICU when I left to return to England at the end of my two-month stint, and I do not know if she survived her medical misadventures, and if so, what kind of a life she had afterwards.

And the Swan-Ganz? It had shown no heart failure, so all she had needed was antibiotics. Having added diuretics to that would have cost an extra dime or two.

The remarkable feature in this story is that such a complication would never have taken place in a National Health Service hospital in the UK, where treatment decisions are often guided by pragmatism and with an eye on the likely costs and invasiveness of procedures. Let me now tell you a bit about the NHS, because it is truly an amazing organisation, despite the constant scare stories and negative media coverage that it receives on a weekly and sometimes even daily basis. In fact, if you are a reader of the Daily Mail and one or two other newspapers, you could be forgiven for thinking that the NHS is a dysfunctional and decrepit system populated by careless and incompetent staff hell-bent on doing harm to patients. Nothing could be further from the truth. Of course, mistakes are sometimes made, and of course awful things happen every now and then. As in most large organisations, there are a few ‘bad apples’. There are people who are not up to the job, lazy workers and others who simply do not care enough about the quality of service that they deliver, but, by and large, these are the minority, and probably a smaller minority than that which exists in many other large organisations, be they public or private.

The NHS delivers a pretty good standard of health care from cradle to grave without requiring any significant form of payment from the user at the point of care, and it does so very well. Everything from the contraceptive pill to a coronary bypass is available to you and you do not have to prove an ability to pay before being treated, which means that, if you are suddenly taken ill, you can go to the Accident and Emergency Department without your wallet or credit card. Most of the workers in the NHS are salaried and are not paid by procedure or by item of service. Because of that, unnecessary treatment rarely takes place in the NHS. Compare that with the United States — where everything done to a patient can potentially bring hard cash to the doctor that does it and to the hospital that provides the setting — and you can see the direct and unrelenting monetary pressure to do something rather than to do nothing. Add to that pressure the ever-present fear of litigation in case something is missed or not acted upon immediately and you can understand the irresistible drive to over-investigate and over-treat, which can so easily lead to catastrophes like the one I witnessed in Connecticut. Most investigations carry some risk, even if that risk is merely a small amount of unnecessary radiation, but the risk of over-investigating does not stop there.

There is an apt aphorism in medical investigations: ‘Nobody is normal: they just have not had enough tests.’ If you subject yourself to every conceivable blood test, ultrasound, X-ray, magnetic scan, nuclear scan, endoscopy, electrical recording, swab, smear and scrape, then something is invariably bound to be unearthed and found to be abnormal, even if you are perfectly happy and healthy.

What is even worse than the above is the fact that, whenever a test is carried out, there is always a possibility that it can actually identify as wrong something which may not be wrong — and it may miss something which is not right. When a test shows that ‘something is wrong’ which isn’t, that is called a ‘false positive’. Similarly, a test missing something wrong which is actually there is called a ‘false negative’. False negatives, apart from the inherent risk of the test itself, are no worse than not having the test done at all, but false positives — even when the risk of the test itself is small or non-existent (such as ultrasound or magnetic resonance imaging) — inevitably lead to additional tests, interventions and operations to sort out the thing thought to be wrong, but which was not there in the first place, and the size of the risk begins to pile up alarmingly. That is why screening can be bad for you.

Liam Hughes, the Norwich cardiologist who referred Emma Chapman, was once discussing a patient who had gone through a very large number of increasingly invasive procedures, because of some probably benign finding picked up at a heart-screening test. After listening to the case being presented, he declared that in his opinion the patient was a VOMIT. We all looked at him, perplexed. He then explained that he had coined the term to describe patients who were ‘Victims of Medical Investigation Technology’. The NHS, in comparison with the health-care systems of other prosperous countries, is a conservative system with relatively little in the way of VOMIT. Much of the rest of the world sees NHS care delivery as rather slow, not sufficiently proactive and with a tendency to under-investigate and under-treat. This may well be true, but at least events like those that befell that poor old lady in my US student elective do not often happen here.

The other remarkable thing about the NHS is its staff: there is a degree of pride in the professionalism of all NHS staff, be they nurses, doctors or paramedical professionals. Most NHS workers stay to finish the job without clock-watching. They generally work much harder and longer than they are paid to do. They feel a duty towards their patients that few service providers have towards their customers, and they gain enormous satisfaction from doing a good job and doing it well. The sense of duty that we have towards our patients sometimes borders on the ridiculous: most NHS heart surgeons that I know are on call for their own patients 24 hours a day, seven days a week. They do not hand over their patients’ care, except when they are physically out of the country, and even then, they will call often to check on their patients’ progress and have input into their management from all corners of the globe. Of course, the ubiquitous roaming mobile phone has made that task even simpler, and we are now almost never ‘off duty’.

A few years ago I was asked to speak at a conference in Sydney. I was there for only three days, which passed in a blur of jet lag. One of my lifetime ambitions was to sail under the Sydney Harbour Bridge and, as I was talking about that with other delegates, one Australian anaesthetist said he had a big yacht moored nearby in the harbour area and asked, ‘Would you like to do that tomorrow?’ Thus it was that on a gloriously sunny day, with a gentle wind propelling us past the Opera House, he handed me the helm of his beautiful 50-foot sailing yacht, and we slowly approached the bridge. Just as we were passing under it, my mobile phone rang: ‘Hi, Mr Nashef. It’s Dr X from Papworth. Mrs Brown’s leg wound looks much better now. Can she go home tomorrow?’

Despite its monolithic and unwieldy nature, the NHS somehow brings out in its staff a level of dedication to duty that is second to none, and if the NHS is truly the jewel in the crown of the British way of doing things, then my hospital is the jewel in the crown of the NHS. So now, let me tell you a bit about Papworth. Its physical location and appearance could not be less impressive: it is housed in a randomly scattered group of low-rise buildings, a ramshackle arrangement of old Victorian, red-brick structures interspersed with all shapes, sizes and colours of prefabricated Portakabins and the occasional, slightly more modern, functional, purpose-built block. A narrow road with frequent and vicious speed bumps snakes through it, and at one edge of its grounds is the famous duck pond, home to a variety of ducks and coots, the occasional black swan, some large carp and a regular visiting heron, who presumably feasts on them. The hospital is in a little Cambridgeshire village, which started life as a small residential community containing the headquarters of a Trust that looks after many disabled people and offers them employment and support. The hospital itself and the village within which it resides are so underwhelming that on my first visit (to be interviewed for the job of consultant surgeon) I arrived, looked around and was absolutely convinced that the taxi driver must have delivered me to the wrong address. And yet, from this unpropitious setting, some of the most amazing, world-leading developments in heart surgery have emerged over the past three decades.

This hospital, housed in buildings which look barely fit for a Third World nursing home, carries out more than 2,000 major open heart operations per year, the largest number by far of any heart surgery unit in the UK, with risk-adjusted results that are a ‘positive outlier’, which means the survival rate is statistically better than the nation’s average, despite operating on the sickest and oldest patients in the country. On top of that, there is an operation called pulmonary thrombo-endarterectomy (or PTE) — developed mostly in San Diego in California — to treat patients whose lungs become progressively clogged up by clots flying in from elsewhere in the body. These patients are desperately breathless and will die soon unless their lung arteries are cleared out. It is a laborious, technically demanding and difficult operation, which usually takes all day to complete. Papworth performs more PTEs than any other hospital worldwide, again with excellent survival rates. We also do more heart and lung transplants than anywhere else in the UK with similarly excellent survival rates.

We have no formal academic or professorial departments and the overwhelming majority of our doctors are full-time jobbing clinicians. Despite that, we produce an astonishing amount of research relating to medicine and surgery of the heart and lungs, and have the best training programme in the country, if not the world, for aspiring heart surgeons. We have a string of firsts, including the first successful heart transplant in the UK, the first successful heart-lung transplant in Europe, the first minimally invasive coronary bypass in the UK and many others.

In short, this is a very good hospital, worthy of nurture and support. And yet it does not receive the support and help it needs to develop and expand. After decades of trying to rebuild the hospital so that we have decent facilities, we are now finally moving to a new hospital in Cambridge. You would have thought that, having proven our worth to the nation’s health service, and having produced, against all odds, such fantastic outcomes from so inauspicious a setting and for so long a time, the Department of Health would have provided us with a generous capital investment to build a state-of-the-art facility from which we could continue to serve and improve. Sadly not. We are largely funding the building ourselves, through a Private Finance Initiative. The new design is indeed a very pretty structure, but, unfortunately, not big enough for the work that we do, want to do, and need to do to secure the income to pay for it. The new building is all we could afford and many compromises have had to be made. Papworth may end up financially broke, and if the austerity drive that is curtailing NHS spending continues at this pace, this could happen sooner than we think.

The NHS, as I have said, is a wonderful organisation, but its main problem was always — and still is — a lack of money. For one of the top economies in the world, the UK simply does not spend enough on the health of its citizens. Successive governments of different political persuasions have consistently tried to brush that fact under the carpet, while pretending to improve the health service of the nation by achieving greater ‘efficiency’.

At Papworth we use our operating theatres seven days a week, including Saturdays and Sundays, for routine elective operations. On weekdays, the theatres routinely run till eight o’clock in the evening, and often beyond, with elective surgery. If an emergency operation is needed, we often have to cancel an elective operation to deal with the emergency. Most hospitals manage two major heart operations a day per operating theatre, but we often squeeze in three. The occupancy rates of our intensive care unit hovers around the 100 per cent mark, which means that we frequently have to cancel operations when something unexpected happens and the beds in the intensive care unit are fully occupied. We discharge patients from the intensive care unit as early as humanly possible to make room for the next batch. Sometimes we discharge them a little too early, so that they ‘bounce back’: we have the highest rate of readmission to ICU in the country. Our surgical wards are so full that we often admit patients for major heart surgery on the actual morning of their operation to save on bed occupancy. While these patients are in theatre or ICU their beds get used for other patients in a process called bed-hopping. There is no rattle room anywhere. Members of the clinical staff work very long hours and most of them work far harder and much longer than they are paid to do.

Dear Health Minister: how much more ‘efficient’ would you like us to be?