CHAPTER 14
Brazilian
There are precious few advantages to getting old in any walk of life, and that also applies to surgery. Age brings with it bad backs and sore necks, eyesight that is less sharp and a rising intolerance of standing for hours on end at an operating table. One advantage of the passing decades, however, is the multiple opportunities, over several years, of becoming an increasingly ‘senior’ surgeon, to arrange one’s professional timetable in a way that is a little more conducive to leading something of a normal social life. An essential part of such normality is to have at least some down time at weekends. To achieve that, one has to reduce as much as possible the likelihood of being disturbed by the sort of clinical problems which necessitate a return to the hospital or, even worse, a return to the operating theatre. Over the years I have gradually managed to ‘front-load’ my working week with a lot of operations done on Mondays and Tuesdays, so that most of the inevitable problems that follow major heart surgery have already happened, been dealt with and sorted by the time the weekend arrives.
Despite that, we, as a group of surgeons, all try to use every available operating theatre space on every single working day, and even also at weekends. This is partly to give timely treatment to our patients and to reduce the time that they spend on waiting lists, but also to maximise the efficiency of our service by not having operating theatres stand idle. This means that when some of us are away on leave, the others who are here tend to take over and use their empty operating slots whenever possible. I am always more than willing to take Wednesday morning slots and will often accept Thursday slots, but my enthusiasm wanes when it comes to operating on Fridays. This is for the purely selfish reason that a Friday operation is more likely to disrupt my weekend.
When the surgical patient booking officer called to offer me a Friday afternoon operating slot in a week’s time, I was not at all keen. The booking officer explained that she had tried all the other surgeons and none would take this particular slot for a variety of reasons, at least one of which may have been related to its timing at the very end of the working week. I hated operating on Friday afternoon, but I hated the idea of an operating slot lying fallow even more. I had already arranged to go out to dinner with my partner Fran that night, so I reluctantly agreed to operate, but asked her to find a straightforward patient from my waiting list who was having a low-risk, elective, two-to-three-hour operation to be brought in. The booking officer identified a healthy young man on my waiting list who just needed his aortic valve replaced. I readily agreed that he would be eminently suitable.
Unfortunately, the booking office omitted a rather important detail: the young man himself was not informed. When he did not turn up as expected at eight o’clock on Friday morning, somebody telephoned him and it was quickly apparent that he had no idea whatsoever that we had scheduled him for surgery. He had already made other plans for the weekend, which were not at all compatible with having a heart operation at a moment’s notice. He politely declined our offer of surgery that afternoon. The booking office called me on Friday morning to explain the fiasco. My immediate response was that I had done my best to ‘fill the slot’ and that, for once, we could perhaps live with an unused theatre slot at Papworth. But the booking officer informed me that there were several patients in scattered beds around the hospital awaiting urgent surgery, that there was no space for them in the operating theatre for the foreseeable future, and that it would be so, so helpful if I at least operated on one of them that day.
‘Fine,’ I replied, ‘but only the most straightforward case.’
She called again an hour later. She had indeed identified the most straightforward case, but it was not the most urgent. That distinction belonged to an 80-year-old man who had come in with a heart attack, had a weak heart and very severe coronary disease. What’s more, he was having dreadful angina just lying in his bed, and that means he was heading for another heart attack. Would I please at least just take a look at him? Please?
The pressure was mounting. Feeling a little less than enthusiastic, I went to see the patient. He was as described, having recently had a heart attack and given an angiogram which showed critical and dangerous coronary disease. He would need all of five coronary artery bypass grafts to sort him out, and if this was not done soon there was a real risk he would not last the weekend. What’s more, he was a really nice man with a charming and supportive family round his bed. I know that these factors should not influence clinical decisions, but they undoubtedly do. I agreed to go ahead that Friday afternoon. I informed the registrar who was allocated to me that there was no chance of her actually doing the case: the patient was old and sick and needed too many grafts for a trainee to do it, I declared. I did not declare that I also had a vested interest in finishing the operation quickly, so as to make it in time for dinner.
After some delay, which is not unusual when operating lists are changed at the last minute, the patient was brought to the anaesthetic room and put to sleep by one of the senior anaesthetists. He was wheeled in to the operating theatre and, unusually for me, I was already scrubbed and I started the operation myself right at the beginning. More often, I allow my registrar to open the chest and prepare the connections to the heart-lung machine and I only saunter into the operating room when all that has been done and the vital part of the operation is about to begin, but this time I was in a hurry. I cut the skin with a scalpel and cauterised all the tissues to the breastbone. I then sawed through the bone with a power saw from bottom to top and the chest was opened. I placed a retractor which raises the left half of the breastbone to expose the mammary artery which lies on its inner surface. With a forceps and cautery, I dissected this artery out until it fell off its attachment to the chest wall and lay free, ready to be joined to the left anterior descending coronary artery (or LAD), which is the most important bypass target.
There is something strange about the left internal mammary artery (or LIMA). It leaves the subclavian artery just behind the collarbone and travels inside the chest and just in front of the heart alongside the left edge of the breastbone, all the way down to the diaphragm between chest and belly, where it divides into small and somewhat insignificant branches. It was first used as a bypass graft in 1964 by a pioneering and visionary Russian heart surgeon called V. I. Kolesov, who joined it to the all-important LAD on the front of the heart. After many years of being ignored by surgeons in the West, the LIMA has finally gained its rightful pride of the place as the best tube there is to bypass the LAD, and for very good reasons, too. It’s these reasons that are a bit strange.
Whenever we do a CABG, if the LAD needs a bypass we almost always choose the LIMA as the bypass tube. This is because of the following:
When you read all of the above, it is tempting — especially if you are a creationist — to take the existence of the LIMA as proof of the existence of God: you could easily argue that the LIMA was intelligently designed to serve as a bypass graft to the LAD, since it fulfils that function so incredibly well. Perhaps it was put there just so that my surgical colleagues and I can make use of it in coronary bypass. (If you are an atheist, don’t worry, as you could also argue that a far easier and more intelligent piece of design to solve the problem of atheroma in the coronaries would be for us not to get atheroma in the first place. You would, of course, be right.)
The rest of the bypass grafts would be built using veins from the leg, a good option, but nowhere nearly as good as the LIMA to the LAD. Essack, one of our surgical care practitioners, was harvesting these veins at the same time as I was preparing the internal mammary artery. I then opened the pericardium and looked at the heart. It was covered in bright yellow fat and was beating somewhat sluggishly and not too elegantly, but it was an 80-year-old heart, after all.
I placed the pipes in the aorta and right atrium to connect the patient to the heart-lung machine, and asked Essack if the vein from the leg was ready for use. He said it was, and I said, loudly and clearly, ‘On bypass, please.’
The perfusionist started the heart-lung machine. Blood flowed from the right atrium into the machine and came back, oxygen-rich, into the aorta. The anaesthetist switched off the lungs. I had a quick look around the heart and identified where in the coronary artery network the five bypass grafts were going to be attached, and then applied the clamp to the aorta, isolating the heart from the circulation. I gave the protecting potassium solution to cool the heart and make it stand still while it received no blood supply. I took the piece of vein from the leg and joined it to the first coronary artery to be bypassed, using a very fine polypropylene suture. I gave some more potassium solution down the graft to ensure that it had good flow, and that there were no leaking points at the join. I then trimmed the vein to the right length and did the second join, then the third and fourth. Four coronary arteries now had four ends of pieces of vein joined to them beyond the blockages, but the other ends were still lying free.
Finally, I joined the end of the mammary artery to the LAD. The part of the operation that required isolating the heart from the circulation was now over, so I removed the clamp. Blood flowed down the patient’s own coronary arteries, washed away the potassium solution and, slowly, the heart began to beat again.
All that was left to do now was to connect the four pieces of vein to the aorta, and the bypass operation would be complete. For that, we apply a partial clamp on to a bit of aorta to allow us to work without blocking the aorta completely. I applied the clamp, did the necessary stitching and the four vein grafts were now functional. The entire procedure on the heart itself had taken 78 minutes and it had been a good and slick operation. The anaesthetist switched the lungs back on and ‘Off bypass, please,’ I asked. The perfusionist stopped the heart-lung machine and the heart took over its old job with no difficulty whatsoever. Just a bit of ‘tidying up’, placing drains and pacing wires and we would be ready to close. I felt virtuous because I had given the patient a timely and possibly life-saving operation and selfishly pleased for having done this so quickly that I would be able to make my dinner date.
Life was good.
Just as I was about to begin closing the chest, there suddenly appeared to be a lot of bright red blood. It was coming from one of the joins between leg vein and aorta. ‘I must have botched that join,’ I thought, and irritably asked for a suture to fix it. I was just placing the suture when a second join next to it began to bleed, even more profusely. I stopped. I could not remember having any difficulty with this part of the operation, so why were two of my four joins bleeding so much? While I was busy pondering this, the third and the fourth also started to bleed. Horribly. With all four joins hosing, it was a blood bath. Then illumination dawned. I asked the anaesthetist to insert an echo probe down the patient’s gullet to look at the aorta, and it confirmed my worst fear: there was acute aortic dissection. The layers of the aorta were separating before our very eyes as we were looking at the echo images and the aorta itself. This was a real heart-sinking moment.
Denial. Isolation. Anger. Bargaining. Depression. Acceptance.
There was only one thing for it: back on the heart-lung machine, replace the ascending aorta, and, to add insult to injury, redo the entire four vein joins, since the bit of aorta to which they were attached was now fit only to be discarded. Unfortunately, the heart-lung machine can no longer be connected to the aorta, as the latter is now in shreds, so another artery must be found (and found quickly, since the bleeding was continuing apace and barely controlled by the registrar’s two hands compressing the aorta with large swabs). The most accessible artery for such desperate situations is the femoral artery in the groin. I cut a circle out of the drape overlying the right groin and asked for some surgical prep solution to sterilise the skin. I splashed it on the area, took a scalpel, cut across the groin and proceeded to cauterise some minor skin blood vessels. The patient’s groin went up in flames.
Total panic ensued. The flames were blue and orange and were already beginning to set fire to the surgical drapes in the few seconds it took me to realise what had happened. The prep I had used was 70 per cent alcohol, not one that we would normally go for when cautery is being actively used, but I had stupidly neglected to check the solution and, with massive haemorrhage at the chest end, I was in too much of a rush to wait for the alcohol to dry. The flames were almost reaching the theatre operating light before we finally managed to extinguish the blaze by smothering it using whatever was available in the vicinity, including sterile swabs and towels and the surrounding surgical drape material.
With the incendiary crisis over, I carried on. I found the femoral artery, joined a tube to it and we went back on the heart-lung machine. The tattered aorta was clamped again, more potassium was given to stop the heart, and I cut out the ascending aorta. I used surgical glue and Teflon to reconstruct the layers of the aorta at the cut ends, and then sutured a Dacron graft to replace the part I had excised. I finally redid the four vein joins on to the Dacron graft.
The original operation had taken 78 minutes on the heart-lung machine, during which the heart was isolated for a mere 45 minutes. Repairing the aortic dissection had taken 200 minutes on the heart-lung machine, during which the heart was isolated for a whole 80 minutes — and the poor old heart, after all this abuse, understandably somewhat struggled to take over the circulation this time. It finally managed to support the circulation with the help of some drugs and ‘tincture of time’, but the restaurant to which we were going for dinner had long closed by the time I was able to leave the hospital.
The following day, the patient was making excellent progress, and the entire surgical team and I were delighted with this amazing ‘save’. The hospital management, however, was less than delighted, and did not see things the same way we did. As far as the managers were concerned, the singular and most salient feature of the entire episode was that one of their senior, experienced surgeons had set a patient on fire, and that would simply not do at all.
In March of 2015 the NHS published a list of ‘Never Events’. These are things that the NHS considers should never happen in health care, and quite rightly so. They include horrendous and unthinkable incidents, such as ‘Never Event Number 1: Operating on the Wrong Site’ — for example, taking out the healthy kidney and leaving the diseased one, or doing the right operation but on the wrong patient. These highly unlikely catastrophes do happen in health care, albeit very rarely, and when they do, thorough investigations are conducted and heads may roll. Interestingly, the ‘Never Events’ list also includes ‘Never Event Number 10: Falls from Poorly Restricted Windows’ (see Chapter 4). The relevant item here, however, is ‘Never Event Number 14’. It is ‘Scalding of Patients’ and is defined as the patient being scalded by water used for washing or bathing, but this specifically excludes scalds from water being used for purposes other than washing or bathing (such as from kettles or teapots). I tried very hard to convince our clinical governance team that my setting fire to the patient did not really qualify as a ‘Never Event’ and was not worthy of a massive investigation, because (a) no water was involved, and (b) nobody was bathing the patient anyway. But this did not go down well with my managerial colleagues and a full investigation was nevertheless carried out, with several recommendations aimed at preventing such an event ever happening in the future. This was, of course, the right thing to do.
In the meantime, the patient himself made a good recovery from both his surgical and incendiary tribulations, and he was bemused, a few days later, to find that he had not a single pubic hair left as a result of the accidental ‘Brazilian’ by flames. We candidly explained the events to him in detail and I pointed out that he could sue us if he wanted to, but he was happy with the end result and took no further action.