Open Heart

one The Ether Dome

THE FINEST OF MARGINS SEPARATES LIFE FROM DEATH, triumph from despair, hope from extinction. A few more dead muscle cells, a fraction more lactic acid in the blood, a little extra swelling of the brain. The Grim Reaper perches on every surgeon's shoulder. Death is always definitive. No second chances.

November 1966. I was age eighteen, a week into my first term as a student at the Charing Cross Hospital Medical School in the center of London. Having been underwhelmed with a slimy piece of lifeless muscle on the dissection table, I was impatient to see a vibrant, beating heart. I learned from a hall porter at the school that heart surgery was done across the road in the hospital on Wednesdays. Look for the Ether Dome, he told me, an antiquated leaden glass dome above the operating theater in the old Charing Cross Hospital. Find the green door on the top floor under the eaves where nobody goes. But don't get caught. Pre-clinical students were not allowed up there.

It was late in the afternoon and already dark. Drizzle was falling on the Strand. I set out to find this hidden viewing spot. Not since my entrance interview had I entered the hallowed portals of the hospital itself. We students had to earn that privilege by passing exams in anatomy, physiology, and biochemistry. So I walked quickly by the Grecian portico of the main entrance. I sneaked in through the Casualty (or Emergency) Department, under the blue light, and found an elevator—a rickety old cage used to take equipment and bodies from the wards to the basement. Inconspicuous enough.

I worried that I would be too late, that the operation would be finished. But to my delight the green door was still unlocked. Behind it, a dark, dusty corridor. Unchanged for one hundred years or more. This was a depository for obsolete anesthetic machines and discarded surgical instruments. Ten yards away I could see the glow of the operating lights beneath the dome itself. It was an old operating theater viewing gallery respectfully separated by glass from the drama below. My hand found a handrail and I lowered myself onto one of the curved wooden benches worn smooth by the restless backsides of would-be surgeons. I found myself no more than ten feet above the operating table.

I sat quietly clutching the handrail and peered through glass hazy with condensation. As the porter had promised, it was a heart operation. The chest was still open. I shifted to find the best view and settled directly above the surgeon's head. He was famous—at least in our medical school. Tall, slim, and imposing, with long fingers. In the 1960s, heart surgery was still relatively new, and its practitioners were in short supply. Few had been properly trained in the specialty. Often they were skilled general surgeons who had visited one of the pioneering heart centers, then volunteered to start a new program at their home institution. There was a steep learning curve, the cost measured in human life.

The two surgical assistants and the scrub nurse were huddled over the gaping wound, frantically shuttling instruments between them. I squinted, trying to get a closer look. And there it was, the focus of their attention and my fascination. A beating human heart. More squirming than beating. Still attached by cannulas and tubing to the heart-lung machine. Cylindrical discs were spinning through a trough of blood bathed in oxygen. A crude roller pump squeezed the tubes and accelerated this life blood back to the body. I could only see the heart. The rest of the patient was covered by green drapes and therefore anonymous, a relief to all concerned.

The surgeon restlessly shifted his weight from boot to boot, those big white operating boots that surgeons used to wear to keep blood off their socks. On the wall behind me I spotted a box labeled "Intercom." I threw the switch. Now the drama had a sound track. I learned that they had replaced the patient's mitral valve, but the heart was struggling to separate from the bypass machine. This was the first time I had seen a beating human heart, but even to me it looked feeble. Blown up like a balloon, pulsating but not pumping. Against the din of amplified background noise, I heard the surgeon say, "Let's give it one last go. Increase the adrenaline. Ventilate, and let's try to come off."

There was silence as everyone watched the desperate organ fight for its life.

"There's air in the right coronary," the first assistant said. "Give me an air needle." He shoved the needle into the aorta. Frothy blood fizzed into the wound. The blood pressure started to improve. Sensing the window of opportunity, the surgeon turned to the perfusionist—the specialist responsible for the heart-lung machine—and said, "Come off now! This is our last chance."

"Off bypass," came the tentative reply.

The heart-lung machine was switched off. The heart was now free-standing. Left ventricle pumping blood to the body, right ventricle to the lungs. Both struggling. The anesthetist stared hopefully at the screen, watching the jagged lines indicating blood pressure and heart rate. Understanding that this was the last attempt, the surgeons silently withdrew the cannulas from the heart and sewed up the holes. All willing it to get stronger. For a while it fluttered feebly, but the pressure drifted down. There was bleeding somewhere. Not torrential but persistent. Somewhere at the back. Somewhere inaccessible.

Lifting the heart caused it to fibrillate. It was now squirming, not contracting. Wriggling like a bag of worms. Incoordinate electrical activity. Wasted energy. It took the anesthetist a while to spot this on his screen. "VF," he shouted. I would learn that it meant ventricular fibrillation. "Shock it." The surgeon already knew. He was holding the defibrillating paddles hard against the heart expectantly. "30 joules"—zap. No change. "Give it 60"—zap. This time it defibrillated but went still, stunned and devoid of electrical activity. Asystole as we call it. Blood continued to fill the chest. The surgeon poked it with a finger. The ventricles responded by contracting. He poked it again and the rhythm returned. "Too slow—give me a syringe of adrenaline." The needle was shoved unceremoniously through the right ventricle into the left. The syringe squirted in clear liquid. Then he massaged the heart with his long fingers to push the powerful stimulant into the coronary arteries.

The grateful heart muscle responded rapidly. Straight out of the textbook, the heart rate accelerated, then the blood pressure soared. The barometer rose. Up and up, dangerously testing the stitches. Then, as if in slow motion, the cannula site in the aorta gave way. Whoosh. The crimson fountain hit the operating lights, sprayed the surgeons, soaked the green drapes. Someone murmured, "Oh shit." An understatement. The battle was lost.

Before a finger could plug the hole, the heart was empty. Rivulets of blood streamed across the white marble floor and dripped from the lights overhead. Rubber soles stuck to it. The anesthetist frantically squeezed bags of blood into the veins, but to no avail. Life ebbed away. As the injected slug of adrenaline wore off, the turgid heart simply blew up like a balloon and stopped. Stopped for good.

The surgeons stood silent. Despairing as they did week after week. Now the senior surgeon walked out of my view. The anesthetist turned off the ventilator and waited for the electrocardiogram (ECG) to flatline. He removed the tube from the patient's windpipe. Then he left. The brain was already dead.

Just yards away, mist descended on the Strand. Commuters rushed into Charing Cross Station to avoid the rain. Late lunches were finishing at Simpson's and Rules. Cocktails were shaken in the Waldorf and the Savoy. That was life, this was death. A lonely death on the operating table. No more pain, no more breathlessness, no more anything.

The perfusionist wheeled out his machine. It would take hours to disassemble, clean, restore, and sterilize for the next patient. Only the scrub nurse lingered. Then she was joined by the anesthetic nurse who had comforted the patient in the anteroom. They took off their masks and stared at the body. Unconcerned by the sticky blood that covered every surface. Unconcerned by the chest still splinted open. The anesthetic nurse searched for the patient's hand beneath the drapes and held it. The scrub nurse pulled away the blood-soaked covering from the face and stroked it. I could see it was a young woman.

They were oblivious to the fact that I was watching from above. No one had seen me there. I gingerly shifted along the bench to look at the patient's face. The eyes were wide open, staring into the dome. She was ashen white but still beautiful. Fine cheekbones and jet-black hair.

Like the nurses, I couldn't leave. I needed to know what happened next. They peeled back the bloodied drapes from her naked body. My brain was screaming for them to take out that hideous metal retractor cranking open her breastbone. Let her heart go back where it belongs. They did. The ribs recoiled and the poor lifeless organ was covered again. It lay flat, empty and defeated in its own space, now just a fearsome deep gash separated her tender, swollen breasts.

The intercom was still switched on. The nurses started to talk. "What will happen to her baby?"

"Adopted, I guess. She wasn't married. Her parents were killed in the Blitz."

"Where did she live?"

"Whitechapel. I think maybe the London don't do heart surgery yet. She got really sick during the pregnancy. Rheumatic fever. She nearly died during the delivery. Might have been for the best."

"Where is the baby now?"

"On the ward, I think. Matron will have to deal with it."

This was so matter of fact. A young woman had died. Her baby left without a relative in the world. No more love. No more warmth. Gone amid that tangled blood-soaked technology in the operating theater. This was what I aspired to. Was I ready?

Two student nurses came to wash the body. I recognized them from the Friday night freshers dance. They were respectful public schoolgirls. They brought a bucket of soapy water with sponges and set about scrubbing the body. They removed all of the tubing but were visibly upset by the wound and what lay beneath. Blood kept dripping out of it. "What did she have done?" said the girl I had danced with. "Heart operation, obviously," came the reply. "Valve replacement, I guess. Poor kid. She's only our age. Bet her mum's upset." They covered the wound with gauze and tape to soak up the fluid.

The scrub nurse returned and called back the surgical resident to close over the wound before the move to the mortuary. All deaths on the operating table are referred to the coroner for autopsy. She would be sliced open again, so there was no point in closing the breastbone or bringing together the different layers of the chest wall. The resident took a big needle and stitched the opening temporarily with thick braid. But the wound edges still gaped and oozed serum.

It was now 6:30 p.m. I was supposed to be in the pub down the road getting pissed with the rugby team. But something compelled me to stay. I was attached to this empty shell. This skinny corpse I had never met but now felt I knew intimately. I had been with her at the single-most-important event of her life.

The three nurses manhandled her into a starched white shroud with a ruff around the neck. Tied at the back. They then secured her ankles with tape. She was beginning to stiffen with rigor mortis. The students had done their job with kindness and respect. I knew that I would meet them again. Maybe ask them how they felt.

There were just the two of us left. The corpse and me. The operating lights still shone on her face. She was staring straight up. Why hadn't they closed her eyes like they did in the movies? I could see through those dilated pupils to the pain etched on her brain. From the fragments of conversation and with a little medical knowledge, I could evoke her life story. She was in her twenties. Born in the East End. She could only have been a small child when her parents were killed in the bombing. As a child she carries the scars of those sights and sounds. The fear of being alone as her world disintegrates. Brought up in poverty, she develops rheumatic fever. A simple sore throat that triggers a devastating inflammatory process. Rheumatic fever was common in areas of deprivation and overcrowding. Perhaps she had painful swollen joints for a few weeks. What she didn't know was that the same process was happening in her heart valves. There was no diagnostic test in those days.

She develops chronic rheumatic heart disease and is known as a sickly child. Perhaps she develops rheumatic chorea. Involuntary jerky movements, unsteady gait, and emotional turmoil. She gets pregnant. Perhaps that's an occupational hazard. This makes things worse. Her wounded heart must work that much harder. She becomes breathless and swollen but makes it through to term. Maybe the London Hospital delivers her safely but recognizes heart failure. A murmur. A leaking mitral valve. They prescribe the heart drug Digoxin, but she doesn't take it. Soon she is too tired and breathless to look after the baby. She cannot lie flat. With worsening heart failure, her outlook is grim. They send her to the city to see a surgeon. A real gentleman in a morning suit, pinstripe trousers. He is kind and sympathetic. He says only surgery on her mitral valve can help. But it didn't. It terminated her brief, hard life and left another orphan in the East End.

When the porters came, the operating lights were switched off. The mortuary trolley, a tin coffin on wheels, was drawn up alongside the operating table. By now her limbs were rigid. The body was unceremoniously dragged into this human sardine can. Her head bounced with a sickening thud, but nothing could hurt her anymore. I was relieved to lose eye contact. A green woolen blanket was folded over the top of the box to make it resemble an ordinary trolley. Then away they went to put her in the fridge. Her baby would never see her again, would never have a mother again. Welcome to cardiac surgery.

I sat there, arms on the rail, chin on my hands, staring at the black rubber surface of the empty operating table. Staring down from the Ether Dome as generations had before me. The Ether Dome was a gladiatorial arena. People came here to look down on a spectacle of life or death. Perhaps if others had witnessed it alongside me, it might have seemed less brutal. Someone to share the shock of this poor girl's death, the misery for her child.

Auxiliary nurses appeared, with mops and buckets. There to wipe away the last traces. Her blood now dry on the floor. Bloody footprints heading toward the door. Blood on the anesthetic machine, blood on the operating lights. Blood everywhere now meticulously cleaned away. A slip of a girl reaching up to clean the operating light saw me in the dome. My pale face and staring eyes against the gloom. It frightened her. My cue to leave. But one spot of dried blood remained on top of the light where no one could see. Adherent and black. It said, part of me is still here. Remember me. The green door closed behind me and I walked away. Down the shuddering lift where her body had been taken to lie in a cold fridge in the mortuary.

Notices of autopsies were posted on a board in the entrance hall of the medical school. Usually the patients were elderly. Young ones were either drug addicts, road-traffic accidents, suicides from the underground system, or cardiac surgery patients. Friday morning, I found her on the list. She was called Beth. Not Elizabeth, just Beth. She was twenty-six years old. It had to be her.

On the day of the autopsy the bodies were brought from the hospital mortuary in the basement. They were dragged under the road to the medical school in a tin box on rails by a pulley system. Then up the lift to the autopsy room. Should I go? Should I watch her insides and brain be cut out? Watch her dead heart carved into slices? Tell them how she really died, in a crimson fountain?

I couldn't do it.

Beth taught me an important lesson that day in the Ether Dome. Never get involved. Walk away as her surgeons did. Try again tomorrow. Sir Russell Brock, the most renowned British heart surgeon of the era, was known for his bluntness about losing patients. At the Royal Brompton Hospital, he used to say, "I have three patients on my operating list today—I wonder which one will survive." This may seem insensitive, even callous, but to dwell on death was a dreadful mistake. It was then. It still is now. We must learn from failure and try to do better the next time.

To indulge in sorrow or regret brings unsustainable misery. I grappled with this later in my career, when my interests veered toward the sharp end. Specializing in heart surgery for complex congenital anomalies in babies and young children, I daily walked the tightrope between the beginning and the end of life. Some patients came toddling happily into the hospital, teddy bear in one hand, mummy holding the other. Blue lips, little chest heaving, blood as thick as honey. They had never known a different life. I strived to provide that for them. To make them pink and energetic. In good faith, yet sometimes without success. What could I do? Sit with the weeping parents in a dark mortuary, holding a cold, lifeless hand? Blaming myself for taking that risk? All heart surgery is a risk. Those of us who do it don't look back. We move on to the next. Always expecting the outcome to be better. Never doubting it.

two Humble Beginnings

JULY 27, 1948. IT WAS THE POSTWAR BABY BOOM. AT 6:30 IN the morning, I arrived at the Maternity Department of Scunthorpe War Memorial Hospital, wailing from the depths of my newly expanded lungs.

My mother brought me safely back from the carnage of the delivery suite. Bleeding and exhausted after a long and painful labor, but happy to finally meet her first child. A pink, robust son, star sign Leo.

My mother was an intelligent woman, caring and gentle, well-liked. During the war she had managed a small business-district bank, and even with other assistants freely available, the old folks would still queue to tell her their troubles. My father joined the Royal Air Force at sixteen to fight the Germans. After the war, he got a job in the local co-op's grocery department and worked hard to improve our circumstances. Scunthorpe was a deprived and grimy steel town some two hundred miles north of London. The poor man's Pittsburgh.

Life wasn't easy. We were church-mouse poor in a grimy public-housing complex. House number thirteen. No pictures allowed on the walls in case the plaster crumbled. We had a corrugated tin air-raid shelter in the backyard 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 in the steel rolling mills but during the war had been the local air-raid warden. On payday I would accompany him to the steelworks to collect his wages. I was intrigued by the spectacle of white-hot molten metal pouring into ingots. Sweaty, bare-chested men in flat caps stoked the furnaces, steam trains belched fire, clanking up and down between the rolling mills and the slag heaps, sparks flying everywhere.

Grandfather patiently taught me to draw and paint. He would sit over me, puffing away on his favorite Woodbines as I painted red night skies over the chimneys, street lamps, and railway trains. There were no golden sunsets in Scunthorpe, but when the blast furnaces opened at night, the whole sky lit up. Grandfather smoked twenty cigarettes a day and spent his whole life working in smoke. It wasn't the best recipe for a long and healthy life, but no one knew that then.

In 1955, we got our first television set. A ten-inch-square box, with a grainy black-and-white picture and just one channel, the BBC. Television dramatically increased my awareness of the outside world. That year two Cambridge scientists, James Watson and Francis Crick, described the molecular structure of DNA. In Oxford, the physician Richard Doll linked smoking with lung cancer. Then came exciting news that would shape the rest of my life. Surgeons in America had closed a hole in the heart with a new machine. They called it the heart-lung machine because it took over the functions of both. The program was called Your Life in Their Hands. The doctors on the television wore long white coats down to the floor. The nurses had fine starched uniforms, white caps, and rarely spoke. The patients sat stiffly at attention with their bedsheets folded back. Politely grateful for our new National Health Service (NHS).

The show described heart operations in the United States and revealed that surgeons at the Hammersmith Hospital in London would attempt one soon. They, too, would close holes in the heart. This seven-year-old street kid was captivated. Right then I decided that I would be a heart surgeon.

At age ten I passed the tests for entry to the local grammar school. By now I was focused on my goal of becoming one of those white-coated doctors. As one of the "promising" set, I was forced to work hard. I loved art, but I had to stop those classes in favor of academic subjects. But one thing was clear: I was good with my hands. My fingertips connected with my brain.

One afternoon after school, I was out walking with Grandfather and Whisky, his Highland terrier, on the outskirts of town when he stopped short on a hill and began clutching the collar of his shirt. His head bowed and his skin drained of color. Sweating and breathless, he sank to the ground. He couldn't speak. I could see 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 held his head until the pain abated. It lasted thirty minutes, and once he'd recovered we slowly made for home.

My grandfather's ill health wasn't news to my mother. She told me that he had been getting a lot of "indigestion" while cycling to work. Reluctantly, he 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 would climb the stairs, gasping for breath. Cold was bad for his chest, so the old iron bed was brought down and put in front of the fire, the commode brought inside to save a journey outdoors.