The Angina Monologues

Samer Nashef


Conflict of interest

Sometimes, in the words of Bob Geldof, I don’t like Mondays, and yesterday was just such a Monday.

It was the first working day in January after the long Christmas break and, as such, it was something of a shock to the system. Instead of a gentle start, easing back in to work, I had two big operations on the first day. They were both complex, dangerous and challenging.

The first patient was a 47-year-old man. He needed two procedures done on his heart. Neither of the two was particularly challenging in itself, but the combination of them together in one operation was something I had never done before. The first procedure was a pericardiectomy and the second was a mitral valve repair. The first simply means removal of the pericardium or, in plain words, stripping the heart of its outside lining. This lining is normally a smooth and slippery bag, with plenty of room for the heart to move within it, and a little bit of fluid in which the heart can beat freely. This patient’s pericardium was no longer a smooth bag with a bit of fluid. The fluid had long gone as his pericardium had become thickened, scarred and rigid, firmly stuck to the heart within it and shrunken, strangling the heart, as in a straitjacket. This restricted the pumping action of the heart and caused heart failure. The second procedure was to repair his leaky mitral valve in the middle of the heart, which was making his heart failure even worse.

The trouble is that these two conditions do not usually come together and the two operations needed to fix them do not agree with each other. The first should ideally be done without using the heart-lung machine — to reduce the risk of bleeding from the raw area after the lining is stripped off the surface of the heart — and the second simply cannot be done without the heart-lung machine, thus greatly increasing the risk of bleeding from the first. To make matters worse, during the operation there was one bit at the back of the heart where the lining was so calcified and stuck that it proved impossible, despite many attempts, to separate it from the heart muscle without tearing the heart to shreds, so that the heart remained stuck at that point, making access to the mitral valve very difficult. Without being able to see the valve properly, I ended up repairing it mostly by feel. Thankfully, it worked, but this was more by luck than by judgement or skill.

The second patient, a grand, 79-year-old man, was the retired chairman of the board of a nearby hospital. He had sought treatment at Papworth as he was considered neither fit enough nor young enough to have such a complex operation locally. He needed a quadruple heart procedure: an aortic valve replacement, a double coronary bypass, a hole in the heart closed and a ‘maze’ operation to correct an irregular heartbeat. This would be really pushing the limits in a 40-year-old, let alone a patient approaching his eightieth birthday. At his age, nobody would have been unduly surprised if his elderly body struggled to cope with such a heavy surgical assault.

Fortunately, both operations went well. At home, just before going to bed at about midnight, I made one final phone call to the intensive care unit (ICU) to check on the two patients, and was assured that both were stable and progressing well. As I woke up the following Tuesday, the first happy thought that crossed my mind was that there had been no phone calls from the ICU during the night — a good sign!

A bright winter sun was shining in a cloudless sky and I briefly considered riding the motorbike to work. I immediately dismissed the idea as daft as soon as I stepped outside, felt the bitter cold of that January morning and sensibly decided to take the car. Driving the car to work provides the added double advantage of a cup of good black coffee on the way to the hospital and the ability to listen to the Today programme on BBC Radio 4 to catch up with what is happening in the outside world.

On that particular Tuesday morning the Today programme was reporting that Israeli forces had widened their attacks in the Gaza Strip after heavy fighting, with disparate claims and counterclaims by each side in the conflict on the numbers of soldiers and civilians killed. I remembered that, two years previously, I had been asked by a charity to help set up a heart surgery service in the Gaza strip, and I had declined in view of the volatile situation. I had felt a bit of a coward at the time and volunteered my services instead to the much less dangerous West Bank.

I parked the car at the hospital and walked the short distance to my office. This took me along the border of the famous Papworth Hospital duck pond, a circular body of water about 100 metres across with a small island in the centre of it. The pond was now mostly frozen, but the resident ducks were nevertheless still quacking happily, despite being confined to a small crescent of still liquid but near-freezing water towards the edge. At the time, I was the Chair of the consultants’ committee at Papworth Hospital and, a few years previously at one of our monthly meetings, one consultant colleague, who was a chest physician, had asked a pertinent question about whether the duck pond posed an infection risk to our chest and transplant patients. I referred the matter to the consultant microbiologist. She then stood up and addressed the assembled group: ‘Who here wants to keep the duck pond?’ All hands went up. ‘In that case,’ she continued, ‘do not ever ask me that question again!’

I walked into my office, which had a large window providing a fine view of the said duck pond, switched on my three computers. I used three in those days for the simple reason that information technology in the NHS is relatively slow and the machines are out-dated. This means that every command takes a machine a few seconds at least to deliver the goods. With three computers, while one of them is thinking about opening a file, I can move on to the next to do something else. Even a few seconds saved here and there will help in making me more efficient. One computer is my clinical patient database exclusively. One allows me to see all the images of medical investigations. The third is for email and everything else (including crosswords). Since then, things have moved on, but not, sadly, the quality of the computers. I now use four.

I reviewed the tests on the day’s patients in preparation for surgery, quickly checked for any urgent emails requiring an immediate response and went to change into scrubs. Our male changing room is small, windowless and utterly chaotic. It is stuffed with banks of lockers and its floor is always haphazardly strewn with operating theatre shoes and discarded scrubs. To make matters worse, somebody in the department must think it funny to empty the rubbish from his pockets into other people’s theatre shoes and I had, in the past, found all manner of detritus in mine. On this occasion I found a pair of disposable scissors, a sweetie wrapper and a slip of paper with the results of a blood test. I removed them and, just before I threw them away in the dustbin, I recognised the name of the person who had requested the blood test – it was one of the ICU nurses on duty the previous night. I wondered briefly about confronting him about this bizarre antisocial behaviour, but promptly forgot all about it.

Before going to the operating theatre I paid a very quick visit to the ICU to see yesterday’s patients. They were both, to my relief, looking very well indeed. The younger man had not bled after all, had made a rapid recovery and was awake and having his breakfast. The older man was still a little drowsy, but looked far better than could have been expected after my massive surgical onslaught on him the previous day, so it was with a light heart and a spring in my step that I went to the operating theatre to start the morning case. It was an operation that is a pure joy to do: a single coronary artery bypass graft (or CABG) in an otherwise fit and healthy patient.

One feature of heart surgery, when compared to some other surgical specialties, is that there is no ‘small fry’: a single coronary bypass is about as close as we heart surgeons can get to a simple, straightforward operation, and even that can be fraught with hazard, although, in comparison with the previous day, this would be a breeze. I resolved to assist Betsy Evans, my then registrar, in performing the procedure and, while she was setting up the case, I went to the theatre dining room for coffee, banter and a glance at the cryptic crossword. It was going to be a good day. The only cloud on the horizon was that I was on call for emergencies but, much of the time, very little happens on that front.

Betsy did a superb job in the single CABG. We were finishing and tidying up in preparation for closing the chest when another registrar came into the operating room. He, too, was on call for emergencies that day, and he informed me that we had just been referred a 39-year-old woman from Norfolk with a confirmed diagnosis of acute aortic dissection. She was already on her way to us from Norwich, some 90 miles away, in an ambulance with the blue lights flashing.

Acute aortic dissection is possibly the only real emergency in heart surgery. Most urgent heart conditions can be made less urgent with drugs and devices, so that the operations needed to fix them can then be carried out in a safer and more-or-less planned manner a day or two later. Acute aortic dissection cannot be treated this way: it demands surgery, and demands it immediately.

This is what happens: the inner lining of the aorta — the biggest artery in the body — is suddenly torn because of weakness or high blood pressure or both. The patient experiences a sudden, searing chest pain that shoots down the back. The pain is so severe that the patient sometimes collapses as a result. Meanwhile, the highly pressurised blood within the aorta is seeping into the tear and advancing between the layers of the wall of the aorta, peeling it off like badly applied wallpaper: in this manner, the blood ‘dissects’ the wall of the aorta. In doing so, it travels backwards towards the heart, where it can disrupt the aortic valve, making it leak. It can also shear off the coronary arteries, producing a heart attack; and, travelling forwards, it can threaten to block or disrupt any artery that comes off the aorta, which is, essentially, all of them. The heart, the brain and every single organ in the entire body are put at risk in acute aortic dissection, and on top of all of that, the aorta itself may rupture, causing instant death by massive bleeding. In the first two or three days of acute aortic dissection, the death rate is 1 per cent every hour, so that this is one condition where there is no time to lose.

This particular patient, however, had a further complicating feature: she was 37 weeks pregnant, and with twins.

If yesterday’s patient had an in-built conflict between the best way to approach the lining of his heart and that for his mitral valve, then Nina, the pregnant woman with acute aortic dissection, had a worse conflict, magnified several times. Both of yesterday’s patients, their trials and tribulations and any preoccupation I had over them immediately went out of the window. This situation demanded immediate and intense concentration.

Nina’s best chance of survival would be secured by keeping her blood pressure really low, until an immediate operation repaired her acute aortic dissection. Nina’s twin babies, however, may not survive their mother being put on a heart-lung machine, and they needed continuous good blood pressure to supply the placenta and keep their little bodies going. All three – the mother and her unborn twins – were in grave danger. Whose interests should we put first?

The on-call anaesthetist John Kneeshaw and I hastily arranged a makeshift case conference in a little side room on the ICU. We considered all of the options, and consulted the obstetricians and neonatologists (newborn-baby specialists) at the nearby Addenbrooke’s Hospital in Cambridge. They told us that as far as they were concerned, 37 weeks is not far off a full term in pregnancy, and that they were confident that — if the babies were delivered now — their chances of survival would be excellent. We immediately dismissed the option of inducing a normal labour: the high blood pressure that would be caused by the pain of contractions would almost certainly burst Nina’s damaged aorta. After brief consideration, we also dismissed the option of going ahead with repairing the dissection and letting the babies take their chances of survival: it seemed so unfair when they were able to survive outside the womb already. Only one option remained: a rapid Caesarean section, under general anaesthetic, with immaculate blood pressure control, to be followed by a brief and somewhat impatient wait for the afterbirth and for the womb to shrink down to reduce the risk of massive haemorrhage from the raw area when the heart operation was begun. We worked out that this should delay the heart operation only by an hour or two at the most, an increased risk to Nina’s life of no more than 2 per cent, which we thought was just about acceptable under the circumstances. (I am aware of the brutality of this sentence: a 2 per cent risk to a young woman’s life being seen as ‘acceptable’ is shocking, but that is one dehumanising aspect of having to deal with situations where life is at risk and the best we can do is choose the least risky of several perilous paths.)

The ambulance then arrived. Nina had a rapid assessment, followed by a quick chat to John and me, in which we outlined our plan. She was in dire straits: cold, sweaty and in shock. Her aortic valve had already been disrupted by the dissection and was leaking badly. As a result of the leak, her heart was failing and she was desperately short of breath. She readily agreed to our proposed plan, shakily signed the consent form, and we whisked her into the operating theatre.

The obstetricians from Cambridge came to Papworth, accompanied by the neonatologists with two incubators in tow, ready for the new arrivals. John put her to sleep and set up a combination of powerful intravenous drugs to control her blood pressure, allowing him to tweak it either up or down as required. The obstetricians scrubbed up, carried out the Caesarean section and delivered the babies, who started breathing immediately and looked perfectly ready to face the world. While the obstetricians were sewing up the wound, the babies were brought out of the operating theatre in their respective incubators.

Babies born by Caesarean section do not suffer the trauma of going through the birth canal, so their faces do not become scrunched up and bruised in the process, and they do not acquire the strangely wizened old-person look that many babies have when they first meet the world. Alfie and Evie looked simply gorgeous: a boy and a girl with beautiful, blue, wide-open eyes, breathing comfortably and without a care in the world. I was looking at them in their cots in wonder, when John came out of the operating room. ‘Yeah, they’re really cute, but that’s enough cooing over them,’ he said. ‘Now bloody get in there and make sure they still have a mother.’

The Angina Monologues Samer Nashef