The Angina Monologues: stories of surgery for broken hearts

THE ANGINA MONOLOGUES

Samer Nashef qualified as a doctor at the University of Bristol in 1980 and is a consultant cardiac surgeon at Papworth Hospital in Cambridge. He is a dedicated teacher and communicator, and is recognised as a world-leading expert on risk and quality in surgical care. He is the author of The Naked Surgeon and a compiler of cryptic crosswords for The Guardian and the Financial Times.

Scribe Publications

2 John St, Clerkenwell, London, WC1N 2ES, United Kingdom

18–20 Edward St, Brunswick, Victoria 3056, Australia

Published by Scribe in 2019

Copyright © Samer Nashef 2019

All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the publishers of this book.

The advice provided in this book has been carefully checked by the author and the publisher. It should not, however, be regarded as a substitute for competent medical advice. Therefore, all information in this book is provided without any warranty or guarantee on the part of the publisher or the author. Neither the author nor the publisher or their representatives shall bear any liability whatsoever for personal injury, property damage, or financial losses.

For the protection of the persons involved, some names, biographical details, and locations have been changed.

The moral right of the author has been asserted.

9781911617785 (UK edition)

9781925713817 (Australian edition)

9781925693416 (e-book)

CiP records for this title are available from the British Library and the National Library of Australia.

scribepublications.co.uk

scribepublications.com.au

Contents

Foreword

1 Conflict of interest

2 Heart surgery for beginners

3 Getting on with it

4 Mild paranoia

5 CABG and how to avoid it

6 An easy cabbage

7 World-class surgery on a shoestring

8 The story of A and H

9 When the pump is broken

10 Sabotage

11 Irony

12 McKlusky’s

13 Will you do the operation, Doctor?

14 Brazilian

15 Keyhole surgery and other novelties

16 This time it’s personal

17 The many forms of Lazarus

18 An accidental fraud

Appendix: My crossword puzzle for Roger Whiting

Acknowledgements

angina

Pronunciation: /anˈdʒʌɪnə/

NOUN

(also angina pectoris /ˈpɛkt(ə)rɪs/)

A condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, owing to an inadequate blood supply to the heart:

‘he had high blood pressure and he suffered from angina’

Latin pectoris ‘of the chest’

Oxford English Dictionary

To all the patients I have been privileged to treat

Foreword

Sometimes even dictionaries can get it wrong.

Angina is not a pain. It is more of a discomfort or pressure, a tightness or weight. And it is not usually severe, but is often accompanied by a feeling of impending doom, which makes you stop whatever it is you are doing in the way of physical exertion until it abates a few minutes later. It is also the Number One symptom that drives heart patients to seek medical help, with Number Two being shortness of breath.

This book relates the real-life stories of patients — with angina and without — who had major open heart operations to fix their cardiac problems. It tells of the triumphs and disasters of heart surgery, of the places where it is done and the professionals who do it, but always with a focus on the people who are at the centre of it all: the patients.

In writing this book I have selected stories that I hope provide a vivid illustration of different heart surgery patients, a wide range of heart conditions and the variety of procedures that a surgeon undertakes. Some of these stories are gory, some are funny and some have happy endings. Some of them have taken place at a time when I was able to put pen to paper (or fingers to keyboard) immediately, and, when that happened, I wrote down the events as they unfolded. Most of the other stories I have selected from memory and I have chosen them because they are memorable. Necessarily, some of these do not have a happy ending and that is precisely the sad reason why they are memorable. The aim of this book is, however, neither to scaremonger nor to sensationalise, but to provide an honest insight into my world. This is of course a world of drama, of life and death. It is also a world in which some of the finest attributes of human nature – inventiveness and resilience – shine most brightly both in the patients and in the people who care for them. Finally, it is a world which actually matters directly to you because, more likely than not, one day, either you or someone you love will need a heart operation. I hope that you will find this insight illuminating as well as interesting.

Few areas of human endeavour are laden with as much drama as heart surgery. With death always a presence and sometimes an immediate threat, the situations faced by patients and those who care for them can be emotional and nerve-wracking. People who deal with such stressful situations often evolve a number of coping mechanisms. Prominent amongst these is a dark and uncompromising sense of humour, one which probably exists in many surgical specialties, particularly those at the sharper end of the field. Some of these humorous and highly irreverent instances appear here, and I should like to apologise in advance if anyone finds such narrative offensive. I believe that I speak for all my colleagues when I say that such dark humour is, to us, merely a way of dealing with what sometimes can be unbearable stress. The fact that laughing in the face of adversity helps us through our working lives in no way diminishes how passionately we care about our patients and our work.

CHAPTER 1

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