Книга - Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table

Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table
Stephen Westaby


SHORTLISTED FOR THE COSTA BIOGRAPHY PRIZETHE SUNDAY TIMES NO.2 BESTSELLERWINNER OF THE BMA PRESIDENT’S AWARD 2017An incredible memoir from one of the world’s most eminent heart surgeons, recalling some of the most remarkable and poignant cases he’s worked on.Grim Reaper sits on the heart surgeon’s shoulder. A slip of the hand and life ebbs away.The balance between life and death is so delicate, and the heart surgeon walks that rope between the two. In the operating room there is no time for doubt. It is flesh, blood, rib-retractors and pumping the vital organ with your bare hand to squeeze the life back into it. An off-day can have dire consequences – this job has a steep learning curve, and the cost is measured in human life. Cardiac surgery is not for the faint of heart.Professor Stephen Westaby took chances and pushed the boundaries of heart surgery. He saved hundreds of lives over the course of a thirty-five year career and now, in his astounding memoir, Westaby details some of his most remarkable and poignant cases – such as the baby who had suffered multiple heart attacks by six months old, a woman who lived the nightmare of locked-in syndrome, and a man whose life was powered by a battery for eight years.A powerful, important and incredibly moving book, Fragile Lives offers an exceptional insight into the exhilarating and sometimes tragic world of heart surgery, and how it feels to hold someone’s life in your hands.










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copyright (#uf798782c-3c73-51a1-bcb1-d9fe66b548ca)


HarperCollinsPublishers

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First published by HarperCollinsPublishers 2017

FIRST EDITION

© Stephen Westaby 2017

Cover design by Claire Ward © HarperCollinsPublishers Ltd 2017

Cover photograph © Shutterstock.com

Text illustrations © Dee McLean

A catalogue record of this book is available from the British Library

Stephen Westaby asserts the moral right to be identified as the author of this work

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Source ISBN: 9780008196783

Ebook edition: February 2017 ISBN: 9780008196776

Version: 2017-12-02




dedication (#uf798782c-3c73-51a1-bcb1-d9fe66b548ca)


This book is dedicated to my wonderful children Gemma and Mark, and to my granddaughters Alice and Chloe.




contents


Cover (#ue1f124b3-b88e-5d8f-ab6e-bf17b137ae56)

Title Page (#ua9162a1a-6b3b-5171-8170-8847cbeeede8)

Copyright (#u6f005df0-760e-5d4d-81f2-766381339760)

Dedication (#u57042ce7-7bb6-50da-b36c-2a1b8f7dc2f7)

Foreword (#u3d74b20d-6879-5315-91d5-d61629ced5bf)

1 The Ether Dome (#u12c69a43-347c-51a6-9a58-8f2cf916c278)

2 Humble Beginnings (#u571cfb99-420e-5529-a7f2-dfd423e50ced)

3 Lord Brock’s Boots (#u610e5da1-31ad-5770-b9d2-adbd4e8a9303)

4 Township Boy (#u14265480-5989-54a7-b2c0-476e82d506a0)

5 The Girl with No Name (#u34a2ab25-4ecd-518b-8265-d13d760eca7d)

6 The Man with Two Hearts (#u3abfda15-0217-5450-97c4-f65399d7ec7d)

7 Saving Julie’s Heart (#u415ec969-535b-560c-beb1-407ccdf8aaa7)

8 The Black Banana (#u9b771ab1-6d7f-54de-a1e5-d1be0d8cc4f7)

9 Domino Heart (#u0f91aec1-4292-5faf-8feb-fec0ed92f6fa)

10 Life on a Battery (#u87e3a2b7-91ac-5eb1-bb16-3dd363e08e86)

11 Anna’s Story (#uab0e426e-b808-54fe-8b13-cc40b73f4cc7)

12 Mr Clarke (#u710cb486-b601-5661-a09e-09f91fc20dc4)

13 Adrenaline Rush (#u8ee8aae6-f37f-5ed5-b0cb-20dd663786df)

14 Despair (#u344f5dd6-de9c-5f1c-bd03-59f41e843984)

15 Double Jeopardy (#uc255c38c-ee3d-588f-95eb-f120648c967e)

16 Your Life in Their Hands (#u482c7ad8-ae4e-53b2-be1e-aff7070cda19)

Afterword (#u37db3c2f-e785-50b3-813d-425563bc79bd)

Acknowledgements (#u1ad87ec3-857b-5a3b-91af-7575157ab50b)

Glossary (#u84c8a058-07b8-5a30-b311-c8e3e0a73e47)

About the Publisher (#u7553f4be-9f09-5d44-9cf0-8fe91db54dd6)










foreword (#uf798782c-3c73-51a1-bcb1-d9fe66b548ca)


Woody Allen famously said, ‘The brain is my second favourite organ.’ I had the same affinity with the heart. I liked to watch it, stop it, repair it and start it up again, like a mechanic tinkering with an engine beneath the bonnet of a car. When I finally understood how it worked, the rest just followed on. After all, in my younger days I’d been an artist. I simply shifted from brush on canvas to scalpel through human flesh. More hobby than job, and more pleasure than chore, it was simply something I was good at.

My career followed a curiously erratic course, from self-effacing schoolboy to wildly extrovert medical student, from ruthlessly ambitious young doctor to introverted surgical pioneer and teacher. Throughout this journey I was repeatedly asked what I found so compelling about cardiac surgery. I hope the following pages will make that clear.

But before launching into the action let me share with you some facts about this vibrant organ. Every heart is different. Some are fat, some are lean. Some are thick, some are thin. Some are fast, some are slow. Just never the same. Most of the 12,000 that I’ve worked on have been desperately sick, causing misery, crushing chest pain, interminable fatigue and terrifying breathlessness.






What’s so fascinating about the human heart is its movement – the rhythm and efficiency of the thing. The facts are staggering. The heart beats more than 60 times per minute to pump five litres of blood. This adds up to 3,600 beats an hour and 86,400 in 24 hours. It beats more than 31 million times in a year and 2.5 billion times in 80 years. The left and right sides of the heart eject more than 6,000 litres of blood daily to the body and lungs. A truly incredible workload that requires huge amounts of energy. So when the heart fails there are dire consequences. And given this astounding performance how could one conceive of replacing the human heart with a mechanical device? Or even with a dead person’s heart?






My school biology classes taught me that the heart sits in the centre of the chest and has four parts – two collecting chambers, the left and right atria; and two pumping chambers, the left and right ventricles. Textbook diagrams show them side by side, like a house with two bedrooms situated above a sitting room and a kitchen. The spongy, expansible lungs surrounding the heart resemble the roof of a Swiss chalet, and they constantly replenish blood oxygen levels and expel carbon dioxide into the atmosphere. (Most of us also know that other chemicals can be discharged in the breath, notably alcohol when blood levels exceed the liver’s capacity to metabolise it.)

Well-oxygenated blood leaves the lungs to enter the left atrium through four separate veins, two from each side. During the heart’s filling phase, or diastole, blood flows through the mitral valve – named after its likeness to a bishop’s mitre – and into the powerful left ventricle. During ventricular contraction, or systole, the mitral valve closes. The contents of the left ventricle are ejected onwards through the aortic valve into the aorta and around the arteries to the body.

Intriguingly, the right ventricle works in an entirely different way. It’s crescentic in shape and applied to the side of the left ventricle, the part known as the ventricular septum. With this ‘new moon’ shape the right ventricle pumps like bellows. So the ventricles depend on each other. It was that rhythm of the heart that I found captivating, like watching a pianist’s hands or a dancer’s feet.

But is it all really that simple? My mother used to buy sheep hearts from the butcher; inexpensive and tasty enough, and great for dissecting. It was while cutting these up that I discovered that real hearts are more complex and difficult to understand than in textbook diagrams, as the shape and muscular architecture of the two ventricles are completely different. Nor are they left and right – more front and back. The thicker left ventricle is conical in shape and has circular muscle bands that constrict and rotate the chamber. Now we can visualise how the left ventricle really works. As the powerful muscle contracts and thickens, its cavity narrows and shortens. During relaxation – the diastolic phase – the left ventricle recoils and the aortic valve closes. The recoiling cavity widens and lengthens, sucking blood from the atrium into the ventricle through the mitral valve. Thus every coordinated cycle of contraction and relaxation involves narrowing, twisting and shortening, followed by widening, uncoiling and lengthening. A veritable Argentine tango … but with two important differences: the whole process takes less than one second and the dance goes on forever.

Every cell in the body needs ‘life blood’ and oxygen; in the absence of these the tissues die at different rates, brain first, bone last. It all depends upon how much oxygen each cell needs. When the heart stops, the brain and nervous system are damaged in less than five minutes. Brain death ensues.

Now you are a cardiologist. You know about the heart and circulation. But you will still need a surgeon to help your patient.



1




the ether dome (#uf798782c-3c73-51a1-bcb1-d9fe66b548ca)


For this relief much thanks; ’tis bitter cold and I am sick at heart.

William Shakespeare, Hamlet, Act I, Scene i

The finest of margins separates life from death, triumph from defeat, hope from despair – a few more dead muscle cells, a fraction more lactic acid in the blood, a little extra swelling of the brain. Grim Reaper perches on every surgeon’s shoulder and death is always definitive. There are no second chances.

November 1966. I’m eighteen and a week into my first term as a student at the Charing Cross Hospital Medical School in the centre of London, just across from the hospital itself. I wanted to see a vibrant, beating heart, not a slimy piece of lifeless meat on the dissection table. I was told by a hall porter at the school that heart surgery was done over the road in the hospital on Wednesdays and that I should look for the ether dome. Find the green door on the very top floor under the eaves where nobody goes. But don’t get caught, he warned me. Pre-clinical students are not allowed up there.

It was late in the afternoon, already dark, and drizzle was falling on the Strand when I set out to find the ether dome, which turned out to be an antiquated leaden glass dome above the operating theatre in the old Charing Cross Hospital. 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 didn’t enter by the Grecian portico of the main entrance, but sneaked in through Casualty under the blue light and found a lift, a rickety old cage used to take equipment and bodies from the wards to the basement.

I worried that I would be too late, that the operation would be finished – and that the green door would be locked. But it wasn’t. Behind the green door was a dark, dusty corridor, a depository for obsolete anaesthetic 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 theatre viewing gallery respectfully separated by glass from the drama on the operating table no more than ten feet below, with a hand rail and curved wooden benches worn smooth by the restless backsides of would-be surgeons.

I sat clutching the hand rail, just me and Grim Reaper, and peered through glass hazy with condensation. It was a heart operation and the chest was still open. I moved to find the best view, settling for a position directly above the surgeon’s head. He was well known, at least in our medical school, a tall man, slim and imposing, with very long fingers. In the 1960s heart surgery was still new and exciting, its practitioners few and far between, and not many had been properly trained in the specialty. Often they were skilled general surgeons who had visited one of the pioneering centres and then volunteered to start a new programme. They were on a steep learning curve, with the cost measured in human lives.

The two surgical assistants and the scrub nurse were huddled together over the gaping wound, frantically shuttling instruments between them. And there it was, the focus of their attention and of my fascination. A beating human heart. In fact it was squirming more than beating, and was still attached by cannulas and tubing to the heart–lung machine. Cylindrical discs were spinning through a trough of blood bathed in oxygen and a crude roller pump squeezed the tubes, accelerating this life blood back to the body. I peered closer but could only see the heart as the patient was completely covered by green drapes, gratifyingly anonymous to all concerned.

The surgeon restlessly shifted his weight from foot to foot, wearing the big, white operating boots that surgeons once used to keep blood off their socks. The team had replaced the patient’s mitral valve but the heart was struggling to separate from the bypass machine. This was the first time I’d seen a beating human heart, and even to me it looked feeble, blown up like a balloon, pulsating but not pumping. On the wall behind me was a box marked ‘Intercom’. I threw the switch and the drama now had a soundtrack.

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, then the patient’s blood pressure started to improve.

Sensing a window of opportunity, the surgeon turned to the perfusionist. ‘Come off now! This is our last chance.’

‘Off bypass,’ came the reply, said more as a blunt matter of fact than with any great confidence.

The heart–lung machine was switched off and the heart was now free-standing, with the left ventricle pumping blood to the body, the right ventricle to the lungs. Both were struggling. The anaesthetist stared hopefully at the screen, watching the blood pressure and heart rate. Knowing that this was their last attempt, the surgeons silently withdrew the cannulas from the heart and sewed up the holes, each one of them willing it to get stronger. For a while it fluttered feebly but then the pressure slowly drifted down. There was bleeding from somewhere – not torrential but persistent. Somewhere at the back. Somewhere inaccessible.

Lifting the heart caused it to fibrillate. It was now squirming again, wriggling like a bag of worms, but not contracting, fed by uncoordinated electrical activity. Wasted energy. It took the anaesthetist a while to spot this on his screen. ‘VF,’ he shouted. I’d soon learn that this meant ventricular fibrillation. ‘Shock it.’

The surgeon was expecting this and was holding the defibrillating paddles hard against the heart. ‘Thirty joules.’ Zap! No change. ‘Give it sixty.’

Zap! This time it defibrillated, but then just sat there stunned and devoid of electrical activity, like a wet brown paper bag. Asystole, as we call it.

Blood continued to fill the chest and the surgeon poked the heart with his 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, and a clear liquid squirted in. 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 and the blood pressure soared, up and up, dangerously testing the stitches. Then, as if in slow motion, the cannula site in the aorta gave way. Whoosh! Like a geyser erupting, a crimson fountain hit the operating lights, spraying the surgeons and soaking the green drapes. Someone murmured, ‘Oh, shit.’ An understatement. The battle was lost.

Before a finger could plug the hole the heart was empty. Blood dripped from the lights and red rivulets streamed across the marble floor. Rubber soles stuck to it. The anaesthetist frantically squeezed bags of blood into the veins, but to no avail. Life was fast ebbing away. As the injected slug of adrenaline wore off, the turgid heart simply blew up like a balloon and stopped. Stopped forever.

The surgeons stood silently in despair, as they did week after week. The senior surgeon then walked away out of my view and the anaesthetist turned off the ventilator, waiting for the electrocardiogram to flatline. He removed the tube from the patient’s windpipe, then he too disappeared from view. The brain was already dead.

Just yards away mist descended on the Strand. Commuters rushed into Charing Cross Station to get out of the rain, late lunches were finishing at Simpson’s and Rules, cocktails were being 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 love, no more hate. No more anything.

The perfusionist wheeled his machine out of theatre, and it would take hours to disassemble, clean, restore and sterilise it for the next patient. Only the scrub nurse lingered. Then she was joined by the anaesthetic nurse who had comforted the patient in the anteroom. They took off their masks and stood silently for a while, unconcerned by the sticky blood that covered every surface and by the chest still splinted open. The anaesthetic 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 the patient was a young woman.

They were oblivious to the fact that I was upstairs in the ether dome. No one had seen me there. Only Grim Reaper – and he’d already departed with the soul. I gingerly shifted along the bench to look at the woman’s face. Her eyes were wide open, staring up into the dome. She was ashen white but still beautiful, with her fine cheek bones 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. I was silently screaming for them to take out that hideous retractor cranking open her breastbone and let her poor heart go back to where it belonged. When they did the ribs recoiled and the poor lifeless organ was covered again. It lay flat, empty and defeated in its own space, with just a fearsome, deep gash separating her swollen breasts.

The intercom was still switched on and the nurses started to talk.

‘What’ll happen to her baby?’

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

‘Where did she live?’

‘Whitechapel, but I’m not sure the London do heart surgery yet. She got really sick during the pregnancy. Rheumatic fever. She nearly died during the delivery. Might’ve been for the best.’

‘Where’s the baby now?’

‘On the ward, I think. Matron’ll have to deal with it.’

‘Does she know?’

‘Not yet. You go and find her. I’ll get some help to finish off.’

It was all so matter of fact. A young woman had died, her baby left without a relative in the world. No more love, no more warmth, lost amid that tangled, blood-soaked technology in the operating theatre. Was I ready for this? Was this what I aspired to?

Two student nurses came to wash the body. I recognised them as respectful public schoolgirls from the Friday-night freshers’ dance. They’d brought a bucket of soapy water with sponges and set about scrubbing her clean. They removed the vascular cannulas and the bladder catheter but were visibly upset by the wound and what lay beneath. Blood kept slopping out of it.

‘What did she have done?’ asked the girl I’d 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 to soak the blood, then taped it up. The scrub nurse returned and thanked the girls for a job well done. She called back the surgical registrar to close over the wound, ready to move the body to the mortuary, as all deaths on the operating table are referred to the coroner for autopsy. The young woman would be sliced open again from neck to pubis, so there was no point closing the breastbone or bringing together the different layers of the chest wall. He took a big needle and some thick braid, and sewed her up like a mail bag. The wound edges still gaped and oozed serum. Mail bags were much neater.

It was now around 6.30 in the evening and I was meant to be in the pub down the road getting pissed with the rugby team. But I still couldn’t leave. I was attached to this empty shell, this skinny corpse I’d never met but now felt I knew well. I’d been with her at the single most important part of her life.

The three nurses manhandled her into a starched white shroud with a ruff around the neck, tied it up at the back then secured her ankles with a bandage. 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 I’d ask them how they felt.

Now there were just the two of us left, the corpse and me. The operating lights still shone on her face and she was staring straight up at me. Why hadn’t they closed her eyelids like they did in the movies? I could see through those dilated pupils to the pain etched on her brain.

From fragments of conversation I’d overheard and with just a little medical knowledge I could sketch 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 carried the scars of those sights and sounds, the fear of being alone as her world disintegrated. Brought up in poverty, she develops rheumatic fever, a simple streptococcal 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 doesn’t know is that the same inflammation is 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, an occupational hazard. But this makes things worse as her sick heart must work much harder. She becomes breathless and swollen but makes it through to term. Maybe the London Hospital delivers her safely but recognises heart failure. A murmur. A leaking mitral valve. They prescribe the heart drug digoxin to make it beat stronger, but she doesn’t take it as it makes her nauseous. Soon she’s too tired and breathless to look after the baby, and 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 with pinstriped trousers. He’s kind and sympathetic, and says that only surgery on her mitral valve can help. But it doesn’t. It terminates her sad life and leaves another orphan in the East End.

When the porters came for her the operating lights had long been 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 bouncing with a sickening thud, but nothing could hurt her any more. I was relieved to lose eye contact. A green woollen blanket was folded over the top to make it look like an ordinary trolley, and then off they went to slot her into 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 down from the ether dome at the black rubber surface of the empty operating table, as generations of would-be surgeons had done before me. The ether dome was a gladiatorial amphitheatre, people coming here to gaze down on a spectacle of life or death. Perhaps if others had been there it might have seemed less brutal, others with whom to share the shock of this poor girl’s death, the misery awaiting her child.

Auxiliary nurses came with mops and buckets to erase the last traces of her – her blood now dry on the floor around the operating table, the bloody footprints heading towards the door, the blood on the anaesthetic machine, the blood on the operating lights. Blood everywhere – now meticulously wiped up. 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. I frightened her, and so it was my cue to leave. But one spot of 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 to the shuddering lift where her body had been taken down to lie in a cold fridge in the mortuary.

Notice of autopsies were posted on a board in the entrance hall of the medical school. Usually the patients were elderly. The young ones were either drug addicts, road-traffic accidents, suicides from the underground system or cardiac surgery patients. I found her on the list for Friday morning. 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, then dragged under the road to the medical school in a tin box on rails by a pulley system and up the lift to the autopsy room. Should I go? Should I watch her guts and brain be cut out, watch her dead heart be carved into slices, tell them how she really died in that crimson fountain?

No, I couldn’t do it.

Beth taught me a very important lesson that day in the ether dome. Never get involved. Walk away as her surgeons did and try again tomorrow. Sir Russell Brock, the most renowned heart surgeon of the era, was known for his bluntness about losing patients – ‘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 then, and it still is now. We must learn from failure and try to do better the next time. But to indulge in sorrow or regret brings unsustainable misery.

I grappled with this later in my career when my interests veered towards the sharp end: heart surgery for complex congenital anomalies in babies and young children. Some came toddling happily into the hospital, teddy bear in one hand, Mummy holding the other. Blue lips, little chest heaving, blood as thick as treacle. They’d never known a different life and I strived to provide that for them. To make them pink and energetic, liberate them from impending doom. I did this in good faith, yet sometimes without success. So what should 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 make it as surgeons don’t look back. We move on to the next patient, always expecting the outcome to be better, never doubting it.



2




humble beginnings (#uf798782c-3c73-51a1-bcb1-d9fe66b548ca)


Courage is doing what you’re afraid to do. There can be no courage unless you’re scared.

Edward V. Rickenbacker, The New York Times Magazine, 24 November 1963

It was at the very start of the post-war baby boom that I arrived into the world in the maternity department of Scunthorpe War Memorial Hospital on 27 July 1948, star sign Leo. Good old Scunthorpe, my childhood home for eighteen years, a steel town and the long-suffering butt of music-hall jokes.

My dear mother, exhausted after a long and painful labour but happy with her first child, brought me safely back home from the carnage of the delivery suite. I was a pink, robust son, wailing from the depths of his newly expanded lungs.

My mother was an intelligent woman, caring, gentle and well liked. During the war she’d managed a small high-street bank, and with other tills empty the old folks would still queue to tell her their troubles. My father joined the RAF at sixteen to fight the Germans, and after the war he got a job in the local Co-operative grocery department and worked hard to improve our circumstances. Life wasn’t easy.

We were church-mice poor in a grimy council estate. House number 13, no pictures allowed on the walls in case the plaster crumbled, with a corrugated tin air-raid shelter in the back garden 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 at the steelworks and during the war had been the local air-raid warden. On pay day I’d go with him to the works to collect his wages. There I was intrigued by the spectacle of white-hot molten metal being poured into ingots, bare-chested, sweaty men in flat caps stoking the furnaces, steam trains belching fire, clanking up and down between the rolling mills and the slag heaps, and sparks flying everywhere.

Grandfather patiently taught me how to draw and paint. He’d sit over me, puffing away on Woodbines as I painted red night skies over the chimneys, street lamps and railway trains. Grandfather smoked twenty a day and spent his whole life working in smoke at the steelworks. Not the best recipe.

In 1955 we got our first television set, a 10-inch-square box with a grainy black-and-white picture and just one channel, the BBC. Television dramatically widened my awareness of the outside world. That year two Cambridge scientists, Crick and Watson, described the molecular structure of DNA. In Oxford the physician Richard Doll linked smoking with lung cancer. Then came exciting news on a programme called Your Life in Their Hands that would shape the rest of my life. Surgeons in the United States had closed a hole in the heart with a new machine. They called it the heart–lung machine, because it did the job of both organs. The television doctors wore long white coats down to the floor, the nurses had fine, starched uniforms and white caps and rarely spoke, and the patients sat stiffly to attention with their bed sheets folded back.

The show talked about heart operations and how surgeons at the Hammersmith Hospital would attempt one soon. They too would close holes in the heart. This seven-year-old street kid was captivated. Quite mesmerised. Right then I decided that I would be a heart surgeon.

At ten I passed the tests for entry to the local grammar school, and by then I was quiet, compliant and self-conscious. As one of the ‘promising’ set I was forced to work hard. I was a natural in art, although I had to stop those classes in favour of academic subjects. But one thing was clear. I was good with my hands, and my fingertips connected with my brain.

One afternoon after school I was out walking with Grandfather and his Highland terrier Whisky on the outskirts of town when he stopped dead on a hill, clutching the collar of his cloth shirt. His head bowed, his skin turned ashen grey and, sweating and breathless, he sank to the ground like a felled tree. He couldn’t speak and I saw 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 just held his head until the pain abated. It lasted thirty minutes, and once he’d recovered we slowly made for home.

His ill health wasn’t news to my mother. She told me that he’d been getting a lot of ‘indigestion’ while cycling to work. Reluctantly, Grandfather 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 climbed the stairs. Cold was bad for his chest, so the old iron bed was brought down in front of the fire and the commode was carried inside to save a journey outdoors.

His ankles and calves were so swollen with fluid that he needed bigger shoes. It was a gargantuan effort just to tie his shoelaces, and from then on he didn’t get out much, mostly just moving from the bed to a chair in front of the fire. I’d sit and draw for him to take his mind off his rotten symptoms.

I remember that dismal wet afternoon in November, the day before President Kennedy was assassinated in Dallas. I came home from school to find a black Austin-Healey outside my grandparents’ house. It was the doctor’s car and I knew what that meant. I stared through the condensation on the front window but the curtains were drawn, so I went around the back of the house and walked in quietly through the kitchen door. I could hear sobbing and my heart sank.

The living-room door was ajar and inside it was dimly lit. I peered in. The doctor was standing by the bed with a syringe in his hand, and my mother and grandmother were at the end of the bed, clasping each other tightly. Grandfather looked leaden, with a heaving chest and his head tipped back, and frothy pink fluid was dripping from his blue lips and purple nose. He coughed agonally, spraying bloody foam over the sheets. Then his head fell to one side, wide eyes staring at the wall, fixed on the placard proclaiming ‘Bless This House’. The doctor felt for a pulse at his wrist, then whispered, ‘He’s gone.’ A sense of peace and relief descended on the room. The suffering was at an end.

The certificate would say ‘Death from heart failure’. I slipped out unnoticed to sit with the chickens in the air-raid shelter, and quietly disintegrated.

Soon afterwards my grandmother was diagnosed with thyroid cancer, which started to close off her windpipe. ‘Stridor’ is the medical term to describe the sound of strangulation as the ribs and diaphragm struggle to force air through the narrowed airway, and that’s what we heard. She went to Lincoln, forty miles away, for radiotherapy, but it burned her skin and made swallowing more difficult. We were given some hope of relief by an attempted surgical tracheostomy, but when the surgeon tried to do it he couldn’t position the hole low enough in the windpipe below the narrowing. Our hopes were dashed and she was doomed to suffer until she died. It would have been better if they’d allowed her to go under anaesthetic. Every evening I sat with her after school and did what I could to make her comfortable. Soon opiate drugs and carbon dioxide narcosis clouded her consciousness, and one night she slipped away peacefully with a large brain haemorrhage. At sixty-three she was the longest-lived of my grandparents.

When I reached sixteen I took a job at the steelworks in the school holidays, but after a collision between a dumper truck and a diesel train hauling molten iron they dispensed with my services. I spotted a temporary portering job at the hospital and negotiated the role of operating theatre porter. There were disparate groups to please. The patients – fasted, fearful and lacking dignity in their theatre gowns – required kindness, reassurance and handling with respect. Junior nurses were friendly and fun, the nursing sisters were self-important, bossy and business-like, and needed me to shut up and do what they told me, and the anaesthetists didn’t want to be kept waiting. The surgeons were simply arrogant and just ignored me – at first.

One of my jobs was to help transfer anaesthetised patients from their trolleys onto the operating table. I knew what sort of surgery was planned for each one, having read the operating list, and I helped out by adjusting the overhead lights, focusing them on the site of the incision (as an artist I was intrigued by anatomy and had some knowledge of what lay where). Gradually the surgeons began to take notice, some even asking me about my interest. I told them that I’d be a heart surgeon one day, and soon enough I was allowed to watch the operations.

Working nights was great because of the emergencies: broken bones, ruptured guts and bleeding aneurysms. Most of those with aneurysms died, the nurses cleaning up the corpses and putting on the shrouds, me hauling them from the operating table and onto the tin mortuary trolley, always with a dull thud. Then I’d wheel them off to the mortuary and stack the bodies in the cold store. I soon got used to it.

Inevitably my first mortuary visit took place in the dead of night. The windowless grey brick building was set apart from the main hospital and I was frankly terrified of what I’d find in there. I turned the key in the heavy wooden door that led directly into the autopsy room but when I reached inside I couldn’t find the light switch. I’d been given a torch and its beam danced around as I plucked up the courage to go in.

Green plastic aprons, sharp instruments and shiny marble sparkled in the gloom. The room smelt of death, or what I expected death to smell like. Eventually the torch beam settled on a light switch and I turned on the overhead neons. They didn’t make me feel any better. There were stacks of square metal doors from floor to ceiling – the cold store. I needed to find a fridge but wasn’t sure which ones were empty.

Some doors had a piece of cardboard slotted into them with a name on it, and I figured that they must be occupied. I turned the handle on one without a name, but there was a naked old woman under a white linen sheet. An anonymous corpse. Shit. Try again on the second tier. This time I was lucky, and I pulled out the sliding tin tray and pushed the creaking mechanical hoist towards my stiff. How to make this thing work without dropping the body on the floor? Straps, crank handles and manhandling. I just got on with it and slid the tray back into the fridge.

The mortuary door was still wide open – I didn’t want to be shut in there alone. I sped out and pushed the squeaking mortuary trolley back to the main hospital ready for the next customer. I wondered how pathologists could spend half of their career in that environment, carving entrails from the dead on marble slabs.

Eventually I charmed an elderly female pathologist into letting me watch the autopsies. Even after witnessing some disfiguring operations and terrible trauma cases this took some getting used to, young and old sliced open from throat to pubis, eviscerated, scalp incised from ear to ear and pulled forward over the face like orange peel. An oscillating saw removes the cranium, as if taking the top off a boiled egg, and then the whole human brain lies in front of me. How does this soft, grey, convoluted mass govern our whole lives? And how on earth could surgeons possibly operate on this, a wobbly jelly?

I learned so much in that dingy, desolate autopsy room: the complexity of human anatomy, the very fine line between life and death, the psychology of detachment. There was no room for sentiment in pathology. An ounce of compassion there may be, but affinity with the cadaver? No. Yet personally I felt sad for the young who came here. Babies, children and teenagers with cancer or deformed hearts, those whose lives were destined to be short and miserable or had been terminated by a tragic accident. Forget the heart as the source of love and devotion, or the brain as the seat of the soul. Just get on and slice them up.

Soon I could identify a coronary thrombosis, a myocardial infarction, a rheumatic heart valve and a dissected aorta, or cancer spread to the liver or lungs. The common stuff. Charred or decomposed bodies smelt bad, so Vicks ointment stuffed up the nostrils spared your olfactory nerves. I found suicides to be terribly sad, but when I verbalised this I was told to ‘Get over it if you want to be a surgeon’ and that it would all be easier when I was old enough to drink. I sensed that alcohol was high on the list of surgeons’ recreational activities, and this seemed more obvious when they were called in at night. But who was I to judge?

I began to wonder whether I could really get in to medical school. I was no great academic, and I struggled with maths and physics. For me these subjects were the real barometer of intelligence. But I excelled in biology and could get by in chemistry, and in the end I passed a lot of exams, stuff I would never need like Latin and French literature, additional maths and religious studies. These I saw as a function of effort, not intelligence, but hard work bought me my ticket out of the council estate. In addition, the time spent in the hospital had made me worldly. I’d never been out of Scunthorpe, yet I knew about life and death.

I started to search for a place at medical school, and returned to the hospital during every school holiday. I progressed to working as an ‘operating department assistant’, becoming an expert in cleaning up blood, vomit, bone dust and shit. Humble beginnings.

I was surprised to be called for an interview at a magnificent Cambridge college. Someone must have put in a good word but I never learned who it was. The streets bustled with lively young students in their gowns chatting loudly with public school accents, all seeming much smarter than me. Erudite, bespectacled professors cycled down cobbled streets in their mortarboards off to college dinners for wine, then port. My mind flashed back to the grimy steelworkers silently making their way home in flat caps and mufflers through the smog for bread and potatoes, and then maybe a glass of stout. My spirits started to sink. I didn’t belong here.

The interview was conducted by two distinguished fellows in an oak-panelled study overlooking the main college quadrangle. We sat in well-worn leather armchairs. It was meant to be a relaxed atmosphere, and nothing was said about my background. The anticipated question, ‘Why do you want to study medicine?’ never came. Wasted interview practice. Instead I was asked why the Americans had just invaded Vietnam and whether I had heard of any tropical diseases their soldiers might be exposed to. I didn’t know whether there was malaria in Vietnam so I said, ‘Syphilis.’

That broke the ice, particularly when I suggested that this might be less of a health problem than napalm and bullets. Next I was asked whether smoking cigars may have contributed to Winston Churchill’s demise (he’d only recently died). Smoking was one of the key words I was waiting for. My mouth fired off in automatic mode: cancer, bronchitis, coronary artery disease, myocardial infarction, heart failure, how the corpses of smokers looked in the autopsy room. ‘Had I seen an autopsy?’ ‘Many.’ And cleared up the brains, guts and bodily fluids afterwards. ‘Thank you. We’ll let you know in a few weeks.’

Next I was called down to Charing Cross Hospital, between Trafalgar Square and Covent Garden on the Strand. The original hospital was built to serve the poor of Central London and had a distinguished war history. Although I arrived early I was always last alphabetically, so I twiddled my thumbs anxiously to while away what seemed like hours. A kindly matron received the candidates with tea and cakes, and I made polite conversation with her about what had happened to the hospital during the war.

The interview took place in the hospital board room. Across the other side of the boardroom table from me was the chief interviewer – a distinguished Harley Street surgeon wearing a morning suit – together with the famously irascible Scottish professor of anatomy upon whom the Doctor in the House films were based. I sat straight-backed to attention on an upright wooden chair – no slouching here. I was first asked what I knew about the hospital. Thank you, God. Or Matron. Or both. Next I was asked about my cricketing record and whether I could play rugby. And that was all, the interview was over. I was the last of the day, they’d had enough and they’d let me know.

I wandered out into Covent Garden past the colourful market stalls and bristling public houses. All life was there: tramps, tarts, buskers and bankers, the Charing Cross Hospital clientele, and the black cabs and scarlet London buses that drove up and down the Strand. Meandering between the crowds and the traffic I came to the grand entrance of the Savoy Hotel. I wondered whether I dared go in. Surely I looked smart enough in my interview suit and Brylcreemed hair. But the decision was swiftly made for me when the immaculate doorman pushed the swing doors open and ushered me through with a ‘Welcome, sir.’ The seal of approval. From Scunthorpe to the Savoy.

I strode purposefully through the atrium, past the Savoy Grill, hesitating only to scrutinise the menu in its gilt frame. The prices! I didn’t stop. A sign pointed to the American Bar. The hall was lined with signed cartoons, photographs and paintings of West End stars, and when I reached it there was no queue as it was only 5 pm. Perched on a high stool I furtively devoured free canapés and perused the cocktail menu. Devoid of insight – this was my first alcoholic drink – I was pushed to make a decision. ‘Singapore Sling, please.’ Like flipping a switch, my life had changed. Had I ordered a second I’d never have found King’s Cross station.

Within the week a letter arrived from Charing Cross Hospital Medical School. Opening it surrounded by my anxious parents felt like defusing a bomb. There was the offer of a place. The conditions? Just pass my biology, chemistry and physics exams, no grades specified. Charing Cross was a small medical school with an intake of only fifty students each year, but I’d be following in the footsteps of distinguished alumni such as Thomas Huxley the zoologist and David Livingstone the explorer. I was the first in my family to go to university, the first to attempt to become a doctor and, hopefully, the first heart surgeon.





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