HEART BEAT: Thousands of operations later, it is still not difficult to remember the beginning. I had as an intern become accustomed to the operating theatres and procedures, far more so than as a student. In other words I was no longer scared stiff.
I was involved in the preparation of the scene and any deficiencies in preparation would rightly, and occasionally wrongly, be laid at my door. Our team did general surgery as well as chest and heart surgery. Some of the heart surgery did not require the use of the heart-lung machine; eg dilating the mitral valve from outside the heart, and repairing congenital lesion like patent ductus arteriosus and coarctation of the aorta, all of which could be approached through the left chest with the patient lying on the right side.
In later years we came to realise that although the machine was not necessary in these cases, it was very comforting to have it in the background in case things went wrong. Even in the best ordered scheme of things, disasters may occur, and given the nature of the surgery, with sometimes calamitous results.
Open heart surgery was another dimension altogether. In the vast majority of cases the heart was approached from the front and after dividing the skin over the sternum (breast bone), the bone itself was divided longitudinally, right down the middle, using an instrument in those days called a Gigli saw. This in essence was a strong braided wire, with loops on either end. This wire was passed up behind the bone using a very long forceps, and eventually retrieved at the base of the neck. Handles were attached to the loops, and the bone literally sawed through.
It sounds crude and it was, but it was effective. Things are somewhat different today but the approach remains the same. The two sides of the bone were separated by a self retaining retractor, ie it did not have to be held in place. This done, the pericardium, (the cover around the heart) was opened and the heart exposed.
Needless to say the patient slept happily(?), during all this time. The drugs required to enable the patient to be connected to the heart-lung machine were given. Tubes (cannulae) were placed in the collecting chamber of the heart on the right side, enabling the blood returning to the heart to be diverted to the machine.
Here, the oxygenator part of the machine, removed the carbon dioxide from the blood and added oxygen, as the normal lungs would do. This blood was then returned to the circulation on the arterial side downstream from the heart. This enabled the machine to support the circulation, thus enabling the heart to be stopped and repaired. Sounds easy?
Well, experience made it so, and better machines, tubing, oxygenators, pumps etc made all of this the routine that it is today, but it did not come about without tears. This is not intended to be the Peter and Jane guide to cardiac surgery, but rather to provide a rough if very foggy clue as to what we were about.
As part of the circulation was now outside the body, a volume of blood (later other fluids), was necessary to fill this system. This unsurprisingly was known as the priming volume. The older machines were large and cumbersome and required a large volume. For such operations, it was customary to order 12 units of blood. This could create problems if blood was in short supply or if the patient had an unusual blood group or had blood problems.
I will say that in my very extensive surgical experience, we were never let down by the Blood Transfusion Service, which always, even in the most desperate of circumstances, seemed to somehow manage. This despite the fact that like the rest of the health system, they were under-funded and under-staffed.
At this time they managed to do without me participating in the actual surgery. My job was that of a "gofer" doing the routine work on the wards and being available to the operating team if required. Occasionally you might be required to scrub-up and participate, usually just to hold something. Despite the fact that you were certain that you had much to contribute, even at that fledgling stage, you were in fact wiser to keep your mouth shut and your opinions to yourself.
The lead surgeon often had problems of his own and the inanities uttered by the most junior member of the team were rarely welcomed. I believe this is called "learning your place". I always had difficulty with this concept. I watched, I listened, I learned, and personally I was fascinated. From those magic early days, I wanted nothing other than to be a cardiac surgeon, a career choice I have never regretted.
Many of the patients of the time were extremely sick and had been deteriorating steadily over the years, waiting Micawber-like for something to turn up. Something as often in medicine did turn up, but sadly for some it was too late. On their misfortune grew our experience and such lessons learned in disappointment and failure were often the best remembered and instructive.
I note that things are still happening in the real world. One really good thing is the appointment of Prof Brendan Drumm, a colleague from both Crumlin and Comhairle Na hOspidéal. I have great personal respect for Brendan, and if anybody can make sense of this, he can. However, he cannot do it on his own, and it behoves all who realise the problems to contribute in any helpful way.
Maurice Neligan is a cardiac surgeon.