Heart Beat: Vitae, non scholae discimus,or it is for life not for scholarship that we learn - (Seneca the Younger) Tell me about it, writes Maurice Neligan.
Surgery is learned from life and experience rather than books and lectures, important as these may be. Sometimes I wished the lessons were not so hard.
Last week I wrote about a bad or good day, depending on perspective, which culminated in an emergency call to our A&E department, after what had seemed like minutes in the bed. The tone of the call brooked no delay. "Get down here quick," the disembodied voice urged, "we have a moribund stabbing."
I rolled out of bed throwing on scrubs and shoes and set out in those awful medical hours of 2-3am, when life's flame seems to be at its lowest. I clattered down the cold staircase and through the swing door into the unit. I saw at once the resuscitation team giving cardiac massage to a recumbent figure on a trolley.
"What's the story?" I asked. "Stabbing after a row at a party," was the terse reply. This was very unusual then, sadly all too common now.
The patient was ghastly, ghostly pale, sweating, shocked. Clothing had been torn away to reveal a linear cut between the fourth and fifth ribs on the left side. There was little obvious external bleeding. There was no recordable blood pressure. No question of X-ray or further investigation here; the only problem was whether to open the chest where we were or head for the operating theatre. The external massage was producing a faint thready pulse and the pupils were not dilated and reacted to light.
I chose theatre and the caravan set off at a run with an NCHD kneeling on the trolley continuing the cardiac massage. We scrubbed quickly, draped the patient and made a longitudinal incision the length of the sternum or breast bone. There was little bleeding, an ominous sign of little blood pressure. I split the bone from top to bottom with the electric saw and spread the halves apart. Before my eyes the pericardium, the covering around the heart, thrust forward, blue and motionless.
Urgent whispers in the background, between the anaesthetists and nursing staff, ordering blood replacement and tests and cardiac support drugs, filtered into my subconscious. I opened the pericardium. Blood and clot gushed forth, relieving the pressure that this tightly contained mass had exerted on the filling and working of the heart. We removed the clot and blood but little fresh bleeding ensued. The heart lay empty and inert. "Cardiac arrest," said the anaesthetist.
Gloved hand around the heart, compressing and relaxing, this artificial pressure recording on the monitor assured us that some perfusion was reaching the brain and vital organs.
"Defibrillator please," one, two, three shocks and the heart started to beat slowly under my hand. Simultaneously blood spurted from the laceration in the left ventricle of the heart. A finger covering the tear, "everything okay - pupils, pulse, blood pressure?" Affirmative answers. The problem now was to stop the bleeding. The wound was about one and a half inches long and as well as penetrating into the heart cavity had severed a medium-sized coronary artery branch on the surface.
"Pledgeted sutures please" and not looking around, the loaded needle holder was slapped into my palm. Suture tied gingerly, hoping that the suture material would not cut through the beating heart muscle. "Again." The process repeated until six such buttressed stitches were in place, spanning the cut. "Bring the pressure up, please." Anaesthetist reacting calmly, dealt appropriately with this. Some oozing and spurting between the stitches remained to be controlled, minor problems.
A period of observation followed. Was the coronary artery damage interfering with cardiac function? Not obviously, was the answer. Had the knife damaged any other vital structures? No evidence of that either. The wound was then closed and the patient returned to the intensive care unit. This gave me the opportunity to review the major case of the day before. The condition was still parlous, but baby steps of improvement encouraged us.
It was now 7am. It was hardly worth returning to bed. I showered, shaved and lay briefly on the bed. What seemed like seconds later the phone rang again; it was 9.10am. "Mr X wants to know where the hell you are and why you haven't started the list?" Idle shower weren't we, us NCHDs, consultants, whatever? We should just have done our work and never complained, whatever the deficiencies in the facilities, in case we were shown a red card. I will return to that despicable remark of the Taoiseach later, but at present I am simply too angry; "grievous words stir up anger" (Proverbs 15:1).
In the meantime I was reminded of a story of Mr X's formidable other half, the archetypal consultant's wife, of the "here be dragons" variety. The wife of a recently appointed junior colleague encountered this formidable grande dame in the nearest that Dublin 4 came to having a supermarket in those days. She noted that there were two cabbages in the shopping basket. "I see that Mr X and yourself are having cabbage this evening," she inanely remarked. The temperature dropped several degrees. "Not at all," was the acid reply. "Mr X and I are having asparagus; the cabbage is for the servants." Those were the days. Even the Highest Authority at her most imperious couldn't match that!
Maurice Neligan is a cardiac surgeon.