Nikolay Amosov    WORLD OUTLOOK

A week of operations passed, followed by a week-end, and now I am on vacation. To hell with this vacation! But there are only a few patients in the clinic; there is nobody to operate on. We have to accumulate enough so that later we can perform two operations a day.

See how frisky I am after a work week. For a long time I have not been in such a state. Each day, I operated for three to five hours and then sat at the patient's bedside until the tube was removed: five or often seven p.m.

I performed a "clinical experiment."

Don't get scared, since there was nothing experimental about it. And in general, I have never allowed experiments on people.

My, how good it is to go home after a complicated operation and leave the patient fully conscious.

The tube has been removed and he is breathing himself. I have not experienced this feeling in a long time.

While I was at home for two weeks doing my scribbling, I did not stop nursing one and the same thought: "Why?"

And I arrived at the conclusion: we overtreat patients.

Obviously this was far from being a revelation. I had wanted to break this tradition for a long time but could not make up my mind to do it. "We have to control as many parameters as possible, then everything will be O.K." This is the path medicine takes. Each time new chemicals are developed to stimulate or depress the function of an organ, they are tested in earnest on rats, rabbits, or dogs. But no one really knows what the dosage should be in the end.

A primitive scheme, rounded figures; similar for all patients. Doctors think in quantities and qualities: "more-less," "better-worse." When an index is higher than the norm, to depress, and when lower, to stimulate. Self-assured medicine is absolutely confident that it can control man better than he can control himself with his own regulators. My cybernetic half cannot stand it. Everything is connected in the organism by thousands of both qualitative and quantitative relations. Without them, there is no regulation, but blind jerking, lashing or stunning of the organism. Therefore, it is very difficult for regulators, particularly those of a patient, to perform their intended functions under these exposures — to control functions. The potential of the organism is limited and if we are too persistent, it falls out of step.

Apparently this is the reason for the deterioration of the state of our patients who first wake up and then decline to "critical condition" as our intensive care doctors put it.

And in fact, fearing stress, we use not only narcotics but what is more, drugs that selectively suppress the vegetative nervous system. Large doses of morphine affect the patient for many hours: he cannot and does not want to breathe. And this means that he must be kept on artificial respiration. The depth of breathing is controlled by analyses. We supposedly know better than the organism itself how much carbon dioxide and oxygen it needs. By the way, each man has his own individual norms. Moreover, our analyses are not ideal or necessarily correct, and we make them only once in six or eight hours. The process of breathing per se is far from being regular; from time to time we take a deep breath, thus stretching the alveoli that have got stuck together. Theoretically, this is what the iron lung has to do. But who will set this regime? And that's the way the person breathes — like an iron lung. Incorrect breathing leads to disturbed activity of the heart, vessel tone and the intestines. And thus we begin to treat the secondary disturbances of each organ: new drugs to stimulate or depress. In addition, they all have side effects, as a result of which the organism falls out of step.

That's how I see overtreatment.

It is quite evident that when air comes to the brain from the AIK machine, natural regulators are put out of action — and then we have to put a patient on artificial respiration — not always, for sure... No doubt the heart muscle, providing it does not contract properly, could be stimulated with drugs... Only why should the heart contract weakly when the load has been reduced? Could it be that we overload it with infusions?

"You are simply bad doctors," specialists would say.

Everything should be done properly and in time — drugs, artificial respiration...

"Let he who is without sin throw the first stone..." I can also make pronouncements on correctness, timeliness and qualifications.

"The problem of principle in optimal regulation is the amount and timeliness of necessary information and accurate performance of the technique used to influence a subject." That is the way a declarative statement can be made. To make it simpler, artificial respiration is more primitive than natural.

It is both harmful to overestimate it and neglect it in grave cases. Superficial knowledge makes a doctor overtreat a patient. This is true not only of our acute patients, but also of chronic ones.

The conclusion at which I arrived is simple: treat less.

If you want an extended statement, you can have it: a simple and a short living anesthesia. Minimal premedication (inhibitors before anesthesia). Virtually, this means ether, nitrous oxide, a small dose of promedol, and tranquilizers. The end of the operation should be performed with nitrous oxide so the patient will wake up right after it. In half an hour the AIK machine should be switched off, and then, the tube removed.

And we have to see not only the analyses but the patient as well, like the old-timers did before they had laboratories. The abundance of carbon dioxide with insufficient respiration should not be feared, providing the patient is given oxygen. Pain killers are undoubtedly needed at night. But not too much. And, in general, the fewer drugs administered, the better.

All these deductions of mine I made public on Monday morning, August 11, at a conference, before the operations of the day.

"I'll keep an eye on everything. No drugs should be given without my permission: I'll stay over until the tube is removed from the trachea."

The others treated my statement with distrust. What can you do about it? My assistants, doctors and candidates of science are well aware of expert opinions the world over and have their as well.

I could easily read their opinions from the faces of anesthesiologists and intensive care unit doctors. And my reply was:

"Previous experience does not give us anything. The mortality rate has increased here one and a half times as compared with 1970. Therefore, do what I say. I take all the responsibility."

The operation was difficult and the case too grave: an emaciated girl of nine, 26 kilograms. The "Elema" showed a deficiency of the aortic valve, the operation revealed a ventricular septal defect. This defect gave us a forty percent mortality rate. I sewed in the valve prosthesis and closed the defect. Perfusion (artificial circulation) continued for 90 minutes. Everything proceeded without a hitch, the aorta was broad and it was convenient to sew in the valve. As I operated, I listened to what the anesthesiologists were talking about so they would not give too many-drugs. Gena Penkov, a Hercules with a fair beard, sings in a deep voice for all to hear; Alyosha Tsiganiy speaks in a low voice. When I heard them say "phentanil," I protested. They said they were sorry.

The girl woke up right after the operation, still on the table. In an hour I entered the post-op room and began my new work methods. First, I took her off artificial respiration, then took her to intensive care, and, finally, removed the tube. I stayed with the girl for another half an hour and saw for myself that she was quite O.K.

They kept looking at me with distrust. It took them a long time to realize all the advantages of artificial circulation and then... Sacrilege. In keeping with our former traditions, only in the morning, before the next shift of doctors should she have been taken off artificial respiration, and by lunch, the tube should have been removed. They strongly objected to my decision making.

But that is exactly the way we did it seven years ago. When we did not have the iron lung in the operating room. And the results were better. Intensive care for infarction patients never requires artificial respiration.

You cannot change their minds; traditions are too strong: you can only order them.

"Intube her if she gets worse. But not before you give me a call."

Her mother and father were waiting for me at the exit. The usual picture: clenched hands, eyes full of fear and hope. But it was easy for me today.

"She is O.K. She's awake; the tube has been removed. Right now, everything is under control, but nobody can guarantee against complications."

That is what we say to all of them. And this is the truth — we cannot guarantee a hundred percent success.

Her mother visited me before the operation — I invited her myself. The same story as if by providence: an only child. She is not on good terms with her husband, and she is already 36.

Usually after difficult operations, I would run from the Institute to the trolleybus stop. Down the hill and not too many people at that time of day. I have already overcome my shyness: I run in crowded streets and pay no attention to bewildered looks. (In Kiev many people know me — from lectures, TV programmes and the cinema. Many people know me by sight: twenty eight years is a long time.)

I came home at eight; I took a nap after lunch but could not fall asleep. I feared the telephone would ring, and they would tell me that they had begun intubation.

But in his usual report at ten p.m. the doctor-on-duty said that the girl was O.K.

Still I did not sleep well that night: the next day, I had a tetrad of Fallot operation to perform.

The same schedule on Tuesday, Wednesday and Thursday. Operations under ether and nitrous oxide, rapid waking up and early extubation (removal of the tube). I operated on two patients with tetrad of Fallot and sewed in one mitral valve. All of them were patients of medium seriousness. There would have been no problems if we had used the old technique. But it was not that easy. This time they were easy as pie.

By five they were already in the intensive care unit without their tubes, and fully conscious. The next morning they asked for food and wondered: "When they would take me to my floor?"

Their state was similar to those after closed heart operations without the AIK machine. All who came to see them were bewildered and had grave doubts. Me, too.

"It's too early to draw any conclusions. You can pass judgement only after, say, thirty patients or so. And even that would be too few."

I was taken aback by all this. Did that mean we could operate with a guarantee of success? No, not to that extent, but almost. Not for gravest defects, to be sure. But for those of medium seriousness, prospects were looking up. Like those this week. Logical arguments had long given evidence of this, but it is so difficult to confide in logic in medicine after forty-one years in surgery.

All this would have to be checked out. And at once.

To understand why this experiment was so important, we need a digression into history. Now to make the long story short. I began to operate on the heart in 1955. My first successful operation with artificial circulation was in 1960 (before that two patients died — in 1958 and 1959). In 1962, I designed petal-shaped valves; within three years they had all calcified and had to be replaced. That was far from easy. Ball-shaped prostheses based on the American design were made at a plant in Kirovo-Chepetsk in 1963—1964. At that time I also tried them. Because of embolisms, I feared putting them into wide use. Thrombi formed on the metal surface of the rim and came off, since they could not stich to the metal. In 1965 I proposed that the ring be covered with plastic fabric to form a surface that would affix even the smallest clots. The first attempt was a success, and these prostheses were put into production. But we were so worried that we followed up on the first five patients for three years until we saw for ourselves that embolisms were rare. In 1968, we began to use prostheses on a large scale — up to a hundred operations a year. In the beginning, one of approximately four to five patients operated on would die. Later, by 1973, the mortality rate was reduced to 17 percent. The conditions were primitive — we used self-made AIK machines; artificial respiration was not used after the operation; and there was no device for analysing blood gases, to say nothing of monitors for tracing the ECG. We knew little (but thought it was a lot; that's the usual thing). But nevertheless life continued, and there were not too many deaths. The outcome of operations on simple congenital defects were good; and tetrads, satisfactory. Total mortality following operations went down to 11 percent with the AIK machine.

All the trouble began from 1974, right after my jubilee and all these awards (one has to pay for pleasure). The incidence of complications and deaths became rather high. I was depressed and decided to give up surgery; I began to receive my salary at the Institute of Cybernetics, but remained at the clinic, as we put it, at public initiative (for free). (What the initiative had to do with it, goodness only knows.) But it is not easy to close the door on your past. There are too many patients — a line three years long, clinic's packed to overflowing. My assistants had been pressuring me for ages to "go to the higher-ups and insist that a new building be constructed." I resisted, but finally gave in. And I was given the red carpet treatment. They ordered that construction be started at once. Since then, I have had to live up to their expectations. First I had to expend all my energy to increase the number of operations in the "old premises" to 1,300 a year, 400 with the AIK machine. Before that, we performed 800 and 230 respectively.

They built our five-storey building over the course of three years. In autumn of 1975, we moved in. Since then, we have had 300 beds — the biggest heart clinic in the country. New doctors were employed and new equipment was purchased. We planned to be doing 3,000 operations annually by 1982, a thousand with the AIK machine... That is four times more than in 1970. There are many patients and they need us. So 1 thought I would work and enjoy it.

But there was no joy. It is true that in 1976, we performed 2,000 operations, seven hundred with the AIK machine. But the mortality rate increased. Things couldn't have been worse.

This phenomenon was strange and beyond our comprehension. We had purchased new Soviet-made AIK machines, introduced prolonged artificial respiration after operations, and installed monitors to trace the ECG. A biochemist was on duty all the time, on taking the necessary analyses. And what a mansion. The intensive care ward took up the whole fifth floor. Doctors had gained an enormous amount of experience, particularly anesthesiologists and intensive care physicians. They read Western journals and used all the most advanced methods.

But the mortality rate continued to increase. All possible complications occurred, and we were constantly in a state of alarm.

Our syndrome gave us no end of worry. (A syndrome is a complex of pathologic processes, involving several organs.)

This is how it happened: after the operation, a patient began to wake up; he was given additional drugs and was kept on artificial respiration the whole night. His consciousness was either inhibited or he did not wake up at all. Convulsions were frequent. Therefore the AIK machine could not be switched off. This was followed by cardiac disorders which required medication. All this was further accompanied by hepatic complications (bilirubin level increases), renal and gastro-intestinal (distention, sometimes hemorrhages) complications. If a patient did not die during the first three days, his lungs were affected: it was either the tube in the trachea or the AIK machine that promoted purulent bronchitis, and pneumonia... Those who survived developed wound infections.

Autopsies revealed small punctate hemorrhages in the cerebral cortex, hematomas under its membranes, and various lesions in all the internal organs.

The "syndrome" occurred not only in initially grave patients (the third risk level, two valves) but, and this was rather common, in normal patients with prosthesis of a single valve.

Experienced (and self-assured) doctors, upon reading this, will immediatelly give a diagnosis: shock, stress, or something else. And would say: "unskilled physicians." I have nothing to say in our defence — we racked our brains over to solve this problem; we tried everything. We did not ignore it, rather we did everything as "science prescribed." And yet we were unable to cope with this terrible problem until recently. Beginning in 1977, our mortality indices went down. (We dared not operate on very grave cases; the intensive care unit could not cope with the complications.) The mortality rate for valve corrections was one in four. The number of operations with the AIK machine reduced to 560. I began to avoid such serious cases, and reduced the number of such operations. There you are with your plans!

We took these failures hard. I thought I took it harder than the others: after all it was I who had knocked on the bosses' doors, pleaded, and promised. I now had an inferiority complex. I had planned to work until 65 and then retire, which I was entitled to do at 60. But I could not bring myself to it. But in the summer of 1979, I would have spent forty years as a surgeon — there had to be an end to everything. But by autumn, my luck had changed for the better, and I began to operate with the AIK machine; the mortality rate seemed to go down, and that kept me from leaving. That is how I kept going until my vacation and this diary.

Friday. On Fridays, we have no operations. I have to catch my breath and see what has been accomplished and what must be done in the future. Rounds and analyses, scientific conferences. Various meetings: for departments heads or scientific councils. July and August — almost free, no science. We finish earlier since we are so busy on other days. Too many extra duties, because of summer vacations. By the way, the clinic is never full: patients do not like to be operated on in summer. They suspect the good doctors are on vacation. That is the situation everywhere, not only in our clinic. We work as if at a factory — without vacations and with no time to close down for repairs.

Today the conference is rather brief: there were only two operations with the AIK machine and 5 closed operations; all the patients were operated on without a hitch. There is almost nothing to report.

Then I took the floor: "I want to make a statement." That was done in a high-flown manner

"You know of the situation in the clinic. It seems that this week there may be changes. Until now it has only "seemed" so, but to make it a reality, we need effort and organization.

"Two years ago, following the deterioration of our indices, I expanded the rights of department heads, and gave them freedom of choice hoping that they, doctors of medicine, experienced specialists, would show initiative, mobilize their efforts and "make a contribution". But... there was no contribution. Nobody contributed.

"Now there is a slight ray of hope for changes. It seems that a change of anesthesia and post-op follow up of patients might correct the situation. But you have all got too clever and scientifically minded, and to call a spade a spade — you are inert and will resist change. If we go only half way through with our innovations, there will be no effect. Therefore, democracy is cancelled for the time being. If there is no effect from the innovations, then... we'll see. To be more specific, we shall make the following changes.

"First, new, or to be more precise, old anesthesia and early extubation. Alexey Alexandrovich, you will see to it. And no arguments.

"Second, surgeons who are department heads should control the introduction of a new system. Demand that your personnel obey these istructions and keep control of the situation; don't trust anesthesiologists and intensive care physicians. You must not leave the clinic until the tube is removed. The decision to continue artificial respiration should be taken only in an emergency, after a joint discussion between anesthesiologists and intensive care physicians. If need be, ask for me. Don't try to play it safe. However, the new system may be abortive if we go too far. We have to bring these losses to a minimum. To do this, we have experience. The losses caused by the old method are well-known. We divided responsibility between surgeons, anesthesiologists and intensive care doctors, and patients died as if they were responsible for this. From now on, the surgeon bears all the responsibility. And he must stay at the patient's bedside as he used to do ten years ago...

"Third, I will operate myself, as much as I can, on patients from all departments. This is all. There will be no discussions."

That's the declaration I made... As I was making it, I thought: "What an adventurist you are, Amosoff. You'll fail; you won't achieve anything, and you will have to give in shame fully. And in the meantime, you'll have to sit at the hospital every night."

Well, what of it. I would just have to sit.