6.12.1913  -  12.12.2002

Books of N.M.Amosov

Diary. Sunday

It's been a long time since I typed anything in my diary.

I was operating all the time. My vacation passed in this fashion and then I took another month for operations. Each day I performed two operations — only difficult ones, with the AIK machine. Six to eight hours without a break. Then I sat at the patients' bedsides until they woke up and the tube was removed. I came home around seven or eight in the evening, and very often even later. After that, I was so tired I could not do anything. Listened to some music and then went to bed.

I did not write or think of lofty matters. On weekends I would walk the dog, watch the TV shows "Animals, Animals" and "Round the World," read medical books a bit and make notes of the week's events for diary so I wouldn't forget.

My family and co-workers at the clinic looked at me with fear: "He's not in his right mind."

This is what I mean by passion.

Last week I came to my senses. The dream I was after cannot be achieved by storm. I have been trying for twenty years and I have failed. Thus a prolonged siege is required. And another thing: for me, such a simplified process is insufficient (almost without a thought). A look, a movement, a brief thought, an image — what is ahead — and once again, a look, a movement. And there is only one thought that gives me trouble: "Has he woken up? Urine? Pressure? Arrhythmia? Relatives?" You can afford it when you have plenty of time — when you are twenty, thirty, or even forty: "I have all the time I need."

I am so eager to finalize my ideas. Therefore now I divide time: three days for surgery (two operations each day), three days for writing and thinking, and one free day. Providing I don't get carried away once again. But how good it is to have a passion. The feeling of youth and fullness of life.

Still I will describe these past weeks, at least in brief.

Here we start...

The week of August from 18 to 24 when I wrote the previous chapter, the thought of returning to simplicity did not leave my mind.

(Could it have such an effect? Will the syndrome disappear? I wish I had returned to the clinic sooner... Four operations — that's not enough... Only two a day is eight operations a week. How many operations must you perform to see if you are right or not? Forty? Fifty? A hundred? You've had other bright periods before, so don't cherish vain hopes.)

Monday through Thursday (25th —28th of August) went by so quickly. They passed with "no problems" (a favourite word among our young doctors, as are the "there we go" of Yuri Gagarin and the American "O.K."). By the way these patients did not give us any fresh evidence. They would have been O.K. without the new method...

On Tuesday I operated on a boy from the fourth floor with "vital indications." This means that without the operation, his life could be counted in days or weeks. He is fourteen, that boy, Sergei by name, thin and pale. And once again an only son. (There are too many unfortunate wretches at present in small and fragile families.) Sergei has septic endocarditis with a defective aortic valve and an enlarged heart. Each day his temperature is just under 40°C; all antibiotics have been tried; due to allergy, he cannot tolerate any drugs. His hemoglobin is only 42 percent. Blood transfusion leads to marked chills... All the attempts to treat the infection or at least to suppress it before the operation were fully abortive. There was no alternative other than the operation to certain death. This was an "operation of despair" — there is such a concept when the chance for survival is minimal. His mother entreated me to operate, since she saw no other alternative.

I deliberately resorted to high risk — it was justified, since it is better to die when operated upon than to die without hope. It should be better for all — for his mother and himself. (The boy has a quick mind — ailing children develop faster.) And then I thought: "Mayhaps the new (old) doctrine will help..." Although "Why should compromise the method? He may die, irrespective of conditions..." But I never changed my decisions to operate for the sake of ambition, so as "not to spoil the statistics." If I refused to operate on patients in serious conditions after a series of deaths, then it was done out of fear of disbalancing the psychological climate for those patients for whom an operation is necessary and safe when there are too many deaths, they begin to leave the hospital out of fear.

They asked me on Tuesday morning:

"Maybe you should cancel the operation. Yesterday Sergei's temperature was 40°."

"No, I'm going to do it."

The operation went on without a hitch. Although it turned out that in addition to the destroyed aortic valve, he had an opening in the intraventricular septum (we call it a "defect") — which means a congenital defect. An artificial valve was sewed in and the defect was closed. Perfusion (artificial circulation) was applied for more than two hours. But the boy woke up on the table and the tube was removed in two hours. We lived in anxiety till the next day: how were his temperature, his heart and liver? Would he tolerate the necessary drugs? But everything turned out fine. Sometimes an operation is such a shock to the body that the whole immune system restructures itself, and its elevated reactivity is reduced. We have been constantly anxious over subsequent weeks. Sergei is still in the clinic, and once in a while he will get chills and fever and we fear to discharge him; sepsis may recur and the valve may come lose. I have done my part. The analyses are good. He should recover.

Two operations on Wednesday and two on Thursday. Another operation was performed by Zinkovsky, bringing the total to three operations with the AIK machine every day, using the same method. It was strange that at night, in the intensive care unit, there were no patients with artificial respiration; the personnel had nothing to do... I could not believe it. Doctors viewed my "experiment" with caution. Most likely, behind my back, they called it an experiment, and added: "The chief is trying to be original, but his little adventure will be a total blunder." But I stayed late at the clinic, nipping all attempts to slip back to the old practices in the bud and did not leave any room for initiative.


On Thursday night, my wife Lida and I took the plane to Tallinn to visit her brother. (I was still on a vacation, and I had been promising to go with her for many years.) I could hardly tear myself away from the clinic and left only on the condition that all the patients were O.K. and that we return on Sunday.

The plane was late. We spent half the night in the overcrowded airport with nowhere to sit down. At the crack of dawn I had had my routine run along the highway. (With my work, it is absolutely compulsory; how can I miss getting my exercise?)

If I were a poet, I would write of the smell of the mowed grass on the side of the road, of willows that rose into the sky like ghosts in the lights of infrequent vehicles. But the beauty was perceived as something auxiliary, whereas my thoughts were always about the same: operations, patients, that I had to call the clinic, and that Sergei might take a turn for the worse before I returned to the clinic.

A prosaic man you are, Amosoff.

We landed in Tallinn in late morning... I had a marvelous time there; I forgot everything for two days and even did not call anybody.

The return by air was also difficult. Planes were delayed, flights were reshuffled, I had even to go to the officer-on-duty, introduce myself and make a show off with tomorrow's operations. That played the trick. The profession is extremely spectacular (we operate on the heart), therefore they all give in. And then I saw once again that they knew me. No, they knew me not as a surgeon or as a writer (they have already forgotten my book The Open Heart), but as a health educationalist: "He is the one who keeps talking about cabbage and running..." They have even devised "to live the Amosoff way"...

Dubious laurels for a surgeon, aren't they?

I returned on Sunday night, kept calling the intensive care unit until I got an answer and found out that everything had been O.K.

Monday was lost for me as an operating day, since I dared not to sign for operations in advance as I did not trust Aeroflot. I don't like to cancel operations knowing how difficult it is for both patients and relatives who have already made up their minds. The results of August were brilliant — one death per thirty four operations with the AIK machine. Before the "new" programme one patient died with a heavy congenital defect. I did not have a single death in twelve operations. True, there was only one high risk patient — Seryozha, others were of the first and second groups of risk.

In general, I was inspired and, although I had to be on vacation this week and write, I put away everything. I had to operate and as much as possible. The rest could be done later...


Tuesday, 2 September — a normal operation day. I sewed in a mitral valve and operated on an adult female with a congenital defect — defect of the interatrial septum and mitral stenosis. Everything was easy, as planned. My hopes were being materialized.

But... nothing goes without a hitch. At least with me.

A spell of bad luck.

On Wednesday there were two operations: the tetralogy of Fallot and the mitral valve. The operation on Nadya, a small girl, went without a hitch. The first assistant, a good surgeon (I don't want to give his name now), made the final homostasis (stopped the hemorrhage), closed the wound, and I was on my way to another operating theatre. I was leaving with a clear conscience: everything was O.K., the girl began to stir, we had to give a larger dose of the anesthetics — she will wake up, for sure.

The second operation... A girl of twenty who was not examined on the "Elema," since everything seemed to be clear, although not so easy. She still went on working a little — a draftswoman, although making herself to do it. (From time to time one comes across such industrious people.) I talked with her mother — she said that her daughter cannot do anymore without an operation, she was fully exhausted. She wanted to live. She was operated in 1972 — commissurotomy had been per­formed at one of the clinics in another town. A professor whom I know, a general surgeon, sometimes "fooled around" with operations on the heart. Let God be his judge, as we used to say, but let him at least tell the truth. And now we have a defect of the mitral valve. I X-rayed the girl, and did not read the case history, I was satisfied with the report of the intern. A high-risk patient, a difficult operation (the Third Risk Group), as in all repeated cases, but we did not expect anything extraordinary.

Kolya Dotsenko made a dissection and had already partially isolated the right atrium, part of the right ventricle, the vena cava and the aorta to switch on the AIK machine and enter the heart.

"Switch it on."

Motors began to murmur.

"We are in the operating regime."

"Pressing out the tapes. Check VP."

"Normal. You may begin."

I opened the right atrium.


This means that the heart is given an electrical stimulus so that it would not contract, and interfere with the operation, so that the air should not be pumped into the aorta.

"The pressure is down."

I quickly dissected the interatrial septum, the blood was sucked off out of the left atrium, two pumps could hardly cope with it... The blood pressure lowered to thirty. I began to get nervous and shouted to Vitya:

"Increase the productivity! Switch on additional pumps!"

And I was completely lost. The thoughts rushed about in con­vulsions. The blood flew from the pulmonary veins in greater amounts than it should. When the aortic valve is loose as is often the case, and lets the blood from the left ventricle, we may clamp the aorta, and in this case it flows from the lungs. The pulmonary artery is overfilled.

A simpleton, a blockhead! What a moron! It was Botallo's duct.

Everything was instantly crystal clear. The blood from the aorta was running through Botallo's duct into the pulmonary artery and from there, through the lungs, into the veins and the left atrium. Therefore, the AIK machine was running half idle, and the pressure was low. If I did not close the duct, I would not be able to finish the operation and the heart would not begin to beat.

And what about the valve? The devil take it! There was no stenosis, to say nothing of commissurotomy. It was simply a broad ring that was causing the deficiency. The prosthesis of the valve was necessary. But I had to close the duct first.

This is far from simple. It is difficult to get to Botallo's duct from the medial dissection as it is commonly closed from the left lateral one. But it is possible. I did it several times myself. However there are pleural commissures after the first operation. The time is strictly limited — the AIK machine is on, the pressure is low, hemolysis (destruction of erythrocytes and the emission of hemoglobin into the blood plasma) is growing, the heart has not been isolated from adhesions...

(Suppose I were to give it all up, leave the operating room, take off my mask and gloves, change, then walk down the corridor and out of the parade for good... And I wouldn't have to look back. Out of surgery forever. Out of life for good.)

That has happened before. And as time passes, the feeling gets Stronger.

But only for an instant. I don't have much time to spare. I have to act. Fast, almost on impulse.

I separated the commissures, isolated the heart, the aorta, the pulmonary artery. Probed deep with my finger between them into Botallo's duct. "Boy, what a scum." That's the way I "praised" that other doctor. He had surely noticed the defective Botallo's duct during commissurotomy. No, for sure, he missed it, otherwise he would have closed it. It could have been done easily from that dissection.

A common procedure is to go around the duct, bring the thread to it, and tie it around. But I couldn't do that, I could only grope for a part of the circumference. What should I do? Time was running out. The pump was barely coping with sucking off the blood, the pressure was low, hemolysis would set in for sure... Despair.

"No, nothing can be done. All is lost."

The only alternative was a clamp. But the duct might break through... the walls were fragile.

I had to take risks! Immediately. It was necessary to prevent the blood from flowing out of the aorta and into the lungs. Otherwise it meant trouble.

I blindly groped at the duct with a long clamp and pressed it.


I did it. The aorta filled with blood under my fingers; the pulmonary artery subsided; and the blood from the veins stopped flowing into the atrium.

A respite. At least the pressure had gone up and the threat of hemolysis was reduced.

Now I had to close the duct along the clamp with separate sutures having a thick flanelette lining. This I did.

I took off the clamp, but goodness gracious, the blood started leaking through all the punctures. The vascular wall would not hold the thread, and the flanelette was soon soaked through with blood. I had to dissect the pulmonary artery and close the duct from inside. Painful efforts. Half an hour had passed, while I had hardly managed to darn the duct. The AIK machine had been on for an hour already. Hemolysis had appeared. I did not believe anymore in a happy outcome.

Finally I could sew in the valve. It was not difficult.

"Defibrillation. We are ready."

I closed the heart.

"Give us a shock!"

The heart began to beat. Shyly, weakly, but to beat. Could it be possible?

No, no miracles. The AIK machine had not been stopped yet when the hemorrhaging began from sutures on the duct.

This was followed by another three tormenting hours. New sutures were put in the duct, aorta, pulmonary artery. The wall under them was collapsing; the punctures let the blood out. The flanelette patches were soon soaked; the blood lost its capacity to coagulate because of the destruction of proteins. But the heart went on beating... That happens on occasion in our surgery when everything is hopelessly lost, but the heart goes on contracting, failing to provide the necessary blood supply even minimally. The brain has died, but artificial circulation maintains a minimum of life. At such moments my only thought is: "Stop it! Give us the right to cease this useless struggle. And may this man rest in peace."

It was already eight p.m. when I left the operating room. Nine hours of tension. I had not lost strength physically, but I was totally wasted.

"Cancel my operations for tomorrow."

A woman for a mitral prosthesis and a man in the Third Risk Group had been put on the waiting list for the next day's operations. I had to replace mitral and aortic valves with comprehensive calcinosis, and there were narrow aortas. He had been operated five years before and had been admitted to our hospital back in July with edemas and ascitis (accumulation of liquid in the abdominal cavity with decompensation of the heart). We did not plan to operate, but his state of health had improved. And I once again gave in. I hoped for a "new miracle."

Now, after this operation, the last ray of hope faded away.

I dropped into the intensive care unit. The tube had already been removed from a girl with tetralogy, but she had cyanotic lips and almost no urine... And what is most important — she was bleeding. The blood was dripping slowly, but steadily from the drainage tube...

Sergei Dekukha, a good surgeon, was on duty.

"I fear we may have to perform a rethoracotomy..." (This is when the chest wound is expanded and a bleeding site is looked for. It is not very dangerous, but undesirable — it often aggravates the state.)

"Well, it's up to you."

Apples and a pot of tea were waiting for me at my office. I didn't need them, since I wouldn't have to sit in the office waiting until my patient woke up...

I had strength enough to run down the hill to the trolley-bus stop. Physical stress destroys adrenaline. I had accumulated too much of it after that operation.

I was home at nine. From my appearance and my voice, Lida smelled trouble. She had learned to do it in 37 years of marriage. No questions asked.

I dined in silence. "Perhaps I shouldn't cancel my operations." I shouldn't show cowardice. We were in trouble because we had overlooked something... We would have to fight and investigate the possibilities of our innovation.

At ten, during the report of the doctor-on-duty, I told him to reschedule my operations for the next day.

Trouble lay in wait for me at the conference on Thursday morning. The girl's condition had gone from bad to worse. Hemorrhaging had continued during the night. Dekukha performed a rethoracotomy. He found the bleeding site on the wall of the ventricle. This meant that the assistant had overlooked it. I did not reprimand him for it. Un­fortunately, such things happen. Although it was the second time with him. There were other sins as well. But why should I scold him if I made the same mistakes on occasion?

We discussed the previous day's operation. A whole chain of errors: an intern had not reported to me that he suspected aortic incompetence. In that case we would have made an examination on the "Elema" and would, for sure, have discovered the problem with the Botallo's duct. We would have closed it quietly as we do with children and sewed in the valve a bit later. This would have been a usual risk. I gave a piece of my mind to that and other inattentive doctors.

"But I am more to blame for it than you others. A surgeon is obliged to look through the case history himself and sign it before an operation. And an intern has to bring it for signature. All this being said and done, the operating surgeon is to be blamed for the death, resulting from hemorrhage. Thus I have to be blamed for it."

The girl from the day before was in bad condition. Confusion, cyanosis. We had to intubate her and apply artificial respiration as we had done before.

I left for the operating room with a heavy heart.

I sewed a mitral valve in a woman without any complications.

The second operation — the replacement of two valves — was rather complicated from a technical point of view, although it proceeded without a hitch. I won't describe it. A lot of time was wasted isolating the heart from commissures, followed by three hours of perfusion. The valves were coated with calcium to such an extent that I had to crush it with forceps to get it off. We hardly had to shock the heart after the AIK machine was switched off. We took him off the table in a satisfactory state.

But he did not wake up. For two hours I sat with the boys at his bedside in the intensive care unit — there were no signs of his regaining conscience.

The first patient was also in serious condition: low blood pressure, almost no urine; we could hardly restrain ourselves from intubation.

We had to perform a tracheostomy on the girl with tetralogy (an opening in the neck, leading to the trachea) and we failed to transfer her to independent respiration.

A surprise lay in store for us on Friday: the patient with two valves regained consciousness. Not completely, but quite acceptable. He gave us a ray of hope. And the girl seemed better. She began to breathe on her own.

That was all for the week. The only thing left was to listen to records of the organ music. I would prefer not to think at all, to forget about the clinic. But how could that be possible? My thoughts constantly return to operations, patients... Perhaps I should have closed the heart as soon as I discovered the Botallo's duct, stopped the AIK machine and then closed the duct through a lateral dissection. But the heart probably wouldn't have started beating then... Or should I have done the same but right after the application of the clamp? Then it might have been possible... It is difficult to think of a better alternative under stress... And that lousy creature, my assistant, was fully responsible for the complications with the girl... The hemorrhaging had spoiled the picture...

There was no use crying over spilt milk.

Should I continue or interrupt my thoughts to write? My vacation was passing... What writing did I mean? I had to see for myself whether it was an accident or a pattern. I had nothing left to do but operate. And as much as possible. I had to sit at the patient's bedside myself and trust no one.

Tuesday was also "without problems." A young male with a tetralogy of Fallot and another one with the incompetence of the aortic valve; a prosthesis was sewed in.

By Wednesday my soul grew lighter — there were four patients already. But...

Once again two operations on Wednesday.

The first on a boy, twenty kilograms. I talked to his mother before the operation. I was a bit hesitant in recommending an operation: "He has a defect of the intraventricular septum and high pressure in the pulmonary artery. Lags behind in weight, and is often sick. The operation is not too complicated, but it should not be postponed." Frankly speaking, I had hoped that not only those with valves, but small children would also recover better with the new method. They, the little ones, have remained a stumbling block for us for many years.

A woman in her forties, elegant, considerate, apparently intellectual, insisted on the operation. If I had frightened her, would she have insisted then? Some demand that we operate at any risk: their seriously ill children make their lives miserable; they want their children to recover or to free them from their cares. But not this one.

The operation was quite ordinary and went off without a hitch. The boy was already waking up as I left for the second one. He had to be given an additional dose of ether.

The second was a patient with aortic valve incompetence. Everything went O.K. with him, too.

On Sunday I took Cherie along the slopes of the Goncharka River. There is such a place in Kiev — a deep gully with old houses at the bottom. The slopes are wild. Fresh air, the smell of trees. The leaves have already begun to fall. Farewell to summer. I walk back and forth along the path and Cherie runs around like mad, jumps, and fetches sticks. She is my favourite. "Our kid" is what we call her. She is our second Cherie; the first died a year and a half ago, also from surgery. I described her death then, and will perhaps, put it into this book as well. I discovered the world of animals through her. But I have no time for them now.

Rather gloomy was the end of the week.

Two operations have already been scheduled for Monday...