6.12.1913  -  12.12.2002

Books of N.M.Amosov

Diary. September, 8-14

There were no unexpected developments on Monday. The girl, Nadya, is much better now. She has already been discharged. She came with her mother to say goodbye, brought flowers, and gave me a kiss... It's touching when they leave that way — healthy children with a whole lifetime ahead of them.

"But don't spoil her, please. She will be almost normal, so treat her accordingly."

The other one, a woman of forty-five with a serious defect of the interatrial septum and incompetence of the tricuspid valve, is still in the clinic. The operation was not difficult, but was rather hard on her.

At four p.m. (that was too early) when I left the operating room, the first boy was still in the intensive care unit. His mother was waiting on the staircase. She looked at me in silence. Many relatives are shy to say hello to me, fearing to seem obtrusive. I said hello to her myself. I found the boy in the ward without a tube — he was fully conscious. A thought came to my mind: "Would the new method make it easier with children as well?"

I comforted his mother in the corridor.

I sat down to have tea in an excellent mood. It seemed that today I might be able to leave early.

Suddenly N. rushed into the room. He had assisted me with the boy.

"Nikolai Mikhailovich, I am afraid I have done something wrong once again. He's hemorrhaging. We'll take him to the operating room at once."

"How could that be? I just..."

I took to my heels. The patient looked as if nothing had changed, but the jar of the drainage tube had about 200 cubic cm of blood, which was flowing rather fast. It was clear to one and all that the wound had to be reopened. Once again this N.! But up till now I saw nothing so terrible: the blood pressure had not dropped. He had just turned a little bit pale. But he was still conscious.

"Rush him to the operating room."

Then I went to finish my tea.

But I could not drink it. (I feared my assistant would make a mess of it!) I got up, slowly went up to the operating room, to the dressing room to change. Our new operating room was spacious, but I heard a suspicious fuss. My ear was trained for all types of noise. Dekukha entered from the "sterile" part of the corridor.

"An arrest there."

That meant a cardiac arrest. At the beginning I did not get the meaning.


"It's your boy..."

I felt sick at heart and, I do not know how to put it — I turned brutal — this could be more accurate.

"Scum! And you (to Sergei) get back in there!"

I found a peaceful atmosphere in the operating room: Vasya was giving anesthesia. N. was with some young doctors over the opened wound of the child. I saw tiny drops of blood on the sheets of the scrub nurse's sterile table. They explained:

"Arrest while opening the wound. We immediately began massage, defibrillation (restoration of the normal cardiac rhythm by an electric discharge) and the heart began to beat. It was still for a minute or more."

I felt somewhat relieved: such a short arrest might have no consequences, but that is not always the case. They went on telling me (I do not remember who, it seemed to be N.):

"A small branch of the coronary artery on the anterior surface of the ventricle was bleeding. Here is the blood on the table — it spurted out when the heart began to beat..."

"How did you manage to cut it? We did not open the ventricle."

"I do not know. Apparently, it was bleeding all the time — we found blood clots there."

No doubt the heart was quite operational, the loss of blood until then had been compensated for by a spasm (remember the paleness?) and then the regulators could not bear it any more, so there was an arrest. Now it was clear to one and all, but quite a big artery had to be cut — judging from the drops... How could that be? We had not done anything on the anterior surface. Could it have happened when the assitant sewed in the electrodes?

I didn't ask him that. I didn't even want to look at him.

"Dekukha, you will finish the operation."

Vasya, Vasiliy Vasilievich, the anesthesiologist, was confused. He was still in the ward when I came, and it was in his presence that the arrest took place. He was also responsible for that.

I examined the pupils — they were mydriatic... Mydriatic is a very bad symptom. Could it be that the brain had died? And they said only a minute. I doubted it.

"Vasya, do you think the danger is over?"

"Might be..."

It had to be. If everything was the way they had told me... I didn't think they would lie — it was not the rule with us — but perhaps they simply did not know when it had stopped — during transportation, lifting, intubation...

And now we would have to wait. Blood circulation was good, perhaps the brain would restore itself.

I headed for my office. The secretary had already left. I warmed up my tea. I didn't think anybody would interfere. When I was leaving, I saw that the second patient was being taken from the operating room into the intensive care unit.

The child's mother was standing on the staircase. She had seen her son being taken back to the operating room. But she did not ask anything, and I told her nothing. What could I tell her? I was ashamed. She must have figured out something was wrong. Surely they weren't taking her son back to O.R. for nothing.

For about an hour, I sat at my office doing nothing, not even reading. I finished my tea, ate an apple and a pear. (Delicious pear. I wonder where they got it?)

Operations cannot save all people from death. To hell with it! There seemed to be no end to small blunders. And I was no exception! Last week I had not even read that man's case history...

Once again it was seven p.m.

I had to see my patients and go home. Tomorrow would be Thursday, the last operating day of the week. Then would come Saturday and Sunday. Time to relax.

The youngster with the aortic valve in the intensive care unit was O.K. Gennady Pankov was going to remove the tube, so he poured a solution down it to enduce coughing — to wash and clean the trachea and the bronchi. This is not a pleasant procedure — the patient was choking, twisting his head, and rolling his eyes maliciously... He would have shouted something obscene, but the tube did not allow for even a sound.

"Don't twist; just cough! Cough as hard as you can! I'll take it out soon, and you'll feel much better..."

The anesthesiologists seemed accustomed to the changes already ana were not afraid of early extubation...

The boy was not in the intensive care unit. That meant he was still in post-op. That was too bad. Or was Vasya afraid to transport him, so as not to shake him? Not infrequently, transportation aggravates the patient's state.

I'm on my way to the O.R. Is he awake or not?

"He's been awake for a minute or two, no more..."

The operation room corridor was already bathed in semi-darkness. An aide was washing the floor. Light poured from the post-operating room. And there was suspicious noise. I hurried.

N. stood over the boy massaging his heart with hard strokes. Somebody was fussing with injections. Vasya was standing with the electrodes of a defibrillator in his hands, looking at the oscillograph... He looked confused.

"We have been massaging for a quarter of an hour... We can't get the heart to beat..."

I did not want either to ask or shout. It was all useless now. That meant that the brain had died, it meant that the heart was still for more than two minutes... They did not even have the opportunity to take him to the intensive care unit... It is better when patients die in the ward, several days after the operation. That gives relatives a chance to get used to the idea.

She had apparently seen from a distance when they took her boy to the operating room in the morning. Or, she might have walked by the stretchers. I had seen her in a white medical smock — apparently she had agreed to help the personnel; she had worked in our department a bit for a pass to the ward. Many mothers do it that way — it's a great help to us (we are short of aides; no one is eager to take this job). The boy did not have time to bid farewell to her — children usually slept after the drugs given to them before anesthesia.

For half an hour, I sat indifferent, fearing to leave and meet her. They went on massaging, injected adrenaline into the heart, defibrillated; his small body jerked from electric shock; such tender fingers, small nails with black edges... Languid waves on the oscillograph. No contractions.

"Give up... It's hopeless."

But they would not listen to me and went on. They — N., Vasya, Alexei, and a nurse — wanted to revive him. They could not reconcile themselves to the death.

I got ready to leave. I had to live anyway. There was no other door from the operating room, so I quietly opened it and looked out.

His mother was standing on the landing clutching at the banister, and her eyes glued on the floor. She rushed up to me.

Hoarsely, she asked:

"How is he?"

"He has died."

She recoiled, collapsed on the stairs, but didn't cry. I went down to my office. Didn't pause to console her.

How? Which words to choose? And what right did I have?

Home. Out into the street. Into the darkness.

But in the corridor of the ground floor, in front of a waiting room, a woman threw herself upon me, yelling:

"Doctor, dear. He has died. How could it happen..."

I could hardly break away from her. She was crying her heart out.

"I am Volodya's grandmother... Tell me what happened. He was already..."

That meant she had been told while I was dressing. Well, nothing could be done, I would also tell her the truth.

And I told her everything. That N. had damaged the vessel while closing the wound, and this caused the death of the patient.

"Does that mean that you are responsible for it?"


"Tell me who that doctor was. What's his name?"

And I gave her the name: doctor N. Away with the cover. Let them take the responsibility... And with this I left...


The whole night and the next morning, I thought about the same: how to avoid mistakes. I decided on a long-known way out: to increase responsibility through organization, discipline and stringency. And I had to set an example. That night, before I went to sleep, I made an outline of my speech for the next conference. It is still in front of me now...

That conference proceeded according to plan.

Our usual procedure right from the beginning: surgeons reported — twelve operations for today, then told of the day before's operations: I did the same.

"I will tell you about second operation at the end of the conference."

Reports of doctors-on-duty were now simplified to a great extent. Patient slept well without artificial respiration the night after the operation. Just think of that; previously up to seven patients were on artificial respiration at once. Doctors and nurses were literally ready to drop from fatigue.

"Now let's get to the main thing. Yesterday's case and the conclusions to be drawn from it..."

"Everything was O.K. in August, worse in September. We make mistakes. Examples: a boy with the Botallo's duct died. Last week — incomplete examination, a diagnostic mistake... There were hemorrhages, rethoracotomies, suppurations.

"The right to an error... No errors are made by those who do nothing. Don't seek consolation from this proverb. It is true that mistakes are inevitable for those who operate frequently on patients in serious condition. But within reasonable limits."

This was my introduction. And now yesterday's events.

(I told them about everything in detail. Including the mother, the grandmother, and the shame I bore for myself and the clinic. I spared no emotions.)

"And now I will speak of Dr. N. A good chap. He has assisted me often and is pleasant to work with. Seems to be quite reliable.

"But last year a patient died of hemorrhage into the pleural cavity after a puncture he made. The death had no repercussion since the patient was initially in serious condition.

"Then: There have been two rethoracotomies in my patients alone after he closed the wound. The latest was only last week. My opinion: He performed hemostasis carelessly. I did not reprimand him for that at the time. But I did not forget it, for this rarely happens to me.

"Now about yesterday's case. If it had been the first time, I would make no comment. Each of us can make blunders. We have to ignore them if they are few and a man performs many successful complicated operations.

"N.'s merits? His thesis is in progress... But the thesis is for himself; his patients do not need it. Operations? Only conventional, simple Botallo's ducts and several commissurotomies... Mayhaps he has made interesting proposals? Designed instruments? Once again the answer is negative.

"There must be justice. A driver does not run over a pedestrian on purpose, but he is brought to trial for that. The slightest punishment is that his driver's license is revoked temporarily, or even permanently. But if he is responsible for someone's death, he will be thrown behind bars. Here is a question for you: would you agree to be operated on by N. or send your children to him for an operation? I would not.

"What shall we do? It would be better if he would leave the clinic. What is the alternative? Pardon him? Never. If he remains at the clinic, then we send him to work in outpatient, to do consulting for a year, so he will not show his face at inpatient to say nothing of being present at operations. I will delay his thesis for a year. I will deprive him of his post as junior researcher, providing there are no complaints from relatives and no trial. I will not protect him otherwise. There must be personal responsibility for what you do.

"I can decide the fate of N. myself. But I don't want to make a mistake... And I am not indifferent to your opinions. Therefore, let's take a vote. Miroslav will hand out ballot-slips and you put your signs: a cross — we let him work in outpatient, a circle — he has to be fired. Miroslav, hand out the ballot-slips. We'll break for five minutes to vote. Here is Anya with the ballot-box..."

In five minutes, the conference resumed its work. While they counted slips with crosses and circles, I repeated my former disciplinary rules. Just then, they brought the summary report and a pile of slips.

I made the results of the voting public: 32 to let him work, 26 to fire him. The conference was over. N. would work under my conditions. They are all too kind... I am not.

Was I satisfied with that decision? Not at the beginning. As soon as I recalled the mother and the grandmother a wave of anger rose inside roe. Several days later, I made my peace with it. What should I have done according to human morals? I do not know... If a person makes a mistake while doing his utmost, most attentively, then he may be pardoned. I am not confident that N. was fully attentive, but neither do I admit to his complete negligence. If you want my opinion, he was to my liking. Was, because I have not seen him for a month. Maybe he does not work with us anymore. I will have to inquire.

If we are to be just, then, in our doings, we have to protect patients not only from the negligent and the careless, but also from those honest but unlucky persons who "want to but cannot." I do not want to say that the profession of surgeon requires some super talent; any middling doctor can be taught surgery, although the clumsy and the indecisive are an exception. Such persons must be deprived of their rights if they themselves do not understand that they are dangerous and do not go into some other branch of medicine.

In the men's dressing room, we had a list of "victims" — those who had been fired. I never saw it myself. But when I was in the mood, my boys liked to remind me of them. "That one was good and that one... but you fired them." This is a difficult question. It needs analysis.

Then I was reproached by some of my employees during a moment of revelation...

Why didn't you let N. have his say? Or any of the other people?

The same could be said by some of my readers.

They think that everything should be solved on a democratic basis, and that justice is the privilege of the majority. I am not at all sure of that. N. told me during the operation that he did not know how the artery had been damaged. It is true that he did not know. And I do not know either. It is impossible to say whether it was negligence or an accident. All I know for sure is that it should not have been either. I know that nothing of the kind has ever happened to me. And any of the "democrats," if it were their son, would want not voting, but strict punishment. Once again, this idea of the driver who runs over the pedestrian. Very often, the victim himself is responsible: he ran across the street in front of a vehicle. In our case, the victim is defenseless and this makes us merciless with respect to ourselves and other people. I do not consider it to be a tragedy if a doctor of 26 takes additional training in the outpatient diagnosis of heart defects before he continues his surgical career.

You see for yourselves that I cannot calm down and put this out of my mind. It is very difficult to solve moral problems. Moreover, when you yourself act as an equal. This is the main difference between a surgeon who is an administrator as well and other surgeons. (Are you sure you would have been satisfied with the decision taken by your chief if you were N.? I think I would. But I realize that the potential for reincarnation is limited.)

The week ended peacefully after that shock.

Shall I write further — day by day, week by week — until I make peace up with the present?

There was no joy, since success was only partial. I experience it anew when I read through these scant Sunday notes. There was no other life during the week for me but the clinic.

Besides operations and everything related to them, the clinic puts out scientific papers, theses which I have to look through, or at least scan over, so as not to miss any stupid mistakes. I also have to hear all the complaints about the director and economic managers, check up on how repairs on the old operating room are coming along, and elucidate the situation with personnel and hostels. I do not want to exaggerate, but I do not take to heart anything that does not directly jeopardize "production." When, for instance, the central heating was not switched on time — that disturbed me, and I criticized those responsible severely.


The next Monday, 15 September, was once again an unlucky one.

A girl of seven, 21 kilograms; an intraventricular septal defect and stenosis of the pulmonary artery. Could the operation be postponed for a year or two until she grew a little bit and put on weight? Possible. However, if we followed the recommendations of science and experience the world over, she should have been operated on long ago... The experience the world over, but not ours. So that is what we did — postponed it as long as possible without increasing the danger. We have been doing this for almost 20 years, and every time, we feel our inferiority. Nowadays, with the new achievements in valvular transplantation, it seemed to me that we could operate earlier. But I was careful with relatives and did not tempt them. However, I tended not to refuse those who pleaded for us to operate. This was situation with the present girl, Valya.

"We are so tired of living with constant anxiety, fcivery doctor who examines her scares us: 'Congenital defect... There is no other alternative but an operation... otherwise it may be too late.' Please do it, Professor Amosoff. Don't postpone it any longer. This is already the year we have been coming to your clinic. Our daughter should be in but she stays at home."

I did not persist. (I could have.)

The operation was quite normal. A patch into the defect, expansion of the pulmonary artery, perfusion for 42 minutes, perfect hemostasis, my work. Left for the second operation in a peaceful frame of mind.

That second one was extremely difficult. If I had known it would be that way, I would have refused to operate. But we underestimated the difficulties during the examination.

A young man of 25, a driver, cheerful. But cyanotic. And that was his great concern. Hemoglobin more than 100 percent, edema. (But he kept on working.) The diagnosis was made: a major defect of the intraventricular septum and stenosis of the pulmonary artery, similar to a Fallot's tetralogy. Formally, the diagnosis had been confirmed, but the anatomy... An enlarged heart; aorta and pulmonary artery springing virtually off the right ventricle, a seven cm defect of an intricate shape in the septum. The heart muscle was thick, altered as a result of extreme hypertrophy, would not hold sutures. It was impossible to describe all difficulties of the operation. Perhaps I did not do it correctly. I have never overestimated my capabilities. Could be. Anyway, for me, this operation was extremely difficult. I was assisted by Petya Ignatov and Larissa. Good assistants, but I found fault with everything out of my impotence to do it well and quickly. We sewed an eight cm patch into the septum, another one, external, even bigger, into the right ventricle to expand the entrance into the pulmonary artery.

All this took 100 minutes of perfusion. Three pumps could hardly cope with it, sucking the blood out of the heart cavity. (In adult cyanotic patients, up to one-third of all the blood runs along pulmonary anastomoses between the aorta and pulmonary artery, and all of it flows into the heart, impeding the operation.) This resulted in hemolysis; the blood had almost lost its ability to coagulate. When we finally stopped the AIK machine, blood oozed out of almost all the tissues. We spent another 4 hours to stop the hemorrhaging. There was almost no urine, blood pressure was low; little hope that he would awake...

Only a surgeon who has gone through all this can visualize all these difficulties. How many times did I curse myself and that man... (Without the operation, he would have lived for another five to ten years, no more. In twenty-five years of heart surgery, we had seen only a few cyanotic patients over forty years of age.)

There is an end to everything, be it good or bad. At eight p.m. (after ten hours of operating on the man) I left Petya to close the wound and went to change. I will not say that I was dead tired; I could have worked more. The psyche is something. But that is not the point.

Alyosha said cautiously:

"There are problems with your first patient..."

I had completely forgot about her: I was perplexed since I did not expect anything bad.

"Why didn't you tell me earlier?"

"She won't wake up... Convulsions. How could I trouble you when you had all that trouble here."

He was right. I could not have helped them, but would have operated even worse.

I went to see her. Her pupils were different sizes. She was jerking, they had to inject tranquilizers. "Cerebral cause." Too bad. I am sure the air was not getting from the heart; it was too easy an operation. Vitya was also reliable with his AIK machine. Once again these mysterious complications. Independent respiration was out of the question... They are already cooling her head with ice bottles — op­posite the cerebral edema. They infused drugs. But I knew it would be almost impossible to save her. Once again two deaths. Both were still alive, but I was already interning them... Regrettably gloomy prognoses are very often materialized. This driver L. had little chances after the operation.

Let me have tea to drown my sorrows while they closed the wound and took her out.

A nurse in the corridor was friable, aged, important. Looked at me with regret. The news about the girl crushed me at once... I was just too old for it.

"Anya left the keys for you..."

My office was big. Designers planned this office for the manager of a large Institute for Cardiac Surgery. Then the Minister of Health ordered costly hand-made furniture. They had been working on it in Lvov for two years, but they had not yet supplied the whole set. A table, a small one, book cases, and two walls were decorated in artificial leather — everything up to the mark, but they had no time to supply chairs and a sofa: I used the old ones that were all ill-matched. I kept an eye on my old armchair, a small table, and a bookcase — I'd had them for twenty years in my other office. I was planning to take them to a small ward later to do consulting or simply doze until somebody entered out of politeness.

By the way I am not pretending. If it gets to the point that I cannot operate, at least the way my assistants do, I will leave for good. But this decision should be treated seriously. The whims of the Lord are inscrutable. Now I would put it in a different way: "Self-organization of a complicated system is unpredictable." Determinism and uncertainty are the most important philosophical issues. I am more inclined to the former. Possibly as a result of poor physical education.

These or similar fragmentary thoughts lazily glided in my brain in the intervals between the main thought: "What shall I do with these two patients?"

"What can I do now? I just have to wait."

This I said out loud. The girl — yes, it was just a matter of time. The young man — much could be done yet. What if they couldn't stop the hemorrhage? He would not survive thoracotomy. Should I wake him UP or keep him on artificial circulation, bearing in mind his critical condition?

I was the only one who could answer these questions — nobody else. I did not trust anybody anymore. I had to call home.

"Lida, I have just left the operating room. I do not know when I shall go home. I'll give you a call. Trouble here."

I sat in the ward by my patients, mainly the driver, till midnight. Vitya Sinelnikov took him into the ward with satisfactory blood pressure; urine slowly dropped into the vessel; it was only lips and feet that were still cyanotic — from the vascular spasm.

"Wake him up, don't let him sleep. If he regains consciousness, we'll remove the tube..."

"When he's in such a condition? You can't do it, Nikolai Mikhailovich. He'll kick the..."

Vitya's language is very figurative, but my old memory could not hold all his maxims.

"Driver, can you hear me?"

He barely nodded his head.

"Is the tube in the way?"

Once again a nod. Some more questions and we saw that he had regained conscience.

"Switch off the AIK machine. Have you got me? Don't dodge. I take all responsibility."

Vitya was firmly convinced of the necessity of artificial respiration, at least for the night, but he had to obey.

A tracing system, a monitor from the GDR, highlighted the ECG on the oscillograph; a sound signal beeped in time, an arrow showed the frequency of heart contractions. Unfortunately, the blood pressure pickups were out of order; therefore, it had to be measured manually, the old way; Vitya measured it almost continuously.

Nothing dramatic happened under independent respiration. "Self-reliance" is the term anesthesiologists use when a patient provides himself with oxygen.

In an hour the tube had been removed. The man's consciousness had been suppressed, but it could have been revived easily. He even pronounced several words in a hoarse whisper. The tube had been in his trachea for almost twelve hours.

But then hemorrhaging began. Blood dropped frequently from the drainage tube into the ampule, and if we "milked" the tube (there is such a vulgar term) it flowed in a stream. Bitter thoughts: "You cannot save him now..."

The nurse prepared him for an operation. And Petya Ignatiev had to be found. Until then, they would give him fibrinogen.

Fibrinogen is the blood protein which promotes the formation of a clot; it is heavily destroyed under artificial circulation. We gave him four grams in the operating room, but what was left to be done? Thoracotomy, wound revisions, new intubation, anesthesia — all this was too dangerous and did not guarantee that the hemorrhaging would be stopped; moreover, it was being caused as a result of some coagulation disturbance and not as a result of some surgical mistake which could be corrected.

The nurse had already scrabbed before the operation. Sleepy Petya had come. (To assist for nine hours was much more difficult than to operate oneself, although he had been a good sport in the past.)

But after additional four grams of fibrinogen, the hemorrhaging decreased to allowable limits. It was already midnight. The girl was no better — still unconscious. There was nothing more that I could do. N. was also among those on duty. He gave no sign; me, too; as if nothing had happened.

Half past twelve. I ran towards my house, having called before so they would not reproach me for hard-heartedness.

A trolleybus caught up with me when I was almost home. I had run for 45 minutes. ("See what endurance!" — such boastful thoughts wandered somewhere in the back of my mind, breaking through the barrier of self-criticism.)

Nothing good came of it.

True the girl Valya had regained consciousness by the morning; during the night, she was extubated. I was greatful to her.

The driver was rather tense on Tuesday, but did not give us any cause for worry. However, the following Monday, at dawn he had a sudden heart arrest and they could not get it beating again... I was informed of this by the doctor-on-duty the next morning in the corridor. I was thunderstruck...

That's how hopes vanish...

But the whole week, I performed two complex operations a day. Sewed in three aortic valves, tetralogy after anastomosis, closed intraventricular defects in other kids. No fatalities. One was extremely small, 15 kilograms, could hardly get him awake, then he had convulsions; we had to perform a tracheostoma. He was literally brought back to life by our intensive care physicians Natalya, Sveta and Larissa.

Finally, the boy came to say goodbye with his mother: he was a funny creature, bespectacled. Later, I saw Natalya give him a kiss at the entrance to the intensive care ward. I told his mother how this kind woman held him in her arms almost the whole night. I was not sure whether the mother would come to thank her otherwise. Intensive care physicians, like anesthesiologists, seldom receive flowers or gratitude, although half of our successes (and failures) are due to them. They are our "unsung heroes."

Here I have to take a breath - my days as a writer are over, and tomorrow come the days as a surgeon. Tomorrow u. Wednesday; two complicated operati6ns ahead. Wait till Sunday.