Nikolay Amosov    WORLD OUTLOOK

The new year has been rolling forward like a snow ball. I want to write down the main events of the last two weeks. Actually, they were uneventful: just swinging back and forth, like a pendulum.

One day I was going to the hospital by tram. It's a long way, and I take one and the same tram every time. So, I was sitting by the window when I was joined by an ordinary looking middle-aged man.

"Are you Nikolai Amosoff? May I join you?"

What should I answer? "Of course." Maybe I sounded impolite, I don't know.

"You saved my life in 1953... Don't you remember?"

I'm very cautious when people say such things. At the same time, it's a pleasure to hear these words: man is weak.

The man who joined me told me the following story.

He was a war veteran with many decorations who had been badly wounded in the spine during the final days of the war. Until 1953, he had spent most of his time in hospitals. The problem was a large piece of shrapnel embedded in his spine and another in the chest, close to the root of the lung. Continuous suppuration and fistulas resulted. All in all, he had undergone eleven operations which hadn't brought any radical improvements. He told me that I had removed the shell fragment from his spine, cleaned up the cavity and put in a "tube" (i.e., a drain)-. According to him, I had said that the wound would heal. It did. The man developed a liking for sports: jogging and swimming in rivers and lakes in winter. His health had improved; he was in perfect shape, and nobody believed him when he said how old he was.

As he was telling me his story, I recalled those distant years when I had first arrived in Kiev and was put in charge of a department in a hospital for war veterans. Most of the patients had shell fragments and bullets in their lungs and suffered from abscesses.

Well, there are some pleasant moments in this life. I don't know whether I saved his life or not. Perhaps I did: the suppuration would have killed him inevitably. And now he was not only healthy but looked happy...

Yesterday had been a hard bay: I arrived at the hospital early in the morning gripped by anxiety — two of the three patients to be operated were in the highest risk category.

The first was a man of forty named Semyon. He had undergone commissurotomy eleven years ago and had been admitted to the hospital two months before: thin and weak, with an enlarged liver and edema. The results of the examination showed that the mitral valve was entirely calcinated and worst of all, the lungs were in very bad shape: his breathing potential was only forty per cent of the norm. We tried to discharge him several times, telling him about the high risk of the operation, but he refused off-handedly. We replaced his mitral valve with a prothesis the day before yesterday, and there were no complications, disregarding a mild psychosis — he's too talkative. This is quite understandable: he'd been walking on the brink of an abyss for many years, balancing between life and death, and now he was on the side of life. Not yet, actually: he had just made the first step in that direction. A little pneumonia or infection would definitely kill him, but he does not know this. We tried to scare him before the operation, but now we're doing everything to cheer him up.

The second case is a woman from Odessa, Zinaida. Her condition is the same, if not worse. We admitted her because there was no alternative — she might have died on her way home. The first man has poor lungs, while Zinaida's liver is barely functioning, and she has rheumatism besides. We treated her and tried to discharge her.

I had a serious talk with her husband: "The risk is extremely high. I cannot refuse to operate; there is some chance, but it's very slim. Please, take her home, we can't keep her here: the treatment we're doing is the same as in your town." He refused. "O. K., then sign the required papers," I said and dictated the standard form: "I hereby insist on an operation despite the warning of extreme risk." Then the bargaining began: he wanted to write that he "agreed to the operation." We wanted the word "insist." Finally, the husband called her sister and brother in.

I tried to persuade them all over again, saying that I could not operate when the risk was so high. They kept asking me: "Will she die without an operation?"

What could I tell them? She could hardly survive at home. It was difficult to say how long she would live in a hospital. In any case, time was measured not in months but weeks.

Finally, I was ashamed that I had cornered the man, demanding the word "insist" from him and told my assistants that we would do without any paper.

We operated on her the day before yesterday; her condition is quite tolerable, but she's also talking too much.

During one of the weekly conferences, I had a quarrel with one of my assistants, Yuri — he had accused me of constantly changing my instructions and guidelines, etc. I explained my stand to him — very politely — and asked when he was going to begin a new study of the heart functions... Without any afterthought, he said:

"You don't read medical journals thoroughly — just the titles or abstracts. I'll read them and report back..."

What else could I do? I blew up sky high: my nerves were shot — I was afraid of the two forthcoming high-risk operations, not to mention the third, ordinary one.

First, he was wrong. Second, such things are not said to the elders at least publicly.

I was very rude to him calling a milksop and even worse. I find it disagreeable to recall the event: I feel ashamed that I debased myself to his level. Relations between us are strained now, and he's one of my closest assistants. An excellent specialist in his field. I'm even a bit scared: what if he resigns? I won't be able to find another like him, so it's better to apologize — our work is more important than my self-esteem.

So, you see for yourself what complications arise in our profession. In general, I don't bear a grudge against my subordinates for their outbursts, I even tolerate their rudeness, if they are right of course. A man must defend his positions. However, it's a rare quality among our medics — they are much too dependent on their superiors.

Unfortunately, that Thursday didn't end as well as I had wished. The first operation was an easy one: a congenital aortic stenosis. The second one was a mitral valve replacement. Both went well.

The third was a serious case: a man of thirty-six (he was admitted only a week ago). In 1968, I had placed his aortic valve with a prosthesis: he suffered from congenital endocarditis. Although I had very little experience at that time, everything was all right... However, his condition worsened several years after the operation; he came to us for an examination and we saw that the prosthesis was about to tear off — some of the stitches had ruptured, resulting in decompensation. In 1974, I replaced the prosthesis, Repeat operations without the AIK machine are always difficult, but there were no complications this time. He came to me again last year with the same problem — partial rupture of the valve. His condition was more or less satisfactory, and I decided against the operation. Now, he was back to the hospital, and his state had worsened drastically. We made a contrast examination: it showed that the prosthesis had torn almost completely away. There was no chance but operate without delay.

The operation lasted ten hours. To reach the heart, we had to go through numerous adhesions, cutting them millimetre by millimetre and cauterizing the cuts. The aorta was five centimetres in diameter and very thin. The prosthesis was almost half torn away, but the tissues were in normal condition. I had no idea why it tore away. We put in a new valve. Perfusion lasted two hours. Unfortunately — as it often happenes in similar cases — the main difficulty came at the end: all the tissues were bleeding heavily; hemostasis took two hours, and blood loss amounted to one litre...

I left the operating room at ten in the evening. I took off my shoes and kept walking barefoot on the cold floor of my office, cooling my burning feet. Three operations in one day, eleven hours at the operating table — and I'm sixty-seven.

The doctor-on-duty reported in the morning that the patient's condition was bad: they had been unable to wake him, he was being kept alive by artificial respiration.

I found him in the state I'd left him the day before: all processes drastically inhibited, respiration controlled by a resuscitation apparatus. During the night, the doctors-on-duty had made several punctures of the right and left pleural cavities — they thought the lungs weren't breathing properly, that they were being suppressed by blood or air.

The other patients were in relatively satisfactory condition: the psychoses of Zinaida and Semyon were disappearing. (It's funny that in the intensive care unit, the doctors and nurses call the patients by the Christian names, regardless what they are. They say it's easier to remember them all by name and, besides, it's more homey. The patients don't seem to mind.)

I dined and sat down to write in my diary. Suddenly, the doctor-on-duty called and said that the patient's abdomen was in bad shape. We decided to call in Dr. Sitar — he's the surgeon who does all the abdominal operations in our hospital: all the others have forgotten how to do them. And I don't want to start anew. Sitar phoned me around ten in the evening:

"I suspect the thrombosis of the intestinal blood vessels... If I'm right, the patient will not survive an extensive stomach resection: his condition is very serious."

We agreed that he would make a small abdominal section (laparotomy) and have a look: if the intestine was black, he would not go any further. Maybe there was something else. In any case, the catastrophic condition of the abdomen required an operation. It is no good when a corpse is forwarded for an autopsy without a diagnosis. Please, do not be shocked: an autopsy for us is a part of the technological process, as it were. It also helps to advance our knowledge and serves a means of control on our work.

I can't concentrate on the diary now. The only thing I can do is await the outcome of the operation.

Saturday, five in the morning. Insomnia, but it's too early for jogging: I'll wake up everybody in the house. The best time to sit down and write in my diary. They phoned me yesterday around eleven in the evening and said that Sitar had opened up the abdomen, found a lot of blood there and was looking for the source of bleeding.

Good heavens! Where was the blood coming from? The most probable source was the damaged liver: it could have been done during that first night when the pleura was punctured.

(The reader will definitely condemn me — what a callous man! Instead of going to the hospital to have a look at the patient he stayed home: but there was no point going there, and the night would be lost.)

I told doctor-on-duty I would be at the hospital around ten in the morning and asked him to have the analyses ready by then. I'm a rare visitor at the hospital on week-ends, but this was an exceptional day — I had to.

And now I can tell you a story about lukich. In principle, this is a patronimic, from Lucas. Dr. Sitar, for example, is affectionately called Lukich — after his father's name — by many nurses and junior doctors. But the story I'm going to tell now has nothing to do with him. It's about my years in Bryansk: just an association.

My wife Lida and I lived in an apartment next to the hospital: it was convenient, because we were often called to perform emergency operations. There was a nurse, Nastya who lived in the same building and assisted me during operations.

One night, at two in the morning, I heard a knock at the door and Nastya's voice: "Hurry up, there's a man in the operating room, he wants to slash his wrists..."

There was no point in asking any questions: they didn't call for nothing. So I dressed and went to the operating room. I was met there by Doctor Natalya Khudyakova and the nurses crowded in the vestibule. Natalya pointed to the door of the nurses' room:

"There's a madman in there. If you only knew what he's doing!"

I opened the door and saw a man with no shirt and a half-shaven head. He had wild, insane eyes. That was not the main point, however: his belly was open, and he had a razor in his hand. He was cutting out his intestines, piece by piece... Some bloody knots were lying on the floor.

"We've tried to approach him," said Natalya, "he won't let us. So, we called you."

I had to act quickly, otherwise he could cut up all his intestines and bleed to death. Near the door, there was a tall stand for I. V. bottles — some two metres high. I grasped it and struck the man on the head. He lost his balance and fell. The others came in and disarmed him... As I learned later, this stand had been called lukich by Nastya: we had an orderly almost as tall. Telling this story to her friends, she would say: "Amosoff struck that mandman with lukich, and he collapsed..." (These are the roots of the association.)

The man was put to sleep, and Natalya treated the wound and put in some stitches. He recovered the next day. We learned that he had been brought to the hospital by militiamen: they had found him unconscious by the railroad tracks. As it turned out, he had delirium trements: he had been in Moscow on a business trip and had been drinking the whole time. He kept drinking on the train, had a nightmare, descended between the cars and received a blow to the head. Thank God, not a fatal one. Natalya wanted to treat the wounds on his head, but before she could do it she had to shave him. Since he had been talking sense, they didn't tie him up. Suddenly he took the razor away from the nurse, ran into the adjoining room, and locked it from the inside. The rest of the story you already know. His wife and daughter came the next day — quite respectable people, by the way. Everything ended well.