6.12.1913  -  12.12.2002

Books of N.M.Amosov

Diary. Sunday, January, 26

There is some hope that she'll wake up and recover. And all these hysteric outcries about becoming a monk are nothing but a tribute to the emotions. Who was it that developed personality models which enable one to calculate happiness? I did, and I have calculated the measure of my happiness more than once. What should I do: retire? become a writer? be a pure scientist? or perform three operations a day? try to combine both perhaps? I guess I'll attempt the latter.

Yesterday, I was lying on the sofa, handkerchief in hand, miserable in my illness... So, I was lying there looking at my books — I have some fifteen thousand of them at home. How much information I have gathered, thinking that one day I'll be able to read and digest all of them...

Well, I've no right to complain: work and passions are never fruitless. Only one patient has died this month out of 38 operations with the AIK machine. His name was Nikolai. I've operated on twelve patients this month, emplacing valve prostheses; ten of them had the highest risk assessment. I don't understand how they manage to survive... Maybe, by sheer luck?

The past week was as follows: Monday and Tuesday were devoted to recollections. Nothing disturbed my writings, since only one critical case was expected. Well, man proposes...

The first operation was on Wednesday: Fallot's tetrad, a man of 23, and a case of medium seriousness. The operation went well: the heart was started to beat with an impulse from the defibrillator. It began to beat, but was unwilling to increase its pace. And a war of nerves broke out...

In the morning, a young-looking woman stopped me in front of my office, introducing herself as Nikolai's mother. She asked me to "do my best," as if I discriminated among my patients. I particularly disliked her words:

"His daughter, my granddaughter is four today."

It was then that I first felt uncomfortable; and when the heart failed after five minutes of independent beating, I sensed trouble in the air — I was about to give a "surprise present" to his daughter for her birthday...

I've described on numerous occasions this strange feeling of being suspended in the air that a patient experiences when his heart beat is supported mechanically and the systoles weaken before the eyes of doctors. This was just another case; we had been working for almost an hour, injecting various medicines to keep him alive. I was on the verge of losing hope when his heart responded to our efforts and began to work after 126 minutes of perfusion.

Nikolai's mother was waiting for me downstairs. I didn't recognize her first — she had changed beyond recognition and looked like an old woman after the twelve hours the operation had lasted. I tried to comfort her; she thanked me, attempting to kiss my hands... "It's too early, too early. Anything might happen," I kept repeating in a futile effort to get away... I'm afraid of stormy manifestation of emotions, particularly premature, untimely ones: postop complications are more frequent than one might think.

The night was bad, as always, but in the morning Cherie and I went jogging as scheduled.

Again operations. The first patient was supposed to be a serious case: a seventeen-year-old boy with a congenital heart disease — the narrowing of the aortic valve and Botallo's duct potency. Three variants of the operation were possible. First, to ligate the duct and a month or two later _ to repair the aortic valve. Second: to make two separate operations, combining them in one — first, to ligate the duct uthrough a side incision, following the standard technique, then to make a median incision, and to operate the aortic valve, using the AIK machine. It would take more time but was quite feasible. Third: to make one medial incision, to reach Botallo's duct through it, to ligate the duct and to continue the operation on the aortic valve. The last possibility looked more reliable, simpler and quicker: only one incision, less injury.

However, in only seemed so. In surgery, the most important thing is an access — i.e., a surgeon must choose the incision that will ensure the maximum convenience for the major phase of the operation. No one ligates Botallo's duct through a medial incision — it's too complicated and inconvenient. And dangerous, by the way, as my bitter personal experience indicates. Nevertheless, I have ligated this duct through a median incision. Usually, we would come across the duct by chance, before the AIK machine is switched on. Working calmly and methodically, I am usually able to reach the duct and ligate it without any major difficulties. Hence the feeling that I could do anything!

Therefore, I decided in favour of the third variant...

Petr Ignatov sawed the breast bone and opened the pericardium; I came up and touched the pulmonary artery — there was a slight vibration typical of that disease (to hell with it!). I began quietly to free the tissues, going down along the aortic arch. The duct turned out to be a big one; I began to separate it... (I have always thought highly of myself as a master of anatomical exposure — no kidding, I have special techniques.) When I was almost through, the duct burst open and a large stream of blood ran from the aorta...

That was it! I wished I were dead...

I pressed the bleeding spot with a finger — it covered the entire area — but I was unable to free the duct any further: the rupture was too deep, indeed.

The only thing I could do was to block the rupture with my left hand while my assistants and right hand were supposed to turn on the AIK machine. Then we needed to cool the patient, and I would try to sew the duct entrance from the inside of the pulmonary artery. Not as simple or speedy as I had thought.

The hole under my finger was spreading out, and soon I found the top of my finger in it. Another moment, and the duct would erupt completely; blood would flood everything, and there would be no chance of survival... "Keep your finger in place. Hold it," I thought. ("What a presumptuous fool!" I didn't think those words, I shouted them aloud for the entire operating room.)

Petr took great pains over the artery — or maybe I just thought it was a long time. I felt pins and needles in my finger and it lost all sensitivity. Soon, my entire hand was numb.

"Hurry up! Quicker!"

I was afraid to change hands — I could barely keep the duct under control to prevent an outburst of bleeding...

Finally, the AIK machine was turned on; even if the bleeding started, it would not mean a catastrophe — we would be able to save him... I changed hands and exercised my left hand to restore the blood circulation. The AIK machine was working all that time: we would have to bring the patient's temperature down to 25°C, then the AIK machine could be stopped and I would be able to sew the duct without haste...

Sensitivity had gradually been restored to my hand; the patient's temperature was reduced to 22°C. We leveled down the AIK machine flow rate to one litre per minute, and the blood pressure dropped to 25 mm. Only then did I release my finger — there would be no bleeding under pressure that low. I put in stitches with teflon pads, then dissected the pulmonary artery and saw a tiny stream of blood coming from the duct. I placed a probe inside, blew the bubble and blocked the duct. No bleeding at all. Again stitches. The probe was removed, and the rest went normally. It was as simple as that. (I had had to do the same with that woman — alas...)

All's well that ends well. But two hours of perfusion and deep cooling of the body worried me. Would he wake up? The worry didn't leave the entire next day.

Thank God, the patient did wake up, and there were no troubles with his condition.

Addressing the Friday conference, I told the others blatantly about my error — friend or foe, beware of arrogance, for it will lead you into temptation and...