6.12.1913  -  12.12.2002

Books of N.M.Amosov

Home   >   Publications   >   Books of N.M.Amosov   >   The book about happiness and unhappiness. Book One   >   Diary. Sunday. February, 8. Afternoon

Diary. Sunday. February, 8. Afternoon

There is happiness in the world!

I've just come home from the clinic and I'd better write it down in my diary, otherwise the feeling will lose its acuteness. The feeling was already brewing in me on Friday and Saturday, but I kept my fingers crossed. Today, it seems that I can write about it.

I had three operations on Wednesday — valves, as usual. All ended well.

The first, a man — two valves; the second — a woman, one valve. O.K.

The third operation began when dusk was approaching. It was the hardest one: a woman, forty-one years old. She tried to look brave and optimistic. But only tried: she had been operated thirteen years ago: she had her mitral and aortic valves widened, without the AIK machine. They had not been operational for the past five years. She was married and had kids... The final diagnosis was defect valves.

I had been postponing the operation for a long time — the risk had been very high. She had been pleading, not insisting. I saw her husband only before the operation: my assistants had met him without me. He was reconciled to the danger.

(Just imagine: a man or a woman close to you has only a thirty or fifty per cent chance of coming back from the operating theatre alive. Every time I meet the relatives, I'm afraid to tell them the truth — I simply put myself in their shoes. What a miserable feeling it must be to sit in the corridor, waiting for me to come out and pass the verdict "Alive" or "Dead"...)

The operation was not very difficult; it confirmed the diagnosis...

I left the operating theatre around nine. Nikolai was still busy putting in the stitches... The first two patients were in order.

The husband met me in the corridor:

"How is she?"

I told him the truth: "I don't know yet."

I was hungry as a bear and went to the nurses in the intensive care unit looking for something to eat. They were rather sweet and shared some of their bread with me...

At ten, the patient was moved from the theatre to the adjacent room and was recovering from narcosis. She was in bad shape: pressure around 70 mm, urine meager, no traces of consciousness. Almost no traces, to be more precise — a slight movement of the eyebrows, in response to a loud voice. It was impossible to take her to the intensive care unit: it was too far from the operating theatre.

Another talk with her husband; he looked worried and suspicious that time. I felt guilty, as usual in those cases: first, you have to explain the situation and refuse to operate. The relatives try to persuade you, and then you are treated like a swindler or common criminal.

Thirty minutes later I went to the operating unit once again. Alexei had already given her a vasodilative drug (phenylephrine hydro­chloride) and the blood pressure was 90 mm. Urine had appeared; however, she was still unconscious. I told them to bring her to the intensive care unit in twenty minutes, while her pressure was still high enough and went there myself. The time flew while I was examining the other patients. Suddenly, Alexei rushed in:

"Her heart has stopped! Prepare a defibrillator..."

That was all. Nothing even moved inside; just a strange feeling as if the air had been let out of a balloon: my soul shrunk — if the heart stopped in a serious case like this, nothing could be done.

I saw them coming: assistant surgeons were pulling the trolley, an anesthesiologist was massaging the heart, and his aid was using a portable apparatus for artificial respiration.

The wheels of the trolley were creaking unpleasantly: they had never been oiled properly.

Finally, she was brought into the room. We put a broad plank under the mattress to prevent the net from sagging and turned on a stationary respiratory machine. An I. V. and a bed monitor were also connected. One of the assistants continued to massage the patient's heart using the simplest technique: left palm in the middle of the chest, the right palm above it, both hands sending powerful thrusts to the chest, just opposite the heart. The heart, being pressed to the backbone, would mechanically push the blood from the ventricles into the aorta and the pulmonary artery. In such cases, the pulse in the femoral and carotid arteries could even be felt. A hard job, to say the least — the doctors usually change every five minutes, and they're sweating like hell. This procedure may last for hours. A patient, if conscious, may even open his or her eyes. It's better not to look into them: his or her whole life depends on the heart massage — if the heart stops for twenty seconds, the pupils dilate, and you can feel death coming... A heart stoppage for five minutes is not lethal, but very dangerous: blood circulation induced by massage is not always effective.

I watched Valery Litvinenko massaging the heart. He worked in shifts with Roman. Every three or four minutes, they would stop, checking the reading of the oscillograph.

"No contractions, but fibrillation is occurring..."

Fibrillation is the appearance of chaotic waves on the display; these waves correspond to equally chaotic heart beats.

A sodium bicarbonate solution was applied continuously to neutralize acid products of metabolism; medicines were also administered periodically: either to activate the heart, or — on the contrary — to reduce excessive activity. Practically every interruption of the massage was used for defibrillation or a high-voltage impulse applied to the chest.

"Everyone off the bed! Impulse!"

The patient's body jerked every time.

We kept following the readings of the oscillograph.

"Has the heart started to beat? No? Continue the massage."

My assistants worked methodically, without any haste or noise in order not to disturb the other patients who had been operated on the same day - they were conscious and couldn't be disturbed. True, they were kept behind plastic curtains and couldn't see what was happening but they could hear everything.

I stood beside her bed, watching but not interfering — they were doing everything needed in such case. But how painful it was to look at their efforts... Would the heart begin beating or not? Would she survive? It's possible to make the heart start beating in almost all cases, but only in every third case are we able to avoid defibrillation and maintain adequate blood pressure. Many of the patients simply do not wake up. Poor blood circulation under massage coupled with the consequences of artificial circulation results in brain edema, and only every fifth patient can be saved.

"Off the bed! Impulse!"

"It's beating."

Yes, it's beating; the oscillograph showed a typical ECG, though the waves were somewhat modified...

We held our breaths, waiting.

"It's stopped again. Massage..."

"Olga, prepare an adrenalin injection for the heart..."

The nurse filled a syringe, diluting adrenalin with a saline solution. The massage stopped. Andrei made the injection with a long needle, aiming right for the heart. In another jiffy, the medicine was in the ventricle.


Two more minutes, another break, again defibrillation... I don't remember when the heart started: thirty minutes in the ward seemed like an eternity...

"The contractions are stable... We've got a pulse! The rhythm is correct..."

Everybody gave a sigh of relief. Valery wiped his forehead with a palm: he'd done more massaging than the others.

I spent another thirty minutes at her bedside: the heart was working normally: her pressure was around 80, and urine had appeared... We took the analyses. No one asked whether she had woken up. The massage seemed to be effective — the pupils hadn't widened too much. But she hadn't woken up before the heart had stopped. We shouldn't deceive ourselves: only very strong people could survive such an ordeal... There was no hope left.

"I'm leaving, guys. Good night. No calls, please."

Her husband was waiting for me downstairs. It would have been better if he'd left.

"Unfortunately, I've got bad news for you — when she was taken to the ward her heart stopped. We've managed to restore the heart beat, but the chances are very slim."

He looked at me, seeing nothing. No details were asked. That, at least, was easier.

"Where can we collect her tomorrow?"

Here again: the same word — collect. The corpse, of course. He had understood me and, obviously, was cursing me like hell.

Music was playing over the radio — I hadn't turned it off, thinking I would be back soon. The pile of ballot papers for the forthcoming conference was still on the desk. I wasn't interested in them any longer: it didn't matter how my staff would assess my performance. The worse, the better — there would be another reason to retire and not have to see any more relatives of the dead, trying to avoid their eyes.

I phoned home, saying that I was about to leave.

I ran rapidly downhill... I reached home at about midnight. The family wasn't in bed, but no questions were asked: everything was clear on sight.


I had a late meal but couldn't force myself to sleep: again insomnia.

Friday morning was a routine one. Why should I bother with jogging? It was cold and slushy outside... If not for Cherie, I wouldn't have gone outdoors. My dog is a tiny source of warmth and happiness. Every evening, she's squealing with delight when I open the door, jumps on me when I enter, licking my cheeks, and then starts barking quietly — accusing me of being late.


When I got to the clinic, I didn't ask anybody in the foyer about the outcome of the last operation of the day before. Why should I show impatience? What's done cannot be undone.

The first thing I did in the conference room was to cast a sidelong glance at my desk: the woman's case report was missing. Was she still alive? No, the doctor-on-duty had not brought it yet. Nevertheless, I hoped against hope that she was alive. My subconscious was in favour of my hope; the conscious mind was against it, saying there could be no "ifs, ands or buts."

Valery Litvinenko began his report, case by case: "The woman X. A mitral-aortic prosthesis, correction of the tricuspid valve, the heart stopped, intensive care... woke up in the morning. The tube has not been removed — I was waiting for you, although we can do it right now..."

"Go and remove the tube. Thank you for the good news..."

I winked, trying to conceal the tears — what a weak man I had become...

Now, a new life had begun!

Then, we listened to two reports presented by Professor Alexei Tsygany who spoke for the anesthesiological department and Dr. Mikhail Atamanyuk for the intensive care unit.

They made good objective reports.

In general, both of the departments are good ones. Anesthesiologists are peculiar people and require a careful approach. They are in high demand — they're needed everywhere, although their profession is not a prestigeous one. Patients have not yet realized that their lives depend on anesthesiologists no less than surgeons. Words of thanks are rarely said to them, not to mention flowers. Our doctors are rated high: there are vacancies in any clinic, so they can leave at any moment if something displeases them, although we pay them more. They have heard a lot of unpleasant words from me in recent years. It is very difficult for Alexei to keep them at the clinic: he has to give them themes to write theses on. All the same, they leave us. Therefore, be careful, boss, and don't overdo it, otherwise you may lose the best and the brightest. Hey, guys! Don't be scared: I'm not going to criticise you — you really do a good job. Or maybe you've only done it today?

Experts in resuscitation emerged as a profession separate from anesthesiology not very long ago. The words "intensive care unit" are already known to the general public, and people do know that the doctors who work there fight for the renewal of the human life. The work in these units is hard and unprestigeous. The patients from intensive care units are sooner or later transferred to other wards and they — when discharged — don't remember to whom they are obliged for the extension of their lives. (I'm more or less an insider these days — my daughter has already been working for three years in the intensive care unit of a cardiological clinic.)

People who work in intensive care wards are modest; there are many women among them, some of them have major shortcomings in terms of their professional skills — a rare conference goes by without complaints about their work. But no one can deny that they work honestly.

I have been thinking about my assistants: good people for whom I have warm feelings. One thing is obvious: I deeply respect most of them... Strange, isn't it? In principle, I take a rather sober view of human nature — both of strangers and human beings in general. At the same time, concrete and not very close people seem to be good. I see through each of them, or at least deep enough: the shortcomings and egoistic qualities of their characters. However, they have turned their good qualities toward me. There have been no quarrels in the* clinic, although I often hear about them in other places. Maybe the reason lies in the work? Or perhaps I don't have time to go into minor details. Or maybe we are just shy in the face of death?

Concluding the conference, we decided to assess the performance of the anesthesiological department as good, and the intensive care unit's as satisfactory — they still have many drawbacks, do not know how to handle small children, and the techniques of artificial respiration have not yet been mastered. Besides, their scientific research is still not up to the mark. But Misha is trying to do his best; everybody loves him for his modesty and simplicity, honesty and self-criticism.

"And now, we're going to have the secret ballot — the routine assessment of staff performance. Senior and junior staff members will be assessed on separate pieces of paper. Try to be objective..." (The latter phrase means that they must be objective towards me. I wish they knew how important their opinions are to me...)

I was very worried when I introduced that procedure, since I had been rather rude to my people over the past six months. They had more than enough material and reasons to bear a grudge against me. I always thought that I had been objective towards them, although I noticed that I'd' often been impolite and apologized. Self-esteem, false pride and self-authorization tend to shift assessments, enlarging the evils of other people and diminishing one's own.

My declaration caused an outburst of joy — it's not very day that you can tell your neighbour — even your superior — that he's full of shit. Without taking any chances, by the way. The ballot papers had, as usual, the names of all department chiefs and that of Miroslav — acting Head Physician.

The meeting was adjourned, and Friday went on normally.

In the intensive care unit, I found that our X. was in good shape. Victor Krivenky had removed the tube immediately after his report; the patient was conscious and was able to talk.

How I cherish those faded smiles on the first morning after the operation. I could give a kingdom for them.

Whispering with dry lips, she said:

"Have I crossed the line between death and life? What do you think, doctor?"

"Yes, almost."

It would have been better not to say this "almost."

At three in the afternoon I took the ballot boxes, and went home with the papers. Before leaving I asked my secretary Anna to stay a little bit longer — I would be in the clinic on Sunday to pick up the rest of papers...

I was so nervous and eager to look through the ballot papers that I didn't have lunch when I got home.

Out of forty-two present and voting staff members, only one had qualified me as "not coming up to the standards required of a boss, in personal and professional qualities."

Well, some twenty more people had not voted yet; their ballots would be collected later. But I'm sure there would not be many black balls among them.

That Friday was the happiest day in my life... What else did I need? I enjoyed the continued confidence of my colleagues, and my patient had come back to life... Perhaps the latter fact was more important: I felt so miserable about the possibility of losing her.

At the same time, if the doctors had voted against me, I would have been unhappy. I simply don't know in what direction I should change. I was thinking about that during the voting. In everything I do in the clinic, in my attitudes towards patients or colleagues I pursue no selfish interests. But am I sure? Perhaps I should examine my subconscious more carefully. I've tried that, too, and found nothing. Who knows — maybe egoism lies even deeper?

No, I can't change my attitude towards the patients — I have nothing to change for the better. True, I could be more delicate and polite in my relations with other doctors. To avoid useless and rude words like "idiot" or "imbecile," etc. True, I use these words only in stressful situations, during operations. And how else should I behave if they don't understand the simplest words, if they don't work properly? Well, Amosoff, don't try to rehabilitate yourself; you are wrong by the way — you haven't tried to be delicate but firm like Professor Petr Kupriyanov, for instance...

Most probably, I can't change. Or should I give this idea some more thought? Who knows...

I was in the clinic and went to the intensive care unit — all the patients, including my goddaughter, were in good shape. Then I took the remaining ballot papers and quickly looked through them. Another one against me, on personal grounds. The final results: two against (out of sixty-two). In past years, there were always five or six "nay" votes.

The situation is not bad at all: a complete vote of confidence, and I have the right to remain in charge of the clinic. Naturally, I went through the ballot papers for the department heads. Opinions varied, and I don't have the right to disclose them. However, there was no reason to take immediate action.

While I was typing all this stuff, the pleasant feeling left me. Perhaps I was tired? Or maybe such a feeling disappears when it is expressed?

Yes, some more words for today: yesterday was my daughter's birthday — turned twenty-five. A significant date.

When I was young and middle aged, I didn't have any affection for children; on the contrary, they irritated me — perhaps, because I grew up an only child. I had no children from my first marriage, and we didn't rush in the second one, either. We had married during the war and had lived quietly for twelve years. In short, Lida suddenly decided to have a daughter. She was thirty-five, had a teacher's diploma, and was a medical student at the time. The pregnancy was a difficult one, and she behaved heroically- When her time approached, eclampsia (a combination of kidney disorders and high blood pressure) developed. Professor Alexander Lurie said that the delivery should be stimulated. Some complications followed. So, one morning the final decision had to be taken: either a Caesarean section with the risk of peritonitis or losing the child. She didn't hesitate a minute: "Any risk, but I want a daughter!" It took the professor twenty minutes to perform the operation. The child was not breathing when it was born, and they did everything to instill life in her. Finally, we heard her cry. The mother, who had been operated on under local anesthesia — kept asking about her child. When the stitches were in place, I was called to have a look.

I'll never forget that moment.

I saw a tiny reddish creature of 1,800 grams who was making strange movements with her lips, as if licking them. A new source or a tap opened inside me at that moment, as it were. It marked the beginning of the greatest feeling I have ever had. A biological feeling, of course. The memory of that day and feeling has already begun to fade, but the daughter has given me numerous pleasant days. I better stop here to avoid sentimentality. Unfortunately, my feelings towards her changed as she grew up - Nevertheless, I understand her inner world even today, although I don't approve of it entirely. In any case, she's a good daughter!