Nikolay Amosov    WORLD OUTLOOK

I live in a world of horror if I look at myself with the eyes of a stranger.

I ruined a patient's life. Negligence if you judge me formally and severely. I would not say it of others, but I have every right to say it of myself.

Patient B. A high risk patient according to my standards. Mitral disease with stenosis, an enlarged pulmonary artery in an X-ray means high pressure. You can see calcium in it. But these are just details.

On Wednesday, B. was the first patient I operated on. When I came up to the table, the incision had already been expanded. I was struck by the greatly enlarged heart, which was protruding from the chest. Diastolic pressure was 220 mm and more than 500 mm in the left atrium. The heart had failed and might stop at any moment. I injected heparin so that the AIK machine could be switched at any time. It was just in time: contractions slowed down; I had to squeeze the ventricles between my palms — this procedure is known as an open massage. As soon as the AIK machine was switched on, the work became easier...

The operation turned out to be quite difficult. The left ventricle was small, and the valve was clad in calcium. It could be cut off, making sewing in the prosthesis even more difficult. Each suture was made after several attempts.

This procedure is horrible beyond description. You have to select needle-holders; with one you make a puncture, with another you meet it and push the needle through; then you have to push the thread by to reach the new puncture site. The blood is rushing from the aorta. It gets on my nerves. Instead of forty minutes, it took me two hours to sew in the valve...

Finally everything was done. I had to close the incision as quickly as possible. To this end, I had to disconnect the tubes along which the blood was flowing into the AIK machine. They are fixed to the instrument for closing incisions with thick threads almost directly above the wound of an opened atrium. We cut them off. (The details are clear only to those who operate.) We got the heart beating. It began to beat well — it had rested during the two hours of artificial circulation. The pressure in the left artium was about 100 mm. We switched off the AIK machine. And suddenly, right before our eyes, the column of blood in the tube that was measuring this pressure began to rise rapidly. 150, 200... 400! I shouted to the AIK machine operators:

"Switch on the AIK!"

The machine was switched on at once. The heart seemed to contract well. But as soon as we reduced the AIK machine productivity, the heart "would not pull" — the pressure in the left atrium increased. Thus, we could not stop the AIK machine.

What had happened? The only thing that came to mind was: the valve isn't working, it either is not closing or opening. It was quite possible that tissues in the lumen were squeezed... Moreover, I had sewed it in blindly, since the access was blocked.

"We'll have to make a revision. Ella, put the AIK machine on full productivity!"

We dilated the heart wound. I examined the prosthesis and tried it with a clamp; it moved freely. Nothing was wrong with the prosthesis. There was only one thing left — weakness of the heart muscle. I sewed in the heart, defibrillated and it began to beat. Once again, parallel circulation. Once again the attempts to switch off the AIK machine, but this proved impossible...

That is the way we worked for another two hours. I had lost all hope... And I did not dare to stop the AIK machine.

And there was a second patient with an open chest in the second operating theartre — I had to sew in two valves.

I called Sitar so he could try to bring this heart around. Then I left for the next operation with a heavy heart myself.

Luckily, the operation was successful. A young girl from Moldavia with defects of the mitral and aortic valve, we made prostheses for both valves. Perfusion lasted about two hours, and the heart began to beat without any problems... (Lyonya dropped in during the middle of this operation; he said that they had stopped the AIK machine — they had failed to get the heart beating.)

About that time, Kolya Dotsenko had made an incision into the thoracic cavity of the third patient. Nine years ago, I had sewed an aortic valve in that man. Everything went without a hitch for the first three years; he worked, then he began to feel bad. Finally, he appeared at our clinic with a grave decompensation. Examination showed that the aortic valve was functioning well. But he had mitral stenosis, and once again with calcium. I had to replace another valve.

The operation took eight hours. When I returned to my office to have tea, it was already ten p. m. Thank God the patient had awakened.

I couldn't get my mind off the first patient. Why had he had cardiasthenia. Why did the heart fail to function properly? I came to the conclusion that his heart had exhausted all its resources — he had been sick for a long time and had not worked for ages... (I talked with his wife before the operation...)

I almost forgot. That week I had had three operating days. On Tuesday I had also performed three operations.

On Thursday, three more operations...

The first was a boy of fourteen with congenital stenosis of the aortic valves. The ugliest defect. I had failed to sew in a valve (a narrow ring) and the boy might die... Without an operation, he could have lived for another ten years if spared heavy loads...

(How many times would the thought come to mind in such circumstances "Why I am doing it? I'm sixty-seven, and I have already paid all my debts to society...")

The second operation was no problem.

The third operation turned out to be the hardest one.

A girl of fourteen, Anya by name, a thin and gangly teenager with ridiculous black rimmed spectacles and a constantly surprised expression. She had been admitted to the Zinkovsky department three months before. Suffice it to look at an X-ray to say: "How can you touch such a heart?" It occupied almost the whole diameter of the chest, and on the left it reached the ribs. On the right, there was still a strip of lung four centimetres wide. As to its volume, the heart was ten times larger than normal. In weight, without the blood, it was no doubt less, since the atria were expanded as bags.

We would not have admitted her to the clinic or would have discharged her long before if not for the mother. She came to us many times, wept and pleaded, and each time, I gave in and told her physicians "Let her stay..." Later I promised to operate on her, almost without any hope for success. But there were two circumstances that pushed me to operate.

The first: her mother was divorced, and she was an only child. Bless these divorced mothers! One cannot envy them... She was an educated woman and knew everything: the girl would live only a few months more and only in a hospital...

The second: the girl's present condition was clinic's fault. To believe the mother (and we could believe her with some reservations: she wasn't one to lie, but it wasn't the whole truth — such is the subjectivity of estimates) so to believe the mother, then the girl had been under observation at the clinic since she was four and different diagnoses had been made. She had felt rather well, but had begun to feel worse only during the past two years. This meant that we, and our clinic as a whole, were not up to the mark. At the beginning, we refused, because we had no doubts, and then we said: "Too late." Let's be honest. And that's why we had to take risks. I do not even know whether she had 10 or 5 chances out of a hundred to live. I told the whole truth to her mother. She said, "Let it be only one, since without an operation, she will not have a chance of surviving and will die soon."

Here is the diagnosis: Ebstein anomaly — an underdeveloped tricuspid valve which does not function at all. We correct such defects with a 1:5 risk by sewing in a prosthesis. But she had mitral valve defect into the bargain, as big as in patients with rheumatism. We would have to sew in two valves with a dreadful decompensation (diuretics and heart preparations every day, but still the liver went down to the navel, although she was bed-ridden!).

The operation was a success (two valves).

It was not too late when I entered the intensive care ward to have a look at my first patients. The boy's tube had already been removed. (I heaved a sigh of relief!) And the second, a grey-haired man, was still on artificial respiration.

At that time, Misha Zinkovsky's patient, who had been operated on, a fat fifty-year-old teacher from the Caucasus with a congenital defect, with a high risk of dying, was on the edge of clinical death. All the doctors were fussing around him to delay fibrillation. I sat and watched. Suddenly I heard a noise from beside my grey-haired patient:

"Bring the 'concertina'; heart arrest!"

Those who were still free ran up to him and began the heart massage; they injected drugs, and soon the heart began to contract; then the pulse appeared... But... he was still unconscious. I sat for another two hours and waited until the girl was brought (she was doing quite well when I left the operating theatre). The patient did not regain consciousness. Cerebral edema. It meant, they had registered the heart arrest too late. It also meant another death... And now this girl with two valves, also half "there."

My balance sheet for the week was three deaths out of nine operations.

And with that I went home. I was lucky one of the clinic chauffeurs recognized me and gave me a lift...

Friday morning was full of surprises. News, both bad and good. Good news — the grey-haired man was coming around. Anya, the girl, was alive. Gennady Penkov, who was on duty the previous night, had removed tubes from both patients. And there was hope already.

And now, the bad news... Valya (Valentina Petrovna Zakharova, our coroner, a young woman whom we all liked very much, although she never brought us good news) reported the results of the autopsy.

The patient who had died on the table on Wednesday had passed away because a thread got into the opening of the left coronary artery. A thick silk thread, four centimetres long with a knot. It half-closed the lumen of the left coronary artery, reducing by 50% the blood flow to the left ventricle; therefore, it was unable to function to its full capacity, and the heart stopped as soon as we switched off the AIK machine. Now everything was crystal clear...

I wracked my brains: where had that thread come from? I recalled each step of the operation and all the difficulties encountered. I arrived at the conclusion that it was the thread which fixed the tube from the inferior vena cava to the instrument that closed the incision. We usually cut it off when we began to close the heart to reduce the pull of the incision's edges. I usually cut it off myself or my assistant did it. Usually the thread was pressed to the linen and did not fall. We did not always pull it out.

Which meant that at that time, it fell into the atrium. At the beginning, the heart began to work well, but later the thread with the blood flow got into the ventricle, the aorta, and then into the coronary artery and narrowed its lumen. That caused cardiasthenia which we were unable to cope with.

It was technically possible to extract the thread, but the thought of it never occurred to me at the time. In more than six thousand operations with the AIK machine, there was not a single occasion when foreign bodies had gotten into the coronary arteries. There had been times when pieces of lime from valves fell into the heart during dissection and disappeared without a trace, as well as the three millimetre tubes we used to strengthen sutures, and fragments of broken needles. But they had not caused a single death...

And now, this...

Any uninitiated individual, a surgeon even, who had not seen these extremely difficult operations, would say it was negligence. The thread, after being cut loose, should be pulled out and thrown away from the operating field.

This is correct; this is as it should be. That's the way we do it, try to do it, demand that it be done. But when the AIK machine has already been working for two hours, and the incision had to be closed as quickly as possible and the heart made to beat... When hemolysis had already appeared, and I had begun to fear the heart wouldn't begin to beat at all. When a surgeon works for many tormenting hours and fears that he won't be able to sew in the valve due to anatomic difficulties...

What would I tell another surgeon in this case?

"You have to be careful!"

And that's all. I know that I have been; I know that we are careful but, alas! — do not always see. Due to stress.

Be it this way or another: "Death caused due to the surgeon's error." This is what I explained at the conference, and this I recorded on the medical history.

But the heart of the matter lies not in the public admission of your guilt. The main thing is that A MAN HAS DIED.

The morning after the death, on Thursday, the wife of that patient came. I told her everything that I thought then, before the autopsy: "Cardiasthenia. It started before the AIK machine was switched on, a difficult operation, and a long one... An inevitable risk of which I warned you before the operation. It's a pity, but... Such is heart surgery..."

I learned about the thread only on Friday morning. And secretly, subconsciously, I rejoiced: "The corpse has already been taken away..." If the wife had come today, I would have had to tell her the whole truth.

I have never overestimated myself when I interrupt the glorifications of my abilities. I get irritated when patients say: "You have such skilful hands." But still, is it far from easy to say:

"Your husband died as a result of my error."

No doubt you may reassure yourself that the operation was ab­solutely necessary and that the man was doomed to death in a year or two. That the risk of the operation was too high, that the heart was in a bad state, that it stopped before the AIK machine was even switched on, and that there were many complications ahead... All this is true, but why should you deceive yourself? The heart began to beat well in the beginning! You could hope that the post-op period would be successful as in the case of all patients you have operated on. Therefore, "Let's not dwell on it." Take it as it is. Now I have to expect other mishaps. (I have already written about "retribution.") I must watch my step from now on.

I must work hard.

The intensive care and Bendet's and "Elema" departments reported their activities at the conference on Friday. They work well. (I finally made up with Yura Panichkin.)