Books of N.M.Amosov
Diary. Thursday, July, 8
Once again a break for almost a month. There was nothing to be happy about. But today, it seems, is somewhat better, I do not feel so gloomy.
A brief report on events (in surgery, for sure).
Wednesday, 17 June. Three operations on children five to eight years of age with congenital heart defects. Everything went without a hitch.
On Thursday I did not operate.
There were unpleasantnesses on Friday. Two valve patients (not mine) with grave cerebral complications since Thursday: our "syndrome."
I was in a bad mood on Saturday and Sunday. What was the matter? What should we do? Was it the effect of the heat? But the patients were not overheated; their temperatures did not go up.
I made up my mind to operate only on Wednesday, the 23. The first operation — an atrial defect and mitral stenosis in a woman of 46. The second, a girl, G. by name, who had been previously operated on in another clinic. Once again she had a ventricular defect and pronounced tricuspid valve deficiency. Pronounced decompensation, her parents made me do it: vital indications, death without operation. I managed rather easily to darn the residual defect, to make the plasty of the tricuspid valve; perfusion went on for 35 minutes, the heart began to beat properly...
The third patient. Central prosthetics after commissurotomy. "Without peculiarities" as they put it in an op-record when an operation is typical, even if it is complicated.
Two patients have not regained consciousness. To be more correct, there were signs of awakening, which later disappeared... The third was the same, only with another surgeon. Our "syndrome" again.
There was every reason to go crazy.
A sleepless night and the decision: to begin everything from scratch. So that they would give only ether and nitrogen dioxide, would wake patients immediately and remove tubes — the procedure we used last August... And what is more important — I would have to keep an eye on everything.
A test on Thursday. Three high risk patients for prosthetics of the mitral valve and correction of the tricuspid valve.
A girl of twenty-three, 45 kilograms, all transparent: the light seemed to shine through her. She was on the fourth floor for two months with a serious decompensation. Her's was a congenital failure, and she had been under observation for years. Besides that, she had a heart block; her pulse was about forty. The felt fine, graduated from the Institute, and besides that, studied Polish, became a guide, and escorted tourist groups. A year ago, she had a break down. She had edema, her liver was enlarged, ascites... Since then, she had been in and out of hospitals almost continuosly. When she was admitted to our clinic, we were unable to operate on her, since she was inoperable. But we implanted an electrode into her heart, switched on the stimulator, and accelerated the frequency of contractions to eighty. As a result of this, her state had improved slightly. That made it possible to examine her thoroughly. We found a complex defect, a reverse position of the ventricles, mitral and tricuspid incompetence, and a congenital defect into the bargain. A combination that could not be reproduced intentionally. Her mother often came to us and pleaded for us to operate on her daughter. "She will die otherwise." An elderly woman of the same slight build as her daughter, grey-haired.
Two other patients — rather usual, but extremely exhausted and decompensated, with ailing hearts, third risk group every one...
I had a serious talk with anesthesiologists and the AIK machine operators. I controlled each injection and measurement myself. The operation went normally; I even managed to sew a valve in the first patient — the girl — and to close the defect in only one hour of perfusion. I did not leave for home until they extubated all the patients, and it was not too late then — about eight p.m.
On Friday, the 26-th, we had a serious talk at the conference. (I wanted to write "I had raised a fuss," but how many fusses can I raise?)
First, I gave the tables from my report at the Congress, told them what we had achieved in ten months, until the end of May. Then I gave them the data for June... (76 operations with the AIK machine —16 deaths). The "syndrome" was in full swing: ten patients had died of cerebral complications of unknown origins, just like before... I did not think that the heat has to be blamed. I did not know the reason. I suspect that it did not follow the attitudes of the previous year, but I was not sure of it.
"I will perform all operations with the AIK machine myself, four operations a day, if need be. There will be a couple of exceptions — Knyshev will do shunting, Zinkovsky — tetralogy. I will keep an eye on everything and punish strictly for violations of recommendations. If we fail to return to achieved indicators, if the mortality rate remains high, well, we'll have to admit defeat. In that case I will retire."
The speech I gave was unpleasant. But I took a firm decision — I would give up everything. My colleagues — the other surgeons — do not agree with the concept of "leaving surgery" when you can perform four operations a day... They see all my other hobbies as a waste of time.
On Sunday, I went to visit Fedorovsky. During the week, they told me he was too sick. An X-ray specialist, my old friend Lyonya Rozenfeld, called Lida while I was in Czechoslovakia and told her he had diagnosed carcinoma of the pancreas in Fedorovsky.
He had already been bedridden for a week; he became too weak and lost weight. His grandson was summoned from the army, his daughter came from the town she lived in...
My last friend who did not fear frank discussion of any subject was dying. (With the exception of intimate subjects, men do not discuss such things even with their close friends.)
Over the last several years he had visited us every month. Lida would set the table and feed us. He would have a couple of shots of brandy or vodka with pleasure. At the end of March, he had turned 84, but his head was clear and he was interested in the world developments, large and small. He worked as a consultant, and not just for the sake of working. He used to drive himself hard. He was seldom ill. Five years before, he had buried his beloved wife, which was a heavy blow for him.
He had been born into the family of a rural teacher with many children; then his father became a sexton so his children would be able to study for free at a theological college. It was there that Alexei Aleksandrovich received his training for the university. He graduated from there after the Revolution of 1917.
We became acquainted at a meeting of the scientific council when I was elected to the Chair of the Medical Institute. We had been friends for the twenty-eight years since.
"My friends are all leaving..."
Fedorovsky had never been an outstanding surgeon, even when he was young. But he was a true professor who excelled in erudition, culture, and honesty. He worked in two areas: blood transfusion and burns. In both he had scored great success, had huge prestige throughout the country, and received the State Prize.
First he worked in Kharkov as director of the Institute of Blood Transfusion, and later he moved to Kiev. The war, the occupation, and liberation followed. He was promoted to a high surgical position in the army. He became the Head of the Chair at the end of the 1940s and remained at that post for twenty years. After reaching seventy, he became a consultant. He later admitted that this had been a hasty decision. He was strong almost until his death.
I felt sad when I went to visit him. It was the beginning ot the end. The tumor in the abdomen could be palpated, and he had already found it himself. Only one thing gave me joy (if I can use such an expression in this situation): he kept himself in hand, or at least it seemed so. "I don't want to die, but if the time has come, well, let it be."
He asked me about the Congress of Surgeons, about the events in my clinic, sympathized with my misfortunes... He moved from the chair to the armchair with great difficulty; we had coffee. He ate almost nothing; he said that the food passed with difficulty from his stomach... And he did not want to eat.
He wanted to be operated on. He did not want or hope for a radical removal of the tumor, but just a gastroenterostomy so he could eat... And not only for that reason. He had said for a long time that he would poison himself so as not to die in pain; "I already have the pills." I doubted this; since many people say such things but rarely do it. The disease weakens the psyche, paralyzes the will.
Here is what he said about the operation:
"If they do not perform an anastomosis, the drug will not pass into the intestine and will not have any effect."
I know very well the double and triple meaning of human statements. Even sincerely made, they are not necessarily true. The truth is known only to the "Ruler of the Subconscious." I presume the old man was really still hoping for a radical operation. I talked with him frankly, surgeon-to-surgeon, but made this slight hint. What if...
He had already turned over all the surgeons in his mind and had chosen Alexander Alekseyevich Shalimov. His Institute specialized in pancreatic diseases. I agreed with him. I promised him to talk with Sasha, who was an old friend of mine...
I left home with a heavy heart. A man close to me, a friend was departing forever. I asked him:
"Are you afraid?"
"No."
I admitted it to myself. Apparently I would also be able to convince myself not to be afraid when the time came.
On Monday, the 29th, four operations with the AIK machine — we could not risk doing more because our blood reserves would not allow for it. (Summer. Very few donors.) Three congenital defects, the fourth was a valve. Everything was done in keeping with the instructions. I finished around 6 p. m. but went home only when all the patients had been extubated and were fully conscious. I cautiously but quietly rejoiced:
"Perhaps everything will go smoothly from now on!" From now to the end of the year, I should not weaken my control; I would have to be in the clinic all the time to compensate for the losses of June, to feel respect to myself once again, the joy of the victory, although incomplete.
But my hopes did not materialize.
At 10 p.m. the doctor-on-duty reported:
"Half an hour ago, patient B. with a mitral prosthesis suddenly had an attack of convulsions. We had to intubate her; the patient is now unconscious."
On the very first day and such a blow! This meant there were unknown forces I could not control. They could not be stopped by my methods... My self-sufficient declarations that, "I will operate all of them myself and will not allow..." turned out to be abortive.
On Tuesday, after a sleepless night, I performed four simple operations on patients with atrial defects. "With no complications." (That would be surprising!) Patient B. was still unconscious — on artificial respiration.
But we had established one very interesting fact: she had attacks of convulsions before the operation, apparently due to sustained microem-bolisms. This was not manifested in nervous disorders, but her husband had not told us about it. (We would have operated for sure, since this disorder was not a rarity...)
After these misfortunes I began to warn the relatives in the following way:
"I guarantee that I will do my job well. The possibility of surgeon error is one per hundred. But artificial circulation and accompanying destruction of organs very often result in different complications which we cannot envisage one hundred percent. Therefore, an operation is really necessary only if your relative may die in the nearest two to three years, if he or she cannot work and lives on drugs..."
But these warnings do not stop anybody. Despite the misfortunes encountered by our clinic, not a single patient has refused to have an operation.
On Friday, I took the plane to the Crimea. The Crimean Znaniye (Knowledge) Society had invited me long ago to give a series of lectures — I took this chance to visit my relatives in Stary Krym. In the morning, I presided at conferences in the clinic and made my rounds — patient B. was alive. (But what if?)
Two days in the Crimea were sufficient for me — I had relaxed enough.