When I started writing this piece at the end of last year I was awaiting some cardiac investigations. After a lifetime in medicine I was finding out what it’s like to be ‘on the wrong side of the desk’ as an oncology colleague once put it. An episode of chest pain had ended with an attendance at A&E. After negative tests on the day, I was recruited to a study (TARGET-CTCA) looking at whether a CT scan of the coronary arteries (CTCA) might be helpful in the setting of acute chest pain which did not appear to be a heart attack. There are two arms to the study – scan or no scan. I was ‘randomised’ to the scan arm of the study. The examination was to be performed at a later date. In the meantime my cardiologist ordered an MRI myocardial perfusion scan – which was normal – then I had the study CTCA – which wasn’t.
The following piece contains medical details, technical stuff and a great deal about death – so be warned. Medical jargon uses acronyms because the full titles of things are too cumbersome to use in rapid communication. For example, coronary care units, where they take you when you have a heart attack, are referred to as CCUs. Referencing this sort of thing, one of the sketches in our cabaret at the Final Year Club Ball consisted of nothing but such acronyms. The punchline involved an SEN from OPD and an SHO with an MGB GT V8. We opened the show with the line: ‘From the people who brought you I Tedious and The Sound of Mucus…’ which set the intellectual tone for the evening. We knew our audience.
In those days the medical school was still in the purpose-built Italianate building next to the McEwan Hall and the Teviot Row Union. As clinical experience increased, students made the short journey across Middle Meadow Walk to the Royal Infirmary more and more frequently. The proximity of these sites has now been lost – and with it some of the magic of an Edinburgh medical training.
Clinical medical training only began in earnest after graduation with pre-registration house officer (PRHO) jobs. They lasted a year, split evenly between surgical and medical experience. House officers are also called residents because they were once expected to be resident in the hospital throughout that year. The Royal Infirmary of Edinburgh where I did my surgical house job (an unfashionable orthopaedic post) had a residency, also known as the Mess, where we ate and, if possible, slept when on call. Originally residents had to pay for the honour of training under the surgical and medical gods. In the Mess we ate around a huge dining table covered with a white tablecloth. We were attended by Robbie the Butler who would take orders for breakfast while our bleeps went off, summoning us to the nearest telephone. The food was the same modest canteen fare from the kitchens that everyone else in the hospital ate and there was little sense of privilege.
The mess silver, donated by previous residents and accumulated over many years, had been stolen, but the billiard room was hung with interesting old mess tabletops carved with the initials and dates of previous residents going back to the nineteenth century. The signatures of illustrious visitors such as George V, Queen Mary and Prince Philip had been professionally carved into the surface for permanence. Philip visited in 1961. He enjoyed the event so much that proceedings overran and the London train had to be held at Waverley for him. The mess table tops hang in the new Royal now, ignored by the passing throngs. You can read more about the history of the Mess here:
https://www.rcpe.ac.uk/journal/residency-mess-royal-infirmary-edinburgh-history-and-traditions
By my time we were only resident in the hospital when on-call for the wards, but the frequency of this could be onerous; some posts demanded every second night and every second weekend in the hospital on top of the standard five-day week. Non-medical friends would ask how much time we got off at Christmas and I would have to point out that ‘we never closed’. Having completed this first year satisfactorily, you were eligible for full registration with the GMC.
Being a house officer turned out to be even worse than the appalling accounts I had heard from my seniors. It was like the stress you might expect during a war, and like a war, it bound us together in relentless adversity. Life-and-death crises, interpersonal aggro and steep learning curves all took place in a setting of extreme sleep deprivation. Any hint of flakiness under fire would affect your reference, so we all suffered mutely behind a mask of cheery efficiency. I suppose it did generate a degree of camaraderie among us. Certainly anyone who hadn’t experienced it couldn’t truly understand what we were going through. We propped our brains up with fags and black coffee. At 4am when you’d worked 20 hours straight, the pleasure of tea, toast and marmalade prepared for you by a kindly yellow-uniformed domestic lady was intense. I developed the ability to go to sleep in an instant and wake up fully functional just as quickly. I had no sleep pattern. This proved very useful when off duty as you could seamlessly enter party mode without the need for any rest. Time off was never sweeter.
My second house job, from February to July 1980, was at the Northern General Hospital on Ferry road. I was the sole house officer for the neurology wards and throughout that post I experienced the nagging anxiety that every fleeting symptom I experienced was the harbinger of some horrific ‘nervous’ disease. I was, after all, surrounded by genuinely awful cases. Uncertainty about what I wanted to do with the rest of my career added to my general unease.
The opportunity to apply for senior house officer (SHO) posts arose early in the year and I realised my indecision had led me to miss the deadline. Checking the closing date in the British Medical Journal, I was seized with panic. I decided I did want to give the big game a go instead of drifting off into a subspecialty – or general practice. I went to see one of my consultants, the notoriously brusque Clifford Mawdsley, to explain the situation. I told him I wanted to apply for the Edinburgh SHO jobs. I thought I might have a chance of the CCU post at the Royal Infirmary. This job involved nine months working in the unit with three months of general medicine tacked on at the end – and was the least popular of the various SHO options. It all depended on whether it was still possible for me to be considered. Mawdsley called me a silly bugger – then phoned John Matthews who was the senior physician in Wards 28/31 with the attached CCU. Putting the phone down, he said, ‘Right, get yourself up there now and he’ll see you’.
In his office the patrician former international cricketer and I had a chat about my future. I did my best to seem decisive and keen. To my relief he said a late application would be accepted. I submitted my CV, was interviewed and subsequently appointed to the cinderella CCU post. I later learned that my success had caused consternation among my contemporaries. They had spent six or seven years slaving to be ‘top’ while I’d had to repeat the third year of medical school. This was due to a combination of my own indolence and my father’s illness and death in the weeks leading up to my resits. I had no academic profile whatsoever and worse; I was considered an eccentric.
As advertised, the CCU job was heavily weighted towards the unit but it transpired that one of my medical school contemporaries, fellow SHO and budding cardiologist, Mike McLeod, wanted some additional CCU experience. I gladly swapped a three month block with him and ended up with a full six months of general medical experience. Shortly after completing our SHO year, Mike contracted a severe viral infection that had been circulating in the city. He returned to work, perhaps not fully fit, and collapsed and died while on call at the Eastern General Hospital. Ten years later when I was appointed consultant radiologist at the Eastern we held clinical meetings in the seminar room where a memorial photograph of Mike hung on the wall.
House officer duties in neurology with a bit of on-call respiratory medicine weren’t really adequate preparation for running the CCU of a large teaching hospital. Apart from other appropriate skills, I had never intubated anyone. Just before taking up my new post I went to Philadelphia to stay with friends. I read Samuel Shem’s novel House of God, about junior doctors in Bellevue Hospital. It reminded me of my NYU student elective there in 1977. I also spent some time lying on a scorching beach at Ocean City, New Jersey, reading Leo Schamroth’s An Introduction to Electrocardiography (a textbook on ECG interpretation). In early August 1980 I returned to the Royal and reported for duty, a rank above the poor residents in the mess.
One of the commonest complications of a myocardial infarction (MI), known colloquially as a heart attack, is ventricular fibrillation (VF). In this condition, the heart muscles simply tremble and circulation of the blood ceases. The patient has no pulse and is clinically in cardiac arrest. The ECG is easy to interpret in VF because it shows only chaotic electrical activity. During my six months in CCU I did little else but ‘defibrillate’ people who had gone into VF. This was achieved by passing a powerful DC electric current through their chest known colloquially as ‘shocking’ them. The hope was that this would induce an electrical ‘silence’ in the heart allowing a normal heart rhythm to become re-established.
The patients in CCU were treated in separate rooms with ECG monitors above the doors. The monitors indicated instantly when a patient had gone into VF. You then grabbed the resuscitation trolley with the defibrillator and made for the relevant room. Sometimes a degree of residual cardiac function meant that patients entered a twilight state of diminishing awareness before becoming fully unconscious. Humanity demanded that you wait until the victim was completely unaware before putting 200 joules of electricity through their chest. On one occasion a patient took an unusually long time to pass out. I paused over the bed with the paddles raised ‘unaware’ that some of the conducting gel I had applied had oozed down onto my fingers. Once the patient appeared to be completely out, I told the nursing staff present to stand away from the bed. I applied the paddles to the patient’s chest and pressed the buttons to deliver electric salvation. The charge threw me backwards against the wall where I slid to the floor, stunned. Fortunately, the patient and I were both in ‘normal sinus rhythm’.
Another procedure frequently performed in CCU was the insertion of a temporary pacemaker if the patient’s heart rate had become too slow (bradycardia). ‘Temporary’ indicated that it was only required during the acute phase of an MI. If the condition persisted then the patient might require a permanent, implanted, pacemaker. The pacing room was separate from the CCU, lying across a corridor which led to the adjacent general medical ward. A pacemaker drives the heart by delivering a regular electrical pulse to the inner surface of the right ventricle. Pacemakers were positioned under X-Ray guidance, a process known as ‘screening’ and the image was displayed on a TV monitor. A foot pedal turned on the screening which showed a real time image of the patient’s thorax on the monitor. A lead apron was required to protect your body from the almost daily exposure to scattered radiation. Over this onerous garment you were gowned and gloved-up as required for a sterile procedure. Later, I would do this many times as a radiologist. It was hot under all those layers.
The right side of the heart receives venous blood returning from the body. The right ventricle pumps it through the pulmonary arteries into the lungs where carbon dioxide is expelled and replaced with oxygen. Venous blood is noticeably dark in colour while oxygenated arterial blood is bright red. To place the pacing catheter inside the heart, a Seldinger Technique was used. This is a means of increasing the calibre of the access to a vein until it will accept the thickness of the pacing wire.
The patient was tilted slightly head down on the table to avoid the potentially fatal ingress of room air into the central venous circulation. This head-down positioning also caused the central veins to become more distended creating a bigger target for the initial venous puncture. After infiltrating local anaesthetic, a small syringe attached to a long needle within a plastic sheath or cannula around it was used to work your way backwards from under the right clavicle until you hit venous blood. You slid the plastic cannula forwards and pulled out the syringe and needle leaving just the plastic cannula (hopefully) in the right subclavian vein. A stiff metal guide wire was passed through the cannula then the cannula itself was removed. A nick was made in the skin with a scalpel at the point where the wire entered the body, then a larger bore catheter was fed over the guide wire through the incision. Finally the guide wire itself was removed leaving just the largest catheter. You had to put your thumb over the end of the catheter to stop blood pouring out. The pacing wire could then be fed down the catheter into the superior vena cava leading directly to the right side of the heart.
The X-ray image intensifier allowed you to see the progress of the wire from the subclavian vein, through the superior vena cava, into the right atrium, through the tricuspid valve and on into the right ventricle. One hoped to place the tip of the wire against the inner ventricular wall where it could drive the heart at a normal rate. Only the air in the lungs, the soft tissues, the bones of the thorax and the pacing wire can be seen on X-Ray screening. The chambers of the heart are invisible and the progress of the wire through the various structures had to be inferred from the shapes it made. It was possible to get lost down the coronary sinus that drains into the right ventricle. The leads at the proximal end of the wire was then attached to the pacing ‘box’ strapped to the head of the bed. The box delivered a regular electric pulse, the rate and voltage of which could be set. It also told you what voltage was required to ‘capture’ the heart rhythm This was known as the pacing threshold. A low threshold meant you were in a good position, a high threshold a poor one, possibly up against dead infarcted heart muscle. Once everything seemed satisfactory you stitched the wire securely to the skin to maintain its position and covered it with a dressing. This was my first experience of using X-ray equipment to guide a procedure.
An elderly lady with a profound bradycardia (very slow pulse) needed a pacemaker. Her heart rate was so slow she was barely conscious – and very confused. I had successfully placed the wire but the problem was that as soon as I put her heart rate up to normal, she came round, tried to pull the pacing wire out of her neck and get off the table. The nurse assisting me with this tricky procedure suddenly announced to me that she didn’t feel very well. While gently restraining the patient to maintain the placement of the wire, I suggested the nurse go and get someone to relieve her and help me stitch in. She set off across the room but half way to the door she began to sway and then fainted, striking her head loudly off one of the big cast-iron radiators. She ended up motionless on the floor, apparently unconscious. ‘Scrubbed’ and unable to operate the intercom while pinning the patient down, I had to yell for help – which seemed to take forever to arrive. The fainting nurse recovered without any major sequelae.
When the blood supply to the heart is blocked by a coronary artery thrombosis the heart muscle supplied by that artery dies and stops working. It may also generate abnormal electrical activity of its own (see under VF above). One of the patients I paced during the early part of the post developed pleuritic chest pain. This is a sharp pain when you breathe in and usually indicates irritation of the sensitive lining of the lung called the pleura. My registrar did a round of the unit and when he came to the patient with the pain he pronounced that the pacing wire must have gone through the patient’s dead heart tissue and was now irritating the pericardium causing symptoms identical to pleuritic pain. He clinched this opinion by pointing out that the pacing threshold had risen. He told me I must reposition the tip of the pacing wire to relieve the pain and place it on a healthy bit of heart muscle so that we could continue pacing him. Just as I made the arrangements to return him to the pacing room for this, his wife turned up. I explained that we had to make a minor adjustment to the pacemaker and she would soon be able to see him.
I got the patient positioned head down, cut the anchoring stitch on the wire and pulled it back a little. He immediately went into ventricular tachycardia (VT). This isn’t quite as bad as VF but it is a serous arrhythmia nevertheless. I asked him to cough, as this sometimes terminates the rhythm without any formal intervention. That worked and I made to move the wire again. He immediately went back into VT. After this had happened three times, each time terminated by coughing, he went into proper VF and I had to shock (defibrillate) him. I had to shock him twice more and although the final position of the wire was not ideal the threshold was OK and I accepted it with gratitude. As we pushed him back across the corridor to CCU his wife was sitting in the corridor waiting, handbag on her knees. ‘That’s all fine’ I said cheerily. ‘You can see him now.’
Some cardiac arrests are true arrests, i.e. the heart is not fibrillating but has ceased to beat at all. This is known as an ‘asystolic’ arrest, systole being the contraction of the heart’s ventricles. In this setting I learned how to insert pacing wires ‘blind’ at the bedside without the help of X-ray screening. It was usually a last ditch effort involving inserting and re-inserting the pacing ‘wire’ through the large bore cannula. You hoped to place the tip in the right ventricle by trial and error. Pushed far enough, the tip would either be in the right ventricle or have gone past the heart altogether into the hepatic portion of the inferior vena cava in the upper abdomen. It might even have passed through the right ventricle and into the pulmonary arteries. If, when you turned on the pacing box, you could capture the heart rhythm, you knew you were in the right place. You could then force it to beat at a normal rate. If there was still no pulse you knew the heart was too badly damaged to recover, a phenomenon known as electro-mechanical dissociation.
Ultrasound imaging of the heart was in its early stages then but I witnessed the first use of a portable cardiac ultrasound scanner in CCU. The cardiology registrars were keen to try out their new equipment and a suitable case appeared. A young woman had been admitted, suffering from multiple pulmonary emboli (solid material passing through the right ventricle and blocking the pulmonary arteries). There was no obvious origin for these emboli. Usually the source would be blood clots travelling up to the heart from veins in the legs or pelvis known as a deep vein thrombosis – or DVT. She had none of the usual signs or risk factors for a DVT. We watched in silence as the scan showed a large mass oscillating in the right ventricle. It was clear now that clots or pieces of this tumour were breaking off and going into her lungs. We hoped this would turn out to be something benign called a myxoma. I was able to go to theatre to watch the attempt at curative surgery. Sadly, the external surface of the heart had a ‘peau d’orange’ appearance due to malignant infiltration. The tumour was a sarcoma and there was nothing to be done. I was intrigued by seeing the physical proof of what I had seen on the grainy greyscale image. Much later in life, ultrasound would become the mainstay of my clinical practice as a radiologist.
By December of 1980 I was feeling a great deal more confident, almost blasé, about my duties in CCU. I was never a ‘good riser’ and always left my departure for work to the last minute. It didn’t take long to drive from my flat in India Street to the Royal Infirmary where I had a coveted parking permit. On the morning of 9th December 1980 the radio alarm went off as usual. I heard the presenter say, ‘…and we will return this morning’s tragic news after the weather forecast.’ I wondered who had died. Someone important it seemed. The forecast completed, the ‘pips’ went for 8 o’clock and the presenter, Brian Readhead, said. ‘It’s 8 o’clock on Tuesday the 9th of December. Former Beatle John Lennon has been shot dead by an unknown gunman who opened fire outside the musician’s New York apartment where he lived with his wife, Yoko Ono, and his son.’
In CCU life and death went on as usual. A couple of weeks after Lennon was shot, on Christmas Day, we had five deaths before lunchtime. I’d seen five sets of grieving relatives by the time the sister and house officer from Ward 28 bounced into the unit bedecked in tinsel, intending to hand out presents. We suggested they didn’t bother.
A few years ago, I visited the Science Museum in London. On the top floor are the Wellcome Galleries, a museum covering 500 years of medical history. There are many interesting exhibits: pieces of ancient equipment, scale models, dioramas of historic breakthroughs and life-sized figures. There is a model of a British Man-of-War with a naval surgeon carrying out an amputation below decks and a Victorian chemist shop complete with the chemist in his stovepipe hat. Having circumnavigated these tableaux, I came to the final one labelled ‘A Coronary Care Unit of the 1970s’. There in front of me was the very set-up we had in the Royal. I’d lived long enough for the working environment of my junior doctor years to end up in a museum.
Oh, and my CTCA showed ‘moderate coronary occlusive disease in my left anterior descending (LAD) coronary artery and a possible narrowing at the ostia (origin) of the LAD from the aortic root’. Most of us wander about unaware of any cardiac sword of Damocles hanging over us, but thanks to the trial I am now aware. Better the devil you know?
The Bohemian Waxwing 