The Knife's Edge: The Heart and Mind of a Cardiac Surgeon

Preface / Introduction

swinging sixties 1960s 英国“摇摆伦敦”新浪潮青年运动。

The whole riveting story of modern heart surgery evolved during my lifetime, and I was proud to be part of it.

作者的职业生涯经历了现代心脏外科的革命：心肺机（使开胸手术修补心脏问题成为可行）、心脏移植、人造心脏、ECMO等各种技术和医疗实践均在这一阶段出现并发展成熟。当然，代价是技术试错和完善过程中死亡的患者生命——但是那些危重的患者如果不治疗也很快会死亡，所以患者和家属都愿意接收新技术的巨大风险——作者在本书后文中也提到了这一点。

现今的文化和(NHS)培养体系下成长出来的新一代英国医学生过于怯弱，不可能再进行那种程度的大胆创新。整个社会文化氛围对于医疗中的失败也愈加不宽容，对比，本书作者深恶痛绝。在后来一次接受记者采访时作者说道 (来源: How to save the NHS… by five bestselling medical memoirists)

>新闻媒体开始报道外科手术高居不下的死亡率，这样一来，这个行业的发展就受到了威胁，最终倒霉的还是患者。为什么要因为救死扶伤而把自己的前途赔进去呢？我认为，越是手艺高超的医生，越应该接诊高死亡率的病例，因为这些患者往往都是病入膏肓的。虽然结果可能成功，也可能无法妙手回春，不过这不正是开创性的意义所在吗？

《Do Not Harm》里提到 NICE(National Institute of Clinical Excellence) 决策 NHS 是否愿意为某种药物或治疗方法付费的依据：QALY。在2016年对于末期绝症患者，这个值是 5万英镑 per QALY (Quality Adjusted Life Year, 质量调整寿命年)。我觉得这种方式没有任何问题。医保永远不可能满足所有人。

swoop, scoop and run: Termed “scoop and run,” this strategy involves administering only Basic Life Support (BLS) at the trauma site before rushing patients to a hospital while they are still in their “platinum minutes”.
现代急救体系可以在危重病人送到医院前的黄金时间内提供高级生命支持(Prehospital advanced life support)

Bart Simpson

Because of a freak sporting accident, some qualities possessed by the vast majority of people were lost to me for a while, which proved an unexpected but substantial boost to a career at the sharp end – life perpetually on the ‘knife’s edge’.
// what ?

Chapter 1. Family

Play-Doh

These have been summarised in the medical literature as the ‘dark triad’ of psychopathy, Machiavellianism – the callous attitude in which the ends are held to justify the means – and narcissism, which manifests as the excessive self- absorption and sense of superiority that goes with egoism and an extreme need for attention from others. This dark triad emanates from placing personal goals and self-interest above the needs of other people

‘Tight on beds’ means not enough nurses. In the NHS, every intensive care bed must have a dedicated nurse. In other countries they double up quite safely to get the work done, but here we just cancel operations as if they were appointments with the hairdresser
// NHS的官僚主义: 为了提高医疗服务质量制定的规则（ICU每个床位必须配备专属护士）在实际上让病人等待手术时间更久：必须等待ICU有空余护士才能做手术。（术后需要进ICU)
// 甚至 ICU 病人情况稳定后也要等待普通病床有床位时才能转出。有时因为普通病床没有空位,病人直接从ICU出院回家。

This was not how it used to be. When we fought to build the department, just three heart surgeons would perform 1,500 heart operations each year and we’d cover the chest surgery between us. Now in the same modest facilities we had five heart surgeons performing half that number of cases, alongside another three chest surgeons operating on the lungs. This was the price of progress – twice as many highly trained professionals doing much less work amid a disintegrating infrastructure.

进步的代价。NHS(以及所有其它现代国家公立医疗机构)的“働き方改革”，让医生和护士工作时间更加接近普通上班族（减少加班）。今天的医生选择医疗职业初衷是作为一个普通职业，而不是出于救死扶伤的道德感召。

Chapter 2. Sadness

ortic dissection is a dire emergency, where the main artery supplying the whole body suffers a sudden tear through the innermost of its three layers. This exposes the middle layer, which usually splits along its entire length under the high pressure, all the way from just above the valve down to the leg arteries. Branches to the vital organs can be sheared off, interrupting their blood supply and causing stroke, dead gut, pulseless legs or failing kidneys. Worse still, the split aorta is likely to rupture at any time, causing sudden death.

Aortic dissection: 主动脉夹层(ja: 大動脈解離)：非常危险。

Great dissection repair, pity about the outcome.
NHS 官僚主义导致的人为悲剧？。

但是我们必须避免 Argumentum ad passiones (Appeal to emotion, 诉诸情感)这种谬误。NHS对社会总福利的贡献——无论是正面还是负面——不可能只由一个案例判断。并且 NHS 的所有制度构成一个（互相妥协的）有机整体，不可能单独评判其中某个制度的优劣。

Chapter 3. Risk

blue baby operation

Phineas Gage 的经典案例在很多书籍里都出现过。

In short, I emerged from the head-injury experience both disinhibited and ruthlessly competitive. Born with both the coordination and manual dexterity to become a surgeon, I had now acquired the necessary personality traits as well. Yet I never lost my empathy, that element of emotional intelligence enabling us to appreciate the feelings of others, the ability to care about people that all doctors and nurses are meant to have, although many don’t.

神奇的转折使作者最终走上成功外科医生的道路。这种经历可以总结称为"post-traumatic boldness" (出自本书下一章)。

Even our so-called clients are routinely risk stratified, with the implication that while it is not satisfactory to terminate a low-risk candidate, bumping off the odd high-risk patient is excusable. What a miserable way to view any profession.

我认为质量调整寿命年是(唯一）科学的衡量医疗行为收益/风险比率的方式。

Chapter 4. Hubris

Jehovah's Witnesses beliefs / 耶和华见证人的信条是指基督教非傳統教派耶和华见证人的信仰。其信条部分与传统的基督宗教有很大分別。 // 这个教派拒绝接受（手术中）输血

Chapter 5. Perfectionism

John Webster Kirklin 美国心脏外科医生。改良了现代心脏外科开胸手术(direct vision open heart surgery with the heart–lung machine)。

作者在美国进修期间的临床研究大幅降低了体外循环手术后因为（血液与体外循环设备，如心肺机里的尼龙材质接触导致白细胞释放毒素，造成全身炎症反应）并发症和由此造成的死亡。

Chapter 6. Joy

Interestingly, Jehovah’s Witnesses celebrate neither Christmas nor birthdays, are politically neutral, do not enlist in the military nor salute flags.

所有宗教都是傻逼。

Red blood cells are needed to carry oxygen to the tissues, but dropping the temperature from 37°C down to 32°C would decrease oxygen consumption almost by half, around 7 per
cent for each degree of cooling. The lower the temperature, however, the greater the risk of lethal heart rhythm problems.
// 所以一些心脏外科、神经外科等手术会降低患者体温，减少组织缺氧造成的伤害。

Steinbeck: 小约翰·恩斯特·斯坦贝克（John Ernst Steinbeck, Jr.，1902年2月27日—1968年12月20日），是20世纪的美國作家、戰地記者，1962年度的诺贝尔文学奖得主。其主要代表作有《愤怒的葡萄》、《伊甸之東》和《人鼠之间》等。: ‘It means very little to know that a million Chinese are starving unless you know one Chinese who is starving.’

Two years after her reoperation in Oxford, Megan’s artificial mitral valve became infected. I was abroad when the family tried to contact me, and her closest cardiac centre was unwilling to attempt a third procedure without blood transfusion. She died from sepsis.

That cold winter’s day in 1988 helped change my perspective on life and probably made me a better surgeon – not technically, needless to say, but as a result of becoming a much better human being. Love brings joy, yet until then I had been afraid to admit it.

如何评价这个故事的结局？

Chapter 7. Danger

runner nurse: 医疗行业俚语。Emergency medicine,  A nurse or other healthcare worker responsible for obtaining supplies or medications needed during emergency.
scrub nurse (器械出し看護師): 器械护士。手术中给医生递工具的。

tricuspid valvulectomy (without replacement): 切除(因严重细菌感染损坏的)三尖瓣，但不植入替换。这种严重感染常见于静脉注射药物成瘾者(intravenous drug use (IVDU))。自上世纪70年代开始，美国公立医院通常对(医保支付的)成瘾者在第一次治疗时只切除三尖瓣，如果患者成功戒毒，后续再施行三尖瓣置换手术。——这是出于社会整体利益考虑(可供替换的三尖瓣资源有限且价格昂贵)，而IVDU可以轻易引起三尖瓣感染——所以给瘾君子施三尖瓣置换很多时候纯属浪费医疗资源。
* 机械瓣膜：需要终身服用抗凝药物(例如warfarin(华法林)-药理是减少肝脏生成的凝血蛋白)
* 生物瓣膜(来源于猪心或牛心)：不需要抗凝，但寿命有限(临床统计10~15年)

HIV PEP, or post-exposure prophylaxis // HIV 暴露后预防
// workplace exposure, such as from needlestick injury
HIV PEP, or post-exposure prophylaxis, is a short course of HIV medicines taken very soon after a possible exposure to HIV to prevent the virus from taking hold in your body.

You must start it within 72 hours (3 days) after a possible exposure to HIV, or it won’t work. Every hour counts!

PEP should be used only in emergency situations. It is not meant for regular use by people who may be exposed to HIV frequently.

The World Health Organization estimated that 66,000 hepatitis B, 16,000 hepatitis C and 1,000 HIV infections were caused in medical or nursing staff by needle-stick injuries in the year 2000 alone. While 10 per cent of hepatitis B-positive needle-sticks eventually infected the recipient, the risk for hepatitis C was less than 2 per cent and for HIV it was just 0.3 per cent. But blood from terminally ill AIDS patients was substantially
more infective. // 这个数据是进行暴露后预防之后的结果。

Chapter 8. Pressure // the story of Cara

The Ross procedure: also known as the switch procedure or pulmonary autograft procedure, is a cardiac surgery in which a diseased aortic valve is replaced with the patient's own pulmonary valve. This is followed by the replacement of the pulmonary valve with a pulmonary allograft

The ductus arteriosus is a short vessel that connects the fetal pulmonary artery to the aorta and involutes it following birth. During development, the ductus arteriosus allows oxygenated blood to bypass the pulmonary circulation and provides nutritional and oxygen-rich blood directly into the systemic circulation.

The Ross procedure // 来源于作者以前的boss: Ross came up with the ingenious idea of removing the patient’s pulmonary valve and transposing it to the aortic position, then replacing the pulmonary valve on the low-pressure side of the heart with a pulmonary valve taken from a dead donor.

Chapter 9. The Hope // The story of Sophie

Materials used in repairing the heart valves or blood vessels:
* The fibrous membrane from around the heart // best
* cow pericardium // sheets of sterilised tissue prepared by the cardiovascular industry
* strip of human aorta // from dead body

Henry Marsh 也参与了这个病例中小女孩的诊断和治疗？

Chapter 10. Resilience // The story of Oliver // and his mother Nicky, and her recollections and letter

But one thing I did understand by then was always listen to the mother, because no one knows her child better. If Mum insists there is something seriously wrong, you can bet your life there will be.

Cor triatriatum: is a rare condition occurring when a child is born with a thin, fibro-muscular membrane subdividing either the left or the right atrium into 3 chambers. The condition is also classified as a congenital heart defect.

Cross-matching: is a way for your healthcare provider to test your blood against a donor's blood to make sure they are fully compatible. It's essentially a trial transfusion done in test tubes to see exactly how your blood will react with potential donor blood.
// 输血前下应该对病人血液和供血进行额外的Crossmatching (除了基本的Blood typing(ABO, RH 血型鉴定))，完整过程需要1小时。
// 紧急情况下可以跳过此步骤直接输血。

Bristol heart scandal

作者把英国的(僵化、官僚、民粹的) 目前的 NHS 医疗体制喷的体无完肤。

Chapter 11. Misery // 这章的主题是喷 NHS。

Cheyne-Stokes respirations are a rare abnormal breathing pattern that can occur while awake but usually occurs during sleep. The pattern involves a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all, called apneas

My mother died peacefully at home, surrounded by her family. Had she lived in a nursing home, an ambulance would have shipped her off to the accident department to die on a trolley in a busy hospital corridor.

What do Albert Einstein and our treasured NHS have in common? Answer: they were brilliant for their time, but when they reached seventy they both died from something eminently treatable. In Einstein’s case, it was an aortic aneurysm for which he persistently refused surgery, a common obstinacy and resistance to change that is difficult to understand. For the NHS, it’s the ‘free for all at the point of delivery’ principle that is impossible to sustain because the population is aging and only a proportion of us pay taxes to pay for it. And free healthcare has long been a tourist industry
// 爱因斯坦死于腹主动脉瘤急性破裂

所以作者和其家人为什么不(在自己需要医疗服务时)选择 Go private ?

In the 1990s my colleagues in Oxford and I each performed between 500 to 600 heart operations a year. We were a finely honed production line of cardiac surgery, with a great team and excellent results, and surgeons came from all across the world to observe what we had achieved. But it became politically incorrect to work that hard in the NHS and every opportunity was taken to criticise us. We were told we should be spending more time on surgical training, attending outreach clinics in far-flung general hospitals or participating in management meetings. Anything, in fact, apart from doing what we had been trained to do – something that others couldn’t do – which was operate on sick hearts. Political correctness and the system eventually won out. Now the six cardiac surgeons at my hospital each perform around 150 operations per year, fewer than 1,000 cases a year between all of them。
// 归根到底是“働き方改革”的错。

A&E: accident and emergency department

Chapter 12. Fear // 最后一章主题是集大成地喷NHS

circulatory arrest: Deep hypothermic circulatory arrest (DHCA) is a surgical technique in which the temperature of the body falls significantly (between 20 °C (68 °F) to 25 °C (77 °F))and blood circulation is stopped for up to one hour. It is used when blood circulation to the brain must be stopped because of delicate surgery within the brain, or because of surgery on large blood vessels that lead to or from the brain. DHCA is used to provide a better visual field during surgery due to the cessation of blood flow. DHCA is a form of carefully managed clinical death in which heartbeat and all brain activity cease.

Surgical patients and those recovering from stroke, head injury or heart attack lose up to 10 per cent of their leg muscle mass after ten days of inactivity, which in itself is equivalent to ten years of the aging process. So I am now working to build a ‘state of the art’ rehabilitation hospital in Oxford to maximise activity in the pressurised acute beds.

I rarely lost a child, but when I did I had to walk away from it. I couldn’t keep putting myself in the parents’ shoes, otherwise I wouldn’t come to work the following day. That is what burnout is all about. It was the difference between John Gibbon, the inventor of the heart–lung machine, and John Kirklin, who made that incredibly daunting equipment work for patients. When Gibbon lost a series of children, he gave up. Kirklin didn’t, nor did Lord Brock. I had the great privilege of following in their pioneering footsteps. Sadly, no one else will have that freedom now.
// 贯穿本书的核心观点：优秀的医生必须与患者（情感上）保持距离。

So, if I may, please let me conclude with a quote from George Orwell:
>Autobiography is only to be trusted when it reveals something disgraceful. A man
who gives a good account of himself is probably lying, since any life when viewed
from the inside is simply a series of defeats

Glossary // 非常有帮助的面向普通读者的心脏外科医学术语表

acute heart failure (急性心力衰竭): the left ventricle fails rapidly and cannot sustain sufficient blood flow to the body. The lungs then fill with fluid. Usually caused by myocardial infarction (心肌梗塞) or viral myocarditis (病毒性心肌炎) and has a high mortality rate. See also shock.

angina (心绞痛): crushing pain in the chest, neck and left arm due to limitation of blood flow to heart muscle in coronary artery disease. Typically comes on during exercise. If it comes on at rest it may warn of a heart attack.

angiogram (冠状动脉造影): cardiological investigation where a long catheter is passed through the blood vessels into the heart. This allows blood pressure to be measured in the cardiac chambers and dye to be injected to visualise the coronary arteries or aorta.

aorta (主动脉): large, thick-walled artery that leaves the left ventricle then branches to supply the whole body. The first small branches are the coronary arteries, which supply blood to the heart itself.

aortic stenosis (主动脉瓣狭窄): narrowing of the aortic valve at the outlet of the left ventricle, restricting blood flow around the body. Can be caused by a congenital anomaly or degeneration in old age.

arteries (动脉): the blood vessels that convey blood to the organs and muscles of the
body.

atrioventricular canal (房室管狭窄): congenital heart defect where there is a continuous hole between the collecting (atria) and pumping (ventricles) chambers, and the mitral and tricuspid valves fail to form properly.

blood pressure (血压): pressure within the large arteries. Normally measured by a cuff and stethoscope or a cannula inserted into an artery. Normal blood pressure is around 120/80 mm Hg. The higher figure is when the left ventricle contracts; the lower, when it relaxes.

bridge to recovery (BTR): the process whereby a ventricular assist device is used to sustain the circulation and rest an acutely failing heart pending recovery from a reversible condition. If the heart does not recover, a limited-duration pump can be replaced by a long-term implanted device.

bridge to transplant (BTT): the process whereby a ventricular assist device is used to prevent death from heart failure until a donor heart can be found. At the time of transplant the pump and diseased heart are both removed.

cannula (导管): a plastic tube inserted into the heart or a blood vessel to carry blood or fluid.

cardiac tamponade (心肌梗塞): a condition that occurs when blood or fluid accumulates within the pericardial sac under pressure, preventing the heart from filling.

cardioplegia (心脏麻痹): a cold (4°C) clear or blood-based solution infused into the coronary arteries to stop and protect the heart in a flaccid state during surgery with the heart–lung machine. Usually contains a high concentration of potassium. At the end of the repair the heart is re-animated by restoring normal coronary blood flow.

cardiopulmonary bypass (CPB)(心肺旁路): process whereby the patient’s blood is diverted away from the heart and lungs for the duration of the surgical repair. Contact of the patient’s blood with the synthetic surfaces in the pump- oxygenator system elicits an inflammatory response. This limits the safe duration of blood–foreign surface interaction. The longer the procedure, the more damaging is the whole-body inflammatory response.

congenital heart disease (先天性心脏病): heart deformity that the patient is born with (e.g. atrial septal defect, ventricular septal defect, dextrocardia).

coronary artery disease (冠心病。又称缺血性心脏病): gradual narrowing of the coronary arteries by atheroma. These fatty, cholesterol-based plaques are prone to rupture when they suddenly occlude the vessel, which then clots (coronary thrombosis).冠心病发作称为 heart attack。

crash call (紧急呼叫?): call for a resuscitation team of doctors and nurses.

CT scan: X-ray-based three-dimensional imaging of the chest and heart. By adding contrast medium, the coronary arteries can be shown in detail.

Dacron (达克龙，医用血管缝合材料): a woven fabric used to make vascular tube grafts and heart patches.

defibrillate (除颤): electric shock of between 10 and 20 joules used to restore normal heart rhythm during the disordered rhythm of ventricular fibrillation.

deoxygenated blood(脱氧血。静脉血): bluish blood leaving the tissues and returning to the right heart, now low in oxygen and carrying carbon dioxide to be expelled by the lungs. See also oxygenated blood.

diastole (舒张期): relaxation and filling phase of the ventricles. 对意词是 systole (收缩期)

direct vision (直接目视(开胸手术)): to see within the heart in order to conduct a surgical repair.

distal anastomosis (远端吻合): join between a coronary bypass graft and the target coronary artery.

echocardiogram (心脏彩超): non-invasive ultrasound examination of the heart chambers.

electrocautery (电热烧灼，用于手术中切除组织并止血): the electrical instrument used to cut through tissues and simultaneously coagulate blood vessels to stop bleeding.

endocarditis (心脏内膜炎): bacterial infection that can destroy the heart valves.

endotracheal tube (气管插管): tube in the windpipe through which to ventilate a patient.

exsanguinate (大出血死亡): bleed to death.

heart–lung machine (心肺机): circuit outside the body to keep the patient alive while the heart is stopped for repair. Contains a mechanical blood pump and a short-term (lasting hours) complex gas exchange mechanism known as the oxygenator (artificial lung). Other pumps are used for suction of blood into the reservoir and for delivery of cardioplegia fluid to stop the heart.

HeartMate left ventricular assist device (HeartMate是世界上第一种实用化的左心室辅助装置): an obsolete large pulsatile implantable pump widely used for bridge to transplant in the 1990s. The first device to be implanted on a permanent basis. Thoratec went on to produce a successful rotary blood pump for permanent use.

heart transplant (心脏移植): removal of the patient’s diseased and failing heart, then replacement with an organ from a brain-dead donor.

heart valve replacement (心脏瓣膜替换): removal of a diseased heart valve, then replacement with a prosthetic valve. Prosthetic valves can be biological (e.g. pig’s valve) or mechanical (e.g. pyrolytic carbon tilting disc valves).

homograft bank (同种异体移植库): department that collects and processes human heart valves and blood vessels donated by the deceased for use in patients.

iliac fossa (髂窝?): part of the lower abdominal wall beneath the umbilicus.

inferior vena cava (下腔静脉): see vena cava.

intubation (气管插管): the process of inserting the endotracheal tube into the patient for ventilation.

left atrium (左心房): collecting chamber for blood returning to the heart from the lungs. The blood then passes through the mitral valve into the left ventricle. See also
right atrium.

left ventricle (左心室): powerful, thick-walled conical chamber that pumps blood through the aortic valve and around the body. See also right ventricle.

left ventricular assist device (LVAD, 左心室辅助装置): mechanical blood pump to maintain the circulation and rest the ventricles when the heart fails catastrophically. The cannulas are inserted into the chambers of the heart. There are inexpensive temporary external devices suitable for several weeks of support in acute heart failure (e.g. CentriMag or Berlin Heart). The small, implantable but very expensive high-speed rotary blood pumps (e.g. Jarvik 2000) can be used for as long as ten years in chronic heart failure. As such, the long-term LVADs offer an off-the-shelf alternative to heart transplantation.

metabolic derangement (代谢紊乱): consequence of poor tissue blood flow. Arteries to the muscles clamp down and the tissues produce lactic acid and other toxic metabolites.

mitral stenosis (二尖瓣狭窄): narrowing of the mitral valve between left atrium and left ventricle caused by rheumatic fever. Flow through the valve is restricted, causing breathlessness and chronic fatigue.

mitral valve (二尖瓣): valve between the left atrium and ventricle. Named after a bishop’s mitre.

oxygenated blood (氧合血。动脉血): bright red blood saturated with oxygen and pumped around the body by the left ventricle. See also deoxygenated blood.

perfusionist (灌注师): technician who controls the heart–lung machine and ventricular assist devices.

pericardium (心包组织): fibrous sac that surrounds the heart. Can be used as patch material in the heart. Calf pericardium is used to make bioprosthetic heart valves.

pulmonary artery (肺动脉): large, thin-walled vessel that carries blood from the right ventricle to the lungs.

reperfusion (重新灌流): the process whereby blood is allowed back into the coronary arteries and heart muscle following cardioplegia and cardiac arrest during surgery. The heart is re-animated and begins to beat again.

resident (规培医生): trainee surgeon in the US, so-called because they live in the hospital.

rheumatic fever (风湿热): autoimmune condition triggered by a streptococcus bacterial infection that damages the heart valves and joints. Very common cause of rheumatic valve disease in the pre-antibiotic era.

right atrium (右心房): collecting chamber for blood returning to the heart from the body via the veins. The blood then passes through the tricuspid valve into the right ventricle. See also left atrium.

right ventricle (右心室): crescent-shaped pumping chamber that propels blood through the pulmonary valve and to the lungs. See also left ventricle.

sharps bin (手术中的医疗器械垃圾桶): bin in which to deposit needles and scalpel blades after contact with blood.

shock (休克。心脏骤停。可分为心肌梗塞休克和出血性休克两种): condition when the heart cannot continue to supply sufficient blood and oxygen to the tissues. Cardiogenic shock occurs after a heart attack. Haemorrhagic shock follows profuse bleeding of two litres or more.
* 心肌梗塞(myocardial infarction (MI)), 又称为 heart attack。由冠心病急性发作导致。
* 出血性休克(Haemorrhagic shock)。由(物理创伤等导致)大出血导致。

tricuspid valve (三尖瓣): valve between the right atrium and right ventricle.

valvotomy (心脏瓣膜切除术): surgical manoeuvre to dilate the narrowed orifice of an aortic or mitral valve.

veins (静脉): thinner-walled vessels that return blood to the heart.

vena cava (腔静脉): large vein entering the right atrium. The superior vena cava (上腔静脉) drains the upper part of the body; the inferior vena cava (下腔静脉) drains the lower half.