The Angina Monologues: Heart Surgeon, Author, and Crossword Compiler Samer Nashef 

Siobhan Harris

Disclosures

October 23, 2019

Samer Nashef is a consultant heart surgeon at Royal Papworth Hospital in Cambridge. He practises all types of cardiac surgery, with a special interest in surgery of the aortic root and atrial fibrillation.

Mr Nashef has many research interests, a major one being measuring and monitoring the quality of surgical treatment, and has led national and international projects in this field.

   

Samer Nashef

He is the author of The Naked Surgeon, a book which deals with issues of transparency in medicine. His most recent book is The Angina Monologues, which gives a frank and sometimes graphic insight into the life-and-death decisions of a heart surgeon.

He has written more than 200 scientific papers and in his spare time compiles cryptic crosswords for the Guardian and the Financial Times. He spoke to Medscape UK.

Q&A

Why did you decide to become a cardiac surgeon?

I would like to say that I had planned my cardiac surgical career carefully over many years, but that would be untrue. I sort of fell into cardiac surgery in the same way I did into surgery and into studying medicine in the first place, through a series of ill-informed decisions often based on trivia. Having said that, I am glad to say that I have loved being a heart surgeon and never for a moment regretted this choice.

Do you have to have a particular type of personality to be a heart surgeon?

That’s an interesting question. I was recently interviewed at the Cheltenham Literary Festival by Kevin Dutton, a psychologist who believes that the psychopathic personality has features that may be helpful in certain professions, including surgery. Others have also expressed the view, sometimes less charitably, that surgeons (and heart surgeons in particular) are psychopaths.

Psychopaths have, among other traits, an extreme ability to be coldly detached from emotion. There’s no doubt that such an ability can sometimes be helpful, even necessary to make the soundest decision and to do the best technical job for the patient, especially in moments of crisis. Looking back on the early days of heart surgery, development and innovation were largely driven by an unusual breed of surgeon: big personalities with unlimited confidence and total disregard for the risks they put their patients and themselves through. That is no longer necessary today, as heart surgery has evolved to be an established, routine and protocol-driven specialty where most operations should be highly predictable and preferably even boring. Drama of course does sometimes happen, and when it does, clear thinking, keeping one’s cool and a lot of stamina are what’s needed. These are probably the important personality traits essential to being a heart surgeon.

The Angina Monologues is full of real-life stories of transplants, bypasses, aorta repairs and cardiac arrests. It brings to life extremely challenging cases. What's the most difficult case you've had to deal with?

Cases can be difficult for a whole variety of reasons. In terms of technical difficulty, I’ve always said that the hardest procedure we do is probably a really difficult coronary bypass. When the coronary arteries are tiny, heavily diseased and fragile, it only takes one stitch to be half a millimetre ‘out’ to cause a potentially fatal heart attack. These cases are technically the most challenging, but tremendous concentration coupled with a slow, cautious and deliberate approach during the (relatively brief) crucial part of the operation usually saves the day.

What is most stressful, however, is when operations need a lot of work to be done and when all of it from beginning to end requires both concentration and speed. This is especially true if these operations are being done on purely prognostic grounds on young patients who feel absolutely fine and are only having surgery to reduce their risk of complications in years to come, such as aortic root replacement with valve preservation in young Marfan patients. These patients have a lot to lose if anything goes wrong because of their youth and health, and the ‘stakes are high’. I find these operations hugely rewarding, but at the same time, they are physically and emotionally exhausting.

Your book also mentions a coronary bypass when the patient was accidentally set on fire. What happened there?

One of the truly horrible conditions that can afflict people is called acute aortic dissection. What happens is that a tear develops in the lining of the aorta and the highly-pressured blood within the aorta ‘dissects’ its wall from the heart to the legs. As you can imagine, this compromises every artery and every organ in the body and unless fixed quickly, it is usually fatal. Rarely, this truly appalling condition develops at the end of another heart operation, since the aorta is manipulated and an inherent weakness can give way.

This patient was a man in his 80s coming to the end of an urgent coronary bypass. Up to that point, everything had gone well, but suddenly the aorta fell apart due to acute dissection. There was nothing for it other than to repair the dissection and to do that, we had to put the patient back on the heart lung machine in a hurry. Usually, we do this by putting a tube into the aorta, but that was not possible here since the aorta was in tatters. There was massive bleeding and we had to find an artery quickly, so we went for the most accessible one: the femoral artery in the groin. I cleaned the skin by splashing prep solution on the groin and in my rush to get the pipe in I didn’t allow the solution to dry. The next use of cautery instantly set the groin on fire. We extinguished the flames (which were quite impressive) using whatever came to hand (surgical drapes, towels, swabs etc) and proceeded to fix the acute dissection. I am delighted to say that the patient did very well but was somewhat bemused, when he came round, to note that he had not a single pubic hair left.

When you found out you had angina yourself you wrote about having a beer and a burger to think about your condition. Is this a reflection of what you think of the official public heart health and dietary messages?

I think it was more of a distraction from the problem than trying to face it and think about it (I have useful powers of denial when needed). I do, however, disagree with many of the health messages that we are constantly given. This is partly because some of them are not evidence-based but also because there are too many messages. An excessive number of health diktats, if they are not supported by good science, can distract from the important messages which are backed by evidence, such as ‘don’t smoke’ and ‘don’t get fat’. I have a fair bit to say about this issue in The Angina Monologues and will probably not be popular with the health lobby.

How has heart surgery changed over the course of your career and what do you predict for heart surgery in the next few decades?

The greatest change has been just how safe it has become. Heart surgery used to be a last-ditch effort in hopeless patients. It is now the most studied, researched, planned and audited intervention in health care. The result of this is that corrective heart surgery can now improve quality of life and indeed length of life for more people, [and for] older and sicker [people] than ever before.

Over the years, I have seen cardiac surgeons operate faster while at the same time reaching higher and higher levels of precision. We have become really good at protecting the heart muscle when it is deprived of oxygen during the operation. Our management of patients before, during and after surgery has improved massively. On top of all of that, a lot of innovation has taken place. Among many, we can now repair mitral valves and have begun repairing aortic valves, avoiding mechanical replacements. We have even developed ways of treating electrical problems in the heart as well as the standard 'plumbing' problems.

Perhaps the greatest, and so far most elusive achievement, will be when we can totally replace the heart, when it fails completely, with a safe and reliable artificial pump that is wholly contained in the body. We are not there yet, but over the last decade, progress has been impressive and I hope that we will see that dream realised in the next decade or two.

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