Saving children — life in the hospital

By Frederic Friedel

I have mentioned this before: when I was studying — philosophy, at Hamburg University — I was supporting myself. University tuition costs essentially nothing, but you gotta eat and live somewhere. I financed this mainly by working in a hospital, doing what in German is called “Intensivwache”, intensive patient care. I worked only in children’s sections of the Hamburg University Hospital, in two departments: cardiology and surgery. I had 12-hour shifts and tended to choose the ones at night. From 9 p.m. to 9 a.m. it was my job to keep some child alive. My previous article told the story of Timo and Regina, today it is about another little girl I had the privilege to look after.

So one day I got Melanie. She was newborn, just a day or two old, permanently blue, very frail and very small, and had catheters attached to veins, feeding tubes, a breathing machine. My job was to attend to all of these and keep her alive, for the twelve-hour shift I was on.

Melanie had been born with an insidious heart defect know as “Transposition”, which refers to the great blood vessels, the pulmonary artery and the aorta, that leave the heart. Normally the system forms a figure of eight: the blood transported by veins from the body to the heart is pumped by the right ventricle (shown in blue on the left in the cut-out diagram) into the pulmonary artery, where it is transported to the lungs for oxygenation. From there veins transport it back to the heart, and the left ventricle (red in the diagram) pumps it into the aorta, for distribution all over the the body, which needs the oxygen collected in the lungs.

“Transposition of the great arteries” (TGA) is a deadly congenital defect in which the two arteries are switched. Blood flows from the lungs back to the lungs, and from the body back to the body, unoxygenated! So how can an infant with this O-O heart plumbing survive for even an hour? Well, only if there is some mingling of blood between the two circuits.

Image from MedlinePlus on ventricular septal defect

In addition to her TGA Melanie had a Ventricular Septal Defect (VSD), which means she had a hole in the wall separating the two sides of the heart. This is not unusual, since in the fetus the hole is there to distribute blood, supplied through the umbilical, to the whole body. After birth the small septal opening is rapidly closed, sealing off both sides against each other.

In Melanie’s case it was the septal defect that was keeping her alive. Some of the blood in right ventricle, the lower segment of the heart receiving blood from the lungs, could seep into the left ventricle, from where it was pumped, together with the unoxygenated blood, to the body. It was a very tenuous and inadequate supply, which is why she was blue and unable to display normal infant activities.

Schematic drawing from open-access academic publisher Frontiersin.org

The problem was that the septal hole in Melanie’s heart was closing, and she was consequently getting weaker by the day. The surgeons contemplated a major operation, an arterial switch procedure to correct the transposition defect. It is quite complicated and dangerous — open heart surgery in a very small child — but the only chance to survive and lead a normal life. The procedure is performed a number of weeks after birth, and the infant must be reasonably healthy for there to be a chance of success. Melanie was moving to a state where this would not be the case. So an intermediary procedure was planned: expand the septal hole so that the body could get more oxygen.

I had kept Melanie alive for almost two weeks and apparently done so with enough dedication that the surgeon who was to perform the expansion asked me if I wanted to assist during the procedure. Of course I did. So one morning I found myself in the operation theatre, scrubbed and masked, to participate in the operation.

It was not open-heart or anything — the surgeon was going to use a new method for the very first time in the University Clinic in Hamburg: expanding the hole with a “balloon catheter”.

This is a soft and pliable tube with an inflatable balloon at its tip (image from Boston Scientific). The deflated balloon is guided through veins and positioned in the required part of the heart, where it is inflated to perform the intended procedure.

The surgeon, whose name I unfortunately cannot recall, was a giant of a man, with enormous hands — in fact I suspected he suffered from acromegaly. With Melanie anesthetized he proceeded to cut a slit in her groin and pull out a tiny vein that looked like a small earthworm. He then used a pair of scissors to snip through part of it, and inserted the catheter. He did this so deftly, with his giant hands, that I could only speculate the he was using magic scissors. After the operation I actually stole that pair of scissors, which I have to this day. It is completely normal, something I can buy in a drugstore for ten Euros. No, he was just deft — extremely, extremely deft.

On the x-ray monitor above the operation table we could follow the path of the catheter, through the artery into the heart, where it poked around looking for the septal hole. Once it went through that the surgeon inflated the balloon and pulled back the catheter with a jerk. That ripped at the hole and made it larger. He repeated this a number of times, increasing the degree of inflation after each insertion. The procedure took about half an hour.

After it was over I looked after Melanie for another two weeks, and she improved noticeably. She turned more pink in colour, and one day gave me a wonderful gift: she smiled at me when I approached. I think it was the first smile of her life. In the end she was taken away for the arterial switch procedure, which I learned was a success. I didn’t see her again, but love to think that she is a strapping middle-aged lady today, with a beautiful family of her own — and no memory of the horrific start of her life.

During the procedure described above I got into a fair bit of trouble with the hospital and its administration. But I do not want to bog down the story with details of that incident— it has been narrated in a different article.

Frederic Alois Friedel, born in 1945, science journalist, co-founder of ChessBase, studied Philosophy and Linguistics at the University of Hamburg and Oxford.