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Opinions of Friday, 10 June 2016

Columnist: Konotey-Ahulu, Dawid

Between life and death: They always say it is impossible until it's done

Catheterization Laboratory Catheterization Laboratory

A few times in your life, but maybe never, you get to witness something heroic and awe-inspiring that changes your perception of humanity, the world, God and yourself. Perhaps once, you may get to play your own part in it.

Last weekend, that happened and it has changed me.

I have started writing this in Accra, Ghana, 3,100 miles from home, still in awe at what just took place.

The Background: Six weeks ago, I discovered that one of my school friends was very sick in Accra with a major heart condition. He had been told that open heart bypass surgery was his only option.

For that he would have to go to India. Another good friend, Professor Nicholas Ossei-Gerning, Consultant Interventional Cardiologist at University Hospital of Wales (“UHW”) looked at the angiogram and said “I can treat him with angioplasty. He doesn’t need a bypass”.

So, he applied to the UK Home Office for a visa that would allow him to travel to the United Kingdom for emergency treatment on compassionate grounds and sent all the supporting documentation they could reasonably have needed, including a letter from a leading heart surgeon explaining that he had a cardiac condition that would be fatal if he is not treated urgently.

We had raised all the necessary funding to pay for his treatment in full and we sent the evidence. The Home Office denied him the visa. Said, in effect, that they didn’t believe his application. Said he had failed to prove he would not go on the run if they let him into the UK. To ram it home, they said: “By the way, you have no right of appeal.”

You can read the sorry story in my last piece Dear Home Office: The Quality of Mercy is Not Strain’d. It was shabby. Not our finest hour.

My friend’s name is David. In that earlier blog, I called him “John” because he wasn’t well enough to ask if he minded me using his real name. Now, I have asked David, and he replied: “Absolutely! Tell everyone what happened and let’s make things change.” So, this is what happened after the UK Home Office said Visa Denied on Friday, 27 May 2016:

Friday 3 June 2016 09:30 City of London

Pamela (David’s wife) calls me from Accra. She and David are going to re-apply for the visa. It will take a couple of weeks but they don’t have a choice. Suddenly, David is having severe chest pains, dizziness – cannot breathe properly. He is being taken to the Military Hospital in Accra. Please help, she says. She is about to lose her husband. I hear the rising panic in her voice and her distress. 09:32

I call Nick (the surgeon) and tell him. He says: this is bad news. David is probably having a heart attack and, given the angiogram pictures we have from last week, he is unlikely to make it. I ask Nick what he is doing for the weekend and he says, “For the first time in a long time, I am just going to put my feet up and watch the footie”.

We talk some more and 30 seconds later, we agree that David’s only hope is to get Nick to Accra immediately. If David is still alive when we arrive, Nick will operate. If we can find a cath lab. I say I shall book flights and find a cath lab. He says he is going to see his Clinical Director at UHW to make a plan, and we agree to speak at 13:00. I need to source a cath lab.

09:50 I call Pamela, she says David is in the ICU and on oxygen, but he is stabilising. Two seats left on BA; I book the flights.

10:00 Turns out there is a single functioning cath lab in Accra and it is run by Dr Enoch Anaglate. He uses it mainly for angiograms. It isn’t set up for the kind of surgery Nick needs to do. Also, Dr Anaglate is on a trip to India and so his cath lab is unfortunately unavailable. I call his mobile phone and it goes to voicemail. Three times. I send him a WhatsApp message and after a few seconds the tiny grey ticks go blue. Somewhere in India, Enoch Anaglate has read my message.

10:05 Dr Anaglate replies on WA. He is arriving back in Accra at lunchtime in two days time, on Sunday. Nick can use the cath lab to operate from 2 pm Sunday afternoon. Game on.

12:00 We need travel visas. This is not a trip to France or Germany. No visa, no fly. No exceptions. A visa application usually takes three days and we need a visa now. Three days is too late. I call my father (who knows people) and he says to call SH at the High Commission. “She’s my patient and will tell you what you need to do.”

SH is not around but her deputy is very helpful and sympathetic. But the visa office shuts at noon and it’s impossible to process anything until Monday. We don’t have until Monday.

13:00 Nick has run a detailed planning exercise with his Clinical Director and is bringing all the equipment he can reasonably carry in a giant canvas bag. Stents, balloons, syringes, local anaesthetic. You know, standard weekend complex interventional cardiology angioplasty travel kit.

14:00 My contacts in Accra procure an official letter addressed to British Airways informing them that we will be issued with emergency visas on arrival. It is stamped by the Ghanaian Immigration Department. There will also be a note on the boarding manifest stating “Allow to Travel”. We have the visa thing covered off.

14:30 Check in online. Print boarding passes. Flight leaves LHR at 13:30 on Saturday arriving Accra 18:50. Print Immigration Letter. We are ready. Call Pamela. She is, to understate it, very happy. David is still stable and on oxygen but very weak. Pamela hands him the phone. I tell him that we are coming to him. Mountain Mohammed time.

19:30 I have dinner in Chelsea with my wife to celebrate our 27th wedding anniversary and I tell her I am going to Accra with Nick, back Tuesday. Saturday 4 June

11:00 I arrive at LHR to find Nick in Costa Coffee with an enormous canvas bag. We head over to the BA counter.

I produce the official letter from our sponsor in Accra and stamped by Ghana Immigration. BA guy says: “That’s not the right document. I need to see an official letter from Ghana Immigration stating clearly that your visas are waiting for you. Otherwise, you cannot fly to Accra today”. Very calmly, we explain that David is in need of immediate cardiac surgery and we have to fly today; they say thank you for explaining that so clearly; you are not flying without the right documentation.

This is not good. This is really not good.

I call my contacts in Accra, and explain that we have an hour to get an official letter to the BA desk here at London Heathrow. Nick calls his own contacts. We call a lot of people.

12:00 The official letter from the Immigration guys in Accra has not arrived. We call the Deputy High Commissioner in London on FaceTime. She is at home in her kitchen having brunch and BA says they can’t take her seriously because she is in her kitchen. She asks where else she would be on Saturday morning. It doesn’t help.

She shows them her ID over FaceTime. It does not work. BA guy says: “There is a process, and this isn’t part of it”. Gate closes in 40 minutes.

12:20 Still nothing. Half of Accra seems to be calling BA but they are resolute. “We’ll get fined £25,000 per passenger if we fly you. Get the official Immigration Letter or you cannot go. Gate closes in 20 minutes.

This isn’t about missing a flight to Vegas or Mauritius. If we miss this flight, David’s life is in serious danger. I am trying to stay calm, but I am close to the limit.

12:30 Nick and I explain once again that THERE IS SOMEONE WHO WILL NOT SURVIVE MUCH LONGER and we HAVE TO CATCH THIS FLIGHT. PLEASE!! BA has now worked out that there really is someone who will not survive much longer. They are all calling Accra and Accra is calling them. Mobile phones are going off everywhere. But still no letter. Still no fly. I begin to suspect David isn’t the only person in danger of having a coronary.

12:31 Michaela on the BA desk smiles. A letter has arrived with the required heading, format and signature. We are good to go! Gate closes in four minutes. We get there in three.

19:00 Sunset – Sahara Desert

21:00 We arrive in Accra, Ghana. We pay our three hundred bucks, (all official, folks) and our visas are duly issued.

21:50 We collect our stuff from the carousel. I sense Nick thinks I am overdoing it with the selfies. He’s probably right.

22:05 We arrive at the Military Hospital in Accra (known to all as “Thirty Seven”) and are ushered into the Intensive Care Unit. David is clearly weak and breathless but he cannot hide his elation at seeing us. Nick checks David’s notes; then we gather around his bed, join hands with the nurses and pray for a successful operation tomorrow, Sunday. The Lord’s Day.

Sunday 5 June 10:00 I interview Nick and record it on my iPhone. He talks to me through the planned angioplasty procedure; but this is unknown territory and he is a bit anxious.

12:30 David’s cousin, Naana Halm, picks us up and we drive to the clinic where the operation will take place. It’s a small single storey building in the middle of Osu, one of Accra’s bustling districts. It is a long way from being Grey’s Anatomy’s Seattle Grace Hospital. A very long way.

David is already there and so is Pamela, his wife. Dr Anaglate is waiting for us. He is clearly keen to help. He explains to Nick, however, that this is a mobile cath lab. Nick looks at me.

13:00 The family’s pastor arrives and prays for David; a prayer of strong confidence and faith.

14:00 Nick makes final preparations. There are three other people in the theatre with him including Dr Anaglate but two of them are apparently in training.

“Let’s go to war!” he says!

I think to myself: At this moment, given the setting, this is probably the most demanding operation being performed anywhere on the planet. David’s original angiogram had shown several major coronary blockages and lesions. It soon becomes clear that his actual situation is more serious than the pictures showed. In semi-disbelief, Nick says:

“This is a blocked left main distal trifurcation with double chronic total occlusions in the Left Anterior Descending and right coronary arteries. It doesn’t get any worse than this.”

This is like pushing David in a wheelbarrow on a wire across Niagara Falls. Without a safety net. There is no back up, no Arrest Team, no cardiac physiologist, no registrar and no specialist hospital attached. Nick said afterwards that a savage tiger was screaming inside his head: “This is total insanity. What are you doing performing this operation in these conditions?”

The only response he could think of was: “What else am I supposed to do, Tiger?”

His face gave away none of his misgivings. Despite being on his feet for four hours, at no time was there even a hint of anything apart from confident control.

We were watching a surgeon at the peak of his powers performing far outside conventional parameters. Climbing Everest without oxygen; flying a fast jet at Mach 2 with only a compass and a paper map; climbing Dawn Wall the 3,000-foot vertical granite sheet on El Capitan using only your bare hands.

Take your choice of metaphor, my friend. They all work.

David is awake for the entire angioplasty procedure and, as he begins to feel the stress of lying totally still on his back for three hours in what he fully knows is a battle between life and death, Nick needs to keep him calm.

He begins to sing. Guide me O thou Great Jehovah. Appropriate as he probes and feels his way using just a wire that feeds into David’s right wrist up his arm and down into the left side of his heart. Get it right, and he clears the blocked arteries. One wrong move and he perforates. If that happens, David will arrest and it will all be over. Right there and then in the middle of the hymn.

Imperceptibly, achingly slowly, the wire moves forward, micro-millimetre by micro-millimetre. We see it all on a small screen. Suddenly, the pulsating grey canvas fills with an intricate myriad of pulsing lines. Blood vessels!

As the occlusion is destroyed by Nick’s wire, for the first time in a long time, the arteries and veins fill with blood and the front wall of David’s heart starts to work the way it is supposed to.

Half an hour into the operation, there is a problem. He is taking on a Chronic Total Occlusion – which is the stuff of nightmares. He attempts to insert a very small balloon but it fails to pierce the blockage. In a full-blown cardio-thoracic operating theatre, he would switch to a Turnpike catheter but he doesn’t have one. He has no options. Or, maybe one.

He tries another slightly bigger balloon – which he doesn’t expect to work. If the small balloon doesn’t do it, a slightly bigger one, albeit different, is unlikely to. But it’s all he has.

It works! The CTO clears and the screen fills with the now familiar myriad of fine blood vessels. Hallelujah! I remind myself of those timeless powerful words in Psalm 23:

Yea, though I walk through the valley of the shadow of death, I will fear no evil: for thou art with me; thy rod and thy staff they comfort me. I realise I have stopped breathing; my chest hurts, and I have to force myself to suck in air. I have never seen anything that comes close to this for sheer insane bravery on behalf of surgeon and patient. For almost four hours, Nick has operated without making any mistakes. That was his mission and he delivered. I am close to tears. So is everyone.

17:50 After four hours, exhausted, but triumphant, Nick looks straight at us through the pane of glass that separates us and him, and mouths: I’m done! We just repaired a blocked left main distal trifurcation with chronic total occlusions on the right. In a mobile cath lab. Without any APTT for crying out loud!Get the tea and biscuits!

As he changes out of his scrubs, I ask Nick what APTT is. Oh, he says, that’s what tells you whether the patient’s blood is coagulating. You really need to know. We didn’t have any, so I had to guess.

18:00 Everyone is ecstatic. David made it!

18:30 David is out of the cath lab; the waiting ambulance takes him back to the ICU at Thirty Seven. He can go home in 24 hours and begin to get his life back.

Starting here

Back home – 5 pm Tuesday 7 June 2016

It always seems impossible. Until it’s done! – Nelson Mandela