How Death Becomes Life

by Joshua Mezrich

  At the end of our conversation, I asked Tina if she knew about the incredible history of heart transplantation. Not really, she told me, but she would love to learn about it.

  Back to Minnesota, 1949

  Norman Shumway arrived for his surgical internship at the University of Minnesota almost by chance. He’d grown up in Michigan and entered the University of Michigan with plans to become a lawyer. But this was 1943, and the world had different ideas. After only a year of college, he found his way into the military, and given how well he did on his IQ test, he was sent to engineering school. After six months, though, the military decided it was short on doctors and gave Shumway a medical aptitude test. He performed so well that he soon found himself at Vanderbilt Medical School.

  At Minnesota, Shumway spent time in the lab experimenting with hypothermia on dogs. He was fascinated by the power of the cold to slow the heartbeat and decrease the physiologic demands of the body and the brain. After two years of training, Shumway spent two years in the air force during the Korean War. Upon his return to Minnesota, Lillehei was working in the lab with his cross-circulation experiments, and when he was ready to use this technique to operate on Gregory Glidden, Shumway was the resident assistant. He was also present at the introduction of the DeWall-Lillehei bubble oxygenator, and took part in numerous open-heart cases using bypass. By the time he finished his training in 1957, he was ready to start a cardiac surgery program in the real world. He had thoughts about how he could combine hypothermia with cardiopulmonary bypass to make the whole thing safer. That was his plan.

  While Shumway was still a resident, another young trainee showed up in Minnesota. He was not from the Midwest, not even from North America. He had never spent a winter in the frozen tundra that Shumway took for granted. His name was Christiaan Barnard, and he was from Cape Town. Barnard had heard of the legendary program sprouting up at Minnesota and knew that no training like this existed in his native South Africa.

  When Barnard arrived in December 1955, Wangensteen put him to work in his laboratory studying the esophagus, a challenging organ to operate on. In the lab next door, Lillehei’s resident was working on a project with his cardiopulmonary bypass machine. This was the first time Barnard had ever seen the machine, and he was immediately fascinated. He started helping out with that project, and before long, the resident asked if Barnard would like to assist the next time they used the pump on a human. Years later, Barnard described that day: “[E]ven now I can recall the details of that morning, the first time I witnessed the life of a human being held in a coil of plastic tubes and a whirling pump.” His description of that first open-heart surgery sounds like a religious experience.

  The bypass machine was switched on, and Barnard watched the dark blood flow into the chamber of bubbling oxygen and the lightcolored blood flow back out. “[T]he longer it ran,” he would later write, “the more exciting it became. This was more than a machine. It was the gateway to surgery beyond anything yet known. While it stood in for heart and lungs, vast repairs could be made inside the body. New valves could be put into the heart, maybe even a whole heart itself. ”

  In this moment, Barnard knew what he wanted to do with his life. He met with Wangensteen the next day, to tell him of his interest in completing a full training program at Minnesota with a focus on surgery of the heart. Wangensteen was happy with that and told Barnard it would take six years. But with a family back in Cape Town and not much money, Barnard was eager to move on. He told Wangensteen he could do it in two. Wangensteen thought this impossible—two years on the clinical service was required, and in addition, he needed to do experiments, write a thesis, and be fluent in two languages besides English. Barnard promised him he could do it. He had already done loads of research that could serve as the basis for some future work. He knew Afrikaans, so he felt he could pick up Dutch and German quickly. His plan was to work on the wards during the day, work in the lab at night, and squeeze in the languages and the writing of his thesis on the side.

  “When will you sleep?” Wangensteen asked.

  “I don’t need much,” Barnard told him.

  “All right. Let’s see what happens.”

  Over the next two years, Barnard worked like an absolute dog. He worked in the clinics, worked in the lab, and still found time to sleep with a bunch of nurses while his family was back in Cape Town. To save time, when Barnard would return to his apartment well after midnight, he would walk into the shower with his clothes on and then hang them to dry so he could put them back on in the morning. His training included an eleven-month stint on Lillehei’s service, probably the most important experience of his career. Unlike Wangensteen, who was a great chairman but rarely let his assistants do anything in the OR other than hold retractors, Lillehei entrusted his residents to perform independently. This came with great responsibility.

  Barnard describes one day early in his training when he was opening a young boy’s chest and preparing him for bypass. The boy had a VSD, and his family had traveled from South America so he could be treated by the world-famous Lillehei. With the boy’s father watching the operation from the viewing area above, Barnard and his assistant opened the chest and began dissecting out the inferior vena cava. That’s when the trouble started. While cutting some tissue in front of the vein, they inadvertently cut into the heart. When blood started spurting out, Barnard panicked and tried to pinch the injury closed with forceps, but the tissue tore under the force of the heart’s incessant contractions. Barnard did everything he could to dampen the exsanguination, but also yelled out for the nurses to get Dr. Lillehei. As the little boy’s heart stopped, and Barnard began squeezing it, begging it to work again, he remembered that the boy’s father was looking down on him.

  Lillehei finally arrived and effortlessly placed the boy on bypass. They fixed the VSD and then sewed up the hole Barnard and his assistant had made in the right atrium. But when they tried to come off the machine, the heart did nothing. It was dead. Lillehei left Barnard to sew up the chest, all under the eyes of the boy’s devastated father.

  Afterward, Barnard walked around the hospital aimlessly, not sure how to deal with what he had just done. He finally went to Lillehei’s office and apologized for killing his patient.

  “Look, Chris,” Lillehei told him, “we’ve all made these mistakes that cost the lives of patients. You’ve made the mistake this time. The only thing you can do is to learn by your mistake. The next time you have bleeding, remember you can stop it by putting your finger in the hole. That gives you time to prepare and consolidate yourself, to get calm, and think of what you have to do . . . So tomorrow, go ahead and open the next patient’s chest. We’ll do the same thing. You go in and loop the venae cava and I’ll wait for you.”

  Indeed, the next day, Dr. Lillehei stayed out of the OR until the last moment. As Barnard wrote, “Then he came in with his cocked head lamp and peered into the chest. ‘Good job,’ he said. ‘Thank you,’ I said, and thought: ‘Thank you for giving me the chance to recover. Thank you for understanding how it is to lose, and how important it is to have the illusion that you can win.’ ” Barnard continued: “The death of the boy was tragic because it was needless—a visible mistake.”

  Despite their overlap at Minnesota, Shumway and Barnard were never friends, and they never would have guessed in a million years that their futures would intersect in so many interesting ways. Their personalities were so different. Shumway was relaxed, self-confident, quiet, humorous, and comfortable in his own skin; everybody loved him. Barnard was driven and brash. He knew why he was in Minnesota and would stop at nothing to achieve what he’d come to do. He was abrasive and intense, and many of his colleagues did not like him.

  When the two men’s training came to an end, it appeared that their paths would diverge. Barnard successfully completed all his requirements in two years. Wangensteen was most impressed, and actually asked him to stay on, but Barnard knew he had to return to South Africa.

  Barnard seeme
d destined for greatness. He had an incredible work ethic, a fire in his belly, a belief in his own abilities, and a desire to do something exceptional. Shumway had a different story. He would have loved to stay on at Minnesota, but no offer was forthcoming. He wasn’t really a researcher at that point, and he had no desire to work like the dog that Barnard was. He did remain interested in the role of hypothermia in heart surgery and thought there might be a role for localized hypothermia on the heart to protect it, and even stop it, while the body was kept alive on bypass. Eventually he took a night job running the Kolff-designed dialysis machine in San Francisco and set up a cardiac lab on dogs during the day. Not long after, Stanford Medical School moved out to Palo Alto, and Shumway went with it. This gave him more room to work in the lab and in cardiac surgery. There, he was assigned a resident by the name of Richard Lower, to help him with his lab efforts.

  With dogs placed on bypass, Shumway and Lower would pour ice on the heart to see how cold they could make it and for how long and still get it pumping again. By 1958, they succeeded, with zero mortality, in restarting the heart after an hour of bypass and no heartbeat whatsoever. Imagine the possibilities this presented for the field of heart surgery. Up to that point, relatively minor surgeries on the heart (ASD and VSD repairs) were the only cases being handled by the majority of heart surgeons. With the early attempts at bypass (with a machine or cross-circulation), the heart still beat but had very little blood in it. And even these procedures, in which all surgeons did was sew up a simple hole in the heart, had a mortality rate of 50 percent. Only the best surgeons could successfully complete such cases. Yet, with topical cooling and cardiac arrest, where the heart was actually stopped, the possibility of extremely complex surgery could become a reality.

  Still, the idea of heart transplantation was nowhere in Shumway’s mind at this point. This was 1958. Successful kidney transplant, other than from an identical twin, was not even a reality yet.

  Of his experimental surgeries with Richard Lower, Shumway said, “We would stand there for an hour with a dog supported by the oxygenator, the aorta clamped, and the heart being cooled. We were both getting bored as the dickens, so I said to Dick, ‘We can take the heart out and put it in cold saline,’ which we were using for cooling the heart, ‘and then we can stitch it back in. ’ ” But this they found extremely difficult to do with the rather primitive instruments and needles then available. So, they came up with the idea to get a second dog and take its heart, leaving more tissue on it so they could bolster it as they sewed it into the first dog. Thus, in this rather inglorious way, the journey toward heart transplantation began.

  Shumway and his team spent the better part of the next decade researching the details of cardiac transplantation in dogs and other animals, focusing on the operation and then the postoperative care, immunosuppression, and rejection. They presented their results at surgical meetings around the country and published their findings in numerous journals. At first, their presentations attracted only a smattering of people, and the results were considered bizarre and irrelevant. But as their successes grew, so did interest among the medical community and the press. In the meantime, Shumway was growing a cardiac surgery program in humans at Stanford that boasted some of the best outcomes in the world.

  Shumway was a naturally gifted surgeon, always calm, always able to find humor even in the darkest and most challenging cases. Contrast this with Barnard, a grating, driven, and in many ways tragic figure. Barnard treated many of the people around him poorly, blaming them for errors and bad outcomes. Those who worked with him recognized his brilliance and persistence, but found him annoying, demeaning, and a bit of a phony. Also, unlike Shumway, he was not a natural surgeon—he was clumsy, had a tendency to become agitated and nervous when problems arose in the OR, and suffered from constant pain and trembling in his hands from rheumatoid arthritis.

  Despite all these negative attributes, he also deserves some serious praise. When he returned to South Africa from Minnesota, he was virtually alone in a country with no other legitimate heart surgeons. There had been one previous attempt at open-heart surgery, at Cape Town’s Groote Schuur Hospital, but it ended in disaster. The surgeon had no previous experience using the pump on a human, and after he hooked it up, he exsanguinated the patient onto the floor of the operating room. The chief of surgery declared that there would be no further attempts at heart surgery until the return of their prodigal son from Minnesota.

  Upon his return, Barnard awaited the shipment of his DeWall-Lillehei bubble oxygenator (a gift from Wangensteen) and put together a team to assist him. They practiced on dogs, simulating operations and going through all the potential disasters that could be caused by malfunction. Barnard was not fickle, or flippant about surgery, and he did not underestimate what it would take to succeed.

  After months of training his team, they performed their first case together, a simple repair of a pulmonary valve stenosis (a narrowing of the valve) in a fifteen-year-old, for which Barnard figured they’d need only a short pump run. Disaster did almost strike in the OR, when a clamp came off the femoral artery in the leg and the patient nearly bled out, unnoticed, but the team managed to pull her through. Barnard sat at her bedside for days after the procedure, until he was sure she was out of the woods.

  He had a few other successes in simple cases, and then expanded to more difficult ones, succeeding with complex surgeries to repair congenital defects such as transposition of the great vessels and tetralogy of Fallot. He developed his own prosthetic valves in the lab, which he used to replace diseased valves in adults. He operated on hearts with blocked blood vessels using the various mediocre techniques that existed back then. What Barnard lacked in natural technical skill and serenity in the operating room he made up for in his ability to manage patients postoperatively. He was highly detail oriented, meticulous, and had an innate ability to anticipate problems and plan for what to do about them. He would spend hours, even days, at a patient’s bedside, mostly because he didn’t trust anyone else to be able to deliver the kind of care he could. And he was probably a bit too honest about what drove him to do this: “I couldn’t leave the patient in the hands of other people . . . You know, I’ve stood at patients’ beds when they died, and I’ve been upset with everybody around me . . . It wasn’t really the death of the patient—it is the ego that is hurt. I should not have had a death with this particular type of operation; I’m too good for that . . . You kill yourself for your records, but at the same time you kill yourself to save the patient.” To his credit, though, Barnard enjoyed some of the best results in the world with the complex operations he took on. This continued throughout his career.

  It was in those years that Barnard started thinking about the possibility of replacing the heart entirely rather than trying to repair it. In talks to medical students, he spoke about cardiac transplantation as the future of heart surgery. By 1966, inspired by the advances in kidney transplantation, he decided it was time to get educated on the advances in the discipline. He secured a training sabbatical with Dr. David Hume in Richmond, Virginia, where Hume was now running one of the major transplant programs in the world. What Barnard likely didn’t know was that Hume had recently recruited Lower, Shumway’s protégé, to start a cardiac transplant program. This ended up being an unexpected bonus for Barnard.

  In the fall of 1966, Barnard began his mini-sabbatical at Richmond. His stated purpose was to learn about the care of kidney transplant patients, including the details of the operation and postoperative immunosuppression. He had told Hume that he was planning to start a kidney transplant program in South Africa. This wasn’t a lie. Barnard saw the organ as a stepping-stone to heart transplantation, and indeed, after his time with Hume, he did one kidney transplant. It was a smashing success. His patient was still alive, with a functioning kidney, more than twenty years later.

  Barnard loved his time in Richmond, and he and Hume clicked immediately. The two almost never slept. Barnard assisted Hume in
the OR, went on rounds with him and his team, and immediately made his presence felt. He was attracted to Hume’s tireless energy and also his swashbuckling personality.

  Something else happened in Richmond. Barnard was invited into the lab where Lower and his team were practicing cardiac transplantation in dogs. Barnard stood silently watching as Lower cut out the donor heart with its atrial cuff and sewed it easily into place in the recipient’s chest. Barnard was likely surprised by the ease with which Lower performed the transplant. He shouldn’t have been. Lower had spent the better part of the last decade doing it in dogs. (Barnard himself had spent much less time doing so.) He was also shocked that Lower hadn’t yet tried the procedure on humans.

  Barnard left Richmond inspired to devote himself to cardiac transplantation and probably thought he had a good chance to be the first. He was aware of the efforts of Lower and Shumway, had read their publications since 1958, and knew that even though eight years had passed, something was holding them back from doing the surgery in humans. He likely knew what it was. Brain death hadn’t been defined yet in the United States. This wasn’t a problem in South Africa, where the law specifically defined death as the moment when two doctors declared a patient dead.

  By this point, Barnard, Lower, and Shumway had all picked out potential recipients for heart transplantation.

  Cape Town, South Africa, December 2, 1967