The day seemed like any other for the Darvall family. They had been invited for afternoon tea at a friend’s house and decided to stop at a downtown bakery for a cake. Edward Darvall and his fourteen-year-old son, Keith, waited in the car while Edward’s wife, Myrtle, and twenty-four-year-old daughter, Denise, ran inside to get the cake. When Myrtle and Denise left the store, they headed toward the family’s car, waiting across the street. They tried to look both ways before crossing, but a large truck blocked their view of a car being driven by a drunk thirty-six-year-old salesman. The motorist was so focused on passing the truck that he barreled right through the two women. Myrtle was killed instantly, and Denise flew through the air and landed on her head. Blood poured out of her nose and mouth. When Edward saw Myrtle’s lifeless body lying in the road, he knew she was gone. Denise seemed to be alive, though; at least, she was breathing.
Barnard was jolted out of an afternoon nap by the phone ringing. It was a Saturday, and he had recently returned from the hospital. He hadn’t been sleeping well lately. He was consumed by thoughts of his patient Louis Washkansky, fifty-three, who had been admitted in September with severe heart failure after multiple heart attacks. Washkansky was blue, swollen, and short of breath. He was in kidney failure and had severe liver dysfunction, both of which were secondary to a massively swollen heart that was barely pumping. And yet there was still life in him. When Barnard met him a couple of months before and told him about the idea of a heart transplant, Washkansky had given a short reply: “There is nothing to think about. I’ll take the chance as soon as possible.” And that was it. He then ignored the rest of what Barnard said and put his head back in his book.
Washkansky loved Barnard, saw him as his savior, and called him “the man with the golden hands.” Washkansky’s wife did not feel the same. She did not trust the surgeon, was nervous about the idea of a transplant, and was not optimistic when Barnard gave her husband an 80 percent chance of surviving the operation. I don’t know where he got that number, given that the operation had never before been done in a human being.
When Barnard got the call, he knew immediately what it meant. There was a heart available: Denise Darvall, a twenty-four-year-old white girl, blood type O, was brain dead. Barnard had promised his team that his first donor would be white—these were the days of apartheid in South Africa, and they would be pushing ethical limits already just by doing the transplant; they didn’t want the negative press that would come with the very first brain-dead donor being black. But Denise Darvall was perfect. This was it. He was going to do it.
Edward Darvall, after having accepted the fact that the two women in his life were dead, for something as stupid as picking up a cake, consented to the donation. “If you can’t save my daughter, you must try to save this man,” he said. Maybe the knowledge that his daughter would be the first donor for a human heart transplant was a comfort to him.
Barnard knew he would be criticized for removing the young woman’s heart, but he also knew it was the right thing to do:
Denise Darvall had entered a no-man’s land between life and death—an area created by modern science and medicine. She was being held there by drug stimulants, blood transfusions, and, most important, artificial breathing provided by the automatic ventilator. How long it would take her to cross over to total death depended mainly upon how long we continued to run the ventilator. A flip of the switch, turning it off, would result in immediate cessation of breathing. Her heart would continue to beat for three, four, maybe five minutes—and then stop.
At that point we would have the three criteria that doctors have used for centuries to determine death: no heart beat, no respiration, and no brain function. Denise Darvall, who had been medically dead, would then be legally dead. We could consign her for burial—or, as we intended, open her chest and remove her heart. On the other hand, if we restarted the ventilator immediately, and at the same instant gave her heart an electric shock, we could in all likelihood set again in motion the twilight existence we had just terminated. From being legally dead, the patient would be returned to the same no-man’s land she had just left—and where she could continue to exist for an indeterminate length of time as a biological vegetable.
At 2:20 a.m. Denise’s ventilator was turned off. She was hooked up to catheters so that the bypass pump could be turned on with a flick of the switch, and then the team sat and waited. As she was already brain dead, she would not take a breath on her own. With no respiration, no oxygen would enter her lungs, diffuse across the capillary membranes into the bloodstream, bind with the hemoglobin in her blood, and be delivered to her organs, including her heart. Cells in these organs would start dying, and the organs would stop functioning. At some point, the heart would stop beating. How long would that take? Minutes, most likely; agonizing minutes, with every tick of the second hand representing more dead heart muscle.
Barnard was in his right not to wait. South African law would have supported him if he had clamped the vessels in and out of the heart and cut the organ out. So, what should he do? This is what he reported: “So we waited, while the heart struggled on—five, ten, fifteen minutes. Finally, it began to go into the last phases, its wild peaks slowly sinking into exhausted rolls that became longer and longer until it finally revealed itself in a straight green line across the screen—death. ‘Now?’ asked Marius. ‘No,’ I said. ‘Let’s make sure there is no heart beat coming back.’ ”
That wait must have been excruciating for Barnard and his brother Marius, who was assisting him in the procurement of the heart. At least, it would have been excruciating if it in fact had happened. Roughly forty years later, after Christiaan Barnard was dead, Marius Barnard told the writer Donald McRae in an interview that, with Barnard’s consent, he, Marius, had injected a huge slug of potassium to stop the heart right after they shut off Denise’s ventilator. Then they opened her chest, placed catheters carefully in the right atrium for drainage and a return catheter in the aorta, and flipped the switch on the bypass machine, making the heart return to its pink color. They then cooled Denise down, and Barnard went next door to check on Washkansky.
Barnard’s team had already opened Washkansky’s chest, revealing the massively enlarged beast of a heart that was (barely) keeping him alive. Barnard and his team placed Washkansky on bypass, and nearly lost him in the process from a technical error with the pump. Fortunately, they were able to work through this, but it reminded Barnard how dangerous the bypass pump could be.
Barnard returned to Denise’s room and began cutting her heart out. While he may not have had the same decade of experience on dogs that Shumway and the others had, he knew what he needed to do. He cut around the heart carefully, being sure to cut the vessels at angles, so they could join nicely with Washkansky’s larger vessels. He then returned to Washkansky’s room carrying a metal bowl with this incredible gift in it. There, he cut out Washkansky’s massive, useless heart, making sure to leave a lid of atria so he would be able to connect up all the vessels. Barnard’s own heart was pounding as he did this. He knew there was no room for error. Once he removed Washkansky’s heart—which, amazingly, was still trembling when he put it into a different metal bowl—he took Denise’s small, beautiful heart in his hands.
He later wrote, “For a moment, I stared at it, wondering how it would ever work. It seemed too small and insignificant—too tiny to ever handle all the demands that would be put upon it. The heart of a woman is 20 percent smaller than a man’s, and the heart of Washkansky had created a cavity twice the normal size. All alone, in so much space, the little heart looked much too small—and very lonely.”
Barnard then got to work—first sewing the left atrium, then the right atrium. It looked perfect. Then he and his team moved on to the pulmonary artery. Because he had cut it at a branch patch, meaning he made a larger orifice by cutting it where it branched into two arteries, it matched perfectly with Washkansky’s. The donor and recipient vessels came together perfectly. Now the aorta.
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Barnard trimmed Denise’s aorta at an even more severe angle, to increase the size of the lumen (or orifice), trying to make it match the large aorta hanging out of Washkansky’s chest. As he did this, he told his team to start warming Washkansky. At 5:15 they started sewing the aorta, and at 5:34 they were done. The heart was in—but it was blue. Would it work?
Barnard loosened the snares on the cavae and let blood flow through the heart. The heart swelled with warm blood. It started to fibrillate. Barnard and his team watched, hoping that the heart would develop a coordinated rhythm and worrying that it wouldn’t. Barnard had done this on dogs at least fifty times, but it hadn’t always worked. He called for the paddles and gave the heart a shock, twenty joules. It froze for a second, and then, slowly, started to contract. The contractions started in the atria, and then the ventricles. Slowly, they picked up pace, until they reached 120 beats per minute. They had a heartbeat, but would it be strong enough to support this big man?
Barnard prepared to take Washkansky off the bypass machine. When everything was ready, he delivered the command “Pump off.” But Washkansky’s blood pressure started to drop. One of the nurses called out the numbers: “Eighty-five . . . Eighty . . . Seventy-five . . .” The heart looked distended and unhappy. “Sixty-five.” Barnard had the team put the pump back on. They gave Washkansky some IV drugs, corrected some electrolytes, and checked his temperature. They tried again—and the same thing happened.
Barnard tried to sound confident, but inside he was dying. “I was horrified,” he would later admit. But he persisted, and on the third try, at exactly 6:13 in the morning, it worked. They turned the machine off for the last time.
Barnard scrubbed out and went into the tearoom. His brother Marius joined him. Washkansky’s new heart was holding at a steady 120 beats per minute. Barnard took his own pulse: it was 140. He stayed around the hospital for the next few hours, making sure Washkansky had been settled into the ICU and was stable. He finally made his way home at around noon, and shortly after that, the world exploded.
It started with a short report on the local radio, about a heart transplant that had just taken place—Barnard’s name wasn’t mentioned. Then, over the next hour, the report expanded, and that’s when the phone started to ring. Barnard fielded calls from all over the world. One of the earliest was from a reporter in London whose first question was whether the patients were black.
That night Barnard couldn’t sleep, and he made his way back to the hospital. He spent the next eighteen days essentially at Washkansky’s bedside. Over those eighteen days, Washkansky recovered, was able to have his breathing tube removed, was talking, and was wheeling around the hospital and improving. Unfortunately, after a couple of weeks, he started having fevers. He developed a severe postoperative pneumonia and, despite a beautifully working heart, succumbed to infection, likely because of all the immunosuppression he was receiving.
Barnard was crushed by Washkansky’s death, but the rest of the world didn’t seem to care. Barnard was an international superstar. He was about to begin a tour around the United States that would include an afternoon with the president, appearances on Face the Nation and Today, and cover stories in Time, Life, and Newsweek.
The next transplant Barnard performed was on January 2, 1968. The patient was Philip Blaiberg, a fifty-eight-year-old retired dentist with a failing heart. After Washkansky died, Barnard had met with Blaiberg and his wife to tell them the news and see if Philip still wanted to proceed with his transplant. “Professor, I want to be a well man, and if I’m not well, I’d rather be dead.” Blaiberg’s donor was a twenty-four-year-old black man who had suffered a sudden brain bleed while on a beach. He was declared brain dead, and he and Blaiberg were brought to the operating room for transplantation.
Barnard again encountered trouble with the bypass pump, but was able to work through it. Maybe even more amazing, just as he was getting ready to take the transplanted heart off the pump, the power in the hospital went out. They were standing in the dark, with no electrical power going to the bypass pump. Barnard quickly had the team remove the venous tubing and hand-crank the bypass pump and ordered rapid rewarming. As Barnard stopped the pump, the heart fibrillated (quivered), slowly coming to life. When the lights came on, the rhythmic beating had already commenced.
Blaiberg was extubated by post-op day one and was discharged after a ten-week stay. He went on to live an astounding nineteen months; photos of him during that time show him enjoying the beach and other activities. With Washkansky, Barnard had proved the operation could be done in humans, and with Blaiberg, he proved that heart transplantation would eventually become a viable option for patients with irreparable heart disease.
The Americans Get Their Chance
On January 6, 1968, in California, Shumway got his first chance at a transplant. The donor was a forty-three-year-old woman who had suffered a brain bleed. The recipient was a fifty-four-year-old steelworker who had severe heart disease. The surgery itself went well, but the recipient suffered virtually every complication known to man. Shumway did everything he could, including multiple reoperations, but the recipient died on post-op day fourteen.
Dick Lower finally got in the game on May 25, 1968. The donor was Bruce Tucker, a fifty-six-year-old black man who worked at an egg-packing plant. He had been drinking that evening after work with a friend, and when he got up to stumble home, he fell and hit his head on the pavement. He was brought to the hospital at 6:00 p.m., unconscious with a devastating head injury. The neurosurgeons took him to the OR later that night, but by the next morning, the examining physician wrote a note that read, “[T]he prognosis for recovery is nil. Death is imminent.” By 1:00 p.m., after an EEG failed to show any cerebral brain activity, the staff neurologist agreed with that assessment.
Hume and Lower were notified. Hume contacted the police and asked them to search for the dead man’s next of kin. It is hard to know how extensively they searched, but at 2:30 p.m., they let Hume know the man’s family could not be located. Hume obtained permission from the state medical examiner, and with that, he urged Lower to proceed. Tucker’s respirator was disconnected at 3:30 p.m., and minutes later, after Tucker’s heart ceased beating, Lower began splitting his chest. His heart and kidneys were removed, and Lower proceeded with his first heart transplant in a human. Lower was probably the most experienced heart transplant surgeon in the world by this point, having performed this surgery in hundreds of dogs. As expected, the surgery was a total success, and the recipient, Joseph Klett, enjoyed this gift from Bruce Tucker for a whole week until he died from rejection.
A few days after the transplant, Bruce Tucker’s brothers were finally located and came to the morgue to claim their brother’s body. It was only then that they discovered that his heart and kidneys had been removed for transplant. This was devastating for the Tucker family. Not only had they just found out that their brother had died alone in the hospital, but his organs had been harvested from his body without the family’s knowledge or consent. And he was taken to the operating room while his heart was still beating. Sure, the neurologist had considered Tucker brain dead, but this was three months before the diagnosis of brain death had been defined in the American literature and more than a decade before brain death became legally synonymous with death. I can only imagine the effect this had on the Tucker family. After all, this was Richmond, Virginia, in the 1960s, not the most hospitable location for blacks in the United States.
No criminal charges were filed, but the Tuckers did bring a lawsuit against Hume and Lower. It was prosecuted in civil court in a seven-day trial. The Tuckers were represented by Douglas Wilder, later a state senator and, in 1990, governor of Virginia, the first African American to be elected governor in the United States. Wilder argued that “the transplant team engaged in a systematic and nefarious scheme to use Bruce Tucker’s heart and hastened his death by shutting off the mechanical support systems.” He also hammered home the point that Tucker was labeled “
unclaimed dead,” and that he belonged to the “faceless black masses of society.”
Early in the trial, the judge instructed the jurors to stick to the “legal concept of death and reject the defense’s attempt to employ a medical concept of neurological death in establishing a rule of law.” This may have signaled the death knell for Hume and Lower’s case, but they were helped by the fact that, since the transplant, a major article defining brain death had been published in The Journal of the American Medical Association and was generally supported among the thought leaders of the time. Hume and Lower’s team defended the concept that Tucker was truly dead when his brain died, and because of that, the removal of his heart was not what had killed him. Their expert witness list included Dr. Joseph Fletcher, a well-respected professor and bioethicist. Fletcher convincingly summarized Tucker’s state at the time of his organ donation as follows: “When cerebral function is lost, nothing remains but biological phenomena at best. The patient is gone even if his body remains and even if some of its vital functions continue. He may be, technically, ‘alive.’ But he is no longer human. He is, as a human being, undoubtedly dead.”
After seventy-seven minutes of deliberation, the jury returned with a verdict of “not liable.” The removal of Tucker’s heart for organ donation had not caused or accelerated his death. After the trial, Hume spoke confidently of their victory for the press: “This simply brings the law in line with medical opinion . . . I think this is an issue that had to be decided, and I think it will have an influence on the medical community for a long time to come.” He was right about that.
Regardless of the outcome of this trial, a great disservice was done to Bruce Tucker and his family. Hume and Lower were so motivated to get into the heart transplant arena that they proceeded with the transplant without thinking about the effect it might have on the Tuckers. This goes against my very core belief about organ transplantation: that the donors (and their families) are our patients, too. They are the heroes, the ones who make it all happen, and they also benefit from the process. Hume and Lower focused solely on their recipient, and thus deprived the Tuckers of that benefit. The fact that Tucker may have been dead (or at least not alive) does not mean he and his family did not still own his body, even if his soul was gone. Hume and Lower disrespected that.
How Death Becomes Life Page 14
