Solving the Mysteries of Heart Disease

by Gerald D Buckberg

  I was astounded by the orchestration of movement between the surgeon and the assistant, the anesthesiologist, and the scrub nurse. It had a great flow to it, like music. It was fully a demonstration of the inter-relationships of working with a team — that interdependence I spoke of before. The camaraderie was something I relished and hoped to embrace throughout my career. Their enthusiasm was palpable. It seemed to me that they were having all the fun.

  All of this was an eye-opener for me. My goal suddenly changed.

  I wanted in on the action.

  I wanted to be a cardiovascular surgeon.

  CHAPTER 3

  A Compelling New Path

  Dreams sometime do transform into reality. Imagine the excitement when this kid from the Bronx gets selected to serve his internship at the renowned Johns Hopkins Hospital in Baltimore, Maryland, where I would have daily face-to-face contact with the legends of surgery in America. What a place to launch a surgical career!

  And as it would turn out, what an auspicious time to be there.

  The era of open-heart surgery had just begun in 1953 with the invention of the heart-lung machine by John Gibbon. During surgery, this apparatus takes over for the heart and lungs by utilizing a pump that circulates the blood through the body… while an oxygenator simultaneously adds the right levels of oxygen to the blood as it removes carbon dioxide. This allows the surgeon to stop the heart — and perform the needed delicate procedures in a motionless environment. Unfortunately, the initial mortality rate using these new machines was disturbingly high, at over 50%. Working with The Mayo Clinic, Gibbon was able to improve his device and by 1956, the mortality rate dropped to 20%, and then 10% by 1957.

  I would arrive at Hopkins just four years later, in 1961.

  In the early days, when the mortality rate was 50%, only the pioneers would perform open-heart surgery with a heart-lung machine. But when the success rate went up to 90%, a new generation of surgeons embraced the technology and began creating all types of new procedures. Many of these treatments are now commonplace. They define the practice of heart surgery and include replacing damaged heart valves, bypassing obstructed arteries to create new pathways to bring blood flow to the heart, treating traumatic heart wounds, and repairing congenital defects in the heart muscles of children.

  Role Models

  Leaving the classroom behind, my interning at Hopkins offered a steady infusion of wisdom from the masters, beginning with Alfred Blalock, Professor of Surgery and Director of the Department of Surgery. Dr. Blalock was world-renowned for developing an innovative procedure before the heart-lung machine was invented. It helped children with cyanosis (known as “blue baby syndrome,” where insufficient blood travels to the lungs for oxygenation due to heart defects) — and gave life to these fragile infants where no possibility had existed before.

  I saw in him the kind of surgeon I wanted to be: smart, dedicated, caring, highly skilled, and willing to try new things — even after experiencing heartbreak when he realized his innovative operation didn’t fix these children forever. Yes, it offered them life since it would flow more blood to the lungs to receive oxygen, but he also knew there would be problems later as they grew, since his procedure couldn’t correct the hole in the ventricle that was the source of the problem.

  Yet he was the quintessential leader. Dr. Blalock had never used the newly developed heart-lung machine or the novel surgical procedures emerging from its capability. But he could foresee that this apparatus would someday allow for the development of a more complete solution to fixing heart defects like those in blue babies, and so made his goal to provide support and encouragement to his students to begin evolving new ways to care for damaged hearts.

  It was here that I witnessed that the magic of true excellence starts by appreciating work done by others. One must then become an educator and pass your baton to those who can execute the next steps of this endless path of growth.

  As many of his residents subsequently became famous all over the globe, this beautiful lineage of contribution continued to flourish as they similarly trained their own residents. Watching Dr. Blalock’s selfless actions gave me new goals with regards to how I would conduct my future research, and encourage and support my own students.

  Earliest Mentor

  Johns Hopkins brimmed with faculty members that had a powerful impact on my career. After all, the climb up the mountain path is made upon the shoulders of those who have pursued the journey before you, and I was at a place that provided a lovely trail.

  My first rotation at Hopkins was on the heart surgery team, and its chief was Dr. Henry Bahnson, an early adopter of the heart-lung machine and who became my first “hands-on” mentor. He was a phenomenal surgeon who had a commanding presence: tall, self-possessed, humble, and someone who knew exactly what he was doing.

  He was a man’s man, a gentleman, and everybody’s hero. (Figure 1)

  Figure 1: During internship in 1961, I (on right) helping Henry T. Bahnson at Hopkins, where open-heart surgery was just starting.

  You’d climb the hill with him without question. Sometimes literally. We used to make rounds with him to see all the patients. Sometimes he would bypass the elevator and run up eight flights of stairs, jumping two at a time. We’d barely keep up and when we’d get to the top, he’d turn to us and say, “All right, tell me about our patients.”

  Only problem was the other intern and I couldn’t breathe!

  He was a true leader, in part because he had fallibility. He wasn’t full of braggadocio like so many others. You see those types all the time that care only for themselves and not about anybody who works with them. They’ll sacrifice anyone to reach their ends, blaming problems on others and never taking the fall. Dr. Bahnson wasn’t that way. To him, winning meant we won, not he won.

  He wasn’t always perfect in diagnosis or treatment (no one is), but was always willing to listen and learn, and led by doing the right thing.

  I met him for the first time in an intensive care unit where we were examining a patient that was having some trouble. I said, “Dr. Bahnson, I think the problem is his calcium levels are too high.” I followed up by naming a particular drug we could use to bring the calcium down.

  He just smiled at me a moment and asked, “So tell me about his drug.”

  It wasn’t so much that Dr. Bahnson didn’t know what the drug was, but rather, he marveled that an intern could stand there and try to figure out what to do and make suggestions. Here I am, a new intern telling the guy who’s the head of heart surgery what I think was going on and remarkably, he wanted to listen. This too had a pivotal impact on me — because I realized that great people had open ears. You not only hear, but you listen. We tried the drug and it worked.

  Dr. Bahnson’s attention went far beyond just surgical technique. He always engrossed himself in any problems that arose even after the technical surgery procedure was done. Again, with an open mind, he would seek all input, determine a strategy, and then lead others toward a solution. This was particularly important at the time, since this new era of open-heart surgery introduced fresh problems that had to be overcome. These problems became the “seeds” for the growth of future breakthroughs.

  Hidden Dilemma

  One such problem was that while the heart-lung machine allowed intricate surgical procedures to take place, we still needed to understand why the heart’s performance was often impaired afterward, despite our having performed a perfect technical correction of the underlying defect.

  While we didn’t know precisely why this happened, we suspected the heart might have been damaged when it was made quiet (stopped beating), which was done since operating upon a moving heart was difficult. But this speculation only suggested the problem’s source without solving it, so the mystery persisted. Our dilemma was that the repaired heart often appeared more hurt than helped.

  While the patient survived the operation, new issues arose because the impaired performance of the damaged heart reduced bl
ood flow to other organs, so that kidney, liver, and brain failure developed. These complications created terrible problems for the patient, and intense frustrations among their physicians who had to try to overcome these new ailments. Moreover, we didn’t know the long-term impact of this heart injury at the time, though now recognize it subsequently leads to an increased death rate.

  The steps of the researcher’s eternal learning process became evident through this quandary as Dr. Bahnson brought us to the peak of one mountain (showing us how to fix the heart’s obvious problem) — and simultaneously taught us to look toward the more challenging peak ahead (avoidance of this lethal injury). I remained haunted by this enduring puzzle of damage resulting from an otherwise flawless heart procedure. This riddle continued long after I left Hopkins, and my initial research efforts were galvanized into finding its solution.

  Never Give Up

  Such challenging situations can really test a person, and reveal traits that foretell how they conduct their future professional life.

  Among the many outstanding individuals at Hopkins was Warfield Firor, the prior surgeon-in-chief, President of the American Surgical Association (our premier society), and chairman of the Joint Conference Committee on Graduate Training in Surgery in the United States. Dr. Firor was a general surgeon that did not do cardiac operations, but he remained clinically active and had a patient named Libby B. who experienced persistent intestinal obstructions. He had operated on her many times, but the obstruction recurred again and again. Finally, he concluded it was a terminal situation and ordered an ongoing morphine injection so she could pass away comfortably.

  I was intrigued by Libby’s expressive features and the glint in her eyes. I thought Dr. Firor was being hasty. He knew I disagreed with his prognosis, as my ceaseless telephone calls kept bringing him back to surgically try to relieve the intestinal blockage.

  I’d phone him, “Dr. Firor….”

  “Buckberg. Again? When are you going to let go of this?”

  “I have another idea, sir. You have to operate on her another time.”

  He did, and one of these procedures was completely successful. Libby survived the illness and went home, her sparkling eyes seeming ever more beautiful.

  While I knew Dr. Firor was very pleased that she recovered, I also knew I’d really been bugging him. Still, he kept teaching me, leading me to become a better surgeon at every step. He was committed to the work he did.

  For that reason, when I was to leave Hopkins in December of 1963 for the rest of my training in Los Angeles, I phoned Dr. Firor at his home to thank him for his instruction. He hadn’t known I was going and appreciated the call, adding, “Don’t leave yet. Please go to the operating room desk and await my arrival.”

  While surprised that he wanted to say goodbye in person, I was delighted and waited for him. In he came, in the middle of winter, wearing an old brown coat, dark brown muffler, shabby hat, and carrying a paper bag under his arm. He thanked me for helping him with Libby and presented me a gift. Inside this brown paper bag was an old book about Harvey Cushing, the world’s most famous brain surgeon who started neurosurgery at Hopkins and with whom Dr. Firor had studied when his own training began.

  I was puzzled why he would give a cardiac surgeon a book about a neurosurgeon. Then Dr. Firor asked me to open the book.

  Today, treasured mementos line the edge of my tall cherry wood bookcase, where four books live upon the top shelf. One, wrapped in a shaggy cover, is this book about Harvey Cushing. Inside, the personal inscription that Dr. Firor had written to me that night when I was about to leave Hopkins:

  To Gerald Buckberg, who has been

  irrepressible but not irrestrainable

  determined but not obstinate

  energetic but not aggressive

  tough but not rough

  kind but not soft

  irreverent but not uncouth, etc

  From Warfield M Firor, in appreciation of the fun we’ve had working together at the Johns Hopkins Hospital, December 14, 1963.

  This was unexpected. I knew how much he meant to me, but truly did not know what he thought of me, especially after our experience with Libby.

  Even today, I remain touched by what he wrote back then to a very young, fairly green intern. Dr. Firor recognized he was working with someone truly concerned with caring for sick people, someone who was not overly concerned with what his professor or others might think of him, but dedicated to doing everything he could to help patients get better. Dr. Firor was a bedrock in my formation. He recognized and encouraged my positive traits, and kindled our shared outlook: that passionately pursuing solutions to help people is fun.

  UCLA

  I exchanged the cold winters of the east with the sunnier climate of Southern California as I traveled next to UCLA, where I was to spend six months in cardiac surgery during the final year of my residency. My good fortune traveled with me and I continued to be surrounded by eminent leaders in the field.

  One of those I was privileged to work with was Dr. William Longmire, the founding chief of surgery of the UCLA School of Medicine and internationally respected surgeon. Not only that, he had a history at Johns Hopkins Hospital. He’d been on the surgical team with Dr. Blalock that successfully conducted the first “blue baby” procedure.

  Dr. Longmire was an inspiring individual who had mastered many phases of surgery, and was the ideal person to demonstrate the qualities of a dedicated physician by taking care of both patients and their families. From him, I could see the primary attribute of a cardiac surgeon was to be a complete physician, combining knowledge, precision, and teaching with the full understanding that all of these qualities should be directed toward the ultimate goal of quality patient care.

  Despite a demanding travel and lecture schedule, Dr. Longmire continually demonstrated these caring traits by visiting his post-operative patients immediately after his trips. The knowledge that he would return from a trip at 2:00 a.m. and immediately go to the hospital before heading home had an impact on all of his resident surgeons. Dr. Longmire made us understand that you could be the greatest surgeon in the world, but if you did not put your patients and their families first, you were still a lousy physician. The doctor-patient relationship became the central theme of his clinical practice.

  It was a lesson I learned under the most uncomfortable of circumstances.

  One morning at 5:00 a.m., a resident called to inform me of a brief convulsion in one of Dr. Longmire’s patients. From what the resident said, I determined the cause was low calcium, which I had him cure by calcium restoration. I did not call Professor Longmire, knowing I would be meeting him at 7:00 a.m. for an operation.

  As we both arrived and prepared for the surgery at the scrub sink, Dr. Longmire spoke to me first, saying only one thing:

  “How would you feel if you came to see one of your patients and the family asked you if their mom would convulse again… and you had no idea what happened earlier?”

  He had visited the patient and their family early that morning before coming to surgery. Before I could reply or apologize, he walked off into the operating room. I had no choice but to follow.

  A ten-hour liver resection ensued under the technical mastery of this surgical genius — without a word exchanged between us. In his silence, he taught me a profound lesson about the completeness of surgical care.

  The Search Continues: We Begin to See the Enemy

  The dilemmas of heart surgery are universal.

  My time on the cardiac rotation at Johns Hopkins Hospital had lasted only two months, but I repeatedly witnessed an outcome of a heart becoming seriously damaged, despite the performance of a faultless technical operation. This injury caused deaths from impaired heart function. Yet the problem was not isolated, as the same thing was also occurring at UCLA.

  Even when the outcome was not fatal, temporary impaired heart performance was expected whenever the patient was on the heart-lung machine more than 60 minutes. Yet, we c
ould only deal with the symptoms of this damage, since answers to the overriding question, “Why does the heart function diminish after an excellent technical repair?” were unknown.

  The frustration was overwhelming to me. My visit to the pathology department to look upon the now-still body that had previously pulsed with life, stirred a mixture of deep sadness and intense curiosity. The common denominator of these deaths was always extensive damage to the inner shell of the left ventricle (inner muscle closest to that chamber), as shown in Figure 2.

  Figure 2: These are cross sections of the heart. In the healthy heart (left image), the left ventricle is on the left side, the midline structure shows the septum, and the thin wall on right side is the right ventricle. The thickened heart of a patient (right image) shows a massive amount of blood in the inner shell of heart wall due to bleeding (hemorrhaging) into dead tissue, caused by extensive damage developed despite a technically perfect operation.

  We knew the blood vessels supplying this region were unobstructed, so the problem had to be elsewhere. Like others, I desperately wanted to reverse this cause of death, and my search for an answer would drive me toward a deeper exploration of its cause and prevention.

  But before that could occur, I had a two-year military obligation that began once I completed my residency at UCLA.

  Military Man

  I entered military service in 1967 and served in the Air Force at Wright-Patterson Air Force Base in Dayton, Ohio. I would treat people stationed on-base as well as soldiers flown back to the states for surgery. It was here that the first glimmer of insight unexpectedly arose toward how to address the heart muscle damage that commonly occurred during cardiac surgery.

  During the Vietnam War, a strategy of rapid retrieval of injured soldiers was developed so that medics could enter the battlefield to treat them. In the past, medics would have to wait for the battle to finish before they would retrieve the soldiers to bring back to the hospital. But these brave paramedics were now trained to go out in the field during the fighting just after the soldiers were wounded. Typically, the injured soldiers had lost a lot of blood and the medic would transfuse the victim, providing them fluids through an intravenous needle. They could not give them blood since they couldn’t know their blood types, so they administered large quantities of saline solution directly into the veins to replace the massive blood loss.