A part of me wanted to go up and tell the narrative I’d dreamed up about my cadaver. He had come to America for graduate school, one of the brave first in a wave of South Asian immigrants after World War II. He had probably never set foot outside the country. He had only known his gray house in Punjab, with the white railing on the rooftop, and the congested streets where farm animals roamed amid noxious vapors of dung and exhaust. When he was accepted to an American university, his father surely regretted that he’d pushed his son into demanding an American education. He’ll get lost, his father thought, and won’t remember how to come home. Or worse, he thought, he won’t want to.
I would have liked to tell my fellow students a story about an immigrant with a broken heart. It would have been in keeping with the atmosphere that evening. But I had a change of heart and remained seated.
At twenty-seven years old, I had been introduced to a man with no name. I had handled his body, cut it apart, and put it back together again. From that point on, I thought, every careless mistake I might make in the hospital would be a slap in his face, every success a tribute to him, my first patient. He had given himself freely—wholeheartedly—and now I had to give him back and leave him to restful peace.
*Unlike the cells of lesser organs such as the liver, heart cells do not regenerate in large amounts. When they die, they are gobbled up by cells called macrophages and replaced by scar tissue.
*The importance of turbulent flow for closing the aortic valve, an idea originated by Leonardo, has been confirmed only in the past decade.
*In his later years, Harvey reportedly said to a friend, “You know very well the storm my previous research caused. It is often better to grow wise in private at home, than to publish what you have amassed with infinite labor, to stir up storms that may rob you of peace and quiet for the rest of your days.”
†Capillaries were discovered three decades later, in 1661, when Marcello Malpighi looked at sections of frog lung under a microscope. Malpighi referred to frogs as the “microscope of nature” because they allowed him to see structures that were not visible in larger animals. Nature is accustomed, he wrote, “to undertake its great works only after a series of attempts at lower levels, and to outline in imperfect animals the plan of perfect animals.” He added, “For the unloosing of these knots I have destroyed almost the whole race of frogs.”
*Through experiments, Harvey proved that when the pulmonary artery is ligated and the right ventricle is injected with water, no fluid crosses the septum into the left ventricle.
†Harvey’s analogies extended to the body politic. He wrote to King Charles I in the preface to De motu cordis, “What I have here written of the motions of the heart I am the more emboldened to present to your Majesty, according to the custom of the present age, because almost all things human are done after human examples, and many things in a King are after the pattern of the heart. The knowledge of his heart, therefore, will not be useless to a Prince, as embracing a kind of Divine example of his functions—and it has still been usual with men to compare small things with great. Here, at all events, best of Princes, placed as you are on the pinnacle of human affairs, you may at once contemplate the prime mover in the body of man, and the emblem of your own sovereign power.”
PART II
Machine
3
Clutch
Man cannot live with a broken heart.
—Gabriele Falloppio, sixteenth-century anatomist
From the beginning of my cardiology fellowship, there was never really any doubt about how we were supposed to think about the heart. Despite its metaphors, the heart in disease was best understood as a complicated pump. At orientation, on July 1, 2001, a dozen of us white-coated fellows scattered into a large auditorium at Bellevue Hospital in New York City to listen to the faculty tell us about the myriad procedures we were going to learn that year. Isaac Abramson, the chief of echocardiography, boasted of the many applications of cardiac ultrasound, which allowed cardiologists to make diagnoses that had once required bodily invasion. Sporting a dusty tweed jacket, Abramson was an old-school Israeli curmudgeon, grumpy and growly for even that part of the world. He had basically pioneered an important advance in echocardiography in the 1970s and had spent the intervening years gathering laurels. He once said to me, “Sam, I want the fellows to feel they are so unimportant that I cannot be bothered to even remember their names.” Abramson had certain tenets, nuggets of wisdom, and on that day he dispensed one of his favorites: “Everything depends on pressure differences.” He would encourage us to think about blood flow, lung congestion, and even human affairs in those terms.
Sitting next to him were his associates: David Asch, the straitlaced assistant echo chief, who thought almost as much of himself as Abramson did because he worked with the master, basking in reflected glory, which in his mind made him a bit great, too; Cindy Feldman, the only woman in the group, whose wicked humor and crazy blue eyeliner belied her astonishing clinical competence; and Richard Belkin, the associate fellowship director, who always seemed worried about how the fellows reflected on his job performance.
The electrophysiologists sat two rows behind. The chief, Robert Dresner, an electrical presence himself—more rabbi than physician—spoke of the wonders of radio-frequency ablations, in which radiation-emitting catheters were threaded through veins into the heart to cure many common rhythm disturbances. Seated next to him was his assistant, Mitch Shapiro, a sharp and avowedly vulgar man with a neatly trimmed goatee, faintly canine in appearance, who took pride in saying outrageous things in the name of candor. (“What do you mean, ‘in my heart’? ‘In my fucking heart’ won’t hold up in a court of law.”) In attitude and deportment, Shapiro was a boxer dog. Their colleague, Jim Harwood, the token researcher, was sitting off to the side, probably thinking about the cellular ion channel research he’d been muttering about for years that nobody—perhaps including Harwood himself—understood.
Sid Fuchs, the cardiac catheterization chief, had the last word. Fuchs was a weird guy; word around the hospital was that his studio apartment was occupied by a massive train set. With arched eyebrows over narrow-set eyes, Fuchs resembled a bearded Art Carney. “Don’t mind my colleagues,” he told us fellows after everyone had said his or her piece. “In the end, cardiology is mostly a problem of plumbing.”
Whatever their idiosyncrasies, I looked up to these doctors. I wasn’t sure how much I had in common with them, but essentially I knew I wanted to be like them. Understanding how and why my grandfather had died, and what implications his premature death had for my father, my siblings, and me, was fundamentally intertwined with my decision to train in cardiology. The field was also fast-paced and exciting, as if flowing out of the steady beating of the heart itself. Just as important, the considerable effort of cardiology practice was balanced by tangible rewards for patients. Unlike neurologists, master diagnosticians who had depressingly little to offer their patients, cardiologists had been at the forefront of technological innovation over the past half century. This golden period had witnessed a hailstorm of life-prolonging advances, including coronary bypass surgery, coronary stents, and implantable pacemakers and defibrillators. The dazzling technological complexity of the field was reflected in the apprehension most doctors had in managing heart disease. The same doctor who felt comfortable treating diabetes, kidney failure, or anemia would consult a cardiologist for even a mildly abnormal electrocardiogram (EKG). The heart can kill quickly, without warning, faster than any organ, which inspired fear in even the most seasoned doctor. And so a fellowship in cardiology was like entering an exclusive club, a club that incredibly had decided to take me as a member.
Of course, I was nervous. Every new doctor should be. Cardiologists specialize in emergencies. The culture is pressurized. In neuroscience, there is the concept of the reflex arc, in which a threatening stimulus can effect a response without passing through the conscious brain—for example, when you see the taillight flash red on the
car speeding in front of you and your foot automatically moves to the brake pedal. I was afraid that now, as a cardiologist in training, I would have to acquire a new reflex arc.
For the first few months of my fellowship, that summer of 2001, I spent a portion of every call night pacing back and forth in my living room, my armpits moist—and not just because of the broken air-conditioning—trying to memorize algorithms for treating the major cardiac emergencies; I might as well have been in the hospital. I often thought back to an experience I’d had in medical school. It happened during my first clinical clerkship in internal medicine at the beginning of my third year in St. Louis. I was working with a star resident of the internal medicine program. David, cardiology bound, was confident, competent, and quick. He thrived under pressure.
One afternoon, my team was called to the cardiac care unit (CCU). A patient, James Abbott, had just been admitted with excruciating chest pain that had started a few hours earlier. He was in his early fifties, extensively tattooed, just the sort of tough I wouldn’t want to meet alone in a parking lot at night, but right then he was whimpering. He kept stroking his sternum up and down, as if trying to rub the pain away. It was obvious that he was having a heart attack. He had all the classic risk factors: hypertension, high cholesterol, a history of cigarette smoking. His electrocardiogram and blood tests showed characteristic signs of low blood flow to the heart muscle. I don’t recall our examining him, but for this most common type of cardiac emergency, there is little diagnostic role for the physical exam.
A few hours later, we were paged back to the CCU. Abbott was now writhing in pain, and his blood pressure was dropping. David had a nurse get another EKG. He ordered an intern to prepare to insert a catheter into Abbott’s radial artery. Then he asked for an intubation tray to put him on a ventilator. “Check his blood pressure,” he told me.
As a medical student, I had measured blood pressure only a few times, mostly in my classmates. I carefully wrapped the cuff around Abbott’s left arm and inflated it. Then I let the pressure out slowly, listening with my stethoscope at the bend of his arm. “One hundred over sixty,” I called out.
“Check the other arm,” David said. By then he was scrubbing Abbott’s arm with iodine soap in preparation for an arterial line. More people arrived, attracted by the commotion. I wrapped the cuff around the right arm and quickly inflated it, but when I let out the pressure, I heard nothing. Must be doing something wrong, I thought. I tried again while people jostled me, with the same result. Must be the noise, I told myself, so I shrugged and let it go. For a moment I thought to ask David to check the pressure himself, but he was busy doing more important things. So I stepped aside to give others access, before being quickly pushed to the fringe.
The next morning, David caught me before rounds. His face was pale. “That guy had an aortic dissection,” he said. A CT scan had revealed a corkscrew-like tear from the abdominal aorta all the way back to the heart. “The night resident picked it up,” he said. “He noticed there was a pulse deficit between the arms. No pressure on the right.”
I listened in silence. A pulse deficit is a classic sign of aortic dissection, but in the hubbub of the previous afternoon I had somehow ignored it. I thought about telling David about the blood pressure measurement I had taken, but I didn’t. Abbott’s dissection was by now far advanced, and surgeons who had been consulted said he would not survive an operation. He died eight hours later.
For weeks I couldn’t get over the idea that I was somehow responsible for Abbott’s death. If we had caught the dissection the previous day, there was a chance at least that he could have been saved. I eventually managed to convince myself that the death wasn’t entirely my fault. But that didn’t make me any less afraid of cardiac patients.
•
As a first-year cardiology fellow, the main reason you’d get called in the middle of the night was to perform an echocardiogram, using an ultrasound probe to take pictures of the heart, which residents were not trained to do. There were many possible reasons to do an echo urgently, but the most common was to check for cardiac tamponade: fluid accumulating in the pericardium, the sac around the heart, thus squeezing the heart and hindering its ability to fill with blood. Cardiac tamponade is life threatening; rapid collection of pericardial fluid or blood can quickly put the heart into a standstill. Without proper cardiac filling and emptying, blood flow and pressure plummet and a person goes into shock. (Christ, nailed to the cross, likely succumbed to tamponade after receiving a laceration to his heart by the lance of a Roman soldier.)
In 1761, Giovanni Battista Morgagni, an Italian anatomist, spoke of the dangers of cardiac compression from hemorrhage into the pericardium. He noted that puncture of a coronary artery on the external surface of the heart could cause blood to pour into the pericardial sac, squeezing all chambers. How serious the compromise depends on how quickly the fluid accumulates. The pericardium is like a balloon. When you blow up a balloon, you must generate enough pressure to overcome the tension of the rubber. It gets easier the second time because the rubber has already been stretched. Similarly, slow accumulation of fluid stretches the pericardial membrane, making it thin and compliant and keeping the pressure inside the space low. Rapid filling, on the other hand, before the pericardium has been stretched, can result in a quick rise in pericardial pressure that can push on and collapse the heart’s chambers, thus compromising blood flow. At that point, you would have to put a needle through the chest and into the pericardial sac to drain the fluid, which I had never done.* As I paced the living room on those summer nights in 2001, it occurred to me that there was a curious analogy between tamponade and my first nights on call. I knew that my tolerance for emergencies would develop. I knew that a slow accumulation of experience would eventually deliver confidence and courage. But until it did, I was terrified that a patient I was responsible for would crash and burn.
Senior fellows had warned us that surgeons would request echos on flimsy grounds. A post-op patient might have a slight decrease in blood pressure, and they’d want an echo to rule out tamponade. A patient might have a slight increase in his liver enzymes, and the surgical fellow would say it was because of hepatic vein congestion—unlikely!—and want to rule out tamponade. Sometimes you’d ask for a patient’s vital signs, and it would turn out the patient had normal heart rate and blood pressure, and the surgical fellow—on call and under the gun himself—would admit he was just being cautious. In that case, senior fellows urged us to push back, question, cajole—“Dude, can’t this wait until morning?”—anything short of outright refusal, which could get you fired.
Most nights just the expectation of the pager going off was enough to keep me awake, anxiously rubbing my feet together in bed, waiting for the inevitable call. And just when my consciousness would begin to fade in the pale darkness, the piercing ring. You’d never know how long the beeper had been going off, just that the night had finally begun. I’d pull myself up, being careful not to wake up my wife, Sonia, quickly push the jigsaw pieces of my awareness back together, and then tiptoe to the living room to answer the call.
The first page I ever got was to do an echo on a woman with breast cancer who had become acutely short of breath. I started off by challenging the request—what were the patient’s vitals, how long had her pressure been low—but something about the surgical fellow’s tone told me to shut up and just go in. So I threw on my scrubs; grabbed my stethoscope; stuffed a $20 bill, a ballpoint pen, and my hospital ID into my vest pocket; and hurried down to the street to catch a yellow cab going downtown.
Three o’clock in the morning in my neighborhood was when the rats came out, and the mere threat of one of those monsters darting out from sidewalk garbage was enough to make me stand in the middle of the empty street. The storefronts were mostly unlit, save for a few randomly glowing windows. A speeding taxi quickly came to a screeching halt to let me in. We took a roller-coaster ride down the FDR Drive, under bridges and through tunnels, the concr
ete walls rushing at me as shadows of the metropolis reflected off the dashboard like colonies on an agar plate. In the distance you could see the high-rises on Roosevelt Island dotted with lights, like a yellow pox, and beyond them the Brooklyn Bridge and the smokestacks of the Lower East Side. In my mind, I went through the different ultrasound views I’d have to show Dr. Abramson the following morning. Did I remember how to adjust the frequency filters and sweep speed? Abramson, the echo chief, could be tough. His merciless interrogation at an early-morning conference had already made a first-year fellow faint and drop to the floor.
The driver let me off in the lot behind Bellevue. Here the rats were even bigger, moving almost randomly, like leaves propelled by gusts of wind. The hospital rose up to the cloudless sky like some sort of gothic hotel. Looking up at the building, I could only imagine what life-or-death drama was awaiting me. At the entrance, young hipsters with black leather jackets and lip rings were sprawled on the sidewalk. In the lobby, the air was stale, slightly smoky. I quickly flashed my ID badge to the burly security guard. Then I jogged over to the echo lab on the second floor to grab a bottle of Aquasonic gel and the bulky Siemens machine, which I steered down narrow desolate corridors to the surgical intensive care unit.
Heart Page 5
