Heart

by Sandeep Jauhar

  Not long ago, I took a tour of a cardiothoracic surgical unit at Advocate Christ Medical Center, a major tertiary care facility just outside Chicago. My guide, an Indian cardiologist in her sixties, had started one of the top artificial-heart programs in the country in Louisville, Kentucky, before moving to Advocate Christ. She took me on a tour of a twenty-five-bed unit where patients were getting all manner of cardiac support, from balloon pumps to ventricular assist devices to transplanted hearts. I asked her what she thought about the prospects for a total artificial heart. “It’s an evolving field,” she said carefully, “but the complications are really troubling.” She told me about one of her patients with intractable arrhythmias who received an artificial heart. His pain and suffering with it were so great that his family sued the hospital and his doctors after he died.

  We passed by a patient on a ventilator and dialysis machine; she’d had a large myocardial infarction and was now being supported by ventricular assist devices on both sides of her heart. The multiple consoles surrounded her like a pack of animals. “After so many years of study, I’ve concluded that the best thing we can do for most of our patients is to give them medicine,” the cardiologist told me. “Of course, we need mechanical devices for patients who are crashing and burning, but for most of our patients the technology still has too many problems.”

  The workhorse of mechanical support for heart-failure patients today is not the artificial heart but the left-ventricular assist device (LVAD), which attaches to the native heart, pumping blood directly out of the left ventricle and into the aorta, thus essentially bypassing the failing organ. Approved by the FDA for both permanent and bridge therapy, LVADs have become a lifesaving option for end-stage heart-failure patients. Between 2006 and 2013, more than ten thousand patients, including Vice President Dick Cheney, received LVADs for cardiac support. Unfortunately, LVADs are still not an option for patients with severe failure of both right and left ventricles. For such patients, like Barney Clark, a permanent artificial heart may still be the best hope. For now, it remains a dream, but not quite the pipe dream it was in 1982, when a soft-spoken dentist from Seattle decided to go first.

  •

  It wasn’t easy telling Ravindra’s father that there was nothing more I could offer, that his son was not eligible for a mechanical or a human heart because neither would change his poor prognosis. But I believe he already knew. “The things that are important to my wife are not so important to me,” he said.

  “What is important to you?” I asked.

  “All the pain he going through.” His lips quivered before his face tightened up again. “I don’t want him to suffer no more. He have suffered enough.”

  Unfortunately, there was more suffering to come. Over the next several days, Ravindra had terrible leg pains. I wasn’t sure why—poor blood flow to the muscles, perhaps—but I couldn’t leave him in such agony. I put him on a morphine drip to keep him sleepy and as comfortable as possible. I made sure his father signed a do-not-resuscitate form. It didn’t mean we wouldn’t do everything in our power to help Ravindra, just that at the end we would let him go peacefully. His father understood. He was ready for the ordeal to end, both for himself and for his son.

  On morphine, Ravi went in and out of consciousness. He’d doze off and then open his eyes in a panic, before closing them and sinking back into a fog. At times he displayed “agonal” breathing—loud gulps of air followed by periods of apnea, or no breathing—a pattern that frequently heralds death. His lungs made deep, guttural groans, like a foghorn, so congested were they with fluid. Sometimes he’d writhe with pain, mouth foaming, teeth clenched, a tight scowl on his face. Other times he would scream out, “Mom, help me, Mom!” His mother massaged his legs, day and night, and mumbled prayers and wept. As a doctor and just as a father, I found it a terrible thing to witness.

  He died one morning before I made rounds. When I got upstairs, the door to his room was closed, but I could still hear the commotion inside. A nurse offered to go in with me, but I told her it wasn’t necessary. As a heart-failure specialist, I’d experienced enough death to fill up a lifetime. Once, it was difficult to witness the grief of loved ones. But my heart had been hardened, and this was no longer that time.

  At the bedside was a wooden table with drawers, and on the far side of the room were dark gray curtains framing windows overlooking the parking lot. Ravi’s mother was smothering his face with kisses, talking almost robotically, as her grief erupted in ever more intense swirls. “No more, no more, my son is gone! Oh, my Father, my loving son no more!”

  A relative sitting on the flower-patterned couch tried to comfort her. “He suffer too much, sister,” she said. “It’s God’s choice. He will come back again in a nice body.”

  The father came over and hugged me. He was wearing an overcoat, though it was spring. “She will cool down,” he whispered, referring to his wife. “She seen how he suffered.”

  “Oh, my son be punished and punished,” the mother wailed. “He said, ‘Mom, I’m dying, I’m dying, I can’t breathe!’ I told God to leave him, I would take him at 50 percent. But He wouldn’t even give me that.”

  There wasn’t much I could offer at that moment, so I said I would come back and exited. The father followed me out. In the hallway, he asked me what was next.

  The body would be taken to the morgue, I explained. The funeral home would call to arrange for transportation. He seemed calm talking about the arrangements. Then his cell phone rang. He put in the earpiece. “Hello … yes, my son no more.” And finally, he broke down, too.

  *This was the case in other countries as well. In 1968, a Japanese surgeon was charged with murder after removing a patient’s heart while it was still beating to harvest it for transplant. The charges were eventually dropped, after six years of litigation, but heart transplants were outlawed in Japan—indeed, the very term “heart transplant” was taboo—until 1997, when brain death was officially recognized.

  †Brain death as a legal definition of death wasn’t widely accepted in the United States until 1981, when a presidential commission issued a landmark report on the subject.

  PART III

  Mystery

  12

  Vulnerable Heart

  When the heart is affected it reacts on the brain; and the state of the brain again reacts … on the heart; so that under any excitement there will be much mutual action and reaction between these, the two most important organs of the body.

  —Charles Darwin, The Expression of the Emotions in Man and Animals (1872)

  The morgue was inside Brooks Brothers. I was standing at the corner of Church and Dey, right next to the rubble of the World Trade Center, when a policeman shouted that doctors were needed at the menswear emporium inside the building at One Liberty Plaza. Bodies were piling up there, he said, and another makeshift morgue on the other side of the rubble had just closed. I volunteered and set off down the debris-strewn street.

  It was the day after the attack. The smoke and stench of burning plastic were even stronger than on Tuesday. The street was muddy, and because I was stupidly wearing sandals, the mud soaked my socks.

  I arrived at the building. In the lobby, exhausted firefighters and their German shepherds were sitting on the floor amid broken glass. A soldier stood at the entrance to the store, where a crowd of policemen hovered. “No one is allowed in the morgue except doctors,” he shouted.

  I entered reluctantly through a dark curtain. Cadavers had always made me feel queasy, ever since those dog days in the anatomy lab in St. Louis. In the near corner was a small group of doctors and nurses, and next to them was an empty plastic stretcher. Behind the group was a wooden table where a nurse and two medical students were sitting grim-faced, looking like some sort of macabre tribunal. Brooks Brothers shirts were neatly folded in cubbyholes in the wall. They were covered in grime, but you could still make out the reds and oranges and yellows. In the far corner, next to what looked like a blown-out door, was a pil
e of orange body bags, about twenty of them. Soldiers were standing guard. In the store’s dressing room were stacks of unused body bags.

  The group was discussing the protocol for how to handle the bodies. A young female doctor said that she didn’t think anyone should sign any forms, lest someone think that we had certified the contents of the bags, which we were not qualified to do. That, she said, was up to the medical examiner. Someone asked whether a separate body bag was needed for each body part, but no one knew the answer. The leader of the group was a man in his fifties. I looked at his badge. It read “PGY-3.” He was a third-year resident, which meant that I was probably the most experienced doctor in the room, a thought that deeply disturbed me. I had been a cardiology fellow for only a couple of months.

  At this point, some National Guardsmen brought in a body bag and laid it on the stretcher. The female doctor unzipped it and inspected the contents. “Holy Mother of God,” she said, and she turned away. In the bag was a left leg and part of a pelvis, to which a penis was still attached. The leg itself hardly seemed injured, but the pelvic stump was beefy red and broken intestines were hanging out of it. A pants pocket was partially covering the pelvis and was emptied of change; this pocket was put in a separate bag. A policeman said that part of the victim’s body had been brought in earlier, along with a cell phone.

  That was actually good news. If the victim had the numbers of family members on his speed dial, he would be quickly identified. But identification wasn’t my job. Processing was.

  After five minutes, the bag was zipped up. The older male doctor, who had been working there for hours, said he had to leave. The other doctor also said she had to get away for about an hour. “Are you a physician?” she asked me. “Yes,” I replied. “Great,” she said. “You can take over.” Then she started giving me instructions on how to catalog the body parts. Basically, I had to call out the contents of each bag to a nurse, who would write them down on a form. That was it.

  I was in a fog. Suddenly I was in charge, but I wasn’t a pathologist. I was just improvising. I recalled my friends who had done medical clerkships in Africa. They had told me of the terrible tragedies and deep frustration of not having proper medical supplies. But we were not suffering from a lack of supplies. This was not third-world medicine. It was netherworld medicine, without rules.

  Another body bag came in. This one had a spleen, some intestines, part of a liver. After sifting through the bag’s contents, I began to feel ill. I walked past headless mannequins and out into the smoke-filled air.

  Our triage center had been set up in a firehouse within yards of the World Trade Center plaza. From here, the destruction was even more profound. Bombed-out cars, coated with an inch of cement dust, lined the muddy streets. Steel beams of the demolished towers stood up in the rubble like butts in an ashtray. Giant hoses and wires coiled from the buildings. Everywhere there were shattered windows and broken glass. The ground was strewn with paper and abandoned shoes, as if people had literally vanished in their tracks. Dr. Abramson, the Israeli echo chief who had accompanied me downtown, gazed at the carnage. “I thought I had seen everything,” he said softly.

  Our center was equipped with supplies—oxygen tanks, crates of foodstuffs—that had been ferried down by ambulance. A fire ladder served as a scaffold for bags of fluid. Twenty or so doctors and nurses staffed the different “departments”: trauma, burns and injuries, wounds and fractures. I was in asthma and chest pain. We treated firefighters suffering from smoke inhalation, giving them oxygen to breathe and albuterol mist to help open their airways. But otherwise things were eerily quiet.

  On my way downtown the previous afternoon with a caravan of doctors from Bellevue, I had braced myself to confront throngs of seriously injured people. But there was no one around except rescue workers. “Where are all the patients?” I blurted out when I arrived, thinking they might be at a different location.

  “They’re all dead,” a colleague replied.

  Now we sat in the haze, ash still falling like snow, trading stories. A physician told me he happened to be standing outside the first tower when it collapsed. “I ran under a bridge,” he said. “There was huge debris falling all around me. Every step I took, I kept saying to myself, ‘I can’t believe I’m not dead yet; I can’t believe I’m not dead yet.’ ” Then he began hearing strange thuds. Those, a firefighter told him, were people jumping off buildings.

  We sat for hours, waiting for something to happen. Then, in the early afternoon, word came that a victim, a young woman, had been found alive in the rubble. An American flag was hoisted at the site, and rescue workers began the painstaking work of extricating her. By late afternoon, about fifty doctors and other volunteers had formed a human chain from the street to the top of the rubble, several stories high, and were passing down the debris, piece by piece. Two large cranes with huge jaws then took the shrapnel and transferred it to waiting trucks.

  I stayed until evening, hoping to help in some way, but I’d spent the better part of two days at the site, away from my worried wife, and I was exhausted. They were still working when I left.

  For weeks after I returned to work that fall, the smell of dead bodies wafted from the morgue tents set up at First and Twenty-Ninth, outside Bellevue. I had been cutting through the street to get to conferences at the main hospital, but no more. Then, one day, I heard that the victim who’d been saved at Ground Zero was on the cardiac arrhythmia service, and not because of her broken leg. After her rescue, recurrent ventricular arrhythmias inexplicably set in, causing her to keep passing out. Medications couldn’t suppress the arrhythmias, psychological counseling hadn’t helped, and surgical options, including an implantable defibrillator, were being considered. By the late fall, she was on the catheterization table as electrophysiologists at Bellevue tried to figure out what had gone wrong inside her heart.

  •

  Heart rhythms are strongly influenced by emotional states. But how do emotions trigger rhythm disturbances? How does psychological injury disrupt the heart of a traumatized young woman that has beaten a billion times without fail? Bernard Lown, co-recipient of the Nobel Peace Prize for his work with International Physicians for the Prevention of Nuclear War, performed some of the seminal studies exploring such questions. As a high school student, Lown was fascinated by psychiatry, but in medical school he quickly became disenchanted by the subjective nature of the discipline. However, his fundamental interest in mind-body interactions persisted throughout his career. As a cardiologist in the 1960s, he decided to investigate whether psychological stress could trigger sudden cardiac death. In his earliest experiments, he studied ventricular fibrillation in anesthetized mice. To predispose the animals to fibrillation, Lown experimentally blocked a coronary artery, causing a small heart attack. He found that 6 percent of his animals developed ventricular fibrillation because of the coronary occlusion. However, Lown discovered that fibrillation occurred ten times more frequently when regions in the brain that mediate anxiety were electrically stimulated at the same time the coronary artery was occluded. Lown and his colleagues later found that they did not have to stimulate the brain to produce a fatal arrhythmia. Stimulating autonomic nerves that mediate blood pressure and heartbeat largely did the same thing.

  But what Lown really wanted to show was that psychological stress by itself could trigger dangerous arrhythmias. He decided to study premature ventricular contractions (PVCs) in dogs. These extra heartbeats are often a precursor of fatal arrhythmias because they can strike during the vulnerable period of the cardiac cycle. PVCs indicate that the heart is in an excited and, therefore, vulnerable state. For the psychological stress, Lown put each dog in two different environments: a cage, in which the animals were essentially left undisturbed; and a sling, in which they were suspended, paws just off the ground, and received a single small electrical shock on three consecutive days. When the dogs were later returned to these two environments, Lown observed a remarkable difference. Animals placed in t
he cage appeared normal and relaxed. However, when they were transferred to the sling, they became restless, and their heartbeat and blood pressure went up. The rate of PVCs rose dramatically, too. Even months later, the memory of the minor sling trauma was deeply embedded in the dogs’ brains and profoundly affected cardiac reactivity. These findings, Lown writes in his book The Lost Art of Healing, demonstrated that psychological stress, already known to be a risk factor for coronary artery disease, can substantially increase susceptibility to malignant arrhythmias, too.

  Later, working with psychiatrists at the Brigham and Women’s Hospital in Boston, Lown’s team found that survivors of sudden arrhythmias often experience acute psychological stress preceding their cardiac arrest. Nearly 1 in 5 of a group of 117 patients suffered public humiliation, marital separation, bereavement, or business failure in the twenty-four hours prior to their attacks. Moreover, Lown and his colleagues showed that medications that block sympathetic nervous system activity, such as beta-blockers, protected patients from those arrhythmias. Meditation largely did the same thing.

  Lown’s research confirmed for the first time that emotional stress can initiate life-threatening arrhythmias. This conclusion is now widely accepted in medicine. We all agreed, for example, that post-traumatic stress was exacerbating the arrhythmias in the young woman rescued at Ground Zero. But in the months after 9/11, I learned a remarkable corollary to Lown’s observations: not only are arrhythmias triggered by psychological trauma but they (or at least their treatment) can cause it as well. Such stress can then feed back onto the heart, creating a malignantly vicious cycle. The mind-heart link, in other words, goes both ways. One night in November, two months after the attacks, I got to see this up close.