Hearts

by Thomas Thompson

  Gwen handed, without being asked, a Dacron patch to Cooley, which he accepted and with his scissors trimmed down to a circular affair, larger than a quarter and smaller than a half-dollar. Deftly he sewed it into the septum, closing off the hole. He worked calmly, dispassionately. Disasters have happened—they happen in any surgery—but none has ever broken his calm. A clamp can slip off an aorta and blood can erupt to the ceiling like a geyser. Cooley sews through the blood. Once an assisting surgeon was opening the chest with an electric saw and he cut too far, slicing into the heart. He cried out in horror. Cooley hurried into the room, quietly sewed up the unintended wound, and turned to the defect for which he had been engaged.

  When he was done with Carstairs’ patch Cooley said, almost in a whisper, “Let’s see what happens.” Carstairs was taken off the pump and the life-sustaining responsibility given back to his own system. The heart fibrillated slightly, enough to cause Cooley to put him back on the pump for another few moments. A jolt of electricity started up the heart the second time. It beat regularly and normally.

  Jerry Strong raised his eyebrows as a compliment to Cooley’s surgery, also indicating that there was considerable road to travel before the reconstruction could be considered successful.

  Three hours after Pamela’s surgery, her blood pressure was up to 82/50, a good sign. She was trembling, moving her arms about, and fighting the mouthpiece as the anesthesia began to slip from her system.

  After six more operations, Cooley finished at 5 P.M., made brief rounds, visiting those patients whom John Russell had scheduled for the next day. A mother whose child was recovering nicely asked if he would pose for a photograph. Not only would he, he swooped up the child, instructed the woman to move across the room with her back to the afternoon sun, and held still for one Polaroid and two 35mm slides. A second woman watching expressed disappointment that she had not brought her camera. Did Cooley have any pictures of himself? His office would give her one. Cooley hands out handsome line drawings from a Karsh portrait. DeBakey has a stack of glossies he autographs and distributes to those who ask. It occurred to me that there are two professions where the participant stands directly under a spotlight—acting and surgery—while doing their principal work.

  I had an appointment to eat dinner at a Mexican restaurant with two medical student friends, and as I dressed, another student was combing his hair in the locker room. He had been working in Cooley’s surgery that day, doing the scut work of holding retractors until the fingers ache and pinpoints of pain invade them.

  “Some day,” I said. “Eight cases.”

  “That’s too many,” said the student. “Personally I think the surgeon should do fewer cases and have more rapport with the patient. Some surgeons actually work up the patient preoperatively, do the operation, and stay with him until he is out of danger.”

  But who could do as many sophisticated cases as Cooley can do? “Shouldn’t his skill be used on as many patients as possible?”

  The student shook his head. He had long sideburns and the beginnings of a mustache. Jerry Strong had commented that very day how hip the medical students were starting to look. “Wait till the AMA gets ahold of them,” Strong had said.

  “There might be other Cooleys around if somebody gave them the chance,” the youth said. “But of course I’m still a student, and I’m still idealistic.”

  Medical students know of all the places where dinner is cheap and filling. This being Wednesday it was half-price night at a Mexican restaurant where for 99 cents one got a taco, a combination plate of enchiladas, beans, rice, tamales, a basket full of toasted tortillas, and heartburn (a misnomer, it should be called esophagus burn, because the heart is not involved). Jerry Naifeh and Bob Viles, both second-year students and aspiring surgeons—in their classes, when a theoretical case would be presented and the instructor would ask for possible medical solutions, Jerry and Bob would usually cry, “Cut! Cut!”—were talking about DeBakey’s announced scheme to reduce the number of years a doctor must spend in medical school and residency before he can begin practicing. As it then stood, a heart surgeon had to spend thirteen or fourteen years after he finished college, making him almost 35 by the time he had fulfilled his military obligations. The training period was four years in medical school, one year in internship, four years in a residency, three years in a surgical specialty, and one year as a fellow.

  DeBakey had recently proposed cutting one year out of medical school—“the second’s a waste of time, anyway,” said Jerry—and shortening the residency from four years to three. In a nation critically short of doctors, it seemed a valid idea. Most doctors think they are over-trained anyway.

  “The Professor’s always looking out for the students,” said Jerry. “He’s almost a God to us.”

  It was not always thus. Less than a handful of years ago DeBakey was so caught up in his myriad duties that students complained they never saw him or had access to him. At the annual senior dinner, the class voted DeBakey their “Chicken” award, given by graduating students to the faculty member who had contributed least to their medical education. Stung, DeBakey instituted a series of Saturday-morning breakfasts at which all seniors were invited for free bacon and eggs and an ask-me-anything hour.

  Jerry suggested that DeBakey erupts at people in his operating room to weed out those emotionally unfit to become surgeons. “He really psyches you out if you let him,” said Jerry. “You make mistakes, you forget everything when he goes on a rampage. There was this woman resident who really got it. He used to scream at her, ‘No, deah, no! You’ll never learn! You’re psychologically defeated!’” (The woman is now a successful Houston surgeon.)

  Hans Paessler joined us, weary after three afternoon cases with Ted Diethrich and an hour in the lab inducing heart attacks in pigs. Hans looked like a ski instructor with wide shoulders and strong arms. He was spending his year in Houston not only observing DeBakey and Diethrich but wheeling his yellow Fiat convertible about the southwestern part of the city in heavy pursuit of beautiful and preferably rich girls. “I have a date this weekend with a former Miss Playmate,” said Hans. “She works at the Shamrock Hilton as a hostess.”

  “As a what?” said Jerry.

  “She greets visiting dignitaries,” said Hans. “She is … she has.” Hans was searching in vain for English dimensional terminology. He settled for extending his hands a considerable distance in front of his chest.

  “Medicine is business in Houston,” Hans said, taking a sip of Lone Star beer and frowning, mentally comparing it with the brew of Munich. “The patient is the customer. I’ve never seen a place like this. Doctors are so nice to each other! The reason is they worry constantly about getting referrals. I asked a cardiologist the other day why he was always smiling, always so polite to everybody, and he said, ‘Because you never can tell who’s going to give me a referral some day.’”

  In his country, Hans said, surgeons do not operate on the very elderly. “We send an 85-year-old woman with an aneurysm back to her cabbage patch and let her live out her life. Here, DeBakey will operate on her. It’s incredible!”

  I drove back quickly to St. Luke’s, where I wanted to follow the progress of Pamela and Carstairs through the most critical night of their lives. John Zaorski was on night duty, looking after all of Cooley’s patients. Zaorski, a stocky, crew-cut reserve major in the Air Force and a former sugeon with the military in Korea, was on the last leg of his medical education. At 35, he was anxious to get into private practice. The nursing staff considered him one of the best of the fellows—“They like me because at least I speak English,” said John, who spoke in a rat-a-tat Joisey accent. He was coming out of a woman’s room on Three South when I found him. “That’s an interesting lady, you should talk to her,” he said. “She’s a Jehovah’s Witness.” The patient inside was Mrs. Grieg from Colorado, who had survived open-heart surgery without blood transfusion.

  Cooley is one of the few surgeons in the world who will attempt sur
gery on Witnesses, having vowed to observe their prohibition against accepting blood. He has done some 100 cases, using only saline solution to replenish body fluids, and his mortality rate is about the same, in some series slightly lower, than with non-Witness patients. The feat is astonishing, considering that almost every surgery, even minor surgery, requires blood, if not during the actual operation, then certainly in the postoperative period.

  The ban on blood for Witnesses is strictly observed; there is no cheating in Recovery when a pressure nose dives and the obvious treatment would be “give blood.” Dr. Grady Hallman once noticed an order for blood written on a Witness chart and he quickly found the charge nurse and demanded an explanation. The nurse said that there had been an error, which had been caught, and that the blood had not been administered, only ordered.

  Mrs. Grieg was a retired hairdresser, a neat, thin, prim woman, nine days postoperative. Her heart was tolerating the new plastic mitral valve that Cooley had put in. She was reading her Bible and she found a verse from Leviticus that is the foundation of their belief.

  “‘Ye shall not eat blood.…’ We interpret that as meaning that we cannot use blood, either.… ‘It shall be poured out onto the ground.’” A bony, liver-spotted finger flew across the pages into the New Testament. “And St. Paul told us, right here, ‘Ye shall abstain from blood.’ Both the Old and the New Testament support our faith.”

  “Are there many dissenters to this principle within your sect?”

  “Our organization has no splits. There are no rebels. We know only that it takes courage and we accept the risk. We believe that this is what God wants us to do, else he would not have given it to us in His Word. We cannot violate His Scriptures. When I entered the hospital, I signed a paper stating that, if I got anemia or postoperative complications, I would not hold the hospital or Dr. Cooley responsible. We think God is with us, He is in this room, He is listening to this conversation. We will remain alive only as long as He has need for us here.”

  Mrs. Grieg left the hospital the next day, looking serene and handing me some pamphlets to study.

  Shortly after 10 P.M., Carstairs’ potassium level dropped sharply, causing concern to Shirley Fife, the efficient Recovery Room nurse who was working a double shift, already having put in eight daytime hours in Leachman’s cath lab. She took Carstairs’ chart and hurried into the coffee room, where Zaorski was slumped for a few minutes rest. There had been few problems this night and on his last tour of the hospital, the nursing stations reported that everyone was either resting well, or better still, not complaining.

  “This can be dangerous,” Zaorski said, scanning the chart. “The danger is that the patient can go into arrhythmia, irregular heart beats; they can kill you. His potassium level is, let’s see, 2.9. Normal is an even four. Potassium’s an electrolyte, one of the chemical agents that controls the heart beat. Cooley foresaw this, because he hooked up Carstairs with pacemaker wires in case we needed to slap one on and speed up his beat.”

  Zaorski ordered potassium to be injected into Carstairs’ intravenous tube and no sooner had he returned to his coffee than did Shirley hurry in, this time with Pamela’s chart in hand. The child’s potassium level also had plunged. “Give her some, too, as long as you’re at it,” said Zaorski.

  In the hours after heart surgery, six danger signs watched for are:

  1. Tamponade—bleeding around the heart. This can precipitate a fatal drop in blood pressure and must be corrected by emergency surgery. “This is usually the only thing we’d call Cooley for at home,” said Zaorski. “This or a death.”

  2. Lung malfunction. The lungs can develop resistance to the new pressure system created by revised blood circulation within the heart.

  3. Heart block. When the surgeon sews a patch into the heart, such as Carstairs’ VSD repair, he must avoid hitting a vital clump of nerves called the Bundle of His. If a single suture is placed one millimeter over and into this clump, it can destroy the heart’s natural pacing system and the patient must be hooked up to a pacemaker.

  4. Low urine output, indicative that the kidneys are not being well nourished with blood pumped from the heart.

  5. Arrhythmias.

  6. Bleeding around the graft.

  Shirley hauled Zaorski back into Recovery for the third time in less than half an hour. Pamela’s intravenous tube had come out. “She probably pulled it out, she’s been squirming and fighting everything,” Shirley said. Zaorski sighed and tried for ten minutes to work an intravenous needle into Pamela’s veins, but the child had been catheterized so often that her veins had thrombosed; they simply would not accept another needle.

  “Gimme a cutdown,” said Zaorski, requesting a sterile pack with instruments for cutting into the foot and finding a vein to hook up the intravenous.

  The charge nurse, busy down the line turning a patient, called back, “You’ve got to get her parents’ permission.”

  “For a cutdown?” Zaorski’s voice was incredulous. A “cutdown” has long been a procedure of most routine nature.

  “It’s considered minor surgery now, and the hospital requires you to get the parents’ signatures.”

  “Well, for Christ’s sake that’s a new one on me. What do you recommend? It’s past midnight, visiting hours in most hospitals are over. You have any idea what motel I go to to find her parents? Or what their names are?”

  The charge nurse shook her head. Zaorski asked me to scout the Texas Children’s surgical waiting room; he, in the meantime, would look through St. Luke’s lobby. I ran down the hall and into the dark foyer. An elderly man in cowboy boots was sleeping on a cot he had brought; he sat up with a startled look on his battered face. A woman trying to stretch across two folding chairs stood up quickly and searched for her eyeglasses. Neither belonged to Pamela. I apologized and raced back to Recovery. Zaorski had drawn a blank as well.

  “The rule is,” the nurse said, “that if the parents cannot be found and if the surgeon considers the procedure necessary, then he can go ahead.”

  Zaorski nodded. She could have saved us both a foot race.

  “You just go ahead and start,” said the nurse. “I’ll phone around and try to find her parents. If I can’t, then you can sign the paper saying it was necessary, in your opinion.”

  “Be sure and write down that we tried to find the parents,” said Zaorski.

  “Trust me.”

  “I trust everybody. I just wanna cut the deck.”

  Zaorski put on sterile gloves and cut into Pamela’s foot, complaining the whole time about the constantly multiplying rules that hospitals are initiating to protect themselves against lawsuits.

  “It’s getting ridiculous. We might as well have a lawyer standing beside us. So’s malpractice insurance. I understand it costs $9,000 a year premium in Los Angeles. Plastic guys get socked the worst. Patients scream, ‘Look what you did to my nose, you bastard,’ and sue you for $12 million.”

  When there was a period of almost an hour without a page or a summons from Shirley, Zaorski relaxed with a couple of other doctors on night duty. They were talking about Cooley, his skill, his money—a continuing topic of conversation among the younger men.

  One doctor began doing mental arithmetic and announced that Cooley was potentially the highest-paid doctor in the world. “Look at it this way,” he said, scribbling with his ball-point pen on the leg of his scrub suit. “He does 1,000 pump cases a year at $1,500 each, that’s $1.5 million. Plus another half million, easy, from his vessel work. That’s $2 million if he collects from everybody.”

  Zaorski disagreed. “But he knocks a lot of fees off. I saw him throw six unpaid bills in the wastebasket at one sitting.”

  “He’s gotta be worth $10 million, easily.”

  “In medical school,” Zaorski said, “we learned that a good surgeon can make up to $75,000 a year in a small town and maybe $100,000 to $300,000 in the city.”

  “Why is Cooley so good?” I asked, blinded by the tally sheet on
the doctor’s pants.

  “Speed’s the main thing,” said Zaorski. “It’s so important in these cases. If you keep a patient on the pump too long, his blood loses the ability to clot and he can become acidotic—that’s an abundance of lactic acid. Just before a patient dies, he fills up with this stuff. Speed is the difference between success and failure in open-heart work. Cooley even got down to where he could do a heart transplant in 36 minutes.”

  “But they’re all dead,” said the doctor standing at the coffee pot.

  “Yeah,” said Zaorski. “That’s right. Transplants are a stupid way of doing things.”

  CHAPTER 7

  Seventy-two hours after surgery, Pamela was sitting up, sipping a Coke, brushing her hair, and tearing into get-well cards. The bluish cast to her skin was gone, the sadness had slipped from her eyes, and though she was still pale, there was a general aliveness about her that had not been there before Cooley rearranged her heart. Leachman listened to her heart and she accepted his stethoscope without protest. “You must be sick, Pammy, you’re so quiet,” he said, nodding encouragingly at her mother. “There’s still a lot of getting-used-to necessary for the lungs,” he said later. “It’ll be a few months before those hissing noises go away, but I believe she’s going to be fine.”

  Carstairs went from Recovery to the sixth-floor Intensive Care Unit, where his vital signs were observed for 36 hours, then on to a semiprivate room, where his roommate was disturbing him more than the postoperative pain. The man in the next bed was an 81-year-old farmer, Leroy Castle, who had had a variety of surgery, some vessel work, his gall bladder removed. From a town so small it was not even on the map, he was confused by the hospital and fought off the sedatives given him. When awake he talked constantly in a booming hog-calling voice and was visited frequently by eight large relatives, all of whom talked louder than he did, and all at once. “I thought it was bad in ICU when a man died in the next bed,” said Carstairs. “They pulled the curtains around his cubicle, but I knew what was happening. This is worse. I can’t get any rest.”