Hearts

by Thomas Thompson

  Nora and Dr. John Trenton of Baylor had quickly begun a program of making ALG, the immunosuppressive drug that seemed the most promising in control of rejection. Its preparation was interesting. During open-heart surgery, Cooley would remove a piece of the thymus from some patient, usually a child, and send it to Nora. The thymus, which begins to atrophy when a person becomes fourteen and eventually disappears, is a key organ for cellular immunity. The thymus was then ground down into a serum that was injected into a horse. “Usually,” said Nora, “a mangy, old, broken-down nag we bought for $10 and boarded at a stable across town.” The first such horse used, a sway-back called Preacher, received injections of the thymus serum over a period of several days. At the end of six weeks, during which time Preacher’s system had been manufacturing antibodies, two quarts of blood were drained from an artery in his leg and processed in the Baylor laboratories. Through sophisticated distillation, the horse blood was reduced to ALG—a drug whose most valuable components were the horse antibodies—and administered to the human transplant patients. The need for ALG became so immense, because of the large number of Cooley’s patients, that the process had to be speeded up and the horses sacrificed rather than drained. From thirty quarts of blood in a full-grown horse, five quarts of ALG were obtained.

  The transplants also received massive shots of steroids—chemical relatives of those hormones made by the human adrenal gland. Steroids such as cortisone have a general immunosuppressive reaction, but they can have bizarre side effects.

  With the first large doses of cortisone, the typical transplant patient became positively euphoric. “Many said they suddenly had no pain at all, not even in the thoracic incision,” said Rochelle. “After this God-awful operation, to have no pain!”

  But a week later, many became depressed, and for brief periods psychotic. Some had total withdrawal, lying mute, catatonic in their beds, staring out at a blank unknown that only they could see. Others burst into tears for no apparent reason. One sobbed so hysterically that his wife and child began to cry as well, and tranquilizers had to be administered to all. Some were unable to eat. Others had memory lapses. Alice handed one patient his toothbrush and he looked at it with such total bewilderment that she had to demonstrate what he was supposed to do with it. Some could not move their limbs. Some could not sleep, others would not sleep. To close the eyes was to die, in the mind of one transplant. Nora grew weary of having his telephone ring in the middle of the night and hearing the familiar story from the charge nurse, of dressing and driving to the hospital, of coaxing the man with the new heart to sleep, sitting beside his bed, holding his hand, assuring him that another morning would surely come.

  One patient sat in a chair near the window with his rosary and rocked from side to side. Alice hesitated to interrupt his prayers until she observed that he was staring blankly at the wall. He was in a stupor. The same man was careful not to turn on his left side. He was afraid that the new heart would fall from its place.

  During one rejection episode, a patient was given greater dosages of prednisone, a cortisone derivative, and the resulting euphoria built in his mind a kind of spirit. He called it “lamade” and for a few days it dominated his life. A Baylor psychiatrist interviewed him:

  Examiner: “What is this lamade?”

  Patient: “A beautiful thing. Off and on. This is ozone. That’s as far as I can go. Off and on. Off and on. Beautiful.” (He began to laugh loudly.)

  Examiner: “I notice there’s a scar on your chest.” (Pointing to the incision for the transplanted heart)

  Patient: “I had a cancer.”

  Examiner: “Is there anything under the skin?”

  Patient: “No. All empty.”

  Examiner: “If I put this stethoscope on and listen there, what will I hear?”

  Patient: “Lamade … that’s all.”

  Examiner: “Where’s your heart?”

  Patient: “You are my heart.” (He burst into tears.)

  Before his transplant, one patient of German ancestry had been a gentle barber. After he received his new heart, for brief periods of time, he turned into a loud and troublesome anti-Semite. He raged at the “rich kike friends” of a fellow transplant, he cursed Jews with such venom that Alice finally scolded him. It almost seemed that the surgeon had nicked a hidden sac and out spilled a lifetime of latent hatred.

  At three one morning, a transplant filled his bathtub with water and prepared to enter it, whistling, singing, oblivious to the blackness outside his window and the silence of the hospital. Across the hall of the transplant suite, a patient heard the noise and rang for the night nurse. She ordered the bather back to bed. From that moment on, the two patients were bitter enemies. Later, when the informer died, the bather heard the news and sprang from his bed, rushing down the hall and telling each patient to leave the hospital. “We will all die,” he cried. “Flee!” Alice took the bather by the hand, marched him to his room, calmed him, and sternly commanded him to go to each room and apologize.

  Disorientation, confusion, and memory lapses seldom lasted more than a few days, although all could return with altered dosages of cortisone. But there was another side effect that no one liked. Their faces swelled up like balloons. “If I were in a crowd of 20,000 people at Madison Square Garden, I could spot a transplant,” said one doctor. “Their faces began to haunt me.”

  Several of the transplanted men felt awakened virility. One casually left his pajama bottoms open and exposed himself as Alice entered and left his room. She ignored it at first but finally became annoyed and asked him to fasten his pants. “Oh, I’m just a participant in the hospital transplant program, and you’re a member of the hospital staff,” the man said with an injured look. “It shouldn’t bother you.” “Well it does,” said Alice. “And to tell the truth, it isn’t all that interesting.” Another patient who had been impotent for many years because of his failing heart almost proudly demonstrated an erection after his transplant.

  “Virility and courage,” said Dr. Kraft, the psychiatrist, “seem to be traits the patients associate with the new heart.”

  Some male patients, said Kraft, expressed concern about receiving hearts from female donors. One patient told his daughter, “Now I am a woman.” Another referred to his new heart, in conversations with Kraft, as his “lady,” answering questions about himself in the female gender.

  As the barber with anti-Semitic outbursts prepared to return to his home in a Southern state, he approached Alice in the corridor and, in the manner of the violin teacher in a famous perfume ad, bent her backward and kissed her on the mouth. “I’ve always wanted to do that,” he said. Alice was an unwilling student. She wrenched free and hit him hard in the chest with an Army-nurse punch. “Oh God,” she thought as she did it, “I hope I don’t knock his transplanted heart loose.” Months later she received a long-distance telephone call that the barber was rejecting and she hung up the telephone in despair. “Nobody in his town knows how to nurse a transplant,” she said. “Everybody is sick, the whole world is caving in on my patients.”

  Alice Nye knew she was violating a cardinal rule of nursing, but her life became deeply entwined with the patients and their families. Not content with working shifts that sometimes stretched to twelve and fourteen hours, seven days a week, she spent her time away from the hospital running errands for her transplants, finding apartments for their families, buying groceries and altering the bill so that she would receive but one-half reimbursement. Her shoulder was large enough for the wives to weep when they no longer could accept or understand what their husbands were going through. She told bawdy jokes, she played honky-tonk piano, she invited the celebrated new hearts to her home and stuffed them with boiled crabs and steak and beer. Alice was mother to them all. She was social worker, therapist, fun and games director, and—always—intense watcher; even when her eyes were merry and her face was wreathed in the boisterousness of a joke or a song, she was watching.

  The first storm clouds
appeared in early November, 1968. Everett Thomas, six months into his new and celebrated life, walked into St. Luke’s and told Don Rochelle, “I feel punk.” He could not button his trousers because his abdomen was sore. He did not know that his liver was enlarged, that his new heart was not supplying it with enough blood because it was battling to keep from being rejected. Both Rochelle and Nora were immediately worried, but they attempted to mask their alarm. “Everett Thomas was a man we had watched almost every day,” said Rochelle, “and when he came in and said, ‘I feel punk,’ it frightened us.”

  Two nights later car salesman Fierro was dining at the home of Alice Nye and her husband. Fierro had become a frequent and welcome guest. Alice’s husband, a grocery manager, remembers Fierro as “a man’s man, a fellow who enjoyed a good joke, a good drink, a bet now and then; he was a man who found his new life full and beautiful.” He was also a man who denied the symptoms of rejection that were assaulting his heart. On this night another guest in the Nye home was a former wrestler named Vigali, who owned the nearby Big Humphrey Pizza Parlor. Vigali and fellow Italian Fierro had become close friends.

  At dinner, Alice began to worry. Her patient was scratching his wrists and hands over and over again, something he had not done before. His eyes were puffed and sunken. It obviously pained him to walk across the room, but he denied any discomfort. He even snapped at his good friend, Vigali, for suggesting that he felt less than par.

  “Louie,” ordered Alice, trying to keep her voice good-natured, “you’re so damned grouchy tonight, lemme listen to your new heart.” Alice kept a stethoscope and blood-pressure cuff in her home. She felt her own heart leap as she listened to Fierro’s. It sounded labored; his pulse had a sharp, crackling tone, its rate approached 150. The blood pressure was dangerously low.

  “I tried to hide my horror,” remembered Alice. “I tried to get him to go to the hospital that very night. I made up every lie I could think of without alarming him. He said he was due to go in the next morning, anyway, first thing. I insisted that he get there early and be first so that the doctors would have more time and he wouldn’t have to wait.”

  Alice slept little that night. The next day, Fierro did not appear at the hospital until after lunch. He had vomited the entire morning, yet he had stayed home to watch himself on television selling cars. Because Thomas had been put in the sterile unit, and because there was another transplant being nursed in the second room, Fierro had to be put down the hall in regular floor care.

  Nora and Rochelle fought Fierro’s rejection for 48 hours without sleep. Alice had no nursing responsibility toward Fierro because he was not in her special unit anymore, but when her shift was over, she hovered outside his door. “I heard him calling for me,” she said. “I went into his room and he was begging for ice. They’re always thirsty toward the end.… Nobody was there at the moment and I opened his oxygen tent and reached into his ice bucket and I got a good handful of that soft, mushy ice, and I opened his mouth and stuffed it in and watched him work it down. I closed the tent and left the room. It was the last favor I ever did for Louie. I ran out of the hospital and by the time I was home, the phone was ringing, and Louie was dead.”

  For a month, the fight to save Thomas was waged. Instantly an intravenous drip was started, rushing to his system big doses of steroids and Immural. His blood pressure fell to 75 over 60, perilously narrow. His symptoms of rejection would become familiar. Only in rejection did the transplants follow a pattern:

  1. A rubbing sound over the heart caused by friction and fluid within the pericardial sac. This sometimes happens in open-heart surgery, but it usually goes away. With transplants, it did not.

  2. EKG changes: loss of voltage, changes in the T waves.

  3. Elevation in one enzyme of the heart muscle, the LDH I enzyme, indicating that the heart muscle was damaged and leaking the enzyme into the blood stream.

  4. Breathing difficulty.

  5. Liver enlargement.

  6. Malaise. As Thomas had said, “I feel punk.”

  When everything seemed to fail, when the immunologists could not beat back the rejection eating away at Thomas’s new heart, Cooley suddenly announced a bold decision. He would transplant Thomas again. He would give him another new heart. He presented the idea to the gravely ill accountant. His reaction? “Resignation,” remembered Nora. “He said, in effect, ‘I’ve gone this far with you fellows.’”

  Thomas became the first man in history to have had three hearts within his chest—the one he was born with, the one he borrowed from a child suicide and lived with for six months, and the one he died with. He rejected on Cooley’s table during his second heart transplant, and on the third postoperative day, died. Nora assumed he was sensitized to some antigens in the second transplanted heart that had not been discovered.

  A wave of uneasiness swept the world of the new hearts. Some of those waiting in the motel rooms packed and went away. Cooley had done eighteen transplants by November 30, 1968, but ten were dead and others were failing. The warmth of the summer had a cold breeze blowing against it. “There was supportive interaction among the transplants and the waiters,” said Nora. “But mainly it was the kind of relationship like one might have seen in the Warsaw ghetto during World War II.” Who would be next? was the question. And when he died, “Ah, but he was a bad match,” or “But he didn’t cooperate with the doctors,” or “But he had no will to live.” Nothing, however, was uttered with high enthusiasm. In addition to the scrapbooks of Blaiberg laughing and the headlines of joyful new life, the Houston transplants began keeping scorecards—who was transplanted, how long he lived, when he died, of what he died. Early in the program there had been jealousy among the transplants as to who could stay in Alice’s transplant suite with the wall-to-wall carpeting and plush furnishings. When a patient was moved down the hall to regular nursing care, often he complained of second-class status. Psychiatrist Kraft noted that when the rejection and death become common, “the transplant suite changed its symbolism from the womb-like core center getting its occupants prepared for a new birth of freedom to the place where you went when assaulted by rejection, perhaps not to emerge alive again.”

  One patient demanded that doctors and visitors put on three masks when they entered his room, so terrified was he of germs. Another transplant shared a room with a man whose heart was rejecting. When doctors and nurses surrounded his bed and began to work with only a beige curtain drawn about them, the first transplant paid little heed. Then he turned on his radio and attached an ear plug and heard with mounting alarm a news announcer broadcast that the man in the next bed was dying of rejection. Another patient heard of his own rejection from a television newscast.

  One transplant suffered the horror of having his face chewed away by herpes virus. His body resistance was so lowered by the immunosuppressive drugs that the disease ran rampant. Whenever he fell fitfully asleep, Alice would creep silently into his room and bathe the black scabs with peroxide and try to remove them. The patient had been a splendid-looking man but could no longer even bear to look at himself in the mirror. She worked the longest on his nose. By the time he died, Alice had done her work: there were no more black scabs, not even on his nose. In his last hours, as he lay in terminal failure, Alice urged him to keep trying, to fight for more life. “I’ll try one more day,” he gasped, “but then I’ll give up.” Fifteen minutes later he was dead.

  Toward the end of the transplant year, in the spring of 1969, Alice met a patient who would become, as she put it, “my Waterloo.”

  “We got along exceptionally well until the 49th postoperative day,” said Alice, “and then he turned against everybody, even me. He was varyingly euphoric, withdrawn—he refused to eat, or bathe, or walk or cooperate in the least. He became arrogant, haughty, mean, he shot me with silent stares.” None of Alice’s ploys worked. Her jokes fell flat, her cheerfulness turned sour and stale, her games were thrown against the wall.

  Other nurses became reluctant to
enter his room. Alice was the only one who attempted to deal with him. “I took the bull by the horns and by the tail,” she said. “I begged, cajoled, shouted, pleaded, I did everything but get down on my knees beside his bed and make the sign of the cross.”

  When nothing worked, when for the first time in her life she was totally unable to nurse a patient, Alice decided that perhaps he would improve with a new nurse. Emotionally torn, exhausted, ashamed, she resigned and left the transplant unit. Two days later the patient went into hysterics and had to be tied down. He accused the patient across the hall of forcing Alice out.

  For the first time in almost a year there were no longer those telephone calls in the middle of the night from a wife or a daughter, pleading with Alice to hurry back to the hospital because someone had taken a turn for the worse. Alice had always climbed from her bed and driven across town. But upon entering the room, she had seen so many times that her presence could help only the family.

  “Patients get a look in their eyes and you know they are lost,” she said. “I can’t describe it, but any nurse or doctor has seen it. The patients look at you, they focus on you, but they are looking beyond you, thousands of miles and millions of years.…”

  CHAPTER 13

  “I went into the transplant program with great hope,” said Jim Nora when it was all over, and when he could look back with passion that had more or less cooled. Nora is a well-made man with hunched shoulders bent from the depth and breadth of his practice. He rose from a lower-class section of Chicago to attend both Harvard and Yale, then to Houston, where he became a prominent pediatric cardiologist with a sideline specialty in genetics, as well as one of the few political liberals in a city whose medical community was overwhelmingly conservative. In the beginning he had shared Cooley’s enthusiasm for the new procedure and had zestfully managed the transplants against rejection. “What more noble purpose could there be in medicine than to return dying people to useful life?” he asked himself. But less than five months into the transplant year there began growing a pain within him that he could not deny. “Before we were through,” he said, “I was to feel that it was a small-scale crime against humanity. It became a grotesque joke, a game, a game we cannot ever play again.”