Hearts

by Thomas Thompson

  But the months began to pass and across the way at neighboring St. Luke’s, Cooley began his program in May. And by mid-summer, 1968, when Cooley had become the man who had done more heart transplants than any surgeon in the world, DeBakey, somewhat uncharacteristically, had not yet moved. He seemed almost reluctant to enter the transplant business. He commented more and more about transplants being but a “way station” on the road to an artificial heart, the road he had been traveling for almost a decade. He called for more federal funds to support the artificial-heart research. “If we mobilized our resources like we do to launch artificial satellites,” he said, in the city where science had reached the moon, “say 4 or 5 billion dollars, then we would get the artificial heart much faster.” And in speeches and papers, DeBakey urged the need for exceptional caution and judgment from surgical teams before deciding to do heart-transplant surgery.

  DeBakey, in the March, 1968, issue of the Journal of Thoracic and Cardiovascular Surgery, wrote, “Since the physician can never afford to delay medical treatment until knowledge is complete and risk is entirely removed, he must apply current knowledge cautiously and judiciously, weighing the benefits against the hazards, in his efforts to relieve suffering and cure disease. Continued clinical trials [of transplants] are therefore necessary, but only after the most sober deliberation and most prudent consideration of all present evidence of their potential usefulness and limited scope. The indications for transplantation of the human heart at present must therefore be carefully delineated.

  “The competing risks must be thoroughly assessed: application of a procedure, results of which are not completely known, against withholding of a clinical trial that may save the patient’s life. Such assessment requires the sagest, most deliberate judgment, based on extensive clinical experience in the cardiovascular field and on the knowledge and skills acquired in the specialized cardiovascular research and transplantation centers of the world.”

  Despite DeBakey’s sensible and cool attitude toward transplants, his staff nonetheless chafed to get into the business. The vast medical and scientific resources of Baylor had begun making their own ALG—the immunosuppressive drug; they had arranged a liaison with Terasaki in Los Angeles for rapid tissue-typing. Moreover, the Fondren-Brown Cardiovascular Center, though not yet fully opened in 1968, had an elaborate area for transplant recovery and postoperative intensive care. Ted Diethrich, George Noon, and several of the residents began practicing transplants on dogs. By August, 1968, the DeBakey team was better prepared than Cooley and his staff were when they had begun transplantations three months earlier.

  “We were ready to go,” said Ted Diethrich. “In fact, we were raring to go.” But it went without saying that it would take a spectacular achievement to catch up to what Cooley was doing with such apparent success across the way. Unknown to DeBakey, Diethrich and his friend John Liddicoat, a surgical resident from Michigan, drew up in their spare time a complicated outline of organizational structure, a plan for an incredible operation or series of operations. It was their audacious idea that a multiple transplant could take place using various organs from the same donor. If conditions were suitable, a donor’s heart, lung, and both kidneys could be transplanted into four different people in four different operating rooms at the same time. It would entail breathtaking precision, teamwork, and the talents of almost one hundred medical personnel. But if it could be brought off, it would be an amazing feat.

  When the charts had been meticulously prepared, listing in minute detail everything from how many movie photographers were required for each of the four operating rooms down to weekend telephone numbers for standby nurses, Diethrich sent word quietly out through the hospitals of Houston and surrounding areas that he would like to be notified if a promising donor heart turned up.

  On the last day of August, 1968, Diethrich was driving down a Houston freeway when he received a squawk on his beeper, the radio paging system used by doctors. He answered the call and was told to get in touch with a nurse at St. Joseph’s Hospital. Diethrich was puzzled because St. Joseph’s was a hospital in downtown Houston not connected with the Texas Medical Center and a hospital at which he neither operated nor had connections. He turned off the freeway quickly and found a telephone. The nurse at St. Joseph’s spoke in a whisper. “We have a girl who has shot herself in the head,” she said sotto voce. “That’s all I know, but if you want to come down you can talk to her doctor.”

  Diethrich remembers he tried “not to sound excited” as he thanked the nurse and hung up. He telephoned Liddicoat and said, “This is it, I think we’re on countdown. Change clothes and meet me at Methodist right away.” The two young doctors slipped out of business clothes and into surgical greens with white lab coats—the uniform of office is far more eloquent and persuasive than a blazer and flannel slacks. Arriving at St. Joseph’s at 9 P.M., Diethrich found the doctor attending the gunshot victim. “She’s a kid about nineteen or twenty, Latin American I think,” said the doctor. “She shot herself in the brain. If we shut the respirator off, she’s gone.”

  “What about a heart transplant?” asked Diethrich.

  The doctor shook his head. “We’ve never had a donor here. I simply don’t know the procedure.”

  “First of all,” said Diethrich hurriedly. “She has to be pronounced neurologically dead.”

  “Well, we can do that right now. Just hook up the EEG.”

  “Second of all,” said Diethrich, “we need permission from the next of kin. Who is that?”

  “There’s a husband, I believe. She’d only been married a few months.”

  “Where is the husband?”

  “I have no idea.”

  A nurse hovering nearby interrupted cautiously. “The police came by and locked him up. He’s in jail.”

  “Why?” asked Diethrich.

  “Perhaps they don’t believe it was suicide.”

  “How much time do you have before the heart would be useless to you?” asked the doctor.

  “I don’t know for sure,” said Diethrich. “There’s already a slight decrease in blood pressure.” At that moment, Diethrich remembers, he almost cancelled the entire plan. There seemed to be a police-legal snarl—it might take wasted hours to unravel it. “But just as a chance that it might go,” said Diethrich, “I called the kidney and lung transplant team leaders at Methodist and told them to stand by.”

  That night in Methodist Hospital, four patients were waiting for organ transplants. One man with severe emphysema needed a lung, two others—one 50, one 22—wanted new kidneys. Bill Carroll, a factory worker from Scottsdale, Arizona, had come to Methodist for open-heart surgery, but tests had revealed that nothing could be done. Diethrich had suggested a transplant, offering him the services of neighboring St. Luke’s and Cooley, or, if he was willing to wait a few days or weeks, the untried capacities of the DeBakey team. Carroll agreed quickly to the transplant and said, “I’ll try my luck with you, Ted.”

  Diethrich drew a vial of blood from the girl who had shot herself—whom we will call Mrs. Gonzalez—and rushed it by messenger to the Baylor laboratories. There the typing and testing could begin while Diethrich sought to see if legally the heart could be used.

  Diethrich raced out of St. Joseph’s and drove at high speeds the two miles across downtown Houston to the central police station. In the homicide division, an officer was familiar with the case but said, “Doc, I just don’t know—or can’t tell what happened. We brought the kid in because he was hysterical. He saw his wife at St. Joe’s and collapsed. He hasn’t quieted down long enough for us to question him.”

  “Where is he?” asked Diethrich. “May I talk to him?”

  The policeman nodded. He took the young surgeon to a small questioning room, a barren place with cold walls, a table, two hard chairs, a coffee can for cigarette butts. The young husband, Raul Gonzalez, confused, sobbing, was brought in and left alone with Diethrich. “I’m Dr. Diethrich,” he said, “I’ve just come from the hospi
tal and your wife is doing very poorly. I don’t think she can possibly make it.” The youth began screaming; Diethrich cut through bluntly.

  “I want to know how it happened. It is very important to know exactly how it happened.”

  Suddenly Raul Gonzalez quieted. He cupped his head in his hands and began to talk. His marriage, he said, had been a stormy one and his wife had become despondent over financial problems. She had threatened suicide four months earlier. On this second night they had been driving down a road when she suddenly produced a gun, put it to her head, and shot herself.

  “Right there in the car, sitting beside you?” asked Diethrich, picturing the grisly scene.

  The youth nodded and began to cry again.

  Diethrich cut through once again. He asked his most important question. “Was it an accident? Or suicide? Or did you do it?” If it had been either of the first two, Diethrich felt he could use the girl’s heart. But if he suspected that a homicide had taken place, he could not. Already there had been the unpleasant incident over Cooley using the heart of Clarence (Sonny) Nicks. DeBakey and his staff had agreed with the medical examiner’s plea not to transplant hearts that might be involved in a murder trial.

  “It was suicide, Doctor,” said Gonzalez. “She shot herself.” His face, his words seemed so convincing that Diethrich believed him. A homicide lieutenant came in and talked privately with the youth. When he was done he spoke with Diethrich in an outer office. “I’ll go with suicide,” he said. “I’ll accept your medical judgment. I’m releasing him in your custody, but we’ll still want to talk to him a little more.”

  On the unsettling drive to St. Joseph’s, with Gonzalez sniffling in the back seat, Diethrich brought up the idea of a heart transplant. The youth seemed unable to comprehend what the young doctor was saying; Diethrich dropped it for the time being. In the hour he had been away, all of the girl’s relatives had flocked to the hospital and were crowded outside the emergency room where she was being attended. Diethrich tried to find the voice of authority in the family but none rose above the hysteria. The rosary beads were out in the purging rite of grief. Gonzalez demanded to see his wife, and Diethrich unwisely agreed. The moment the youth saw his wife on her medical bier, the breathing machine forcing her chest to rise and fall, the intravenous tubes sending the fluids of false-hope through her useless body, the monitoring machines clicking and chanting about her, he cried, in exultation, “But she’s alive! She breathes! Her chest is moving!” Diethrich took him by the arm and led him outside and for more than an hour tried to explain what “neurologically dead” meant, with the family flocked about answering in Spanish and English. The girl’s sister and sister-in-law emerged as the most intelligent, rational voices in the family unit and they seemed resigned to the difficult fact that the girl was alive only by the grace of the machines and once their force was shut off, then nothing would be left. They seemed flattered at Diethrich’s suggestion that their relative could perhaps give life to a stranger. They persuaded Raul Gonzalez to agree to transfer his wife to Methodist for “further evaluation.” Diethrich promised to have another EEG taken there. Gonzalez nodded; in one hour he had learned what brain waves are and how they govern the destiny of the earthly soul.

  Convinced that he could win permission from Gonzalez to take not only his wife’s heart but a lung and both kidneys as well, Diethrich once again telephoned Methodist and set the plan in action. Calls went out quickly for the four teams—more than 75 people—to report to the hospital in secrecy. In the hour and a half that it took to arrange for the girl’s transfer by ambulance from St. Joseph’s across town to Methodist, all four of the recipient patients had been prepped, photographed, given antibiotics and ALG, their blood typed. The hospital was swept up in the urgent exhilaration of the event when Ted arrived. A second EEG was taken of the girl’s brain by a neurologist not connected with the transplant team and the waves were flat. Diethrich showed the monitor to Gonzalez, who looked at it only briefly before he nodded. He agreed to the doctors using whatever part of his wife they felt necessary. “Her soul is with God,” one of the sisters had said earlier, and Gonzalez repeated it now over and over again.

  At 11:30 P.M. Diethrich called DeBakey at home and for the first time informed him of what was being prepared at Methodist. DeBakey asked the bare particulars of the case, then wanted to know what any surgeon would: Where would the blood come from in the middle of the night for four sudden major surgeries? “Everything is under control,” said Diethrich. “I’m going to the blood bank right now.” Between sixteen and twenty pints would have to be found. DeBakey was skeptical as to whether four surgeries could be done. He felt only the heart transplant should be attempted. He had not known of the elaborate battle plan that his junior man had drawn up in the study of his own home.

  There were last-minute problems; the hospital’s administration wanted a legal officer to check that the permission forms had been properly signed and that a neutral physician had pronounced the donor dead. The medical photography department had difficulty finding enough photographers to staff four operating chambers and the donor’s room. DeBakey arrived at 1 A.M. and was impressed enough by the fervor of his staff that he endorsed what was to be attempted.

  “We held our breath because DeBakey could have cancelled the whole thing at that point,” said one of the junior men. “He walked around to all of the rooms and saw how everybody was working together, how beautifully Ted and John’s battle plan was coming off, and he realized a series of four transplants would not only be history, but Something Else!” Moreover, six months had passed since DeBakey had written his plea for caution in heart transplantation, and much had been learned.

  At 1:45 A.M. the historic procedures began.

  The dead girl was placed in Room 5, Bill Carroll, who would receive the heart was in 4, the lung recipient in 2, the kidney recipients in 6 and 7. Diethrich opened Carroll and removed his diseased heart. He went across to Room 5 and performed a median sternotomy on the donor, removing her heart and saving a piece of pulmonary vein for the atrium and anastomosis (suturing) to Carroll’s lung. While Diethrich with DeBakey sewed in the girl’s heart, other surgeons went, in turn, to the cadaver in Room 5 and took what they needed—first the lung, then the kidneys. “It could not have gone more smoothly,” said Diethrich later. “If we had rehearsed the thing a thousand times, it could not have come off better.” One by one the patients were transferred across the elevated corridor that connects Methodist with Fondren-Brown and all were installed in the sterile transplant-recovery suite.

  One of the kidney recipients, the 50-year-old man, died of a heart attack one month later. The lung recipient died about the same time. But the young man who received the girl’s other kidney not only recovered but married the nurse who cared for him in Intensive Care. Bill Carroll defied what was known of the then infant art of heart transplantation.

  When the report came back from Terasaki in Los Angeles the day after Carroll received his heart, it revealed that he and the girl were a D-match, the poorest type on the scale. But he not only tolerated the heart, he regained almost robust health, returned to Phoenix and found an active job as a worker in a sheet-metal factory, resumed his passion for golf and told Diethrich proudly that his marriage was better than it ever had been. He was alive, spectacularly alive more than two and a half years postoperatively when this book was completed. He personified everything the operation should be and do, but so rarely was and did.

  The transplanters received one tantalizing clue from studying Carroll’s case. All people are either hyper-reactors, meaning their bodies react strongly to something, or, conversely, they are hypo-reactors. Carroll was a hypo-reactor. When foreign protein is injected into a hypo-reactor, his body pays less attention to it. In a highly sophisticated test, white cells are taken from the blood, grown in a culture dish, and challenged with foreign protein. Either they react or do not react. “Perhaps we should transplant only the hypo-reactors,” mused Ted
as he elatedly studied Carroll’s progress.

  Five days after the multiple transplant procedures, the “DeBakey team,” as it would become known in the press, performed their second heart transplant. Their success was considerably less; the patient died on the eighth day.

  Their third was the most remarkable of all. Duson Vlaco, a sixteen-year-old Yugoslavian boy, had been in Methodist for two weeks while the cardiologists studied him. Shockingly thin, the boy had a grotesque collection of congenital heart defects. He was born with an AV commune, meaning that he had a common atrium and ventricle; only one chamber in effect, rather than the four of the normal heart. Blood sloshed back and forth within the deformed pump fighting to get in and out. The tricuspid and mitral valves were malformed. He had arms and legs like toothpicks and he weighed, upon arrival, less than sixty pounds. It was an act of enormous pain merely to gaze upon the boy, much less probe his pitiful body for the possibility of surgical relief. “He was the sickest human being I had ever laid eyes on,” said Diethrich.

  On the evening of September 15, 1968, Duson lay in his hospital bed half-propped up because his lungs were so filled with edema that fluid bubbled up and spilled from his lips. Had he been flat on his back he would have drowned in his own juices. The decision already had been made that there was nothing to be done surgically. The heart doctors were trying to deplete the fluid so Duson could fly back to Yugoslavia and die on his native soil. At 11 P.M. Diethrich was called to the boy’s room because he seemed to be in terminal failure. The look of death was in his eyes, his mother sat helplessly beside her only child. Neither she nor the boy spoke English and they depended upon a Yugoslavian cardiologist who had accompanied them to translate. Mrs. Vlaco stood up in despair when Diethrich entered the room. He made a brief examination of the boy and took her to a corner where he talked quietly. “I don’t think he will last until morning,” he said. The translator hesitated, then repeated. Mrs. Vlaco threw her hand to her face at the condemning sentence. There was, Diethrich said, a patient who had been brought a few hours earlier to neurological intensive care. He had suffered pancreatis and cardiac arrest but had been resuscitated. His brain was dead. His family had agreed to donating his heart to anyone who needed one.