“Any physician who lets himself become emotionally involved with the patients disables himself. This applies more particularly to the surgeon. In OB-GYN there are rarely deaths … in dermatology, no deaths.… The GP has an occasional death but they’re usually old, worn-out people who are ready to die anyway. The only weapon we have against death is the ability to convince ourselves that we’ve done the best possible surgery.
“People must die! It’s no good to speculate that somebody else might have done a better job, that somebody else might have cut this or that differently.… But unless you do the surgery, how then are you going to become good?”
I interrupted. “Then what you’re saying is that patients must be.…”
Now Hallman cut in. “Sacrificed.”
He said the word softly.
I fumbled. I was, in truth, stunned. “I was going to suggest an easier word,” I said, “like ‘pioneers.’”
“Sacrificed is a better word. Some patients must be sacrificed to the God of Experience. Excellence comes out of experience and nothing else. A doctor can reach the supreme pinnacle of technique, but only after he has done many, many cases and perhaps participated in many, many deaths. If every patient in the world got the best possible surgery, then there would be no resident program and, consequently, no new surgeons. Some surgery simply must be done by those who are less than perfectly qualified.”
I looked down, away, not for a waiter, not to watch the people in the club going about the business of drinking and talking and living, but to hide. I wanted no more truth. Hallman pulled me back. He was not done. He needed to get it all out. “It’s true!” he said. He waited until I nodded. Of course it was true. But truth is not necessarily a defense.
“A surgeon who is the best,” he went on, “is a surgeon who has gained the most experience.” He reached into his memory and found a part he had long since shut away. “And some of the first few people that surgeon operated on are dead. This is blunt talk, but every surgeon would say the same thing.… I know a lot of people who are dead today because I operated on them early in my career. If I could do them tomorrow, they’d be alive.…”
We talked for another restless hour. I don’t remember what we talked about.
I was a father with a son whose heart made an alarming sound and I was a man with access to the great heart surgeons of the world. There were so many judges to stand the boy in front of. I weighed them all in my mind—the exasperating, ruthless genius of DeBakey, the cold beauty of Cooley, the energy, the strength of tested youth that was Diethrich, the chilling honesty of Hallman. Bricker slept beside his patients. But only Nora had wept. I had seen him try to understand why children are defective and die, I had seen him unable to control the pain of having to deliver the ultimate message. I had heard his sorrow of the transplant year. I was not a liberal seeking comfort in another liberal, nor did I equate tears with ability. But tears as I knew them in Houston were strength, tears could mean compassion. I wanted a doctor to lean on. Nora, the pediatric cardiologist, was not even a surgeon—but in the land of kings, I asked a commoner for his favor.
I made the boys dress up and sent them back to comb their hair. Permission had been obtained from Mrs. Sylvester, the operating room supervisor, for them to stand in the gallery and watch Cooley operate. That was the lure. I had expected them to watch with interest for a few moments and then be repelled by the wound. But they stood entranced for half an hour asking questions about anatomy and mechanics and movement, which, after my months in the chambers, I could answer. “Is that his heart?” Scott asked, pointing to the throbbing object encircled by the hands of Cooley and his men. I nodded. “How much will he hurt?” the child asked. Not a great deal, I hoped. I looked at my watch. It was time.
“Come on, Scott, as long as we’re here, I’d like for this doctor to listen to your heart.” I was pulling him from the gallery. He didn’t want to leave.
“Not again,” the little boy said fretfully. His heart had been heard in Paris and an EKG had been taken. The machine with its wires and attachments had frightened him, but there had been no pain. “Très curieux,” the cardiologist had murmured.
“He’s just going to listen. I promise.”
“Can I come back and watch Dr. Cooley some more?”
“Yes. If the nurses will let us. It depends on the case.”
“Can’t we do it another time?” He was stalling.
“No.” Firmly. Parental. “We’re here. Let’s get it over with. It’s all arranged. It’ll only take a minute. He’s a very nice doctor.”
We walked down the stairs. Scott was squeezing my hand. It was a game we had always played. He would grip me as hard as he could and I would feign at last that he was hurting me. “If I’m going to be a surgeon,” he said, relaxing his pressure, “I’ll have to start taking care of my hands.”
“I thought you were going to be a baseball player for the Mets.”
“But I’ve changed my mind. I want to operate on people.”
Nora was holding clinic. There were parents and their children stacked up outside his office. A baby was yelling in her mother’s arms. There was a strangeness, a cast to the infant’s face that alarmed her parents. Nora would run a genetics test to see if the baby had mongolism. They had learned of the possibility and their expressions showed that their jeopardy was perhaps graver than mine.
He worked us in ahead of the others. He accepted the tough handshake from my son and winced as if he knew how to play the game. He was good with children. He knelt down and looked the boy directly in the eye. It impressed me that he did not bend over. “Can you take your shirt and tie off for me, Scott?” My son looked at me with suspicion. It was going to take more than a minute.
Nora placed the stethoscope on the smooth, unblemished young chest and listened. “Okay,” he said, with no commitment. Neither yes nor no. What was he hearing? My thoughts flew to the boy’s mother. Her sister had been born with a heart defect, which Cooley had repaired in his first years of open-heart surgery. Surely her side of the family had passed down the abnormal seed, if there was to be one. I needed someone to blame.
Nora moved the stethoscope up and down and instructed Scott to hold his breath. I heard the baby crying outside. I was annoyed. There must be silence for the doctor to hear. Slowly he took the instrument away and let it drop to his chest; it hung there against his white coat and a thousand years crept by before he raised his head and spoke.
“It’s Still’s murmur. A false murmur. It is a vibration of the pulmonary valve. Here, listen for yourself.”
Nora handed me the stethoscope and placed its disk against Scott’s heart. The beat was firm, but in its aftermath, a quick hiss, a spurt of steam from a radiator.
“Put your shirt on, Scott. It’s all finished.” Nora seemed happy to gently slap the naked back of a whole child. I gave Scott a quarter and he went with his brother Kirk to find the Coke machine.
“There’s nothing to worry about. The vibration will be gone away by the time he’s thirteen or fourteen.”
“Then there’s no need to even think about surgery … ever?”
Nora shook his head.
“But what about those other doctors? He’s been listened to in New York and Paris.…”
“Don’t blame them. We get a lot of business out of Still’s murmur. The state of the art is such that they just don’t recognize some of the things we’ve heard a thousand times.”
Nora walked me out. “I assure you it’s nothing.”
“Nothing?”
Nora was smiling. His face lit up the room and all of my world.
Scott watched surgery for the rest of the morning. He was fascinated, entranced as I had never seen him, by the grace and strangeness of Cooley’s operating room. “Dr. Cooley works very hard,” he said.
“He works all the time. Being a surgeon is more than you think.”
“What did my heart sound like, Dad?”
“Like a bass drum.” I
put my hand to my chest. “Boom! Boom! Boom!”
My son laughed; we left the hospital and went swimming. Scott stood on my shoulders and dived into the water, he prowled the bottom and attacked my legs, he pestered his brother, he squandered every moment of the day because he was rich, blessedly rich with time, newly endowed by the heart doctors.
CHAPTER 17
Bergoni, the Italian police clerk, watched his wife brew espresso in a tiny pot she had found in a hardware shop near the hospital. She had pronounced Houston hospital coffee to be not only inferior in taste but potentially damaging to her husband’s liver. “It might give him a setback,” she announced to one of the staff who spoke Italian. All day long she prepared the thick, heavy coffee of Italy, poured it into thimble cups, dumped in three spoons of sugar, and gaily served it to the doctors and nurses who attended her Nino. She was annoyed they would not let Nino sip a bit of vino blanco.
Few operative results had so delighted the hospital. Maria was radiant, as strength was rushing into Nino’s wasted body. He seemed an old man when he had been carried vomiting into St. Luke’s ten days before. Now his eyes sparkled and there was color pushing away the grayness. The only thing that worried the staff was Maria’s unhidden rekindling of romantic desire. There was a day bed in the room and Maria was permitted to sleep nights on it, but one of the residents had to caution her, tactfully, about invading Nino’s bed for the immediate future. “It’s been two years since they had a married life,” said the doctor. “She’s probably forgotten what it’s like.”
Early in July, a reporter from Johannesburg, on an American tour to write about transplants and heart surgery, interviewed Cooley.
“June was the busiest month in our history,” Cooley said. “We did 115 open-heart operations, our all-time record.”
On another day, another reporter wanted to know why Norman Shumway at Stanford was continuing to do heart transplants, in light of the generally discouraging world results.
“Maybe he doesn’t believe in coronary surgery,” was Cooley’s reply.
The surgical fellows were all talking of how enthusiastic the chief had become over the grueling coronary-artery bypass operation. Only last April, they insisted, Cooley had thoroughly disliked it. Now Cooley was saying things like, “This operation is second only to sexual intercourse.” On some days there were as many as four scheduled on the green blackboard.
“He’s committed to it now,” said Dennis Cokkinos, the Greek cardiologist. “And once he’s committed to something, watch out. He’ll bomb all those other guys and their statistics.”
Cooley had done seven in three days and the seven men in their forties and fifties all seemed to be making excellent recoveries. “People are saying that you have become enamored of this operation,” I ventured, “that you’ll soon be doing more than anybody else in the world.”
He laughed. “Well, there’s a possibility, I guess, that I will. It’s true that others have identified with this procedure before we have. We did, however, an ancestor to this operation in 1964, some of the initial work on kids who had congenital anomalies. Lately we haven’t been considered very bold and aggressive with coronary surgery. It took a while before we were able to impress ourselves with the efficacy of the procedure. I think this is important. I won’t take someone else’s word for it, because the same individuals who are promoting this operation have promoted others in the past which proved to be relatively worthless.”
A few days later he expanded on the subject in a speech given to about forty doctors from Texas and Louisiana:
“I believe there is no other area of surgery that has enjoyed more fads than coronary surgery. In the past twenty years there have been operations which had largely psychological effects and which were very lucrative to the surgeons who did them. This led to the charge of charlatanism.
“This new operation, the coronary bypass, is the most tedious, most meticulous operation known to the surgeon. We must sew in a field no bigger than two millimeters across, sometimes only one. I believe we must have a quiet bloodless field. Therefore I clamp the aorta.
“This operation seems to bring relief. It is not a psychological effect, but a true physiological effect.”
But it would take the judgment of years before the surgeon could win all cardiologists over to his point of view. One, a prominent internist who practiced in downtown Houston and who had little to do with the heart hospitals of the Texas Medical Center, could barely conceal his fury. “I’ve had patients who simply do not need surgery, who defy my will, and who go directly to these ‘great’ heart surgeons. They suggest my diagnosis is based on jealousy. We’re not allowed our opinions anymore!” He was speaking to a visitor and his voice must have thundered through the closed door into the outer office and waiting room.
“With each new procedure, each new one supposedly better than the last, the surgeon rushes in and cries that it is the greatest, the newest, the most hopeful procedure, and he decries the one before it. We’ve seen this so often, we’ve been burned so often that we’ve become dubious of the surgeons waving the flag and beating the drum.
“But imagine the potential here! Every man in America over the age of 45 has some coronary artery narrowing, but many of them are asymptomatic, that is, they have no pain and can function normally and productively. I’ll tell you one thing, we’d better watch the surgeons because sooner or later they’re going to suggest that everybody, and I mean everybody, must have this spectacular operation to prevent having a heart attack. They’re going to recommend that everybody have an arteriogram as part of the annual checkup, and an occlusion will show up on an arteriogram, and WHAM! Onto the table.”
The cardiologist was out of breath and lit a cigarette. He insisted that he did not inhale. “We think surgeons lie like hell about their statistics,” he said. “The best results usually come from those who want to get their names in the papers. They’re even touting something new called an infarctectomy in which they take a near dead man immediately after his heart attack—the fellow is in shock—and rush him into the OR and cut out the dead part of his heart and bring the other parts together and stitch it up. The patient survives the operation, sure, but he dies twelve hours later in Recovery of ‘cardiac arrest.’ That’s crap! The patient dies, that’s all! Use of the term ‘cardiac arrest’ is actually a camouflage to cover the fact that the patient died from what the surgeon did to him.”
Two interesting and poignant pediatric cases arrived at Texas Children’s within days of one another. First came a three-month-old baby in a coma brought in by his mother. While the pediatric cardiologists began drawing blood and ordering all manner of tests, someone suspected an overdose of something and asked the lady if she had given the child any medicine. She had indeed—twelve aspirins that very morning. The baby had a bad cold and she decided to storm it. She had great faith in the value of aspirins and regularly lined her brood up each morning and gave them one aspirin each. “Well, your baby’s dead,” said one of the pediatricians, who was so upset by the woman’s stupidity that he could barely speak to her. It was the third death from acute aspirin poisoning that the hospital had seen in three months.
Next arrived Eric, a frisky black baby of eighteen months who got into his own trouble. Born with a ventricular septal defect in his heart, he was being watched until he grew large enough for open-heart surgery. He was also taking one digitalis tablet a day to slow down his fast heart and strengthen it. One morning he climbed up on his mother’s dressing table, discovered the bottle of digitalis tablets among her cosmetics, and chewed up sixteen—more than half a month’s dosage. The overdose slowed down his heart to the point where it was barely beating when the mother finally brought him in, empty bottle in hand. While one doctor put the comatose little boy on dilantin to stabilize his membranes (the same drug used in epilepsy,) potassium, and intravenous fluids to step up his urination, another went outside to the waiting room and scolded the mother. Later he was talking of the case and
said that massive dosages of digitalis used to be a classic—and perfect—way of committing murder. “The victim’s heart would stop, it would appear to be a heart attack, and there was no way to measure digitalis in the blood stream. But the lab boys have discovered new methods to foil Agatha Christie.”
The danger was that Eric would go into heart block or arrhythmias. After a few days of intense observation, his heart picked up from a dangerous low rate of 60 to 100 and he was pronounced out of danger. Upstairs he delighted all the floor nurses by popping balloons in his bed and by making furious faces at everyone who passed by his door. There was one good side effect. His liver, which had been oversized from the bad heart, shrank from all the digitalis, and his lungs cleared up.
I followed but two more patients through Cooley’s surgery and each became pieces fitted to the puzzle he remained to me. But once they fell into place, the picture was incomplete.
One was a 47-year-old college dean, the other a six-year-old girl. They came from separate cities to enter the hospital within hours of one another and they had their operations a day or two apart. I grew to respect the courage and wisdom of the man, I fell irrevocably in love with the beauty and good nature of the child. I followed one down the mountain and watched death, I ran with the second up the other side to the summit and claimed life. I think I even saw Cooley break toward the end when he paused, then hurried past the room of the one who was dying. But it was but a dropped, perhaps forgotten, moment.
Nobody on Cooley’s staff was glad to see Clement Fisher return, not because he was an unpleasant man—he was, in fact, a cheerful and tolerant patient—but because he appeared at St. Luke’s in late summer needing a fourth replacement of the same mitral valve. The other three that Cooley had sewn into his heart over the space of nine months had, for one reason or another, grown defective. That he required his fourth open-heart operation in such a short period of time was discouraging to all concerned.
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