A Match to the Heart

by Gretel Ehrlich

  Pelicans nest on two of the four northern channel islands in large, noisy rookeries. From the two or three eggs in each nest, stark-naked hatchlings appear—homely, awkward, and helpless. A medieval legend contends that the male pelican often kills its young but if the mother sits on her dead hatchlings long enough and regurgitates the blood of her dead, the young birds will come to life again. Maybe that’s what Sam and I needed.

  On days when we did walk, the birds flew up ahead of us. Once almost extinct from DDT, pelicans flew in a chopped-off V, clipping the crests of waves with their wing tips, flapping in a slow progression, each bird taking the communal rhythm from the bird ahead. When fishing, they can drop from a great height, reaching speeds of sixty miles per hour, their wings folded back into an arrow; and when they hit the water, their long bills act as “cutwaters” to reduce the blow. After catching a fish, they bring it to the surface and swallow it whole.

  Sam’s vitality returned. His brush with death had engendered my own leap in strength. If I was dragging around, how could I expect him to recover? On our morning outings he greeted other beach walkers, whether they wanted to be greeted or not. He’d grown up on a ranch, where every human he saw was a friend; how could he have understood the idea of a world so populous that there could be such a thing as a stranger?

  One woman seemed delighted by his attentions. Smiling, she bent down to pet him: “I was just wondering what it would be like to see God when your dog ran up to me.”

  “He is a god, but spelled backwards,” I replied.

  chapter 18

  At the ranch I’d kept my vet kit in a waterproof bag lined in green plastic. In it were bottles of penicillin, Combiotic, vitamins, handfuls of 16-gauge needles and various-sized syringes, a turkey baster to irrigate wounds, salves, creams, mineral oil, pinkeye medicine, Hoof Alive for quarter cracks on horses, and an aspirator to pull out mucus from the lungs of breech calves. The level of medicine we practiced was crude, but, then, our animals weren’t sick very often and the survival rate was high, which I at tributed to fresh straw and Mozart in the sun sheds rather than to my veterinary prowess. The animals were talked to, touched, loved. Now I wanted to better understand what makes people—or animals—live or die, the intermix of physiology and psychology, and to chart the dynamics of the patient-healer relationship. I wanted to look under the skin and see how the heart worked, how all the systems of the body—nervous and circulatory—achieved their miraculous harmony.

  At 7:00 A.M. on a May morning I found myself in the Coronary Care Unit at Cottage Hospital—not as a patient this time, but an observer. I’d asked Blaine if I could go on rounds with him. I wore a white coat and carried a stethoscope. “Put on your roller skates,” he said as I followed him from room to room, floor to floor. “Are you doing a rotation with Dr. Braniff?” one of the nurses asked. “No, I’m an imposter.” “Oh, there’s probably a lot of those around here,” she said. Blaine scowled at her but he was laughing. We were “on the unit,” in the room where I had been a patient.

  When you are suddenly and acutely ill, you temporarily lose your self-image—no vision of the scenario in which you are involved. Everything is present tense: the gap is a place with no reference points—you float from one breath, one heartbeat to another. Looking at that patient hooked up to monitors, I couldn’t believe it had once been me.

  Blaine is an invasive cardiologist. He doesn’t perform heart surgery, but he does put in pacemakers, defibrillators, and works in the heart catheter lab, where he performs angiograms and angioplasties.

  “What my patients don’t realize is that cardiology, as we know it, has only been in existence since the 1960s,” he said as he pulled charts and went from room to room. We saw a woman with a pulmonary embolism, a man admitted with atrial fibrillation—a rapid heartbeat—another man with myocarditis—an inflammation of the heart sac—and a woman being prepped for an angiogram to determine if her chest pains were caused by coronary heart disease. With each patient he was gentle, gregarious, and full of humor—no deathbed solemnity for this man.

  “It wasn’t very long ago that we simply couldn’t save the lives of people with serious heart problems. Now there are a variety of diagnostic tools and procedures that have demystified the workings of the heart. EKGs give us a record of the electrical activity of the heart—we can see when someone is having a heart attack; echocardiograms are sonograms that show us the heart muscle and valves in action—we can see how well or poorly it is working. When someone comes in with anginal chest pain, I can study their arteries by doing an angiogram—a simple procedure that allows us to find blockages if there are any.”

  Artificial valves, pacemakers, defibrillators, heart transplants, and bypass surgery came into existence in the early to late sixties, and angioplasties, during which obstructed arteries are opened up, thus avoiding open-heart surgery, only came into use around 1980. “We’re still in the middle of a medical revolution and saving lives is routine around here,” Blaine said.

  But first things first. “First I have to discover what exactly is wrong with each patient. Medical students today don’t spend enough time on simple diagnostic skills. They rely too heavily on technology. But when you have a whole bunch of symptoms and a complicated medical history, you have to listen and look and use your hands.” In the nurses’ lounge he poured two cups of coffee. “I can tell a lot by just looking at a patient. If someone’s hair is coarse, it may indicate hypothyroidism; a diagonal crease in the earlobe means an increased risk of coronary artery disease; the angle of the fingernail and the skin around it may mean congenital heart or pulmonary disease. Palpating and taking pulses can tell a lot too.”

  The body is encoded. It is also an instrument inside of which the song of our lives is sung. As he hunched over an elderly patient and placed a stethoscope to the man’s chest, Blaine’s eyes closed in deep concentration, as if listening to music. “Now it’s your turn,” he said and held the stethoscope so I could hear. What he was teaching me was the language of the heart, the notes of its percussion, and what each heart sound signified. The closings of the tricuspid and mitral valves make the normal heart sound: soft thuds. But the heart can gallop: there is the S4 gallop, made when the left ventricle is stiff and incoming blood hits the wall hard; and the “lub de dub” sound of the S3 gallop made when the heart’s chambers have trouble ejecting blood.

  “Can you hear it?” he asked, moving the stethoscope. But the sounds were faint. “The quality of each sound is important and so is the timing,” he explained as we dove down a staircase to another floor, talking all the way. There are plucking clicks, high-pitched murmurs, or the soft blowing sound of a leaky valve. I heard the rubbing sound of an infected pericardial sac, and the harsh sound, “like water going through a kinked hose,” when the aortic valve is too tight.

  We visited a young woman who had had a heart attack while in Blaine’s office and he had rushed her to the hospital where surgery was performed. She was mending well, but when we entered the room she started yelling at him, “I want to get out of here.”

  “You’ve had a heart attack, and if you weren’t in here, you’d be dead. So take it easy for a few days, okay?” Blaine said.

  “I’m going home now,” she said. Blaine asked what was bothering her. “Nothing,” she snapped.

  In the hallway a lab technician delivered the woman’s toxicology report: cocaine. “It brings them in here more often than I’d like to think,” Blaine said. “Cocaine can cause a sudden and severe vascular constriction until there’s a complete blockage, and boom, that’s it. Sudden death, or if you’re lucky, you get to a hospital on time.”

  In the middle of rounds Blaine’s beeper went off. “They love having me on a leash,” he said, calling the heart catheter lab. His patient was being readied for her angioplasty. Earlier, an angiogram had been done to see inside the coronary arteries. A lesion was found. “Here are her pictures,” he said, pulling a long wrinkled scroll from his coat pocket. The arte
ry looked like link sausage where the obstruction pinched the vessel tight.

  “This is what a heart attack-in-the-making looks like. It’s her left anterior descending coronary artery. If there were a complete blockage, with no blood and oxygen getting through to the heart, the heart tissue would die in four hours. That’s why it’s so important to get to a hospital right away when you have chest pain. She still has a little blood getting through, and if we can get our balloon in there, she’ll be home in two days. Otherwise, she’ll have to go to surgery.”

  Blaine looked like Nehru in his starched cap, creased from front to back like a blade, and he wore a leaded vest belted over surgical blues. One of his partners joined him to assist. Even with a mask on, Blaine talked in a continual stream: consoling words to the patient, jokes with the nurses, explanations to me.

  “The groin has been anesthetized and we insert an introducer sheath up the femoral artery, then a guiding catheter to the opening of the left anterior descending artery. It doesn’t hurt.” Blaine grappled with what looked like a mile of thin wire fed to him by a nurse. Up it went. A fluoroscopic camera was positioned above the patient’s chest, and on the monitor I watched the progress.

  “Now I’m going to try to get the wire through the lesion. See it? There it goes.” I saw the narrowing inside the artery and the head of the wire poking through. “And over the wire, I introduce a tiny balloon. Now I’ll try to get it right into the center of the obstruction... and by inflating it there, the plaque in the artery will be flattened against the side of the vessel, opening the artery again. There it is.” To the nurses: “Okay, inflate.”

  A still picture was taken of the newly opened artery, which could be replayed on the monitor. Blaine asked to see it. “Looks like a good result.” He leaned close to the woman’s head. “It’s all over. You’re fine now.”

  Downstairs in the dictation room, Blaine recorded the findings from morning rounds as well as the results of the angioplasty. Dictations were rapid-fire, but during one of them, I heard him say: “Upon inspiration, no discomfort was experienced,” the word inspiration, reminding me that even in this secular culture our language still lets us know the ways in which flesh and spirit are interfused.

  An intake of breath is not just oxygen, a pulse is not just the rush of blood but also the taking in of divinity through an orifice, and as it moves through, it becomes a spark. To be inspired is to have accepted spirit in the lungs and heart, to watch it circulate through miles of blood vessels and capillaries whose tiny fenestrations allow oxygen, nutrients, and grace to leak into the tissues of muscle and consciousness, then be taken up again, reoxygenated, and returned.

  “You’ve seen a lot of technology this morning but not the spiritual part of medicine. That’s just as important,” Blaine said. It was only nine-thirty and he still had to finish rounds before seeing his office patients. We shared a cup of coffee on the run as he described his next patient: “She has diabetes, heart problems, and she’s in here with pneumonia. She’s got a high fever and she’s not responding to the antibiotics. We’ve tried everything, but her attitude isn’t very good. She’s had a hard life. I wish I could think of something to do for her... right now, her chances of surviving are about fifty-fifty and that’s not good.

  Blaine strode into the room calling her name: “Helen, it’s me.... How are you feeling?” She rolled her head from side to side, an oxygen cannula in her nose. Blaine pushed his hands under her shoulders and lifted her heavy torso. “Helen, open your eyes, it’s me, Blaine.” Her eyes opened as he hugged her. “I’m awfully worried about you. You’ve got to help me out. You’re not doing so well and we’ve got to get this temperature down together. Okay, Helen?”

  She finally looked at him but didn’t smile. “We’ve been through a hell of a lot together, and I know you’re a fighter....” Her head rolled to one side. A nurse came in and Blaine shot her a worried look. “Helen, keep trying and I’ll be back this afternoon. If you want something that you’re not getting just ask for it. You can have anything you want.” He gave her a kiss on the cheek. “See you later.”

  In the hall he confessed he didn’t think she would live. “We’ve tried every course of antibiotics there is and she keeps getting worse. There’s no excuse to die of pneumonia at her age. I feel as if we’re failing her somehow.”

  Halfway down the stairs, Blaine was beeped back up to the CCU. A patient of his, a man in his seventies, bright, articulate, but frightened, was on his way to radiology to have an arteriogram of his leg. The prognosis was bad: if his circulation didn’t improve, his foot would be amputated.

  The nurse lifted the blanket so Blaine could see: the foot was gray and cold, and on the verge of turning gangrenous. Blaine held the man’s foot in his hand, then told me to touch it. “I don’t want to have the damned foot cut off,” the man said. When I looked up, Blaine was stroking the man’s forehead. I had seen him touch the face of an older woman, but this was different—this was a rare glimpse of tenderness between two men.

  “Don’t worry, it might not be as bad as you think.... Just hang in there,” Blaine said softly. He held the foot again, looking into his patient’s eyes. “Come on, let’s get some blood down there,” he said to the man. “We’ve still got a day before you have to go to surgery.... Let’s see what we. can do.” At that glimmer of hope, the man snapped out of his misery for a moment.

  Blaine’s beeper went off. “They’re after me again,” he told the man, then disappeared.

  A half-hour passed. While in the ER, his beeper went off again. It was one of the CCU nurses: “Come up here, Dr. Braniff. I think your patient’s foot is getting warm.” We ran upstairs. The blankets were laid back, exposing both of his feet. Blaine touched one, then the other, then I touched them. The gray foot was turning pink. “You’ve done it,” Blaine said, then put his hand on the man’s shoulder and shook it joyfully. “It’s warm!”

  “Bring him a big breakfast,” he said to the nurses, then to the man: “I’m sending you home. You don’t need to be here anymore.”

  We had coffee in the cafeteria. “What are you, some kind of witch doctor?” I asked, laughing.

  “I didn’t do anything. It was pure serendipity,” Blaine said.

  “You were tender with him.”

  “He was scared. The blood’s not going to flow when you’re feeling that way...”

  “That’s the point, isn’t it? That’s the chemistry of healing.”

  Upstairs we stopped at the nurse’s station to look at Helen’s chart. “Helen!” he yelled from the hall. “Why didn’t you tell me it’s your birthday today!” When he gave her a hug, she smiled. He called the nurses in. “I want to order her a special dinner—Greek food. Whatever she wants and a glass of wine—you want red or white? Make it two glasses. I’ll come in and have one with you,” he said. “And a cake. Don’t count the candles—or do you want baklava? The sky’s the limit.” Helen laughed until tears came to her eyes.

  My thoughts about medicine were changing. How dynamic the human body is, the same dynamism as the ocean’s, all the systems—circulatory, nervous, immune, endocrine—so vigorously interactive with the workings of the mind. From cell to psyche, there is a whole intelligence at work.

  “Until recently,” Blaine said. “No one quite understood the connection between the immune and nervous systems, but there are direct links.” He explained that stress hormones from the adrenal gland can kill the brain cells that process short-term memory. “That’s why I spend so much time on what we call attitude, which, when you look at it, is really a complex, mind-body phenomenon. I don’t really believe in medical miracles. People should give themselves more credit for their healing abilities. A doctor participates in the process, that’s all. One of the best things a doctor can do is encourage a tough, fighting spirit and a sense of humor. Those people almost always do better than the others.”

  In the morning we visited Helen. She was sitting up in bed with her hair combed, color in
her face, drinking orange juice. Blaine looked at her chart: no temperature. “How are you feeling today?” he asked. “Fine,” she said flatly, wondering what the fuss was about because she had no memory of how sick she had been. “You look wonderful,” Blaine said, beaming.

  It was a week of minor miracles, even though he didn’t believe in them. His beeper went off. “Put on your roller skates,” he said, flashing a smile. “This is what I love about cardiology,” he said as he ran down three flights of stairs. “There’s never a dull moment. I mean, my god, I could never have been a dermatologist.”

  In the emergency room he saw an older woman who had come in with a severe arrhythmia and tachycardia—a fast heartbeat. He listened to her heart with his eyes closed, then put his hand on her left shoulder. The expression on her face suddenly changed. “Look at the monitor,” the nurse said. Blaine looked up. The woman’s heart had converted to a normal rhythm. “There, feel better? You can go home now,” he said.

  In the hallway I asked if he converted heart rates often. After all, I’d seen him do a cardioversion with a defibrillator earlier in the week. “It only happens once in a while,” he said. “It’s unpredictable. Patients just need to be touched, that’s all.”

  chapter 19

  Does fire put out water? The smell of fire woke me and the eaves of my cottage framed maundering banners of smoke. I had heard how midwestern rivers can combust into rivers of flame, how gaseous slicks that look like floating galaxies can explode. Sometimes I imagined water was made out of flame, that rapids and waterfalls were incandescent coals, and that when fire trucks came their hoses spewed out sparks. But this was no house fire. A city—Los Angeles—was burning.