The Source of All Things

by Reinhard Friedl

  I saw Mary in front of me. She flew down from the sky, her hair billowing, her red, fleshy heart in front of her chest. Today I am astonished that such a sexual depiction would grace a place of pilgrimage. Religion, too, holds many secrets.

  * * *

  Death by hanging occupied my thoughts quite a bit when I was a boy. At Grandma’s I was allowed to watch Westerns, and somehow the rope featured in many of them. In almost every Western, someone was hanged from a tree, often the only one on the prairie. But they were always saved at the last moment. I knew who was behind that, even though she sent her messengers in the shape of Indians.

  On butchering day, I looked forward to the heart, which was what I most liked to eat. It came fresh out of the large, bubbling pot and was cut up; everyone standing close by snatched a piece.

  One day, my mother gave me a book about Our Lady of Marienfried, a place of prayer in Pfaffenhofen. There she was again, the Virgin Mary, this time appearing to a pious, desperate girl. Was everyone in danger of being haunted by Mary? I did not want to experience an apparition of Mary. I did not want to be offered a red, fleshy heart. If any situation became dangerous in this regard, I would squint my eyes firmly—I was mortally afraid of seeing Mary approach me with her bleeding heart. At Claretinerkolleg, where I went to school, the Madonna was also depicted with an exposed heart, pierced by a few arrows. Sometimes she only had a red spot on her chest; I preferred that. The community of Claretian monks call themselves “Sons of the Immaculate Heart of the Blessed Virgin Mary.” Bare-breasted, bare-hearted, merciful. Claret, the order’s founder, was a missionary in Cuba. Five hundred years ago Spanish conquerors had brutally massacred the Aztecs of Central America. They, too, had strange customs: they cut out the hearts of live human victims and held them up, still beating, to their sun god. The Aztecs possessed astonishing surgical abilities, as it is by no means easy to cut out a heart so quickly that it is still beating after the violent act. You definitely can’t go through the lengthy procedure of opening the chest. Instead, the Aztecs would cut the skin and muscles at the bottom edge of the left ribcage and grab the heart from below. It has to be done swiftly. Then the heart can indeed beat for a short while without a brain or a body. It is autonomous; I have known this since my childhood.

  * * *

  My grandma lived on a farm. Her hens ranged freely. In the evenings, we kids were allowed to look for eggs. I often found some in the barn behind the diesel barrels for Grandpa’s tractor. We also loved to chase the hens, but we never caught one. Grandma did, though. She snatched her victim, put it on the chopping block, and severed the head with an axe. Once she held the hen by the head instead of the body and watched, its head in her hand, as the hen ran away. It made it to the vegetable garden. I was thoroughly impressed, and for a long time thought of this hen whenever the word “headless” was used. You don’t get far without a head. Nor without a heart.

  Heart hierarchy

  The headless chicken died and was eaten on Sunday. That was completely normal to me. I was not afraid of it—in contrast to my fear of apparitions of Mary. The heart’s true nature, and why the hen had been able to run without a head—that was what interested me. I don’t believe that as a child I ever wanted to help Mary or other Madonnas with a heart operation, or to close their open chests. I studied medicine and in my doctoral thesis wrote about multimedia simulations of heart cases; this was subsequently published as one of the first multimedia CDs. The connection between technology and medicine really fascinated me; the first computers came on the market when I was a student—my Atari and I were bosom buddies. But after some time at the German Heart Center in Berlin I realized I would not be happy as a cardiologist, even though the work would involve a lot of technology and computer simulations. I wanted to get to the real, true heart. After a stint in Munich as a general physician, I eventually reached my goal: I was appointed as an assistant doctor in the field of heart surgery.

  At various points in my career I focused on my key competence, surgery, and improved at it—which I noticed as my operations became more complex. The difficult cases, too, those which are risky from the outset, were now entrusted to me: emergencies, patients advanced in age, those who’d had a stroke or those whose pumping function was generally bad.

  * * *

  For decades I saw the heart exclusively as a pump; most heart surgeons probably do. Sure, there was a patient attached to the pump, but in the operating room I saw only the orange square of the sanitized chest, surrounded by sterile cloth. Man or woman? It didn’t matter. The main thing was to repair the pump. As one of my colleagues used to say: I am a heart surgeon because I prefer patients under anesthetic.

  I agreed with him because in that way I was best able to concentrate on the work. The “rest” could be dealt with by psychologists and other doctors.

  I know a pathologist who put it even more chillingly: “I prefer cold patients to warm ones.” For a patient not to end up on the autopsy table, a heart surgeon has to learn to remain cool even in precarious situations.

  Double heart surgeon

  I found conversations with relatives after very difficult operations unpleasant. What could I say? The patient was alive after all. The next few days would show if he or she would survive. It is possible, with today’s highly technical medicine, to wheel nearly every patient out of the operating room alive—if necessary, connected to a heart-lung machine that provides something called ECMO, or extracorporeal membrane oxygenation. Some hearts just need time and recover in the next few days, but many patients die in intensive care. Every patient is assessed to determine their risk group. A surgeon who “produces” a disproportionate number of fatalities—which will become evident via the national quality assurance statistics—will quickly be withdrawn from the operating room. Thus, statistics breathe down your neck—and that’s a good thing.

  You can also get a pain in the neck when operating, by the way. Most people have no idea how physically demanding it is to be a surgeon. You stand leaning slightly forward at the operating table, sometimes for seven or eight hours at a time. Without eating, drinking, or going to the bathroom—you can’t simply let a patient lie with an open chest, connected to the heart-lung machine, while going to the canteen to order a beetroot smoothie. You learn to defer your needs, and become conditioned to this after a time. In the operating room, there is a supply of liquids and blood only for the patient.

  * * *

  But it is worth it. Heart operations have helped millions of people. Most of them recover and can enjoy life again. Yet despite these marvelous results, heart surgery is a challenging profession—consider bullying, humiliation, stress, high responsibility, overtime, complaints, teasing, unpleasant bosses, lots of bureaucracy, the need to prove one’s worth, and, oh yes, patients and relatives. For years I preferred conversations with patients to those with their relatives. Both groups want to know the truth. But relatives still hope for miracles, while patients sometimes instinctively know how things stand with them. In the end, everyone is grateful for the truth.

  I never found it hard to calmly and clearly discourage a patient from having an operation. But since I have recovered my lost heart, since I am no longer merely a heart surgeon but a double heart surgeon, so to speak, a lot has changed for me during such conversations, even though their content has remained the same. I do not sugarcoat anything: “You don’t stand a chance. You will remain in intensive care for a long time, and you won’t be well. It is more than unlikely that you will ever be able to return home again, and if you did you would need assistance around the clock. If you were my father or my grandmother, I would not advise you to have this operation. I would tell you to spend time with your loved ones and to make any important arrangements you still deem necessary.”

  * * *

  Such conversations are exhausting, and intense. In them, too, I touch my patients’ hearts. I do not need to open a chest to do so, nor do I need any instruments. But I myself must open up a littl
e as a human being, unlike during an operation. I was lucky to have a few role models who encouraged me to speak the truth. There are many factors involved. If a patient is high-risk but desperately wants to explore their slim chance, one can proceed with the operation—but it requires a frank talk beforehand. I can remember cases where a so-called high-risk patient who was fierce and motivated survived the first thirty days. This is an important milestone in heart surgery. After that time the first big hurdle has been overcome. However, it often still takes a year or more before a heart operation has been fully “absorbed,” physically and psychologically.

  The wise heart

  One day a patient gave me a book. I often received little gifts from my patients: flowers, a bottle of wine, or books—usually ones to do with gratitude or the heart. This one I remember particularly clearly. It was The Wise Heart, by American psychologist and spiritual teacher Jack Kornfield, who is famous for promoting Buddhism in the West. Normally I do not read such books. But I browsed this one a little—and became engrossed. What strange, fascinating, intriguing thoughts! They all revolved around the heart, which in these pages did not bleed or need oxygen or require connection to a heart-lung machine—no, it was wise. As if it were more than a pump. As if it were the source of qualities such as love and compassion—heart qualities, so to speak. These had so far been limited in my mind to data such as pumping function and blood pressure.

  The book awakened something in me. Wanting to know more, I registered for a meditation workshop. There were about a dozen of us, more women than men, sitting on the floor in a light-filled room. It smelled of incense and we drank tea. Just like at my workplace, lots was said about the heart—yet in a way I had not experienced before. I had no idea which field these specialists belonged to.

  The leader of the group asked us to open our hearts.

  I thought: Without anesthetic?

  We were asked to breathe into our hearts.

  Without a lens tube?

  We were asked to feel our hearts.

  Feel? The heart? Meaning mine? I made an effort and realized that I was hungry. What else was I meant to feel?

  The others in the circle seemed to feel a lot, judging from their faces; they looked as if they had been intravenously given a milliliter of diazepam. I, on the other hand, was sober. And hungry, as I sensed in my upper abdomen. But also curious—because even though we all used the same language, I had no idea what they meant. Yet I was a heart surgeon. It was me who was the specialist here. Thousands of hearts had been in my hands.

  At the end everyone was asked to say what they felt.

  “I am deeply moved right now,” I heard. And: “I feel very connected.” Or: “I am in touch with a great sorrow, in touch with the child I abandoned.”

  Well, I was also in touch. With lunatics, I thought. I treated the case as incurable and told the truth when my turn came: “I’m hungry.”

  “That’s a good sign,” the leader replied, without any trace of anger but instead with warmth in her eyes.

  And in that moment I realized: I was hungry for the truth that lies in the pump. That was what had been bothering me for months. That’s what life is often like, after all—changes don’t occur out of the blue but announce themselves long before you can put them into words. And suddenly you know. Because you feel it. Because the heart makes itself known.

  ONE HEART AFTER ANOTHER

  Sometimes it starts with a visit to the dentist. Or with the flu. Germs like to take up residence in the heart valves, and this frequently leads to serious heart inflammation. It may destroy a valve completely, which in turn makes an operation necessary. Heart valve inflammation can also have other causes. A young man had had his nipples pierced and they had become inflamed. Bacteria traveled into his bloodstream and attacked a heart valve. Now he had been admitted to intensive care.

  * * *

  I already had two complicated operations behind me that day. One artificial heart, one bypass. Routine matters, normally, and the bypass patient was going extremely well. But the implant patient was suffering from bad bleeding after the op. That was not unusual; heart operations are among the bloodiest procedures, because in order to perform them you need to stop the blood from clotting (otherwise it would clot in the heart-lung machine). However, most blood is not lost but caught, cleaned, and infused back into the patient.

  * * *

  In the late afternoon—I had just sat down for the first time that day to have a bite to eat—the intensive care unit paged me. The artificial heart patient was still bleeding. My colleagues were unsure if it was due to a clotting problem or a surgical issue. If it was the latter, I would have to operate again. Disrupted clotting can be tackled with a unit of stored blood or an anticoagulant. At the same time an assistant doctor called to tell me the relatives of the patient with the implanted heart were waiting for me, distraught. There were five of them, and the patient’s very pregnant wife was at the end of her tether. She wanted to know how the operation had gone.

  At that moment I could only tell her that the pump was running, that her husband had bled a lot and that we would have to see how things developed. I would have liked to avoid the conversation, but it was part of my job. On my way to meet with the relatives I received another call from intensive care. The patient with the piercing who had heart valve inflammation had rapidly deteriorated. It was feared he would not survive the weekend. I decided to look after him first.

  “The nipple piercer is on five.” A nurse showed me the way. What may sound humorous was far from being funny. The patient was in a really bad condition; he was suffering from sepsis and an operation was both unavoidable and very dangerous. We had to act quickly.

  * * *

  Have I mentioned it was a Friday? It is fairly common for critical patients to be transferred to heart surgery on Friday afternoons because colleagues from other departments fear they will not survive the weekend. Sometimes these colleagues will say: “Otherwise he might fall off the perch.” While I don’t know where this expression comes from, I never want to be the one to blame if that happens. As a heart surgeon I have seen enough dead people, and maybe we develop rather strange ways of talking as we come to terms with such things—humor helps. Somehow. Or cynicism. We line up to save lives, and we fight for every patient until the end, even though we do not know them, perhaps have not even spoken with them before the operation. This patient, however, I would now get to know personally—and I have never forgotten him.

  The nipple piercer

  Despite his weak condition, the piercer looked like a surfer. Long blond hair, very white teeth, a smile that would have delighted all the female nurses and some of the male ones—if he had been healthy. But now all color had receded from his face; it was gray. His eyes had retreated far into their sockets. In his current condition one could only pity him. A colleague briefly explained to me that there had been no improvement despite intense antibiotic treatment, first by the family doctor and then at our clinic. An ultrasound had revealed inflammation of the mitral valve, on which I noticed bacteria and wart-shaped bits of destroyed valve tissue. They could peel away at any moment, travel to the brain, and cause a stroke. In this way the heart can affect the brain. The valve was partly destroyed and leaking, blood was flowing back to the lungs, which were full of water. I could even hear this—the young man was wheezing and gasping for breath, but he did not want to put on the oxygen mask while he was talking to me. He even tried to smile.

  * * *

  The patient had to be operated on immediately. Even though it was Friday. And I was tired. It could well be a severe intervention. The heart tissue was likely to be inflamed, which meant the “anchorage” for the new valve would have to be built with pericardium patches first. Why did he have to get that piercing?

  * * *

  Luckily he was not a young woman. I could implant a so-called artificial valve made from carbon or titanium. If all went really well, he would keep it his whole lifetime. An artificia
l heart valve is a foreign body; blood clots on its surface, which leads to strokes if the clots peel away. Therefore the patient would have to take blood-thinning medication for the rest of his life. A woman on blood-thinning drugs should not become pregnant as there is the danger she might bleed to death while giving birth. So for a female you would implant a so-called organic heart valve made from pig or cattle tissue, to be replaced later with an artificial valve. An organic valve is also chosen for older patients of both genders, as these patients are more prone to injury—for example if they have a fall—and they tend to forget their medication, which can lead to big complications. Also, organic valves last longer in elderly patients than in younger ones, as mechanically they are strained more by young and active people. Despite all attempts, medical technology has not so far succeeded in constructing the ideal heart valve—one that works as perfectly as the one made by Mother Nature. Every type of valve replacement has advantages and disadvantages.