The Source of All Things

by Reinhard Friedl

  * * *

  I explained to the patient: “You have an inflamed heart valve. It’s life-threatening. We have to operate. It is a dangerous procedure, but you don’t have a choice if you want to survive this. Do you agree to the operation.” I used my usual script.

  The young man only looked at me. I read incomprehension in his eyes, and fear. I looked at the clock on the wall. The emergency team would start to operate in an hour. But they were already dealing with another case. My kingdom for a cup of coffee. The young man still did not say anything. Maybe he thought he was dreaming; who would ever expect something like this. Fit as a fiddle, and then out of the blue a heart operation. But I seemed to be dreaming too, because I did something that wasn’t at all like me. I took the young man’s hot, weak hand, which lay limp on the blanket, in mine. I had never done such a thing before. I touch hearts, not hands. Now his eyes changed. He was looking for an answer. I remained silent and absorbed his question. It traveled through my eyes into … my heart.

  And my heart began to talk. “If I was in your place, I would be afraid too,” I said. “A difficult operation lies ahead of you. But you are young and strong, and your heart wants to live. Every heart wants to live. Your heart will do its best, and I will do my best, and together we will make it, okay?”

  I read the “Yes” in his eyes before he said it. And although that was all I had wanted to know, I remained seated beside him. Even though I had things to prepare. Even though I still hadn’t had any coffee. I remained holding his wet, feverish hand—and if the leader of yesterday’s workshop had asked me right then to feel my heart, I would not have had to search in vain. My heart had woken up.

  CHIMERAS OF THE HEART

  I have never been afraid to suffer a stroke. I am not typically one of those medical professionals who feels in their own bodies every illness they learn about during their studies. But now I sensed a twinge in my chest. It was not the sort of pain patients describe when they have a stroke. I did not feel a sort of wrenching, but rather a calling. Where did it come from, and where was it pulling me? The only thing I knew was that something in my life was no longer in tune; something had changed, but what?

  From the outside, everything was fine. I loved my profession. I loved to operate. I loved my wife and my children, we lived in a nice house, we were all well. In my spare time I liked to sail, to cook, and to read—even though I read less than I would have liked as I lacked the time. All in all my life was rich and fulfilled; I felt that was what I deserved, as I had worked hard for it. To get to my position, one had to serve for many years and put up with a lot, swallow a lot from the gods in white who wield the scepter known as the scalpel. And you never know whether you will one day be admitted to that illustrious circle. There is no guarantee you will succeed. You also have to find out for yourself if you can cope with this profession and its responsibilities and if you have the hands for it. And you have to find a heart surgeon who will take you under their wing and believe in you.

  The first five years, if you hold out, are spent in the realm of hope. As heart surgery requires a lot of personnel, there are scores of assistant doctors. You can calculate how long it will take if ten colleagues have their turn before you and if each of them takes five years … it is not going to happen for you. But there is also a certain possibility in the long wait, as many lack the stamina—or should I say the capacity?—to suffer. They drop out. You need an iron will to continue—and it is easier the less you are in touch with yourself and your own needs.

  Stamina will also recommend you to your superior, who at first won’t even know your name. Then comes the day when you are allowed to stitch up a leg after veins have been extracted from it for a bypass. And you don’t know if that will be it, or if one day you will be allowed a go at the holiest of the holy, the heart. It helps if you never contradict your boss. If you complete everything perfectly. If you never reject a weekend shift. And if the boss asks on Friday evening if you can stay a little longer, you don’t say that you have been here for two days straight and today is your mother’s birthday—you say: yes, of course.

  At university clinics it is expected that you write research applications and academic papers in your spare time. That will enhance the department’s reputation, and at some point, hopefully, the boss will notice that you are serious. Then you are a good assistant, no longer a nobody. Maybe you will even be greeted by name. And then you may be allowed to saw open a chest. It is a sign of trust if the surgeon lets you do that. And then close it. Or connect the heart-lung machine.

  And so you continue to serve, and become tougher and more hardened. You swear to yourself that you will never become such an unjust god in white. But by the time you have conquered the throne, once the right to operate on hearts has been bestowed on you, who will you have become? Often simply what you hated so much before. Is this inhuman, or rather all too human?

  The pressure on heart surgeons is enormous. In a recent study, primatologist Frans de Waal observed the behavior of surgical teams in the operating room. It was mostly cooperative and friendly, but in some cases there were serious conflicts involving verbal violence—sporadically instruments even flew across the room. Particularly during long operations—so normal for heart surgery—stress increases dramatically and the probability of conflict rises. If there were predominantly or exclusively men in the operating room, the frequency of conflict was twice as high, compared with the figure for male and female teams. For de Waal the parallels with the apes he has spent his life studying must be obvious.1 Doctors are only human after all.

  * * *

  How do I treat my assistants? I asked myself one day, and then immediately thought: What sort of question is that? What had happened to me since I held the nipple piercer’s hand? Was I contaminated with compassion? Heart surgeons are cool and never lose control. Never. They don’t cry, not even secretly. Fearlessly they foil the plans of the gods. But what if the gods took revenge? What if the gods without a white coat retaliated and sent a bolt of lightning out of the defibrillator? What strange thoughts I had! Was I headed for burnout? What was wrong with me? And what was wrong with my heart? This twitch—no, it was not a pain, it was a calling.

  * * *

  Where should I go? And how much time did I have? Timing is tight with a stroke, every minute counts. Severe pain in the chest is typical and can also be felt in the arms, back, stomach, or neck. In men, anyway. In women, it can be different. They don’t feel the pain so severely, and it can “only” be a pain in the arms or jaw, perhaps accompanied by malaise, nausea, vomiting, or shortness of breath. Their symptoms may therefore not be taken seriously: perhaps it’s just an upset stomach? Precious time is lost.2

  But there is also the “silent stroke.” You feel nothing. Absolutely nothing. Not for a long time. It is often detected by accident. So it was with me when I held that young man’s hand. This was my diagnosis-by-accident. This touch had blasted calcium deposits from my armored heart. I heard different voices in my heart and brain which I could not reconcile; they were wandering through me like those deposits. And if I was unlucky, something would shoot into my brain, I would suffer a stroke … or had it shot into the brain already? And what were these chimera … these new chimerical sensations of my heart?

  The stroke

  During a stroke, an artery is acutely blocked, the heart muscle dies, and arrhythmia occurs. There is often a life-threatening complication as well. Immediate emergency measures are necessary; a small metal tube is implanted to replace the blocked section. Artery calcification does not happen all of a sudden; it is a process called arteriosclerosis, for which there are risk factors. The best-known of these are high blood pressure, smoking, drinking, obesity, lack of exercise, and stress. The sediments in the arteries are often called calcification; doctors also call them plaque.

  Many people survive a stroke, and I sometimes get the impression that it is treated like the trophy of a high performer: I have achieved the maximum, I pla
yed really hard, I had a stroke. A similar prize goes to the burnout patient. All others are low performers. It seems to me that the effects of the performance delusion have changed since my childhood. Previously the most pious people had apparitions, today the toughest burn out. Some professions seem predestined for a stroke, in the same way that surgeons always have back problems, as they stand at the operating table for so long—and had to bend down for a long time before being crowned surgeons.

  * * *

  From the moment the arteries in which the stroke manifests itself are blocked, tissue dies. It is not all dead immediately, it takes a few hours—at least on the anatomical heart.

  Yes, of course on the anatomical heart, what other heart would there be?

  The other one, a voice in me said.

  Apparently something had indeed shot into my brain. Which other heart? Was I hearing voices?

  Yes. The voices of your heart.

  Hearts don’t speak. Hearts are pumps.

  * * *

  What if the anatomical heart was important for life, and the other heart …

  … which other heart …

  … was important for the spirit.

  Rubbish. The brain is responsible for that. Everything important happens in the brain, we know that. We feel in the brain, it is the seat of consciousness.

  Well, in that case I could calm down. I didn’t have a heart attack but a brain attack. Or a heart attack without a heart?

  The choreography of surgery

  A nurse knocked on my door and told me, “Dr. Friedl, your patient is being washed.”

  “I’m coming,” I replied.

  Before a heart valve operation, a patient’s torso and legs are washed thoroughly with disinfectant. Why the legs? Because in rare cases it is necessary to lay a bypass. For this, a vein is taken from the leg, hence the legs are disinfected as well.

  I left my office and walked toward the operating room. I approached the cathedral of the clinic, and the temperature seemed to drop a degree. I entered the door code.

  Peep, peep, peep, peep.

  Click.

  I stepped into another world. It appeared to be under water. A submarine, maybe. The door closed behind me, and I forgot everything that had just been on my mind. My heart was silent—and I thought this a necessary prerequisite for being able to help another person’s heart. Professionalism, performance, hard as steel, and free of any emotion.

  * * *

  In the changing room I stripped down to my underwear and put my clothes in my locker. The green scrubs were ready, my work attire. This was the ritual of putting on my heart surgeon’s armor. I passed the doors with their portholes into operating rooms. I did not feel anything anymore. I was functioning well. That was important because my opponent was powerful. I was fighting with death. During the minutes before an operation I always feel very alone. There is no safety net for the patient. Will I do it well? Will it be successful? What complications might occur?

  Now everything depended on me. The responsibility was weighing on my shoulders. I must never underestimate the danger, even though it had long ago become routine. Nobody must notice that I was afraid of failure. I concentrated on the images and video I had just been looking at in my office. The patient’s heart from all angles, black-and-white and occasionally in color, 3D, pumping capacity, blood flow, location of the aorta. I recalled my strategy. How exactly was I going to operate? Which difficulties may arise, and what did my countermeasures look like? Which assistant was going to support me, which nurse? Could I rely on both, how well did I know them, what could I expect from them, could they think for themselves or would they constantly need direction? A heart operation requires at least four hands. I could not do it alone. It takes a team to help a heart.

  * * *

  I looked through the porthole into my operating room and saw that everything was ready. The patient was on the table, washed and covered. I put on a surgical mask and magnifying glasses. I washed my hands and underarms with soap and disinfectant for five minutes. An infection during an operation will have terrible consequences. The patients lie in intensive care with an open sternum for months because their wounds won’t heal. Thorough disinfection also means respect for and appreciation of the patient. Ignaz Semmelweis, pioneer of antiseptic in hospitals, was called crazy 150 years ago because of his hygiene instructions, which many deemed exaggerated. If they had taken his findings seriously, many people would have been spared a lot of suffering. But back then it was not yet known that bacteria cause illnesses.

  * * *

  Now I was ready. I opened the last door to the operating room with a foot-operated switch so as not to have to touch anything. It fell closed behind me without a sound. I greeted those present. The room fell silent upon my entry. I was known to prefer a quiet atmosphere. Other colleagues would constantly crack jokes or chat relentlessly. A colleague from Bavaria, a superb surgeon, liked to open hearts in a sort of Oktoberfest atmosphere, kept up until the sutures were completed. I can’t stand anything like that. And as I am the surgeon, I set the tone. With me, it is quiet. I like a focused silence, interrupted only by the bleeps of the heart rate monitor and the blowing of the respirator, the clatter of instruments in the kidney basin, the holding of breath and deep exhaling when a difficult stage has been completed.

  * * *

  The nurse dressed me, holding up the gown for me to slip into. A second nurse stood behind me and passed me the gown’s strings. I took them and turned in a choreography I had danced thousands of times, tied the cords in front of me, and finally slipped into the gloves that were being held out to me. After a few turns and hand movements I was sterilely dressed. My own heart was switched off so I could operate on the patient’s heart. Did it have to be like that? Would I be able to operate if it were different—and how did that even work, switching one’s heart on and off? How would this patient perceive it? Which half of humankind did he belong to? Did his self reside in the heart or in the brain?

  The nurse handed me the bone saw. I switched it on.

  THE COLORFUL NEUROSHOW

  During my search for the heart I kept coming back to the same questions—even though the origin of feelings and thoughts was considered fully explained. They came from the head; neuroscientists had proven that with their images reminiscent of modern paintings. And the head, the brain, is the boss—the control center. Attached to the brain is a body that needs to be optimized—a kind of computer governed centrally by the brain. We have become used to this perspective. It is scientifically up-to-date, isn’t it? The many esoteric publications which describe the heart as the center of all-knowing love stand against it. These two ways of seeing human beings are in competition with each other.

  Navigating between them are the readers, who often do not know if they are their body or have one; they don’t know who is talking when they say “I”—only the head, or the heart too?—or what the story is with the soul. It is not rare for the talking I or Self to experience itself as separate from the body, or else its chief supervisor.1 “I would like to do this or that, but my body keeps getting in the way.” In general, the misconception prevails that we are close to deciphering the brain’s code; all the colorful images of brains, no longer restricted to academic publications, contribute to this impression. And who knows—maybe in the future people will proudly show one another their brain scans as well as the ultrasound images of their unborn children.

  I found three sentences that summed up my thoughts in Ian McEwan’s novel Saturday, which revolves around the life of a neurosurgeon: “For all the recent advances, it’s still not known how this well-protected one kilogram or so of cells actually encodes information, how it holds experiences, memories, dreams, and intentions … But even when [the brain’s fundamental secrets are laid open], the wonder will remain, that mere wet stuff can make this bright inward cinema of thought, of sight and sound and touch … Could it ever be explained, how matter becomes conscious?”

  * *
*

  Neurology’s imaging technologies have enabled us to take colored photographic images of the brain. But do they really depict feelings, thoughts, and motivations? Brain researchers enthusiastically explain “Here!” and “See there!” as if they had discovered banners displaying logical thought or love. In reality, color in the brain is by no means direct evidence of nerve activity, a fact that is quite frequently omitted. Instead, it is direct evidence of blood with high oxygen content, which is delivered by the heart. This blood flow flashes up as color in functional magnetic resonance imaging (fMRI), and from this it is concluded that the nerve cells in this part of the brain are firing at this moment. If we feel pain the “pain center” glows, and if we have strong feelings the center of emotion does the same. This is a wonderful scientific method that has revealed a lot about the functions of the brain’s components. However, it is often erroneously concluded from this glow that emotion or pain or whatever else “originates” in this spot.

  * * *

  Neurophysiologist Ernst Pöppel alludes to the fact that some areas of the brain, for example the insular cortex, appear to have multiple functions—“emotions, body awareness, concentration, sex, desire, sense of time or pain”—depending on which study you review. The colorful images mentioned above do not have the straightforward explanatory power many will have us believe. The method is fuzzy; the newspaper Die Zeit even talks of a “big neuroshow” in an article. Now some researchers have suggested that inner experience is in fact created in several cross-linked brain locations simultaneously.2 Psychiatrist Thomas Fuchs comments: “It is completely unclear, however, how all these sub-functions are coordinated and integrated to form homogenous consciousness.”3