The Source of All Things

by Reinhard Friedl

  * * *

  If we—and the society in which we live—perceive our heart as a mere pump, rather than as our most important sensory organ, it becomes sick. And so does the brain. Depression is the most frequent reason worldwide for the impairment of human life, and in 2020 it was the second-most frequent cause of death.2 Part of the reason for this is the fact that heart and brain are so often treated in isolation, while they belong together inextricably. What they would need is “couples therapy” to uncover the disturbances of their reciprocal perception and communication.

  * * *

  I still valued my profession, but I now saw it as too one-sided when practiced in a big clinic. I wanted time away from my green operating room scrubs, and, more than anything, I did not want to reduce a person to the small rectangle of flesh I saw between sheets of sterile green cloth. My life had altered considerably since I had started to listen to my heart more: my hobbies had changed and also my relationships with family members, friends, and patients. But sometimes it took a lot of strength to hear the heart’s voice amid the everyday proceedings of the clinic. When I returned after a weekend of meditation in a monastery or from a mindfulness seminar, from Monday morning I was expected to function and switch off my emotions in this pure-white high-tech environment—it did not fit together. It became clearer and clearer that as a heart surgeon I really wanted to treat the whole heart—especially the part I had found on my journey. I wanted to consider more than the excerpt under the green cloth—I wanted more time for my patients. I did not want to ask merely about their symptoms, but also to find out about their life circumstances, how they managed their everyday affairs, what worries plagued them: in short, what was weighing on their heart, because that plays a fundamental role in the heart’s health. I am convinced that in the following years and decades we will find further proof that the heart also medically lives up to its symbolic importance. It feel-thinks or think-feels. I wanted not only to put a stethoscope to my patients’ hearts, I wanted to listen to them actively. And my own heart, too—I wanted to get to know it a bit more.

  The call of the heart

  For quite some time I had felt a longing in my heart to sail across the big sea. As a small boy I could not get enough of the magnificent sailboats on Lake Constance, which I visited on rare excursions with my parents on Sunday afternoons in the back seat of a Volkswagen Beetle. Without safety belt or child seat. But an exclusive hobby like sailing was unreachable for me back then. Instead, my mother gave me a globe, which I still have today. Back then, I went on an adventurous journey around the world with my friend Jimmie. We were free, we were rich, we spun the ball, stabbed it with our fingers, and in our imagination drove, flew, and sailed to foreign countries.

  * * *

  I had been a heart surgeon for years when I finally learned to sail, and I loved it as much as I had thought I would as a child. That was lucky, as some childhood dreams turn out to be rather unfulfilling in reality. But water was my element, and when the wind filled the sails, my heart would expand. A new longing grew. My family encouraged me to fulfill this dream: to sail across the Atlantic. After a long wait I was able to take my annual leave and saved-up leave from previous years in one go, two months in total. I had got to know my three co-sailors on the chartered yacht some weeks earlier. I got along well with all of them, but I liked Harald the skipper, a retired taxi driver, best. There was also an IT expert and an engineer on board. We set off in February from the small island of Saint Lucia in the Caribbean and only got to Antigua, where our motor broke down. Was it the motor? No. The surgeon we called, in oil-stained overalls, diagnosed a problem with the pump. The fuel injection pump had been irreparably damaged. We would need a transplant. So began the wait for the new pump. Daily we checked the UPS tracking to follow the route of the pump, which was coming from Europe. The crew’s mood was strained: all but the retired skipper had taken time off for the cruise and the time pressure was enormously stressful. On the third day, I started a scuba-diving course. The underwater world fascinated me so much I no longer minded the wait—which the engineer and the IT expert didn’t like as they did not share my good mood. After seven days, the IT guy announced that he could not stand it anymore and wanted to go home immediately. We tried to talk him out of it but soon realized it was pointless. Only now he confided in us that he suffered from panic attacks. He had believed that the stay on the boat would cure him. He had been wrong—he felt like shit. So there were just the three of us now, which the engineer did not like one bit. He complained excessively about the “nasty, false, dishonest” IT guy who had misled us irresponsibly—he felt that it was his fault that our life dreams were falling through. I could not get the engineer to understand that panic attacks are an illness. He wanted to be right. Which can also turn into an illness. Or did he, too, merely need a reason to chicken out? The next morning he informed the skipper and me that he deemed the cruise too dangerous and was calling it quits. The two of us could set sail if we wanted to.

  * * *

  At this point, our boat was already fully supplied with provisions. Apples and potatoes were becoming old and rotten; the banana plant we had tied to the mast was dropping its fruit. And now? I wanted this cruise at any cost. The skipper thought it was possible for the two of us to do it, because I was an experienced sailor—but he was still a little uneasy about it, so we put up an ad: “Sail to Europe for free.”

  In Antigua, where the super-rich berth their superyachts, we were more in the category of social housing, or better: boating. But there were also some young people working as crew members on the yachts, and many travelers. One of them was Solomon from Israel, in his early thirties. And eventually John from New York joined us. He had become stranded in the Caribbean at some stage, broke and without any prospects. At least with us he would not have to worry about his meals for the next few weeks. He had a little bit of sailing experience. Solomon had never been on a boat before, as he freely admitted. “Only once, with my father, on a pedal boat.”

  Once the fuel injection pump had been replaced, we set sail, or at least we wanted to. But our anchor chain was blocked by the chains of the superyachts, and it took half a day for the divers to free us. Gradually I began to ask myself why we had been “told” to stay in the harbor. Was there a deeper meaning to this? That’s what you start to think when you have been delayed a number of times. And, after all, our voyage was by no means without danger. The sea does not forgive any mistakes—all who know it say that—and we faced a transatlantic passage of over 2,000 nautical miles in a fifteen-meter boat against the prevailing wind direction. The Atlantic is a wild, limitless expanse of nature. For a long stretch of time one is far beyond the lifesaving reach of civilization—a veritable adventure, more dangerous than my travels around the globe with Jimmie. For me, though, the adventure unfolded very differently from how I had hoped. As soon as we had reached the open sea, I became seasick. Green and pale in the face, I was on the ropes. I was miserable and no help to the crew. To make it worse, I remembered how impatiently and insensitively I had reacted when my children or my wife went green around the gills during our holiday cruises in the Mediterranean. After three days I finally felt better, and the sea had also calmed down. Instead, John lost his mind. He was always walking around with a metal cup in his hand. At some point I saw him pour Campari into the cup. At eight in the morning.

  “What are you drinking?” I asked him.

  “Rosehip tea,” he replied.

  “Smells different to me.”

  “Yes, okay. Red wine.”

  Some hours later he went completely ballistic. He bellowed and staggered across the deck, nearly fell overboard, lashed out, and insulted us.

  “He is completely drunk,” Harald diagnosed. He inspected the alcohol supplies and noticed that John had blasted through two-thirds of our supplies in less than a week. We had an alcoholic on board. And now? Harald and Solomon were looking at me. It was obvious to them that this was a case for the do
c. So I held a patient consultation with John. He freely admitted to being an alcoholic.

  “Anything else?” I asked, expecting the worst.

  “No, just boozing.”

  I spoke with him for a while and at some stage during the conversation realized that my compassion was not just a pretense to appease him. I was with John with my whole heart and tried to find a solution for all of us. John was not the least bit aggressive, but instead contrite—which was probably because I honestly cared about him and was trying to help. He accepted my plan straightaway. He was to be allowed to keep drinking—but only when everyone was having alcohol, meaning with meals. So he wouldn’t be tempted, I would store the rest of the supplies under my bunk. “You are a sailor, John: you know what this means. A sailor’s bunk is sacred. You won’t touch it.”

  “Aye, aye, sir,” he said with a wry grin and put his right hand on his heart. A person’s word is worth something among sailors, as they are completely at one another’s mercy. It certainly was not easy for him, but he managed. Our mainsail didn’t: it frayed and had to be stitched up. A job for a specialist—me. John assisted me companionably.

  Two days later Harald, usually rather sparing with his words, paid me a pleasing compliment. “I’m really glad to have you on board, Doc. It would not run as smoothly if we didn’t have a ship’s doctor among us. And the way you stitched up the sail—haute couture!”

  Well. Compared with my fine sutures in the operating room, this had been rather quick and dirty. Harald was an experienced skipper and had a good knowledge of human nature. But calling me a ship’s doctor? That amused me a little, because I had wanted to be on a ship to get away from it all. But the words would not leave my mind … ship’s doctor. There was something about it, particularly since I loved the sea so much. And I also wanted to improve my scuba diving.

  Waves

  I sat alone on deck at night, the immense starry sky above me. Again and again I looked up to find our lodestar. The one that pointed us in the right direction, among the 6,000 stars we can see with the naked eye. There are 100 billion galaxies, and 100 billion is also the average number of human brain cells. Is this a mere coincidence, or is the brain also a universe with infinite possibilities and spaces? At night in the vastness of the ocean, my thoughts became freer, my questions bigger. How small I was, and how vulnerable. Endless water. Endless depth, endless expanse, endless waves, endless blue, endless sky. I felt snug in this infinity, in the arms of the wind. We depended on it; it was the only force that could bring us home. The diesel tanks of sailing yachts this size are small and designed for short distances, not to cross an ocean of many thousand nautical miles. By and by I could hear from which direction the wind was blowing and if the sails were correctly positioned. I could hear it because Earth, like the heart, is bedded on a pillow of air. Sounds are air waves without which I would not be able to perceive the swooshing of the huge Atlantic waves crashing into the boat—or the heartbeat of my patients.

  * * *

  Without compass or helmsperson we would be lost, just as we would without brain or heart. The heart trembles within us like a compass needle, and if we pay attention to it, it will pilot us safely through life, in conjunction with the wind. You can get to this wind on many paths, with the waves, with the stars. The heart grants some degree of freedom. But you cannot sail against the wind. It would be foolish to try. You would arrive nowhere. Like Odysseus, a man who was looking his whole lifetime for a way home.

  When I surfaced from such thoughts, I meticulously checked our course, which would take us to the other side of the Atlantic. Sometimes a wave threw salty drops of water into my face. I licked them off my lips and swallowed them. The salt content of the oceans is nearly identical to that of our blood. We come from the sea, and I felt in resonance with this ocean of waves. I. Tiny like a water drop. Where should I anchor? Who am I? A drop of water. What is my task in life?

  Consciousness, for me, is a condensed drop of water. There are certain physical conditions somewhere and suddenly a drop of water is hanging from a leaf or running down a windowpane. Air humidity can’t usually be seen. Only when condensation occurs do we see drops of water. In the same way, our life condensates from cosmic elements in an act of biological creation. We are visible drops in the ocean of being. I am a drop of water that moves, and inside me pulsates a heart. Every water drop will eventually find its way back to the sea. And at some point, a new small heart began to beat inside me here on the Atlantic … the heart of a ship’s doctor.

  * * *

  When we reached the Azores my trip was over, because my leave was used up. I would have loved to simply sail on. But that’s not me. My colleagues were waiting for me, and I would not let them down. Besides, I had arrived. Maybe not in southern Spain, but at a much more important destination: at my self. I knew now where my heart was calling me. And that my time in the clinic was finished. Although I would return for now, I would not continue as a heart surgeon forever. The time had come to work for the whole heart—in the words of a character from Franz Werfel’s novel The Forty Days of Musa Dagh: “There are two hearts. There is the heart of flesh, and the secret, heavenly heart which surrounds the other, just as its scent surrounds the rose. This secret heart unites us with God, and other men.”3

  And, besides, I wanted to find out what I needed to do to sign up as a ship’s doctor. Because in that way I could connect everything. The sea and the sky, the heart and my patients, and myself.

  In new waters

  It took a while until I found the opportunity to sail in new waters. Everything was different from the moment I knew that I would change professionally. From then on, I no longer worried what others might think of me; my decision had been made with heart and mind, carefully thought through.

  In my operating team, I placed even more emphasis on respect toward patients, even though they could not hear or see us. I thought of myself as the guardian of this room; the devout silence in the operating room had always reminded me of a church, and now I took responsibility not only for the vibration of the medical saw but also for the vibe in the room. I noticed that my attitude was rubbing off on my team. Our working together had never been as wonderful as in my last months. I told no one of my decision. I was still in a phase of finding myself and had a lot to consider. One day I read about Markus Studer, a heart surgeon from Switzerland who, in his mid-fifties and at the peak of his career, fulfilled a childhood dream and became a trucker. In an interview with the ÄrzteZeitung, he said: “I did not want to operate for too long—that’s not good, neither for the doctor nor for the patients. Especially in surgery doctors should put the scalpel down in their mid or late fifties.”4 I, too, think that is a good age to follow the GPS of one’s forgotten heart.

  * * *

  The additional training to become a ship’s doctor was not a problem. But a second heart was beating in my chest, and it wanted to be heard as well. For a while, I had been carrying inside me the plan to develop a medicine for the whole heart. I would only be able to implement that if I had my own practice for holistic and operative heart medicine. I wanted to continue to be a heart surgeon, but play on heart medicine’s whole keyboard. First and foremost, I wanted to take the time to find the true causes of my patients’ heart complaints. Those you don’t see at first glance. I was certain that some invasive procedures would then no longer be necessary. The price I would have to pay for this change was that, as an independent heart surgeon, I would no longer be allowed to conduct certain operations, for example implanting an artificial heart, my special field. Thus, these last months in the clinic were also a goodbye, in some way. I began to relish my time in the operating room, similar to my enjoyment as a young assistant when everything had still been very new. And it was indeed very new for me once more—as everything we perceive with an open heart is fresh and unique.

  FAREWELL TO THE ARTIFICIAL HEART

  The heart that lay before me was looking heavenward. It was presumably the l
ast one I would connect to an artificial pump. With several surgical drapes I had put the heart in the right position, so its apex was pointing up. It was connected to a heart-lung machine, but still beating. In the area of the apex I had stitched a metal ring, through the center of which I was now punching a hole slightly larger than two centimeters into the left ventricle.

  * * *

  Ten days earlier, the patient had been admitted to the clinic with a severe heart attack, and cardiologists had implanted several small metal tubes—stents—in the blocked arteries of his heart. Twice he had suffered from ventricular fibrillation, twice he had been resuscitated. We succeeded in saving his life, but his heart remained weak. Too weak to continuously manage the blood supply to his organs. We call this state heart shock, or cardiogenic shock, and it is life-threatening. The body needs to be supplied with energy from outside. An established method of doing so is to first connect the patient to ECMO (extracorporeal membrane oxygenation), an emergency pump that supports the heart and oxygenates the blood. In the first operation, I had joined up two tubes nearly the diameter of a garden hose with the blood vessel system near the heart and had then connected them to an external pump system. Twice daily a team of heart surgeons, anesthetists, cardiologists, and nursing staff had gathered at the patient’s bed and discussed the state of Mr. Rubella and his heart. We had tried several times to reduce the ECMO support. Sometimes hearts recover after a few days and ECMO can be removed. Not so with this patient. The more the pump flow was reduced, the weaker his heart was beating. Everyone involved was able to witness this live via echocardiography, the ultrasound of the heart. Doctors would call the weaning unsuccessful. With the pump, the patient’s condition was “stable.” He was on dialysis because of kidney failure, but his other organs were doing their work relatively well, and the brain did not appear to be damaged either.