The Source of All Things

by Reinhard Friedl

  * * *

  There were now two possibilities: to let the patient die or to implant an artificial heart pump made of metal, a VAD (ventricular assist device). Both options were justifiable; the question was what Mr. Rubella would have wanted. I spoke with his wife and children. In considering implanting a permanent VAD, one needs to be aware of the considerably heightened risk during the operation with such a critically ill patient. However, if it was successful, his life would be completely different. A cable, the so-called driveline, would protrude from his left side under the ribs, and he would spend the rest of his life with batteries on his belt. I once had a colleague who said that such patients and their surgeons were “married until death do them part.” That is ribald heart surgeon humor, but there is a grain of truth in it: because if everything goes well and the patient returns home, the clinic must be available to him day and night in case of emergency. My questions to this patient’s wife and children were: Would your husband and father have wanted a life with an artificial heart implant, and would he be able to manage it? Would he accept the technology and be able to change the batteries every day? Would he take the blood-thinning medication regularly, would he be able to live with a cable protruding from his side, and who would look after the resulting wound? Experience suggests that patients will not manage this by themselves; they need helping hands and lots—really, lots—of loving support. However, if they have this they can lead a life that is nearly normal. Some even still go on cruises. Mr. Rubella was currently embarking on his final journey, his life balancing on a knife’s edge. But his wife and children believed he wanted to live at all costs, and they wished to walk the difficult road ahead with him.

  * * *

  The medical team met again, and we decided to risk it. The timing was favorable, which is a decisive factor in such an undertaking. One must not wait too long. When the process of dying has begun, it is too late. No charts will tell you exactly when that is, but there are signs—and experienced doctors know the many faces of approaching death. And of course the VAD should not be put in too soon, while there are other options. This decision can be a huge challenge. After everything was settled, the operation was prepared for the next day.

  * * *

  Stopping the heart is not always necessary with these procedures, and now I was looking into the patient’s beating heart through the punched-out hole. This spot has to be “perfect” because the suction tube needs to lie free and central in the heart to enable optimal flow. Whether that has really worked will only become clear toward the end of the operation, but at the moment it was looking good. Inside the heart I found nothing that could have disturbed the blood flow through the metallic suction tube. The actual transport of the blood is done by an impeller in a small shiny chrome box that is round and slightly smaller than a palm. From there, the blood is passed on to the aorta with a flexible prosthetic tube. The professional term is left ventricular assist device (LVAD), a supporting pump for the left ventricle, which is mounted onto the heart. For decades there have been attempts to build artificial hearts that would replace the whole heart—apparatuses with valves and ventricles which produce a pulse wave, like the real heart. But the natural technology of the latter is unsurpassed, and the engineered “total artificial heart” often leads to severe complications. So engineers and heart surgeons thought again and constructed something that is very simple but functions better. The old heart remains where it is, the patients survive for longer, and there are fewer complications. Perhaps the advantages compared to the “total artificial heart” also come from the fact that the connections with the body and self-perception can remain intact.1 Even with transplanted hearts it is possible that severed nerve tracts connect again. And the more they do that, the better the transplanted heart will work.2

  * * *

  I lowered the suction tube into the heart, checked again if the box was sitting on the metal ring as planned, and fixed it with a single small clamp screw and a torque spanner. Thorough ventilation followed, as there must not be any air where there should be blood. This routine took at least ten minutes. In the meantime I recalled, as I had many times, the moped (a NSU Quickly) I had owned as a school student and whose motor had so often needed repair. It had always been important to thoroughly vent the carburetor, and once after I had overwound a screw I had bought a torque spanner from my pocket money, not imagining that this tool would one day serve me well during heart operations.

  * * *

  There are some patients who, after an operation, have enormous psychological problems living with a machine in their chest. Some even cut through the cable to the batteries, as they cannot pull the plug for safety reasons. I remember an elderly lady especially well. She considered the “steel box” in her chest a foreign body and wished for nothing more than to get rid of it again. For her four-year-old granddaughter, however, the box was the “darling.” It was due to the box that her grandma was alive. And since she was always asking grandma about her “darling” and if it was still humming well, the iron heart in her chest became Grandma’s darling too. The sonorous hum, by the way, is a calming sign for patients. If it starts to rumble and creak, that indicates a pump thrombosis—a grave complication. One thing I had learned even back then with my Quickly: before the motor stopped and I had to push the vehicle for kilometers, there was always a signal indicating a problem—and if I paid enough attention I could hear it.

  * * *

  Fortunately the turbine in Mr. Rubella’s heart had started to run smoothly in the meantime, and all air had been removed from the heart. His heart was filled, the length of the prosthetic tube measured and implanted into the aorta. What now follows is a subtle process in which the LVAD flow is increased gradually and that of the heart-lung machine simultaneously reduced. The right amount of the appropriate medication is necessary for this, as well as lots of instinct and patience. One has to give the heart time to get used to the new situation.

  The body adjusted to life without a pulse without any problems. Even though the heart is still beating, the blood is now transported to the body by the turbine, with its steady flow. Supported by the heart-love-and-life hormone adrenaline as well as numerous other drugs, the patient was brought to the intensive care department. He suffered from heavy loss of blood for days, and twice his chest had to be opened again to look for causes of the bleedings. Not because the operation had been sloppy, but because this patient’s clotting was “going down the drain.” The lost blood is caught in special containers and infused back into the patient. It is a battle of material against death in which modern medicine comes out all guns blazing. The worrying and hoping lasted for two weeks, and then Mr. Rubella reached calm waters, so we could reduce the anesthetic and let him wake up. His brain had not suffered any damage. He recognized us. Those are amazing moments for patients, family members, and medical team. After more than a month the patient was able to go for the first small walks into his new life.

  Setting sail

  And for me, it was time to set sail. To become a ship’s doctor, I had to go back to school. Together with apprentice ship-builders, as well as fully qualified engineers and doctors, I completed several safety training courses. I had learned to scuba dive in the Caribbean, but now I added the training for diving doctors. My adventurous heart was always glad when we were drifting in wintery water in survival suits or experiencing the rapture of the deep with our own bodies in the pressure chamber.

  * * *

  From the moment I had begun to follow my heart, many wonderful things had happened. But in some dark hours I doubted my decision. Was it really right to change waters? Every now and then I was pestered by existential fears. How would it all unfold once I left the safe harbor of the clinic? In such moments I had to tell my heart to pull itself together, or else my heart told me, in a very healthy way. Again, I experienced that it is the most beautiful thing to be in resonance with my environment and the people around me, trusting them. This trust stayed with me d
uring my training to become a ship’s doctor, and when I became self-employed with my own surgeon’s practice—because I didn’t know if I would be needed as a ship’s doctor, nor if any patients would find me. Both found me, ship and patients. And further wonderful things followed. During a medical seminar I told a colleague about the concerns of my heart. Shortly afterward I received an invitation to give a talk on the topic of heart and brain. This would be my first public appearance on the topic of my heart.

  * * *

  I commissioned a website for my practice. The designer told a friend who was a journalist about my mission of the “whole heart.” Before long I was interviewed for a medical publication in Die Zeit. The article created a stir, I received a lot of mail, a magazine asked me for an essay. And so we had come full circle. Many years ago, a patient had given me the book The Wise Heart by Jack Kornfield and inspired changes. And now I was side by side, so to speak, with this teacher of wisdom—my essay and an interview with Jack Kornfield in the magazine moment by moment. What an honor! This drew the interest of several publishing houses, who asked me if I would be interested in writing a book. And now you are reading the result. What will you do with it? Which circles will close for you, which ones will you open—and where will the voice of your heart carry you?

  Mine was calling me to sea, to the place of my longing.

  The hungry heart

  Those who go to sea need an anchor. That is what my practice is for me. Here I have the time and energy to care for the hearts of those seeking my help, who at times drift lost in the sea of high-tech heart medicine.

  * * *

  One day I received an email from Astrid, a young woman from Austria. Her heart was no longer pumping effectively, and she might need a transplant soon. I learned from scans from several university clinics that she had suffered repeatedly from myocarditis. Histological examinations of her heart had shown scars. The right side of the heart was especially affected, the ventricle was widened, and the tricuspid valve between ventricle and atrium did not close properly. All of the examinations that were possible on the heart had been conducted. The patient was taking numerous drugs, but her condition was getting worse and worse. She had trouble breathing, and her legs were swelling. So after her last stay at a clinic they had suggested she visit a transplant center. The conversation with the chief physician there had been very matter-of-fact and had only lasted a few minutes. After that she had cried for days and felt completely abandoned … and then she asked if I could help her.

  * * *

  A week later she came to my practice. We spoke for a long time, and she told me things you would not find in a typical doctor’s letter. Since her late childhood and far into her youth, she had suffered from bulimia. Her mother had died when giving birth to Astrid, who had been brought up by an aunt, who had not been able to give her the love and care she needed. In her family it had been common to express affection and warm-heartedness through cooking. At some point the girl began to throw up, and after a few years her heart had become inflamed. Ever since then her heart would often race after meals, even though she had overcome the bulimia.

  * * *

  I examined her heart via ultrasound, and we watched the images together. I asked her what she was feeling. “I hate my heart,” she replied. “I hate it because it isn’t functioning, but I am.” I asked her to feel her heart. She refused. “Feeling it is exactly what I don’t want to do, I want it to leave me alone.” After I asked what her heart needed, she was silent for a long time. Then she started to cry.

  My first check of her heart rate variability confirmed on a physiological level that Astrid and her heart were no longer a team. She stayed for several days, and I asked her to try to observe her heart rate during her walks along the Baltic Sea coast. Just perceive, not judge. She trusted me and tried it. On the next day, she said: “I think I know now what my heart wants.”

  “Yes?”

  “It wants to be loved,” she sobbed.

  “Yes,” I said.

  * * *

  Over the next few days we started the therapy, and it turned out that Astrid was able to support her heart’s pump function with conscious, loving breathing. She called it: “I embrace my heart.”

  Within a year, Astrid came back twice to her “heart time at the Baltic Sea,” as she called it. She was much better now. She was able to do yoga again, did not have so much trouble breathing, and even wanted to start going to work again. This positive development was confirmed by the follow-up MRI scans of her heart. Over time, the pump function even increased.

  Psychoneuroimmunology also deals with patients like Astrid and verifies how much our inner experience can affect our immune system. I believe the key to Astrid’s heart healing was her willingness to feel herself and her heart.

  The biggest health issues of our time—depression, addictions of all kinds, and incurable pain conditions—can all be traced back to a disrupted ability to feel.3 I am convinced that is true for many illnesses of the heart too, and that we should embrace our heart every now and then to get closer to ourselves, to feel ourselves and also our fellow human beings.

  HOMO COR

  In the history of evolution, the ability to feel oneself is seen as the beginning of our consciousness.1 Evolving human beings had at one point in their history and the history of the world felt their own heartbeat and how “something” inside was alive. A few million years have passed since then, the brain has grown, and we call ourselves Homo sapiens, the knowing human. There is, however, a central question that has remained completely unanswered: How is subjective experience created within our bodies and where does consciousness come from? No existing theory can be verified metaphysically and empirically.2

  * * *

  Findings from quantum physics allow us to conclude that our borders do not end at the surface of our skin, but that we are connected with everything in existence. Many people are familiar with this feeling of being “connected”—with nature, the universe, a beloved person or animal, perhaps even with a special purpose in life. The findings of multiverse theory, which unites physical astronomy and quantum mechanics, suggest that there are many universes with many different versions of physical laws.3 Furthermore, according to the official theories of physics, we live in an eleven-dimensional entity whose directly perceivable dimensions are three-dimensional space and time. Hawking and Mlodinow rightly ask in their book The Grand Design: “If they are present, why don’t we notice these extra dimensions?” and answer this question straightaway: “they are curved up into a space of very small size” so we do not notice them.4 Is that really the case?

  * * *

  Life on Earth is 3.8 billion years old, and the first prehistoric person lived seven million years ago. I think it is very unlikely that after this long time of human evolution and life with nature there are dimensions that we cannot perceive. Nature has had lots of time to equip us with multiple possibilities of perception. I am therefore convinced that we do perceive the dimensions of M-theory. Love and compassion, truth, wisdom, strength, joy, and thankfulness may be some of them. In short: the consciousness of the heart. Not every one of these qualities is spontaneously available to most of us, but if they become feel-able or “feel true,” if they unwind and unfold, they open a space, a dimension, their own universe. They are not mere “feelings,” but in their full extent are dimensions of humanity. And humans are not humans only because they are cognitively active and have a brilliant brain—but also because they have their heart in the right place. We have developed into Homo sapiens precisely because we feel the dimensions of the heart.

  So we are not only knowing humans but also heart-centered humans. Homo cor.

  * * *

  Nature has made the creative, enterprising, and feeling human being as complex as the universe itself. If even a single star were removed from the latter, we would not have the conditions on Earth which we need to live. With a human being, we must not remove the feeling heart, otherwise we wou
ld vegetate at an intellectual level. That would not be what I call being alive. Life only makes sense if we use our sensory organs to their full extent. Without the heart we would not have created magnificent works of art, would not have developed visions of humanity, and not have made scientific discoveries. The following is my incomplete chain of evidence: Beethoven’s symphonies, AC/DC, the cave paintings from the Stone Age, Picasso, Gandhi, Anne Frank, Einstein, my children, Yin and Yang, Marie Curie, Schopenhauer, Czech children’s TV series Pan Tau, Freud, and Porsche. What does your chain of evidence look like?

  With the whole heart doesn’t mean brainless

  In the last few years there has been a lot of talk about Homo deus, the divine human, who gains godlike abilities through technology.5 But where has that led us? We can destroy ourselves at any time, can poison our Earth irreversibly. With our brilliant minds alone, we are not Homo deus: rather, the opposite. The divine in us can only unfold if we integrate the heart into the achievements of our mind. Critics may object that the heart’s voice has never been measured by anyone. But the age of science and mechanization—from the steam engine to the space station, the letterpress to Facebook—has only been going on for a few centuries, which is a very short time compared to millions of years of evolution. Thus, it is understandable that in this short time we have not yet developed measuring instruments for all dimensions that we humans can perceive. It is no surprise at all that we can’t yet measure our body’s complete sensor system for those dimensions. Maybe that system is simply immeasurable, like the extent of the universe. But we should be wary of claiming that such sensors do not exist and that love, wisdom, compassion, and the many other essential perceivable qualities of the heart are “only” feelings. If one views them with all their possibilities and facets, in their meanings and how they influence our lives, they have the extent of dimensions we can experience with our senses and which become conscious in the heart. Theoretical physics has now calculated the existence of such dimensions. Does that mean we can express in numbers that which we perceive? Basically it can be explained quite simply using an example: we can immediately perceive three-dimensional space with our senses, or we can depict this space mathematically. Both are correct, but they are not the same. There is a tremendous difference between measuring the water temperature in a bathtub with a thermometer, and lying in a warm tub and feeling it with all our senses. They are different representations of the same truth.