On January 6, 1968, Shumway finally had his donor, and the world’s fourth heart transplant took place at Stanford. The recipient was a fifty-four-year-old steel worker, Mike Kasperak, from East Palo Alto. In retrospect, he was a bad candidate for a transplant. Besides being terminally ill, he also had kidney failure and generalized atherosclerosis.
Ed Stinson, Shumway’s chief resident, assisted. He later said the operation had been “awe-inspiring.” It was also a moment when the team reflected on the moral and legal implications of what they were doing. At the time there was no brain-death standard in California. A person was declared dead when their heart stopped beating.
“After we removed the recipient’s heart,” Stinson said, “we stared at the empty pericardial cavity for a good half minute and wondered what we’d actually done.” Stinson asked Shumway if it was legal. Shumway shrugged and continued working. “I’m not sure,” he said. “Time will tell.” When the new heart was in place, nothing happened at first. Then it started to beat a little. Pretty soon the heartbeat became strong. Mike Kasperak lived for fourteen days before he died of kidney failure and sepsis.
Shumway hated publicity, but the transplant operation was big news. Reporters climbed the walls of the hospital to try to get a peek into the operating room. And around the world in the coming months, surgeons began doing heart transplants every few days. Sadly, only Shumway and Lower—who had now moved on to Virginia—understood enough about rejection, both the process itself and also how to diagnose it, a critical consideration in trying to balance immune suppression. Eight of Shumway’s first heart transplant patients lived for more than a year after their surgery. Dick Lower’s first patient died after a week. But his second would survive for more than six years.
Inevitably, though, heart transplants produced dismal results in most of the cardiac centers that tried them. Denton Cooley in Houston did more heart transplants than anyone in the world that year—twenty. None of the recipients survived past eighteen months. In all, 80 percent of the world’s transplant recipients died within a year. It was true that all of these patients would have died without transplant surgery, but critics argued that the expense and the emotional toll of extending life by a few days or months was not worth it.
In 1971, the Stanford group published their results with twenty-six human heart transplant patients. Nearly half had survived for six months, and one in four was alive two years after surgery. Nobody else was even close. The key to survival of the patients had been the diagnosis and treatment of early rejection.
Philip Caves, a visiting fellow from the Brompton whom Paneth had sent to Shumway, introduced another major advance at Stanford in 1973 that furthered their ability to detect early rejection. It was a method to biopsy the heart. A long forceps was introduced through a neck vein and passed down into the heart, where small tissue samples could be taken. For the first time, it was possible to directly observe the rejection process. This was a tremendous development. By 1974, the Stanford group had performed fifty-nine human heart transplants, with survival rates of 43 percent at one year, 40 percent at two years, and 26 percent at three years. These numbers improved steadily over the next few years. Meanwhile, in Cape Town, Christiaan Barnard’s team did only ten heart transplants between 1967 and 1973. Barnard spent more time giving lectures and jet-setting than he did operating, in love with his fame and, as he later confessed, with the endless succession of young women eager to sleep with him at every stop.
In the end, the race had been won not by the swift, but by the careful. While he hadn’t been the first, Shumway was soon regarded everywhere as the father of heart transplantation. Stanford was where I had to go.
PART THREE
AMERICA
CHAPTER FIFTEEN
NOBODY THREW INSTRUMENTS ON THE FLOOR
I went to America at the beginning of 1978, leaving behind my sports car, my apartment, and my life in London—not to mention an ascendant career at the Brompton. Not long before I left, I was interviewed for a multi-institutional job as senior surgical registrar at the Brompton, the National Heart Hospital, and the London Chest Hospital. Competition for the job was intense. Of the many applicants, I was the youngest. At the end of the interview, after discussing my experience, I was asked about the rest of my life.
“What are your hobbies?”
I said I had none.
“Well, what do you do in your spare time?”
Again, I said I had none.
“Well, then, how do you relax?”
I said I relaxed in the OR.
I was offered the job.
But America beckoned. The future of heart transplantation was being born at Stanford, and I desperately wanted to be part of it. I took a deep breath and turned my back on what many heart surgeons would have considered the chance of a lifetime.
California reminded me of Rhodesia. After a decade in England, it was like coming home. The smells, the weather, the flowers were all familiar in a way the concrete gloom of London never could be. Shumway had sent a car to meet me at the airport, something that I was to learn later he rarely did. The driver, holding a sign with “Dr. Jamieson” on it, was waiting for me in baggage claim. We drove down Highway 101, and he dropped me at the Riviera Motor Lodge in Palo Alto. It had been a long trip, but I quickly showered and was soon hurrying across an immense parking lot—the hotel was next to a shopping center, something I’d had little experience with—in search of the Stanford hospital. When I got there and asked for directions to Shumway’s office, I was surprised that nobody seemed to know who he was.
I found Shumway in a nondescript wing of the hospital. I was excited to meet the hero of heart transplantation, who at fifty-four was in the prime of his career. He was dressed in scrubs. Shumway led me into his modest, uncarpeted office. There was a small desk and one chair in it. The room itself was barely big enough for the furniture. Shumway asked me to sit down and perched himself on the edge of the desk. As I would see in the coming months, Shumway never made a show of being an internationally acclaimed surgeon. He seemed to be content that nobody at Stanford paid him much attention. This only elevated my opinion of him.
We talked for a half hour. Shumway asked about Paneth, the Brompton, and my expectations for the coming year at Stanford. I told him I wanted to do clinical work, and that I was mainly interested in heart surgery and transplantation.
“You’d better go see Patrick Rooney,” he said.
Rooney was Shumway’s chief resident. He was tall, wore glasses and had a broken nose. He’d been in the navy after medical school. After that he’d done a residency in cardiology before starting in general surgery and then cardiothoracic surgery at Stanford. He was older than most of the senior residents, always composed, and a great clinician. When Rooney wasn’t in the OR, he was always smoking a cigarette, carrying it in his left hand and holding a can of Coca-Cola in his right. I was delighted that he seemed to like me.
My fellowship stipend wasn’t enough to live on and cover my obligations in London. Somehow I’d have to stretch my meager resources. It began to sink in that I was starting over in more ways than one. Working with Paneth, I’d been doing heart surgery on my own. At Stanford I was the most junior person in Shumway’s group, and as far as they were concerned, a nobody. I would have to prove myself all over again.
I was also a stranger in a new country. Having rarely left the hospital in London for the past several years, I was ignorant about many things that are a routine part of daily life for people who don’t work nonstop. As soon as I could, I bought a secondhand bicycle to get around on. I read something about how you were supposed to have a license for a bike. So I set off to find one. After making some inquiries and getting a lot of funny looks, I was told that I might get a license at the fire station. The firemen were amused when I explained what I wanted. But they dug around and managed to find a bicycle license, which I purchased and dutifully attached to the bike, taking care to follow the instructions about affixing i
t to the wheel hub. I think it was the only bicycle license they had ever issued. And I’ve never come across anyone else who had one. I soon learned that Britain is less keen about rules than America is, but in Britain you don’t break those rules. America is awash in regulations, but many are ignored or winked at.
I found an apartment in East Palo Alto, the wrong side of the tracks. It was a poor area and generally regarded as unsafe at that time. The apartment was just one room on the ground floor of a flimsy-looking complex. I didn’t think too much about it because I knew I’d stay at the hospital most of the time. When I did go home, I rode my bike each way, usually in the dark. It was a rainy year, and I’d get home or to work soaked through. In London I’d taken to wearing cowboy boots, and now found that everybody in Shumway’s group did, but these would fill with water on the way, increasing my misery. I’d expected California to be hot and dry.
One night as I was riding home, I saw a garbage can by the curb that had a coat hanging out of it. I stopped. The coat was old and worn but serviceable. I put it on and went home. I kept it for many years, long after I could afford a new one, to remind me of the days when I couldn’t.
I hadn’t been at Stanford long when I arrived home one night to find my apartment door open. The place had been ransacked. As far I could tell, nothing was gone. I mentioned the incident to Shumway, telling him it was humiliating that at age thirty, having worked hard all my life, I had accumulated nothing worth stealing in even the poorest part of town. He laughed and said the burglars must have figured I was one of them and let me keep my things. On another night, I came home in the dark to find a bullet hole in the window. I dug the spent bullet out of the wall.
I learned how dangerous East Palo Alto was when we had a young boy from Belgium in for a heart transplant. His father had come with him, and while the boy was recovering after surgery, the father visited a bar in my neighborhood. He was accosted by a man with a gun demanding money. Things like that didn’t happen in Belgium, and the father refused to turn over his wallet. The gunman shot him in the pelvis and took his money. The father was brought in to the emergency room at Stanford. His femoral artery and femoral vein were lacerated, and he was bleeding badly. We operated and saved his life. Unfortunately, his son had severe rejection and never left the hospital.
For the first six months of 1978, I worked as a junior resident. This turned out to consist almost entirely of looking after postoperative patients. On a good day, I might be allowed into the operating room to harvest a vein for a coronary bypass operation. Shumway’s group had a saying that until you had taken a hundred miles of vein, you weren’t allowed to do heart operations.
The other junior resident was Ronald Ponn. Ponn was from Boston and came from money. He lived in a big house on a hill with his second wife. Ponn talked while holding a cigarette between his teeth. We spent most of our time in the intensive care unit that was reserved for Shumway’s heart-surgery patients. The nurses on the unit were assertive, as they had to be, and functioned like junior doctors. They knew a lot, and you were well advised to listen to them.
Shumway seemed always to know everything that went on in the hospital, every detail about the patients, about the staff, about the nurses, even the gossip. He managed this by being on good terms with the nurses, who called him Uncle Norm. Nothing happened that the nurses didn’t know about, and they confided in Shumway, who never let anyone think he was their superior.
Shumway’s lieutenants were Ed Stinson, whom I’d heard speak in London, and Phil Oyer. They were close friends and unconventional. Ed chain-smoked. Phil chewed tobacco. They always wore cowboy boots. Once a year they would go on a horseback cattle roundup together, driving a herd of cattle from its summer to winter pastures. Both of them loved guns. Ed was skinny as a rake, and we used to say that even his tapeworm had a tapeworm. One weekend he shot himself in the leg while practicing his quick draw. He was brought to the emergency room at Stanford. The wound wasn’t serious—he’d managed to miss everything important. The emergency room doctor called Shumway at home and said, “Ed Stinson has just shot himself.”
“Well, I knew things were bad,” Shumway said drily, “but surely not that bad.”
Stinson and Oyer were unflappable in the operating room. Ed always wore a red bandanna tied around his head instead of the standard cap. There were two ORs on the cardiac unit. Shumway was in room 13, Ed and Phil in room 12. Ed and Phil’s service was called l’otro, “the other,” service. Shumway was before his time in believing that a general surgery board certification was unnecessary for a cardiovascular surgeon. Both Ed and Phil had skipped years of general surgical training to gain extra time in cardiac surgery. They were among the best I’d ever seen. Neither had taken the general surgery boards, which meant they weren’t certified in cardiac surgery, either, because you needed general surgery boards in order to take the cardiac surgery boards. It took years for others to see it Shumway’s way. Today, both in Europe and the United States, surgeons going into cardiac work spend less time in general surgery, which makes sense.
Oyer was experimenting with a left ventricular-assist device. This was an implantable electrical pump that took blood from the left ventricle, the main pumping chamber of the heart, and pumped it into the aorta, the main artery to the body. The idea was to develop an assist device that could buy time for a patient waiting for a transplant. Such a device could always be on hand and would require no immunosuppression. Oyer spent every Thursday on this project, putting the pump into calves, checking the feasibility of the surgery, and studying the hemodynamics—that is, how effectively the pump could take over the circulation. Phil’s research led to the first practical artificial heart-support device.
My first six months at Stanford were not a happy time. I was cold and miserable. I found the work tedious and uninspiring. One morning, on my way in at around five a.m. in a downpour, the chain came off my bicycle and I crashed into a ditch, badly scraping both arms and one leg. I lay next to the broken bicycle in the dark, bleeding and in pain, wondering how I could have done this to myself. My career was going in reverse. I thought about being back at the Brompton, doing heart surgery on my own every day, driving around London in the Triumph. But I realized that going back would be admitting defeat. I had to stick it out.
Ron Ponn and I alternated every other night on call, sleeping in a bed in the intensive care unit. But I rarely went home on my off nights. There wasn’t much point in riding back to my crummy apartment only to get up again a few hours later to shower and ride back to Stanford, still in the dark. It was easier to stay at the hospital, where it was warm, food was available in the cafeteria downstairs, and I could keep an eye on the patients. When Shumway had performed a particularly challenging operation on a child who was unstable afterward, I napped in a chair at the foot of the bed even if Ron was on call that night. He would be busy enough, as the rest of the beds in the intensive care unit were usually full.
Not everything was bleak. I learned new techniques and experienced a different atmosphere in the OR. At the Brompton there was often tension in the air. Senior surgeons thought nothing of exploding angrily at someone in the middle of an operation. At Stanford, it was relaxed. There were no raised voices. Nobody threw instruments on the floor or looked for somebody to blame when a mistake happened. Operating was calm and fun. Shumway had a sense of humor. In difficult moments, he would relax everybody by telling a joke while the problem got fixed.
Shumway was not particularly fast in the operating room, but his judgment was impeccable. He always knew just what to do, and how to do just enough and no more. Paneth may have been technically better, but it was Shumway’s judgment that set him apart. I’ve long since realized that this, more than anything else, is the hallmark of a great surgeon.
There are a few people who become surgeons who are complete naturals. They’re born with a knife in their hands. And then there are the majority, who work hard and become competent. And there are a few who should
not be allowed inside an OR. But technical skill doesn’t count for much if you lack judgment.
Say you have an eighty-five-year-old woman who needs an aortic valve replaced. Many of the heart surgery patients we see have multiple problems. So maybe in addition to the aortic valve there’s a partial blockage in a coronary artery, the aorta has a minor aneurysm, and the mitral valve leaks a little, too. Your job is to give this patient another few years of life—not to fix everything that’s wrong with her. You have to know when to stop. In a case like this, you do the aortic valve and close her up. A surgeon without good judgment will do more than is necessary, repair all of it, and then be surprised when the patient never comes off the heart-lung machine. When you worked with Shumway, you learned that in heart surgery, less can be more.
I never missed an opportunity to be involved in a transplant case. I went out on the donor runs, flying to remote hospitals to retrieve a heart. These were still early days, and nobody else in California was transplanting hearts. That meant that we had no competition for donors. We took an operating room nurse, a technician, and a medical student with us. We’d get on a plane, often at night, wearing scrubs. Time was critical, especially on the return. The longer the heart was out of the body, the greater the risk to the recipient. On one donor run, we flew to a hospital about five hundred miles from Stanford. After taking out the heart and putting it on ice, we rushed back to the small airfield in the early hours of the morning and took off into the dark. Well into the return flight, we realized we had left the scrub nurse behind. She had gone to the bathroom in the airport, and we had departed in our customary haste without noticing she wasn’t onboard. We didn’t have the time to go back. The nurse reappeared at Stanford three days later, still in her scrubs, and unhappy. She had not taken any money with her and must have had a rough trip back. There were no cell phones then, of course. We never got the full story, because it was several weeks before she would speak to us.
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