Close to the Sun

by Stuart Jamieson

  The patient, a physician from Texas, did well. He was the first of twenty-five heart transplants I did over the next twelve months. This was more than half the world’s total over that span. To match that today, you’d have to do as many as eight a day, every day. Sir Terence English later told me that after starting his heart transplant program in Cambridge in England, he did eleven heart transplants between August 18, 1979, and July 31, 1980. So, between us, we did three-quarters of the world’s transplants during that period. One patient that I transplanted that October in 1979 remains alive and well today and is the longest living heart transplant patient in the world.

  My first heart transplant, July 4, 1979–being assisted by Ed Stinson in his trademark bandana.

  Being Shumway’s chief resident was hard work but also stimulating and a great privilege. I reveled in it. In addition to transplants, we did two routine heart cases every day in Shumway’s room, ten a week—plus emergencies. Shumway would always be present for the main parts of the operation, standing on the patient’s left—the assistant’s side. He was so good that he could operate from the assistant’s side at any time, something that would befuddle many skilled surgeons. He never asked to change places. We would operate together, like partners moving in unison across a dance floor. This was surgery as good as it gets—quick, effective, safe, and fun.

  Shumway was great company in the operating room. We would talk about everything—the patients, politics, gossip, the future. He was invariably considerate and generous. Shumway was shorter than me and always asked for a stool to stand on. He could have lowered the table to a height that suited him, which is what all my other chiefs would have done.

  I was used to working hard, but now my load was doubled as the transplant chief resident and Shumway’s chief resident. While Shumway and I were scrubbing in for a case one day, one of the nurses said, “Dr. Shumway, you’ve got to let Stuart have some rest.”

  “One of these days, he’s going to get a good long rest,” Shumway said with a small smile, “and there’ll be nothing he’ll be able to do about it.” He was making a joke that had an element of truth in it that I understood completely. I wanted to make the most of every minute of what I was doing.

  As exhilarating as the work was, I never forgot what was at stake. You might think a heart surgeon works behind a kind of protective wall, insulated from bad outcomes by the knowledge that you’re operating on patients with no other option, patients who, if they die in surgery, were already living on borrowed time. If you fail, your failure can be at least partially excused. But I have never felt that way. To me, nothing is more important than making a patient’s last hope his or her best hope. I became a surgeon to fix people. I always believe that I will—and I am devastated when I can’t. It’s rare nowadays to lose a patient in surgery. We have so many assist devices to keep someone alive that they usually make it out of surgery. But it can happen, and it used to happen more often. When it did it was awful. You feel drained, almost paralyzed. An inner voice tells you that you just killed someone. Even if the case was hopeless and there was nothing you could have done to change the result, you cannot alter the fact that the patient came into the OR with a beating heart and did not leave the same way. It doesn’t matter if the patient would have died the next day. You may have done everything right, but you were still the instrument of someone’s death.

  I remember everyone I’ve lost.

  There was a heart surgeon in private practice who sometimes operated at Stanford who was not part of Shumway’s team. He wasn’t as good as we were, and Shumway resented him. When a patient came to Stanford for heart surgery, they assumed they were being treated by Shumway’s group. Shumway believed this other doctor’s poorer outcomes reflected badly on him. When the guy—we’ll call him Dr. Smith—disappeared for a time, Shumway turned to a nurse in the middle of an operation.

  “I haven’t seen Dr. Smith for a while,” he said.

  “Oh, he’s away because his father died,” the nurse answered.

  “What happened?” Shumway shot back. “Did Dr. Smith operate on him?”

  John Wayne, the actor, who lived in Los Angeles, had decided to travel across the country to have a heart valve replacement at Massachusetts General Hospital, ignoring Stanford, which offered the best heart surgery anywhere. After Wayne’s upcoming surgery became public, Shumway came into the operating room and was not his usual pleasant self. After a long silence, he said, “I don’t care if John Wayne’s going to the Mass General to have his heart surgery.”

  Nobody answered him.

  The next day the same thing happened. After staying quiet for a time, Shumway said, “I don’t care if John Wayne’s going to the Mass General to have his heart surgery.” The next day, he did it again. Finally, on the fourth day, Shumway brooded in the OR for what seemed an eternity until he said, “I don’t care if John Wayne’s going to the Mass General to have his heart surgery, leastways, not nearly as much as John Wayne’s going to care!”

  Despite the tremendous advances we’d made, heart transplantation remained risky. Outcomes were uncertain. We were still refining immunosuppression regimens and learning how to treat the rare infections we would see in immunosuppressed patients. We weren’t yet using cyclosporin in the human patients. All of this meant that we had to be selective about whom we accepted for transplantation, and we had many more prospective patients than we could take.

  At first, the upper age limit for a candidate was fifty. Then it rose to fifty-five. Over the years, as Shumway got older, it went to sixty, sixty-five, and then seventy. The patients had to be of exemplary character and have the social and family support necessary to ensure that they would commit to taking their medications for as long as they lived, as failure to do so would be fatal. If a patient had a drug problem or alcoholism, they were out. It was the same for divorced patients, the reasoning being that a spouse was the one person who could ensure compliance with medication. This restriction was lifted over time as almost all the cardiac surgical faculty got divorced. At our transplant meetings, I would look around the room at all the wild, diverse, and immensely talented characters Shumway had brought into the inner circle of his team and wonder how many would pass the stringent tests of respectability we had devised.

  A famous film actor from Britain, a household name, was referred to us with end-stage heart disease. He needed a transplant. He had already had unsuccessful coronary artery surgery. We turned him down because he was fifty-four, which at the time was over our limit. He died shortly thereafter. Times change. Today, we have no real age limit. A fifty-four-year-old transplant patient would now be considered relatively young.

  I have learned not to look over my shoulder at the past. You cannot live your life backwards. We live now in a medical world no one believed possible a hundred years ago, when you could die of a trivial infection for lack of antibiotics. But I have often thought of that actor. If we had accepted him, he might still have died before we found a donor, or he might have died after his transplant. Nothing was for sure. But he might have lived on, too, perhaps for a long time.

  The link between the lab and the clinical service remained strong. We relied on Charlie Bieber’s rabbit ATG. Although I no longer had time to do lab experiments, I kept tabs on what was happening. Heart transplantation was considered experimental, and as we were almost the only ones doing it, we were given a lot of latitude to take chances—to try things that would never be permitted now. Our patients had little to lose.

  One day Bieber asked me if he could use one of the monkeys to make monkey ATG. He figured that their ATG might work better than rabbit ATG, because they were primates. This made sense, and I told him to go ahead. A couple of weeks later, he came to me with a vial of bloody fluid, his first batch of monkey ATG.

  “Let’s try it intravenously,” he said.

  For a second, I wasn’t sure what he meant. Then I realized he was talking about giving it to one of the patients.

  “Whoa,
Charlie,” I said. “That stuff looks pretty poisonous. Why is it so bloody? If you want to give it as an IV, let’s at least give it to a monkey first.”

  Bieber went off a little crestfallen. He came back the next day to say it had been a good decision. The monkey he gave it to died overnight. Charlie went back to work and a few weeks later came back to me with a vial of clear fluid. I agreed to give it, but only intramuscularly. It seemed to work. Since there was no adverse reaction, we then tried it intravenously. Again, all was well. We set up a regimen in which we gave the monkey ATG intramuscularly and then intravenously on alternate days. The theory was that the lymph nodes were at least partly responsible for producing the lymphocytes that were rejecting the heart. By giving the monkey ATG intramuscularly, the lymphatic channels would absorb it and take it to the lymph nodes where it could disrupt the lymphocyte factory. By giving it intravenously the next day, we would take out any lymphocytes that were already in the bloodstream. It worked.

  We biopsied the hearts of our patients every week. This was my job. A biopsy of the heart muscle gave us early warning of rejection. Every night, after a long day of surgery, I would take one or two of the heart transplant recipients into the operating room, and under local anesthesia, slip the long forceps into the big vein in their necks and down into the heart. I had to be quick, because this wasn’t part of my regular surgery schedule. I must have done thousands of these biopsies. I got so I could do one in under ten minutes.

  I knew all the transplant patients intimately. In those days, they were in the hospital for two or three months after surgery. Seeing them several times a day, I soon knew everything about them. Late at night, if they were still awake, I would stop by to chat, or to play backgammon with them. One patient I’ll never forget was named Betsy. She came to us from San Diego with an inoperable tumor in her heart. The cancer hadn’t spread, but because of the tumor’s size and location, it couldn’t be removed. After some discussion, we decided we should remove the tumor and heart together and do a transplant. Betsy, who was only nineteen, went to work in our office filing and doing odd jobs while she waited for a donor.

  Heart transplants are usually done in the night. That’s because most donors are declared brain-dead during the day, so it’s after dark by the time you’ve organized a team, harvested the heart, and brought it back. We did Betsy in the night. The tumor had enlarged her heart so much we had difficulty getting it out of her chest. But otherwise the operation came off smoothly. We later wrote up our experience in the Journal of Thoracic and Cardiovascular Surgery.

  After her surgery, Betsy did well. She was discharged and went home to San Diego. Two years later she got pregnant and called me to discuss the situation. Though she was not married, she wanted to have the baby. No one before had ever had a baby after heart transplantation. I was not worried about the ability of the transplanted heart to support a pregnancy and the delivery. The unknown was whether the drugs she was on to prevent rejection could harm the fetus. Determined to see the pregnancy through, Betsy decided to take the chance. She had the baby, and everything was normal.

  Shortly after the delivery, I got a call from a newspaper reporter in San Diego. He asked me if I knew a heart transplant patient named Betsy.

  I said of course, she was my patient.

  “Do you know she has just had a baby?” the reporter said.

  I told him that I did know, and that I’d discussed it with Betsy.

  “Are you aware that she is unmarried and she has called her baby Sierra Jamieson?” the reporter continued. “What have you got to say about that?”

  I told him to get his mind out of the gutter, and that I was honored that she chose to name her baby after the person who had saved her life. I thought I’d set the record straight, but I should have learned a better lesson about dealing with the press—as I would painfully discover a few years down the road.

  Betsy and I stayed in touch. Eventually she developed a tumor in her brain that forced her off her medication. She died of heart rejection. Her daughter, Sierra, was raised by her grandparents. She is now in her thirties and has a family of her own.

  Although Shumway was in charge of the entire program and did more general cardiac cases in both adults and children than the other surgeons, I never saw him do a heart transplant or even assist on one during the time I was at Stanford. The transplants were always done by the chief resident, assisted by either Ed Stinson or Phil Oyer in the early days, and later also by Bruce or me.

  We had our own cardiac anesthesia group, and our own OR nurses in the cardiac unit. It was a good standard of care that emphasized experience and continuity. When I was chief resident, Bill New was one of the staff anesthesiologists. Bill earned a master’s degree in electrical engineering from Stanford, then did his medical training at Duke, followed by a PhD from UCLA. When we were operating together, he spent a lot of time under the drapes that covered the patient, fiddling with a new machine he was inventing. It turned out to be a pulse oximeter.

  When he was six, Bill had built a crystal radio set as a Boy Scout project. He loved to tinker. The idea for the pulse oximeter came to him when he remembered how on camping trips as a kid he sometimes put a flashlight behind his hand—which was illuminated sufficiently that he could see the pink color of the blood inside. He turned this into a device that clipped onto the fingertip to monitor oxygen saturation in the bloodstream. When oxygen levels fell, the color changed. After perfecting his invention for a year and a half in our OR, New founded a company to manufacture it called Nellcor. In 1995 he sold Nellcor for $2 billion.

  When I knew him, New was just one of the guys helping us get through the difficult problems of the day. Ed Stinson, Bill, and I were sitting around in the surgeons’ room waiting for a donor heart to arrive one night. It always took longer than we expected, because livers and kidneys were usually harvested by other transplant teams from the same donor. The teams all came from different places, usually by private jet. Coordinating the donor surgery took time. While Ed and I were talking, Bill arrived with some Chinese food, which he offered to share with us. I eagerly accepted, but Ed just took another draw on his cigarette. “No, thanks,” he said, “I get by on Marlboros, a can of Coke, and chocolate cake.” It was probably true. I never did see him eat a meal.

  Craig Miller joined the faculty when I was chief resident. Miller was a character, a cowboy at heart. He was always in boots and a cowboy hat. Shumway told a story about when Miller was a medical student and first scrubbed in with him to assist on an operation. Shumway noticed a brown stain spreading over Miller’s mask. Ignoring this at first, Shumway was alarmed to see that the stain grew until it covered the whole mask. Shumway sent him out of the OR. Miller had never scrubbed before. He hadn’t realized that he wouldn’t be able to spit out the tobacco he chewed incessantly, and had gone into the OR with a mouthful. After a while he’d felt a little sick and started dribbling the chew into his mask.

  In 1980 there were only three cardiac centers in the world doing heart transplants: Shumway’s group at Stanford, Dick Lower’s group at the University of Virginia, and the bunch at Cape Town. Stanford was the unquestioned leader. We had visitors from around the world who came to find out what we did that they couldn’t. The answer was our history—years of dogged laboratory research by which we’d learned to diagnose and treat rejection.

  The year flew by. Toward the end of my time as chief resident, Shumway asked what I was going to do the next year.

  “Why, sir, I will be going back to the Brompton,” I replied.

  “Why don’t you just stay?” he said. This time he didn’t add “for another year.”

  I told him I would be delighted to. And that was it. I was going to be appointed to a permanent staff position at Stanford. There was no discussion of salary or what my job would be. I didn’t know if I’d even have an office. And certainly there was no contract. I just said thank you and we shook hands.

  I called Paneth. He didn’t seem sur
prised; I think he had an idea all along that this might happen. He said he was happy for me.

  CHAPTER SEVENTEEN

  WINNING HEARTS AND MINDS

  I joined Shumway’s staff at Stanford in July 1980, a year after Bruce Reitz and Craig Miller had come aboard. Counting Ed Stinson and Phil Oyer, I was now the sixth person in the group. Ed and Phil operated in room 12, and Bruce had joined Shumway in room 13. Shumway now generally did the morning cases and Bruce the cases in the afternoon. Bruce was still in charge of the lab, and work continued with cyclosporin and the monkeys. The new chief resident who took over that job from me was John Wallwork, a young English surgeon who had been recommended to Shumway by Terence English in Cambridge. He was coming for a year’s fellowship.

  Wallwork was a jovial sort and got on well with Shumway, who appreciated his sense of humor. When he arrived, Wallwork was surprised that Shumway never used cardioplegia, a cold solution that is injected into the aorta to stop the heart and preserve it while it was being worked on. Shumway had extensive experience with the use of cold saline applied topically. His method was simply to clamp the aorta and bathe the heart in cold saline that was continuously run into the heart cavity. Shumway’s outcomes were impressive, unmatched anywhere in the world. But Wallwork was skeptical. When he first assisted Shumway at an operation, he watched as Shumway clamped the aorta, stopping the heart’s blood supply, started the cold irrigation, and got on with the operation. At first, the heart fibrillated, and continued to do so until it got really cold. Sensing that Wallwork was apprehensive, Shumway said, “You see, the heart is getting really cold.”

  Wallwork, looking down at the quivering, fibrillating heart, said, “Yes sir, I can see it shivering!”

  After I joined the faculty, Craig Miller and I shared an office. He was the only one in Shumway’s group who had nothing to do with the transplants and had not even looked after postoperative transplant patients as a resident. But he was an excellent technical surgeon. He did every kind of heart operation other than transplants. His main interest, though, was vascular surgery. Shumway made him head of the vascular service and also the cardiac unit at the VA hospital, about ten miles away in Palo Alto. Our office was small, with barely room for two desks. I had to get up and step out to make way for him to get in, and vice versa. Fortunately, we were both so busy that it was rare for us to be in the office at the same time. Craig went on to gain an international reputation as a vascular surgeon, and became the president of the American Association for Thoracic Surgery.