Then it was time to go to Boston. My surgeon, the first time he met me, laid heavy emphasis on the risks I faced, the possibilities of infection, heart failure, and death. (“I think he does that,” Mike Freed confided, “because his wife is a lawyer.”) A social worker walked me through the steps of the procedure and explained that I would wake up with a breathing tube down my throat.
“What does that feel like?” I asked.
“Well,” she said, breaking from her smooth presentation, “it’s never happened to me.”
The night before surgery, we stayed in a hotel. Eliza woke at midnight, and Marcia went to tend to the baby, but I said, “No. I’ll do it.” I wasn’t sleeping anyway. I had nothing else on the agenda for that night. I got her from the port-a-crib and held her, sitting at the edge of the hotel bed. I thought, if this was the last night of my life, this was how I wanted to spend it, soothing my daughter one last time, letting my wife sleep.
PART THREE
The Open Heart Club, Reprise
27.
MY MIND CAME back very slowly. Out of a very deep darkness, it returned a little bit at a time. The first thing I was aware of was eighteen words, there in the blackness. I didn’t hear the words or remember them. They were like a hallucination.
James James Morrison Morrison Weatherby George Dupree
Took great care of his mother, though he was only three.
The skin of my shaved chest was sutured and bandaged and taped. A tube ran into the left side of my chest, sucking out fluid. My chest bone was bound together by staples. The heart itself was stitched up with a new valve inside, one that had come from a pig. Two wires slipped through the skin, attached on one end to an outlet in the wall, then to a pacemaking machine, and then to my heart. Into my arm went the IV tubes of saline fluid and antibiotics and morphine, and out of my penis came the catheter that went to the bag that held whatever leaked out of me. In my mouth was the breathing tube, filling my lungs with oxygen every ten seconds. But I didn’t know any of that. Just the little snatch of Winnie-the-Pooh, that’s all, a bit of the A. A. Milne poem my mother must have recited to me thirty years before, the first time I had open-heart surgery, when I was just five years old. That little rhyme was the rope my mind grasped onto as it made its way back.
It was a very long way up, a long time coming to consciousness. The first physical awareness was of the breathing tube, which I imagined as a gun-shaped pipe, maybe two inches wide, shoved all the way down my throat. I felt it pressing into the cartilage of my windpipe. Whenever I tried to inhale, the tube’s airflow shut off, and I was strangled back to unconsciousness. Then the tube gave me oxygen, reviving me just enough so that I tried to take a breath. As soon as I tried to do that, I was suffocated. And once I was knocked out again, it gave me oxygen. Again I woke up and tried to breathe. Again, the tube strangled me. This went on for a while, awake, strangled, asleep, awake, strangled, asleep.
I remember a clock on the wall, but I doubt that my eyes were open. I’m not sure I could have opened my eyes if I’d wanted to. But that’s what I saw, each time I came to, before the tube strangled me and I passed out again, a black-and-white kitchen wall clock with two hands and twelve numbers, about a foot and a half from the ceiling of an ordinary white wall. It was a couple minutes to midnight. Sometimes the clock moved forward. Sometimes back. Then in the darkness a woman’s voice came to me. They were going to roll me on my side, she said, for extubation. There would be some discomfort.
I felt the pressure on my back. I felt the tilt, the turn onto my left side. The split halves of my sternum scraped against each other, like teeth grinding in the middle of my chest. I felt the staples that held together my thorax. There was the shock without the sensation of pain. All my nerves flamed, but they were disconnected from my brain, or from the part of my brain that knew what pain felt like. I understood that there was a rip down in my bones and viscera, but I didn’t exactly feel it. I felt very frightened. The tube felt very long. It came out with some gummy mucus, and when it was out, my mouth felt like it had been frozen, dried, and vacuumed, which is more or less what had happened. They lowered me onto my back again, and my body and bones and the tubes and needles all fell back into place. I think I fell asleep.
Out of the dark, my family came close. Marcia was there, and so were my parents. They asked what I wanted. I couldn’t talk. Someone had the bright idea to ask me to write, and I tried scribbling something. I don’t remember the pad or pen. My hand was like a flipper. I managed to scrawl the word “drink.”
“He’s thirsty!” they celebrated.
The nurses said that they couldn’t give me water, but they agreed to let me have a spoonful of ice chips, which melted in the desert of my mouth. My heart was still not beating on its own.
28.
OPEN-HEART SURGERY WAS an invention of the 1950s, and like rock-and-roll, another great American invention of the time, it seems like the brainchild less of a single person than of an entire nation.
Heart surgery began with kids like me, and it began in Minnesota. For decades, doctors had been operating around the heart, even on the great arteries above the heart, as in the Blalock procedure, but the breakthrough came when they were able to put their patients on bypass, connect them to a heart-lung machine, and open up the heart itself. This happened first in two places in Minnesota: Minneapolis and Rochester. When in the mid-1950s young physicians like Jim Malm and Sylvia Griffiths wanted to learn what was happening in cardiac medicine, they went to the Mayo Clinic in Rochester to see John Kirklin work or to the University of Minnesota to see Walt Lillehei.
Kirklin and Lillehei were the Beatles and Stones of heart surgery, the Bird and Magic, the Tolstoy and Dostoevsky, competitors and partners, driving each other forward, driving medicine toward its new frontier. Kirklin was more dispassionate and technically minded; his biographer nicknamed him “the Ice Man.” Lillehei was impulsive, creative, and wild, a rule breaker. In his memoir, 100,000 Hearts, Denton Cooley describes a trip he took to Minnesota in 1955, along with a few other young, aspiring heart surgeons. In Rochester, Kirklin was gracious but formal. He had Cooley and company over to his house for dinner, where his wife served them a pleasant meal concluded with a “thimble full” of sherry. Kirklin put everyone to bed before nine, saying there was work to be done early the next day. He met them in the hospital in the morning, and they watched him operate. From Mayo the young doctors went to Minneapolis, where they met Lillehei, blond and blue-eyed, with a chin like a movie star’s and a frightening scar on his neck.
For dinner Lillehei took the junior surgeons to what Cooley calls “a little road house on the edge of town,” where the bartender said to Lillehei, “Howdy, Doc, gonna have the usual tonight?” The usual for Lillehei meant four double martinis before a steak dinner, and then three more after, and then dancing with the waitresses. Cooley struggled to keep up. He and his friends crawled back to their hotel rooms in the early morning. Headachy and bleary-eyed, they hustled to the hospital the next morning to find that Lillehei had not yet arrived. At 10 a.m., an hour after the surgery’s scheduled start, Lillehei wandered in “looking clammy, sweaty, and in need of medical attention himself.” The patient was a small child with a hole in his heart. The heart-lung machine was a bubble oxygenator of Lillehei’s design. Hungover and maybe still a little drunk, Lillehei was unimpaired. He performed the operation “superbly and successfully,” wrote Cooley.
“Every ‘original’ genius,” wrote W. H. Auden, “be he an artist or a scientist, has something a bit shady about him, like a gambler or a madman.” Lillehei had a genius unusual in a great heart surgeon—he was prodigiously imaginative, while most heart surgeons are methodical, careful men—and Lillehei was certainly a little bit shady. In the 1950s, he was heart surgery’s foremost inventor, teacher, mentor, fund-raiser, and promoter. He was also a party animal who didn’t mind working outside the law, and his run at the top of his profession burned out soon after it peaked. Late in his
career at the University of Minnesota, he crashed his speedboat, drunk and driving late at night. His wife’s pretty face was broken and damaged when it smashed against the dashboard. When the hospital didn’t promote him to chief of surgery, Lillehei packed up all his equipment and drove to New York, leaving a single long-stemmed red rose on the floor of his lab. In Manhattan in the late 1960s, while his wife stayed in Minnesota, Lillehei lived the life of a swinging bachelor, got into bar fights, alienated his colleagues, and was convicted of tax fraud. Perhaps the single-most influential heart surgeon in history, he spent his last decades humiliated and unable to practice.
Lillehei was born in 1918 in Edina, a suburb of Minneapolis. His father was a dentist, the child of Scandinavian immigrants, and his mother a pianist. Walt skipped two grades in elementary school but was bored in high school and struggled to pass chemistry. From the start, he was not impressed by authority. “I didn’t necessarily believe in signs that said, ‘don’t do this,’ or ‘don’t do that,’” he said. “If I had a reason to do it, I usually did it.”
He remodeled his toy BB gun to shoot .22-caliber bullets. With scrap parts and no manual, he built himself a motorcycle. Walt thought he’d become a dentist like his father, but when he discovered that the entry requirements were the same for medical and dental school, he thought, Why not? And he set out to be a doctor.
At the University of Minnesota, he fell under the spell of Dr. Owen Wagensteen, chair of surgery at the university hospital. Wagensteen was a compelling lecturer and a driven man. He had grown up on a small farm run by his Norwegian father, tending to piglets and hauling manure. When Wagensteen came to the University of Minnesota in the late 1920s, the place was a backwater, but he had a vision. He gathered around him a faculty devoted to surgical research, let them pursue their goals aggressively, and built one of the great surgical departments in history.
As an inventor, Wagensteen is best known for an abdominal suction tube that saved the lives of soldiers with gunshot wounds. (There’s an Ogden Nash poem that goes, “May I find my rest in / Owen Wagensteen’s intestine.”) As a surgeon, he advocated aggressive, radical cancer operations, including the hemicorporectomy, the cutting off of a person’s bottom half, and the eviscerectomy, in which the surgeon took out the bladder, gonads, lymph nodes, spleen, rectum, kidneys, and a chunk of the colon. He had a drunken son who was in and out of prison and a wife who hated him. She knew Wagensteen was afraid of snakes, so she often sent them to him, wrapped up as gifts.
In 1938, when Walt Lillehei was twenty, he heard Wagensteen lecture about experiments he had performed on the appendixes of tigers and bears. According to King of Hearts, G. Wayne Miller’s biography of Lillehei, that was when Walt decided to become a surgeon. He wanted to work with a man who wrangled wild animals. Lillehei finished medical school and, like most doctors of his generation, headed off to war. He crossed the Mediterranean with the US troops and landed in Italy at the Battle of Anzio, where the Allies were pinned down in marshes and Germans shelled them from above.
As a surgeon in a MASH unit, Lillehei saw carnage. “I’ve certainly seen more of the horrors of modern warfare than I ever anticipated,” he wrote home. It was his job to award Purple Hearts to wounded soldiers. “It’s a beautiful medal,” he wrote, “but not much to give a man in return for his leg, arm, or face.”
World War II, as much as any single physician, drove the development of cardiac surgery. The US Army built the first surgical ward specifically devoted to wounds to the heart. The military bestowed the grants that led to the development of the cardiac catheter. Ultimately, it was the war effort that led to the great US government investment in medicine. Between 1941 and 1951 the federal budget for medical research grew from no more than $3 million to $76 million. Before the war, penicillin was expensive and difficult to produce, but it was needed on the battlefield. The Federal Committee on Medical Research teamed with Bradley Polytechnic Institute in Peoria, Illinois, and before war’s end penicillin was being manufactured cheaply in 15,000-gallon drums.
Harvard doctor Dwight Harken had been experimenting with surgeries to remove infectious growths from the heart (before antibiotics were widely available, these things could develop, vegetations like algae blooms). In the war, he was stationed in England when bombs were falling on London. Soldiers from the European theater were arriving with horrific wounds to their chests, shrapnel lodged in their hearts, and if these wounds didn’t kill the soldiers outright, they led to infections of the blood stream, or to blood clots that caused strokes, or, best case, to a life of terror, with soldiers waiting, just waiting, for the metal shard inside to shift from its place and kill them.
As late as 1945, the prejudice against cardiac surgery was so strong that no other doctor wanted to touch patients with these wounds. Harken had to plead his case in order to get permission to operate, and eventually his superiors allowed him to create a unit specifically devoted to thoracic surgery and wounds to the heart. After a struggle, it was built: a set of sheet metal Quonset huts in the countryside by Cirencester, a small town in Gloustershire. These first operating theaters for cardiac surgery had neither insulation nor heating. They were freezing in winter and broiling in summer. But they were equipped with fluoroscopes, EKGs, and (most importantly) penicillin. Patients arrived by the truckloads with hideous wounds to their chests.
Harken failed in his first two attempts to remove shrapnel from the heart of Leroy Rohrbach, an infantry sergeant who had been wounded in a battle near the French town of Saint-Lô. An exploding shell had torn up Rohrbach’s chest, and a piece of metal had slipped deep into his heart. Harken was a large, red-haired man with a red face, a screamer and a shouter in the operating room, charming and garrulous outside it. His students later called him “the Great Red Man.” On August 15, 1945, Harken grasped the fragment in Rohrbach’s chest with his forceps, but it slipped from them and was swallowed up by the beating heart. In November, Harken tried again: again, he clamped the metal in his forceps, and again he lost it. Fluoroscopic images showed the fragment bobbing up and down with each heartbeat. Rohrbach was desperate. He begged the doctors to get it out of him. On February 19, Harken tried again.
He opened the sergeant’s chest and retracted the ribs, and this time got a good view of his patient’s ventricle. Before touching the metal, Harken placed a circle of sutures around the wound. Then he put a Kocher clamp—a scissor-shaped clamp like a forceps—on the shard. He gave it a pull. “Suddenly with a pop, as if a champagne cork had been drawn, the fragment jumped out of the ventricle, forced by the pressure within the chamber,” Harken wrote. “Blood poured out in a torrent.” Harken pulled on the sutures around the wound, and they shut tight like the strings of a purse. Still, blood came, and Harken pressed his finger on the opening. “I took large needles swedged with silk and began passing them through the heart muscle wall, under my finger, and out the other side. With four of them in, I slowly removed my fingers, as one after another was tied.” But Harken’s finger wouldn’t budge. His glove was stuck in the threads. “I was sutured to the wall of the heart! We cut the glove and I got loose.” Rohrbach’s chest was closed up. The patient survived. Eminent English surgeons visited the Quonset huts. Cameramen perched in the rafters above the operating table. Harken operated successfully on 134 chest wounds without a fatality and returned to Boston a hero.
Meanwhile, in Germany, a strange, solitary, driven doctor began entering the heart from a different direction.
The story of the cardiac catheter begins with Warner Forssmann, a urologist and card-carrying member of the Nazi Party. As Forssmann describes it in his memoir, Experiments on Myself, his childhood loves were technology and the kaiser. As a boy Forssmann saw the Wright brothers fly their plane when they came to Germany, and he was thrilled by military parades, the streets crowded with “cheerful, colorful, flag-waving people.” His father died in World War I, and Forssmann’s family was left penniless. They scrounged for rutabagas and fermented black bread. Fo
r Sunday dinners, his mother roasted crows. By the time he had entered university, Forssmann’s intellectual interests had shifted from aeronautics to medicine. He learned about a nineteenth-century French doctor, Jean-Baptiste Auguste Chaveau, who had inserted a catheter through a horse’s jugular vein and from there to the heart. Forssmann had a vision: he could slide a catheter into a human heart.
This was in the 1920s. The Weimar Republic disgusted Forssmann. “The ‘Golden Twenties,’” he writes in his memoir, “never were golden except for a small, self-indulgent group.” Forssmann fell under the sway of a Dr. Freidel, a pale wraith of a man who wore a dusty, black, and velvet-trimmed gown to work and kept a huge sheepdog in his office. Freidel gave political pamphlets to Forssmann and asked him to distribute them to his fellow students, pamphlets including “The Protocols of the Elders of Zion.” Forssmann admitted, “I’m afraid that here and there some of these ideas just may have caught on.”
In 1929, Forssmann got a job as an intern at the Red Cross Hospital in Eberswalde, a small town north of Berlin. He was big and broad shouldered with dark, lank hair and narrow, close-set eyes, a hard-drinking, motorcycle-riding obsessive. He still possessed his mania: he was going to stick a catheter into a human heart.
The chief of staff of the hospital at Eberswalde, Peter Schneider, was a friend of Forssmann’s mother, and when Forssmann approached him with his vision of the cardiac catheter, Schneider said, “I cannot possibly let you carry out such an experiment on a patient.” Over beers, Forssmann explained his idea to a young colleague, Peter Romeis. Romeis objected. The idea was dangerous, inhumane, and pointless. There was no demonstrable benefit to putting a catheter into someone’s heart. Perhaps Forssmann should work on an animal’s first. Forssmann did not answer Romeis’s objections. He only smiled.
The Open Heart Club Page 21