We passed Huntington and the station for Cold Spring Harbor. The world outside was suburban. The guy in front of me had a phone, and he talked loudly enough that I could hear him over the oboe in my headphones.
“Fucking three o’clock,” he was saying, “and the guy says to me, ‘The exhaust pipe’s rusted out.’ He says, ‘The brake pads are worn.’ Then he gives me the estimate. Hundreds of dollars. Fucking hundreds. I go, ‘All’s I came here for was a battery.’ He says, ‘What can I tell you? This is what I see with your car.’ I say to him, ‘Did I ask what you see?’ And we’re standing there, and by now it’s fucking three-fifteen.”
Through the headrests of the seat in front of me I could see the man’s hairy hand and his ear. I had the idea to tap his shoulder, to ask him to dial 911 for me, but the thought was like a dream. Everything was becoming abstracted. Syosset passed and Hicksville. His oration continued.
“I can pay for it. That’s not the problem. You know I can pay. I got my Visa, Discover, fucking American Express. I’ll get miles and points. That’s not the problem here. You know what the problem is. And by now it’s like fucking three-twenty-five or something.” The man got off at Mineola.
The thumping in my chest didn’t slow. The conductor came through, collecting tickets, saying next stop was the last one, Jamaica Queens. I got up, surprised that my body was still functioning. I put on my backpack. I lined up at the door with everyone else. The door opened, and I crossed the platform for the train to Brooklyn, and I stood there, looking down the track for my train, as if my heart were not going BOOM BOOM BOOM.
What was I thinking? I wasn’t thinking. Two hours since my heart had started its pounding, and it still wasn’t hard to stand. It wasn’t hard to walk. I found a seat and handed my ticket to the next conductor, who punched it and handed it back to me, and we rode over East New York, the hospital, the high school, the housing projects, and cheap fast food, Kennedy Fried Chicken, halal butchers, and flat-fix joints. At Atlantic Avenue, I got off the train again and was afraid to climb up the stairs, but it worked, my body went up step after step.
From the Long Island Rail Road, I changed to a crowded subway train, two stops from Atlantic to Grand Army Plaza. I had to stand, and the train rocked under foot. BAM BAM BAM went my heart, which made me feel so alone, so isolated in the crowded train. In my backpack were files of papers and paperback books and Tupperware from lunch and my CDs. I felt a pain not in my chest but in my back, and in my left shoulder, and rising up the left side of my neck. My vision was narrowing. Out of the train at Grand Army Plaza, up the stairs through the turnstiles, past the ticket booth, and up another set of stairs.
Time had now developed a thin quality. I was hoping it would all stop—the tachycardia, my heart, everything. Death seemed like rest, like a relief, like a long warm bath. Hysteria turned to resignation. I doubt enough blood was getting to my brain, had been getting to my brain for hours.
The pain spread more intensely and dug more acutely into my left shoulder blade. I went up the subway stairs and into the twilight with everyone else who was coming home from work. I was in my familiar neighborhood. My house was just a few blocks away. Our apartment was on the third floor. Up the stairs I went, with the wild whacking of my heart, when each step might have been my last. Marcia was home. So was Eliza. And my dad. He had been babysitting, and he had stuck around to see me.
When I was little, my dad had protected me from the world by not letting anyone know I was ill. My father acted to shield me from the world’s pity and to extend the illusion of my safety and immortality. Now I didn’t let him hug me.
I didn’t want him to feel my chest—he would panic; he would go crazy about it. I gave him the brush-off. His anxiety was the last thing I could deal with now. I told him I was tired and snuck past him and to bed. My neck and shoulder ached as I lay down. BANG BANG BANG went my heart. I heard my father leave, heard Marcia lock the door behind him, and only then did I pick up the telephone and call Boston. I explained what was happening to the nurse on the phone.
“Hang up,” she said. “Call 911.”
I said, “Really?”
Marcia stood in the door with our child in her arms. “They want me to call 911,” I said to her. “What do you think I should do?”
36.
AS SOON AS surgeons began cutting into the myocardium, they began to disturb the conduction systems of their patients’ hearts. John Gibbon, Charles Bailey, Dwight Harken, Walt Lillehei, and John Kirklin all lost patients whose hearts would not beat after surgery.
Paul Zoll, a colleague of Harken’s in the Quonset hut hospital in the British town of Cirencester, worked with Harken again after the war at Harvard. Zoll was a small man, with a thin face and enormous ears. Colleagues were struck by the odd combination of Zoll’s elfin looks and his dour disposition. He saw dozens of patients die of heart block on the operating table, both in war and after, patients with their heart muscles stitched up but unable to beat. He became obsessed with the problem.
In the early 1950s, Zoll found a way to keep these patients alive. His wartime experience had taught him, as he put it, “how easily excitable the myocardium is. You just touch it, and it gives you a run of extra beats—so why should the heart, that is so sensitive to any kind of manipulation, die because there’s nothing there to stimulate the chest? It wasn’t sensible.” Though Zoll said he had a “poor background in electronics,” he knew that electrical stimulation was the likeliest solution to the problem.
Zoll used a device called a Grass Physiological Stimulator, designed to deliver regular pulses of electricity in laboratory experiments. He attached two electrical leads from the Grass Stimulator to the skin of a blocked patient’s chest, strapping the leads down with a leather belt. The stimulator gave off sixty shocks a minute. With each shock of Zoll’s device, the patient’s entire upper torso convulsed. All the chest muscles clenched, sixty times a minute. Under the leads, the patient’s skin developed burns and ulcers. The heart beat, and the patient survived, but the pain was unendurable. “The problem with the original external pacemaker,” said Zoll, “was that it hurt too much.”
Zoll’s first patient, an adult after valve surgery, was attached to the stimulator for more than forty-eight hours, his skin scorched, his pectoral muscles and diaphragm convulsing. The second, also an adult, stayed alive for three days. “His heart did not pick up on its own,” Zoll recalled. It was unclear how or when the doctors could get the man off the machine, unclear if Zoll had built a lifesaving or torture device. “Even my cardiac fellow said, ‘Maybe we shouldn’t be doing this.’” Seymour Furman, one of Zoll’s interns, remembered, “We had a patient that I recall, a patient when I was an intern, who had been on a Zoll pacemaker for a long period of time, and finally committed suicide by turning off the switch, just after a pep talk which the house staff, myself included, had given him about the wonders of the future to come, which we didn’t believe in, and he equally didn’t believe.”
Eventually, Zoll was able to devise an interior lead that went down the patient’s esophagus and more directly attacked the heart. No longer did the skin burn; no longer did the chest muscles convulse with each shock. But the machines were unwieldy, and they weren’t portable. So long as patients were on Zoll’s pacemakers, they were confined to their hospital beds.
In Minnesota, Walt Lillehei was bedeviled by the same problem as Harken and Zoll. Every time he sutured the septum of a small child, he risked interfering with the conduction system of the heart. It was a terrible problem: after surgery, one in every ten of Lillehei’s patients suffered heart block. Following Zoll’s lead, Lillehei took a Grass Stimulator from a lab in his hospital and hooked it up to his patients’ chests. But he found that using a Zoll pacemaker on a child was impossible.
“Getting a shock like that fifty, sixty times a minute is torture,” said Lillehei. “With some infants we were able to restrain them so they wouldn’t tear [the chest electrodes] off, but they would develop blisters and ulce
rs in four or five days. So that was totally inadequate.”
Lillehei began attaching electrodes directly to the hearts of his blocked patients—connecting the wires to the heart muscle before he sutured them up. Experiments on dogs showed that direct connection to the heart required far less electricity than did external stimulation. A thousandth of an amp “drove the heart beautifully,” said Lillehei, and the charge at that low level was imperceptible to the patient.
This became protocol at Variety Club Heart Hospital. In 1957, eighteen children were confined to their beds after surgery, electric stimulators attached to their hearts. In seventeen cases, the children survived. The doctors found that once the heart started beating on its own, they could gently pull the wire, and it would emerge out of the heart muscle and out of the chest without the need to ever reopen a suture. But having the children tethered to a pacemaker and to an electric outlet was untenable.
“Many of these [patients] were kids,” said Lillehei. “They wanted to wander around and get active. Well, they were active.” They wanted to get out of their beds, but “they couldn’t get any further than the cord. We had to string wires down the hall,” said Lillehei. “And then, if they needed an X-ray or something that couldn’t be done in the room, you couldn’t get on an elevator, so you had to string them down the stairwells. It seemed that almost everything you wanted was on a different floor.”
A power failure on October 31, 1957, frightened the staff. The hospital had auxiliary power—none of the kids on pacemakers died—but Lillehei saw the risk, and he worried about the opposite of a power failure, a sudden power surge that might overwhelm the pacemaker kids. He dreamed of getting these patients out of their beds, getting them to move about the hospital, attaching them to some kind of portable device. He talked the problem over with Earl Bakken, a graduate student working as a part-time electrical technician in the hospital labs. Outside the hospital, Bakken ran an electronics repair shop out of his garage. His partner was his brother-in-law, Palmer Hermundlie, who had a day job in the lumber business. Bakken, a short man with big glasses and a sharp nose, wasn’t an electrical engineer but a tinkerer. He fixed EKG machines in the hospital and radios and toasters in his business from home. When Lillehei described the problem to him, Bakken’s first idea was to use a car battery, but then he happened to read an article in Popular Mechanics titled “Five New Jobs for Transistor Batteries.” The article showed the circuit designs for a metronome.
In his garage workshop, Bakken cribbed the designs for the metronome and, using mercury batteries, built a little machine that set off a charge once every sixty seconds, regulated as surely as a musical beat. The machine was about the size of a paperback book. It could hang on a cord around the neck. Bakken showed it to Lillehei. Lillehei was impressed.
Ten days later, a young patient lay on the operating table, chest open, heart sutured but refusing to beat. Lillehei applied his electrodes directly to the child’s heart, and before stapling together the breastbone and sewing up the skin, he attached the wires to the metronome pacemaker Bakken had built in his garage. Bakken came into the recovery room the next day and was surprised to see his machine hanging around a little boy’s neck, the wires running from the machine to the boy’s heart, keeping the boy alive. This was the first implanted electronic medical device ever.
In 1958, Bakken built the Medtronic Model 5800 pacemaker. The device was housed in layered, carvable Bakelite housing, the words “Medtronic Pacemaker” in stylish white letters against the black. It had two handles and a strap to connect it to the chest, as well as a blinking red light to assure patients that it was working. It became a device not just for postoperative children but for older patients who needed long-term stimulation of their hearts.
Soon after Bakken’s breakthrough, two Swedish doctors, Rune Elmqvist and Åke Senning, introduced the first implantable pacemaker, one small enough to sew into the flesh. Bakken and Medtronic followed suit. According to Kirk Jeffrey, author of Machines in Our Hearts, the development of the implantable pacemaker coincided in the United States with the establishment of Medicare. The federal government soon was helping elderly patients purchase these lifesaving devices, and pacemakers became a profitable business. Medtronic sold 1,200 pacemakers in 1962, 7,400 in 1966 and 1967, and 25,000 in 1969 and 1970. The company suffered a net income loss of $16,093 in 1968, but by 1972 it made an annual profit of almost $4 million. Pacemakers became a common piece of medical equipment.
Hospitals needed doctors to monitor the patients with difficulties in their hearts’ electrical conduction systems, and so electrophysiology became a growing medical field. As Jeffrey wrote, “The very existence of the technology prompted researchers to intensify their investigations” into other arrhythmias and electrical disorders of the heart, including potentially lethal conditions like mine.
A pacemaker could get a stalled heart beating, but what to do when the heart started on a rampage, beating wildly, beating too fast?
37.
THE EMS GUYS littered our apartment with paper—Band-Aids and syringe wrappers. They hooked me up to a portable EKG. They gave me shots. They slid a needle into the crook of my elbow and set up an IV. They told me to strain, like I was trying to take a shit. (Apparently, in some cases, this can stop an attack of arrhythmia.) But nothing—not drugs, not exercises—could slow the crazy rhythm of my heart.
I remember lying in a curtained-off section of the emergency room with Marcia by my side and my heart beating ferociously. She held my hand. She teased me. “Brownstein, you really know how to bring the excitement.” I gave my history to the attending physician. I asked if I was going to die. The doctors gave me more injections. Grimly, they told me they were going to have to shock me out of it. They were going to have to do it while I was awake. They took out the big electric paddles, rubbed them together, and said, “Clear!”—just like in the hospital TV shows. They applied them to my chest, and my whole body jumped and jolted. After that, my heart beat at its normal rate. I was exhausted, but I was calm.
My sense, internally, was of a ravaged quiet—like a street swept clean after a hurricane. The skin of my chest was seared, as if badly sunburnt. Marcia’s face showed sweet relief. The doctors wouldn’t let me go home. I needed to have surgery, they said. They would not release me from the hospital until I got an implanted cardioverter defibrillator (ICD) sewn into my chest. It wasn’t safe for me to walk around the world without one. The next arrhythmia attack might kill me, so I needed a machine inside me, one that would shock my heart when it started beating too fast.
I really should have gone back to Marlon Rosenbaum. A mystic aura of terror had grown around him in my mind, an aura separate from the man himself. He had come to represent something for me, something I could not face. Was I ashamed that I had run from him, and that he had been right about my condition, and that I had been wrong? Perhaps vanity was involved as well as denial. At any rate, I made arrangements to go to Mount Sinai Hospital, where Dr. Steven Fishberger, a former student of Mike Freed’s, was practicing pediatric cardiology. Dr. Fishberger worked closely with an eminent electrophysiologist, Dr. Davendra Mehta. Dr. Mehta would implant my ICD.
I rode an ambulance across the East River. I was awake for most of the procedure but loopy on anesthetics. A cloth border was hung in front of my face. The doctors tugged on the skin of my chest, and I felt their cuts like scissor snips and the cold baths of antibiotics washing out the pocket of the wound. Dr. Mehta guided wires down through my subclavian artery and screwed the leads into the muscle of my heart. I remember Dr. Mehta in scrubs coming by my head and speaking to me softly. “We have to check the device.” They were going to put me to sleep; they were going to induce arrhythmia; they were going to make sure that the ICD could do its job to shock my heart with forty joules of electricity and knock it back from tachycardia to its normal beating. I woke up in the recovery room. Dr. Fishberger, the kindest of men, came to check on me. He brought some cookies.
“Lorna Doones,” he said. “The choice of cardiologists.”
There were bandages below my collarbone and a strange new bulge in my chest. The skin under the bandages was swollen and tender. I could feel the device, a little palm-sized piece of metal, squirming about in a wash of painful pus. When I stood, I felt its weight pulling downward. There was an illusion that I was wearing a necklace with a heavy medallion, like a police badge, but the medallion was the ICD, and the necklace was my skin. I put my clothes on. The ICD slid around, adjusting itself. Marcia and I met Dr. Mehta in his office.
Davendra Mehta is among the most elegant physicians I have ever met, a man with the kind of self-possession that flatters his interlocutors. Out of his scrubs, in a jacket and tie and sitting behind his desk, Dr. Mehta explained the device to me as if he and I were peers—as if it were only natural to be as smart, as stylish and good-looking, and as knowledgeable as he.
In a healthy heart, Dr. Mehta explained, the heartbeat is governed by the sinus node, that small bundle of electricity-generating cells that sits above the right atrium. The electricity from the sinus node travels in a complex pattern through the beating muscle cells of the top of the heart. The two small top chambers of the heart convulse, and then the charge gathers itself once again in the atrioventricular node, which governs the second firing of the heart, the contraction of the ventricles. Down goes the charge, through the septum, the central wall of the heart, through conduits known as the bundle of His and the bundle branches. At the base of the septum, the charge flares out through to the Purkinje fibers, which rise up to the exterior walls of the ventricles and run through the muscle like spreading rills at the end of a river delta—these fibers control the ventricles’ beating.
A normal fast heartbeat, said Dr. Mehta, is called “sinus tachycardia,” that is, a rapid heartbeat under the governance of the sinus node. That’s what happens when you run up stairs. The arrhythmia I had suffered on the train ride was “ventricular tachycardia”; that is to say, my ventricles were beating on their own. When I was sitting in the sun with Astrid, the bottom half of my heart acted like I was running, while the top half acted like I was sitting still. As a lifelong heart patient and a surgery survivor, I was susceptible to these things.
The Open Heart Club Page 26