I was frightened once I recognized the extent of the injury. There were no physical impairments other than those to my brain, yet depriving this resource to an individual whose world revolves around intellectual pursuits — causes a psychological burden that overshadows everything else.
Harsh Reality
Unfortunately, the full gravity of my new existence became appallingly clear when I helped a resident do a reoperation procedure on a patient of mine.
As there had been a previous surgery on this heart, we would first have to deal with scar tissue, which was wrapped around much of the heart tissues and formed a kind of casing. In such circumstances, the surgeon needs to cut away some of the scar tissue to free and mobilize the heart again, like you would have with a normal heart. This would be necessary so we could then start the heart-lung machine and correct the underlying cardiac difficulty.
However, I did not sufficiently oversee the resident’s technique, specifically in making certain that placement of a drainage tube within a blood vessel was not done in too aggressive a manner. The result was a major tear in the main upper vein (superior vena cava), which returns blood to the heart. Massive bleeding ensued. We quickly responded, but it was impossible to control the site of the hemorrhage because tissue on the surface of the vessel was pulled apart, as there was no elasticity in the scar tissue encasing the vessel. Bleeding was torrential. We promptly started the heart-lung machine to capture and return the blood. But this action was not effective.
I quickly summoned a senior surgical colleague to help us. We were able to control the situation and ultimately correct the underlying problem with the reoperation. But the heart was severely damaged during the process and the patient succumbed three weeks later.
The potential for such injuries is why risks are always greater with re-operations. Even though such problems are the reality of heart surgery, I could not stop blaming myself for my role in allowing the damage. I questioned my decision to assist the resident, though this approach of allowing residents to perform surgeries under supervision is how many were performed at the university, and the approach I had followed for 25 years. While I realized conceptually that these were tough procedures with very sick people — and like every cardiac surgeon, knew this hazard was a part of our world — I wasn’t considering that.
I focused upon condemning myself for this tragedy.
The Depths
The end result of this internal self-recrimination was the development of a profound depression that totally altered my universe.
I immediately stopped operating, and could not provide educational help to my research fellows. I essentially became non-functional since I could not address any medical problems. The symptoms of this mental state took over my thinking, interfering with all aspects of my professional and social life. I withdrew from everything, becoming a shell of the person I had been. Inactivity replaced my productive lifestyle. The emptiness of this plunge into despair had no boundaries, without a foothold to rebound from or a ledge to grasp. It felt like a freefall.
While medical professionals provided me with psychiatric drugs, they had no positive effect. Though such medications are reported to help others, I realized the escape from my depression would require the generation of a solution that came from within. This disease imposes the greatest inward challenge anyone can confront, its resolution only evolving by guidance from the human spirit. In order to climb out of my abyss, I needed to find my own answer.
Light from Shadow
Despite how consumed and isolated I felt, I would discover I was not alone. I read a wonderful book on depression, Darkness Visible, by William Styron, which describes the way this illness engulfs one in despair. This brilliant author described the ravages of this disease upon his existence, and emphasized that creative individuals — those who devise and find their own way out of the despondency — have a better chance than those relying only on the advice and tasks defined by others. Knowing that I was creative by nature gave me hope.
My understanding also expanded after I read Tuesdays with Morrie, by Mitch Albom. Unlike my situation and the one described in Styron’s book, where the mind was affected while the patient lives within a normal body… Morrie’s body was shattered by Lou Gehrig’s disease, while he remained mentally intact. Even as his physical condition continued to decline, Morrie’s vibrant spirit never faltered. Though my situation appeared to have no solution, Morrie’s story told the wonders of how the mind can overcome everything.
But could mine?
Sink or Swim
While Styron’s book helped me to better grasp what was occurring and Morrie’s tale encouraged striving forward, there still seemed so little to hold onto, to guide me, or even impel me forward.
Our ability to think is what uniquely defines each of us as individuals. Descartes described this by observing “I think, therefore I am.” It’s what drives us. Without that capacity, who are we?
I was an intellectual person who had always used that ability to perform those actions most important to me. But my brain had been taken away. My intellect was crushed. Everything had been taken from me. I lived in a sense of doom, because “if I cannot think; I am not.”
Submerging
The time frame of this disease seemed endless. Days and weeks and many months passed without any reprieve from this mental morass. At the same time, I moved my UCLA office up to the 6th floor, after 27 years in a basement space that felt like living inside a submarine. I now had a wonderful office with a view… yet I simply sat at my desk, staring at empty shelves and my boxes of books in front of me. I didn’t care even to take out one of my books. I sat there like a piece of deadwood… listening to the bells in an adjacent church, tolling hour after hour, the only progression in my stagnant world. I awaited arrival of the last clanging bell signaling the end of each successive day when I could leave this moribund existence… only to return again the next morning.
I realized that whatever I was already trying wasn’t getting me better. I couldn’t wait for — nor expect — nature to spontaneously shift it. I had to find some new way to recover myself. Yet I still did not know how to meet this challenge.
My desolation led me to take several steps that would change my world. I needed to purge all of my burdens — escape from the responsibilities that I could not meet. My ability to do the things I spent my life doing had simply evaporated.
First, my career as a clinical surgeon came to a halt. The skill that had been my life’s work was thwarted. Second, I advised our major Journal of Thoracic and Cardiovascular Surgery that I could not continue my editorial responsibilities due to an unspecified medical problem. Third, I now needed to find places for my research fellows to work, since it was impossible to mentor them during our research program that I could not oversee. Fourth, this decision led me to also notify the National Institutes of Health (NIH) that my previously approved research grant had to be placed on hiatus, since a medical problem impeded our progression toward finding solutions to our funded project.
Finally, I would need to cancel 10 to 15 international lectures that I was scheduled to give, since I was not up to the task of presenting. I was basically getting rid of everything. My professional life was ending.
Moment of Truths
I remember being at home preparing to cancel my presentation lectures, starting with a conference in Argentina. Additionally, I was supposed to arrive there early for a pre-conference visit — to oversee Argentinean surgeons employing methods of heart protection that evolved from our studies.
My wife, Ingeborg, had gone to Europe to visit her family. I sat on my lawn alone… as I contemplated my fear of sharing with others my full cognitive limitations. Equally meaningful, I confronted the unbearable horror that the life I had so relished, could indeed be finished. I had already given up my lab, my researchers, my editing duties. Cancelling my Argentina visit and all that followed would be the final nail in the coffin. Everything would be over. But what choice was there?
I thought about how there is an intrinsic difference between how individuals confront these situations. One can either choose to hide their frailties, or confront them by taking the position that it is better to move forward, even if that means you may “fail” in a very profound and obvious manner. I recognized this second choice also describes the basic nature of the surgeon — whose actions define his credo — rather than searching for ways to escape any challenge. The surgeon’s way is to move forward into things… particularly when the stakes are high.
I recalled how this had been so well-put by Claude Bernard, my conceptual hero from the moment I read his book, Introduction to Experimental Medicine. This legendary French physiologist described the world as being occupied by either observers or experimenters. The observers were like astronomers who watched the stars and recorded what they saw. But the experimenters saw the world with a belief of why certain things might be the way they are, and then did studies to understand the reasons behind what they perceived… perhaps uncovering solutions to a problem.
I sat straight up in my chair, realizing I had been living the life of the observer, watching what was happening to me, not testing circumstances to see if what I had experienced so far could be changed. I was behaving like a traditionalist, taking a position that bars progress.
I was planning to cancel the Argentina visit since I expected that I would fail. I didn’t want to relive the sense of failure that followed the devastating operation that spawned my depth of despair. But then, despite my haze of depressed thoughts, I realized something elegantly straightforward: the only way that you really fail… is to fail. You cannot fail because you think you are going to fail. Actions, not fears, must be your credo.
I decided to visit Argentina as planned.
This bold decision followed the same natural path of experimental testing that guided my professional career. Escaping reality at home made me an observer of my own life, and I needed to take charge of it.
While I didn’t know it at that moment, that choice and this trip would have a tremendous influence on the rest of my life.
Through Fire and Water
I would keep my commitment to present at the Argentinean conference in Mendoza — the first in a long while, ever since my condition had been so severe.
But I would stop beforehand in the medium-sized city of Cordoba, where a group of ten outstanding young surgeons, who would likely become their country’s leaders in cardiac surgery, were gathered to try my technique of heart protection. The patient was to receive grafts to replace blocked vessels, and they wanted to use arteries for the grafts rather than veins because they lasted longer. Conventional methods of protecting the heart were often inadequate for the lengthier periods without blood supply that were needed to implant these arterial vessels. So they wanted to see if my protection method would be effective, while I oversaw its use. Everyone spoke English and I was asked to “scrub in” to participate in the operation, but I answered that I would rather observe. None of them realized the nature of my stroke and its role in generating my depression.
Ten young doctors in green gowns and I encircled the operating table as the surgeon performed the operation while using my techniques. Everything seemed to go well and they gave protection in exactly the way that I had described.
But as the surgeon took the patient off the heart-lung machine when he finished, the heart showed a markedly impaired capacity to contract. It would not beat effectively! Pharmacologic drugs to enhance the heart’s contractile ability were immediately given, but these agents did not work. The patient was dying.
I determined that the damage was not related to myocardial protection. That had been administered perfectly. I believed the issue was that the graft connections were done incorrectly, and the heart was not receiving a sufficient supply of blood. The impaired performance of the front and side of the heart looked exactly like a region that had undergone a major heart attack — one getting insufficient blood supply due to vessel blockage.
I realized that they were not looking to me for an answer… but I had one.
“I know the cause. The protection isn’t the problem — that was done well. There is a problem with the graft connections, so that the heart is not getting proper blood supply. This is a correctable problem, but it means restarting the heart-lung machine and revising some of the hook ups. This approach now requires using veins to replace the arterial conduits [the arteries they used for grafting] whose surgical connections are faulty.”
Mine was a sole voice amid this group of potential leaders of heart surgery in Argentina. Following my battle plan would require the cardiac surgeon to stop the heart again, and then impose an even longer period of no blood supply to a heart that was now already damaged. Their alternative involved shoring up the failing heart by administering even higher doses of drugs, together with need to sometimes implant a mechanical device to support circulation if the high drug dose was ineffective — to tide the heart over in the hope it would improve after the procedure.
My proposal was based on my confidence that heart protection was excellent — so that the reasons for impaired heart performance must be mechanical (the operation itself). Their opposition was based on, “If you think the patient is dying, why would you want to take his blood supply away again?” — which dealt with the symptom of acute heart failure, not its cause.
So we were confronted by two diametrically opposed choices: simply accept there is heart failure after a procedure and support the heart with drugs or devices… or accept responsibility for having caused the heart failure by the operation itself and correct the cause.
The team of young surgeons observing the procedure was not convinced my answer was correct. However, decisions during surgical operations are not made by vote. Instead, final judgment belongs to the responsible surgeon. The gravity of this impaired cardiac performance required that something had to be done fast, and the surgeon performing the operation made his choice. “I’m going to listen to Gerry. We’re following his approach.”
The patient was immediately hooked up again to the heart-lung machine. Cardioplegia was given again. The surgery began again. The new surgical connections were carried out as I had suggested.
Answers to the choices we make during cardiac surgery are often quickly apparent, as the efficiency of the heart (or most importantly, its inefficiency) becomes evident as soon as the heart-lung machine is turned off. What would the answer be?
We passed this final test with flying colors. The performance of the heart was totally restored to normal function.
Reality Reboot
From Cordoba, I went forward to the conference in Mendoza, Argentina, where I would address an international gathering. As it would turn out, my worry about my depression causing me to fail during a presentation was unfounded. My lectures went very well. The buoying up that I experienced during the operation in Cordoba likely added to my self-assurance.
Yet even more deeply, I was reminded in Mendoza that the real beauty of traveling to teach is the opportunity to exchange ideas with other participants. Their broad range of experience provides a wonderful forum to share knowledge. My mind, which had been so terribly thwarted and dormant for the past 18 months, was energized as interchange among these colleagues would open the door to new possibilities… and new frontiers.
What kept recurring in my mind was the distressing theme of heart failure that would so often develop following a heart attack.
The most perplexing part is how this progression is hidden at first, as initial mortality is reduced from 20% to 5% by angioplasty. Instead, it only rears its ugly head many years later — as the region’s scar from the heart attack never recovers, and the remote muscle (the still functioning muscle portion away from the damaged region) stretches more and more to compensate — until the heart is no longer able to adequately perform. The patient’s life becomes increasingly diminished and ends prematurely.
I knew the common treatment
for this is to place a graft with new blood supply to the impaired remote muscle, or repair leaky heart valves. But these interventions do not solve this worsening problem. The true enemy was evident — but only if we observed how the heart’s geometry is markedly altered by the heart attack. It was a problem that deeply deserved a fresh and full examination. Recent figures show over 550,000 cases of congestive heart failure are added every year to the 5 million patients already with this disease — in the U.S. alone.
My new eagerness for understanding the role of geometry in heart failure was stirred by my now recalling the work of Vincent Dor, a French cardiac surgeon who I had previously visited in Monaco. He emphasized that the scar was the culprit that caused the heart’s structure to change from a football shape to more like a basketball.
Yet Dor pointed out that failure happens following a heart attack in a heart that deceptively looks good on the surface… since returning normal blood flow by angioplasty makes the bulging heart no longer bulge. But this treatment fails to return contraction to the dead inner and middle layers of muscle of the heart attack region. His successful approach to countering this, involved performing a procedure to exclude the scar so that the rebuilt heart is returned to its more natural elliptical form… but this is an operation no one else had done.
My conference in Mendoza reignited my commitment toward determining if he was correct. Indeed, if his approach was effective, we would have a powerful new tool to confront congestive heart failure — the major cause of death in the world. One that would overcome the ineffectiveness of all traditional treatments.
The siren song of heart failure was now calling. To explore this world, I would need to pursue a series of persuasive and valid findings that explained why this disastrous event happened, and set the sails for many new investigations to further advance our thinking. This search would also draw others into this quest for a solution to our greatest health care challenge.
Percolating Passions
These were the seeds that permeated my thinking, and persisted throughout my visit to Mendoza, Argentina. The evolution of this new approach became the “secret ticket” out of my depression. I was flooded with ideas on how to develop this concept. I wanted to assemble a team of the world’s top leaders in cardiac surgery. As this was a revolutionary idea among those experts that treated heart failure, I realized I would need to go and individually meet with each handpicked surgeon, wherever they practiced, to determine if they would become part of a newly formed group to challenge this immense global problem.
Solving the Mysteries of Heart Disease Page 26