By all accounts, when Clark was hospitalized in late November, he was near the end of his life. For months he had suffered from intolerable shortness of breath, nausea, and fatigue. On Thanksgiving Day, family members had to carry him to the dinner table at his home in Seattle, but he was unable to eat. In the intensive care unit in Salt Lake City, he was placed in a dark room and visitation was restricted; doctors feared that any sort of excitement could precipitate ventricular fibrillation. William DeVries, the lead surgeon, was sure that “death appeared imminent within hours to days.”
Because of his age and severe emphysema, Clark was not eligible for a heart transplant. When his doctors brought up the option of an artificial heart, Clark visited a laboratory at the University of Utah where calves had been kept alive for months with a Jarvik-7 device. The Jarvik-7 was developed in Utah by Robert Jarvik, an engineer working in the laboratory of Willem Kolff, who’d implanted the first artificial heart in a dog at the Cleveland Clinic in 1957 before moving his research enterprise to Salt Lake City. Though the Jarvik-7 carried Jarvik’s name (because Kolff generously named his artificial hearts after the laboratory colleague who had worked on the most recent model), it relied on many of Kolff’s original designs from the 1950s. The aluminum-and-plastic heart had two separate ventricles grafted with polyester sleeves to the native atria and great vessels and was powered by an air compressor that weighed almost four hundred pounds. The sight must have disturbed Clark because he told his doctors that he would take his chances with medical therapy. But worsening heart failure forced him to reconsider, and so in the early morning of December 2, Clark emerged from the operating room with plastic tubes coming out of his chest, connected to a refrigerator-sized machine. Though he was very much alive, his electrocardiogram was a flat line. His own heart had been removed from his body. The Jarvik-7 did its work.
DeVries and his colleagues could not have anticipated the intense worldwide interest in their experiment. Though I was only thirteen at the time, I still remember the daily news coverage. Teams of reporters and television crews swarmed the medical center, hankering for information about Clark’s condition, even sneaking into the intensive care unit to check on him. The hospital cafeteria was transformed into a virtual press club, with hospital spokesmen providing twice-daily briefings. Clark’s private struggle quickly became a public spectacle.
Though he opened his eyes and moved his limbs three hours after the operation, his subsequent course was rocky. On day 3, he underwent exploratory surgery because of air bubbles in his chest wall. On day 6, he suffered generalized seizures that left him in a coma. On day 13, his prosthetic mitral valve malfunctioned, and he had to go back to the operating room to have the left ventricle replaced. Many complications followed, including respiratory failure requiring a tracheostomy, kidney failure, pneumonia, and sepsis. On day 92, DeVries spoke with Clark in a videotaped interview. “It’s been hard, hasn’t it, Barney?” DeVries said. “Yes, it’s been hard,” Clark replied. “But the heart itself is pumping right along.” It continued to pump until he finally succumbed to multi-organ failure on day 112.
Clark’s Jarvik-7 became medicine’s Sputnik; never before had a medical innovation sparked such furious debate, even a kind of national reckoning. Though some doctors viewed the experiment—two decades and $200 million in the making—as successful, most people were deeply disturbed by what they had witnessed. Some were repulsed that the human heart had been replaced by a machine made of metal and plastic. For them, the heart still carried special spiritual and emotional significance that made it impossible to replace with a man-made device. (Una Loy, Clark’s wife, expressed this belief when she worried he might not still be able to love her.) Others felt Clark had not been adequately informed of the hazards of the artificial heart, even though the poor prognosis had been laid out and he had signed two consent forms—eleven pages, double-spaced—twenty-four hours apart to give him time to change his mind. (These concerns seem to ignore the fact that Clark viewed his participation as a sort of humanitarian mission. “It’s been a pleasure to be able to help people,” he said three weeks before he died. “And maybe you folks learned something.”) Still others were troubled by the fact that Clark never left the hospital. He had survived for almost four months, they said. But had he really lived?
After Clark died, there was a period of public disenchantment with artificial organs. The New York Times dubbed artificial-heart research a kind of “Dracula” that was sucking money away from more worthwhile programs. After Clark, three more patients in the United States and one in Sweden were implanted with the Jarvik-7 as a permanent heart replacement. (The longest survivor was a man who lived for 620 days, much of it outside the hospital, but died of strokes and infections.) In 1985, three new artificial-heart models were introduced, including the Jarvik 7–70, which was smaller than its predecessor and powered by fluid, not pressurized air, so large tubes did not emanate from the body. The design, as Jarvik, the engineer, put it, “came from the understanding that people want a normal life and just being alive is not good enough.” However, complications were severe, and most patients died within a few months. By the latter part of the decade, artificial hearts were back to being used almost exclusively as a bridge to heart transplantation. In 1990, the Food and Drug Administration issued a moratorium on the use of the Jarvik-7 device.
Though research began to focus on smaller, novel devices that would assist the native heart, work continued on a total artificial heart. On July 2, 2001, the first fully contained artificial heart with no power lines was implanted in a fifty-eight-year-old man at Jewish Hospital in Louisville, Kentucky. The hydraulically powered device, made of titanium and polyurethane, the stuff of skateboard wheels, was about the size of a grapefruit and had a battery that could be recharged through intact skin, obviating the need for an external power source. The patient lived for five months before dying of a stroke.
Research on artificial hearts continues today. Nearly a hundred patients have been supported with the most recent model, CardioWest. The long-term support record is held by an Italian patient, who survived for 1,373 days before a successful heart transplant. But significant obstacles remain, including infection, bleeding, clotting, and strokes. The most recent devices produce continuous blood flow, so patients emerge from the operating room without a pulse. Continuous-flow devices are simpler than devices that send out pulses of blood, mimicking the native heart. They don’t require valves and have fewer moving parts, resulting in less wear and tear. They still pump blood, of course, but the flow is constant, not periodic. Incredibly, humans, we now know, can live for long periods without pulsatile blood flow. However, continuous-flow hearts produce their own complications. They chew up blood cells because of the shear forces generated by the device and may strip the blood of clotting proteins. For unclear reasons, they cause tiny blood vessels that are prone to rupture to sprout up in the gastrointestinal tract, so patients often bleed internally. They can also cause degeneration in arterial walls and scarring. Continuous blood flow is antithetical to the way that humans, pulsatile beings, evolved. Though continuous flow can keep us alive, it alters our physiology in idiosyncratic and unpredictable ways.
Not long ago, I took a tour of a cardiothoracic surgical unit at Advocate Christ Medical Center, a major tertiary care facility just outside Chicago. My guide, an Indian cardiologist in her sixties, had started one of the top artificial-heart programs in the country in Louisville, Kentucky, before moving to Advocate Christ. She took me on a tour of a twenty-five-bed unit where patients were getting all manner of cardiac support, from balloon pumps to ventricular assist devices to transplanted hearts. I asked her what she thought about the prospects for a total artificial heart. “It’s an evolving field,” she said carefully, “but the complications are really troubling.” She told me about one of her patients with intractable arrhythmias who received an artificial heart. His pain and suffering with it were so great that his family sued the hospital and
his doctors after he died.
We passed by a patient on a ventilator and dialysis machine; she’d had a large myocardial infarction and was now being supported by ventricular assist devices on both sides of her heart. The multiple consoles surrounded her like a pack of animals. “After so many years of study, I’ve concluded that the best thing we can do for most of our patients is to give them medicine,” the cardiologist told me. “Of course, we need mechanical devices for patients who are crashing and burning, but for most of our patients the technology still has too many problems.”
The workhorse of mechanical support for heart-failure patients today is not the artificial heart but the left-ventricular assist device (LVAD), which attaches to the native heart, pumping blood directly out of the left ventricle and into the aorta, thus essentially bypassing the failing organ. Approved by the FDA for both permanent and bridge therapy, LVADs have become a lifesaving option for end-stage heart-failure patients. Between 2006 and 2013, more than ten thousand patients, including Vice President Dick Cheney, received LVADs for cardiac support. Unfortunately, LVADs are still not an option for patients with severe failure of both right and left ventricles. For such patients, like Barney Clark, a permanent artificial heart may still be the best hope. For now, it remains a dream, but not quite the pipe dream it was in 1982, when a soft-spoken dentist from Seattle decided to go first.
* * *
It wasn’t easy telling Ravindra’s father that there was nothing more I could offer, that his son was not eligible for a mechanical or a human heart because neither would change his poor prognosis. But I believe he already knew. “The things that are important to my wife are not so important to me,” he said.
“What is important to you?” I asked.
“All the pain he going through.” His lips quivered before his face tightened up again. “I don’t want him to suffer no more. He have suffered enough.”
Unfortunately, there was more suffering to come. Over the next several days, Ravindra had terrible leg pains. I wasn’t sure why—poor blood flow to the muscles, perhaps—but I couldn’t leave him in such agony. I put him on a morphine drip to keep him sleepy and as comfortable as possible. I made sure his father signed a do-not-resuscitate form. It didn’t mean we wouldn’t do everything in our power to help Ravindra, just that at the end we would let him go peacefully. His father understood. He was ready for the ordeal to end, both for himself and for his son.
On morphine, Ravi went in and out of consciousness. He’d doze off and then open his eyes in a panic, before closing them and sinking back into a fog. At times he displayed “agonal” breathing—loud gulps of air followed by periods of apnea, or no breathing—a pattern that frequently heralds death. His lungs made deep, guttural groans, like a foghorn, so congested were they with fluid. Sometimes he’d writhe with pain, mouth foaming, teeth clenched, a tight scowl on his face. Other times he would scream out, “Mom, help me, Mom!” His mother massaged his legs, day and night, and mumbled prayers and wept. As a doctor and just as a father, I found it a terrible thing to witness.
He died one morning before I made rounds. When I got upstairs, the door to his room was closed, but I could still hear the commotion inside. A nurse offered to go in with me, but I told her it wasn’t necessary. As a heart-failure specialist, I’d experienced enough death to fill up a lifetime. Once, it was difficult to witness the grief of loved ones. But my heart had been hardened, and this was no longer that time.
At the bedside was a wooden table with drawers, and on the far side of the room were dark gray curtains framing windows overlooking the parking lot. Ravi’s mother was smothering his face with kisses, talking almost robotically, as her grief erupted in ever more intense swirls. “No more, no more, my son is gone! Oh, my Father, my loving son no more!”
A relative sitting on the flower-patterned couch tried to comfort her. “He suffer too much, sister,” she said. “It’s God’s choice. He will come back again in a nice body.”
The father came over and hugged me. He was wearing an overcoat, though it was spring. “She will cool down,” he whispered, referring to his wife. “She seen how he suffered.”
“Oh, my son be punished and punished,” the mother wailed. “He said, ‘Mom, I’m dying, I’m dying, I can’t breathe!’ I told God to leave him, I would take him at 50 percent. But He wouldn’t even give me that.”
There wasn’t much I could offer at that moment, so I said I would come back and exited. The father followed me out. In the hallway, he asked me what was next.
The body would be taken to the morgue, I explained. The funeral home would call to arrange for transportation. He seemed calm talking about the arrangements. Then his cell phone rang. He put in the earpiece. “Hello … yes, my son no more.” And finally, he broke down, too.
PART III
Mystery
12
Vulnerable Heart
When the heart is affected it reacts on the brain; and the state of the brain again reacts … on the heart; so that under any excitement there will be much mutual action and reaction between these, the two most important organs of the body.
—Charles Darwin, The Expression of the Emotions in Man and Animals (1872)
The morgue was inside Brooks Brothers. I was standing at the corner of Church and Dey, right next to the rubble of the World Trade Center, when a policeman shouted that doctors were needed at the menswear emporium inside the building at One Liberty Plaza. Bodies were piling up there, he said, and another makeshift morgue on the other side of the rubble had just closed. I volunteered and set off down the debris-strewn street.
It was the day after the attack. The smoke and stench of burning plastic were even stronger than on Tuesday. The street was muddy, and because I was stupidly wearing clogs, the mud soaked my socks.
I arrived at the building. In the lobby, exhausted firefighters and their German shepherds were sitting on the floor amid broken glass. A soldier stood at the entrance to the store, where a crowd of policemen hovered. “No one is allowed in the morgue except doctors,” he shouted.
I entered reluctantly through a dark curtain. Cadavers had always made me feel queasy, ever since those dog days in the anatomy lab in St. Louis. In the near corner was a small group of doctors and nurses, and next to them was an empty plastic stretcher. Behind the group was a wooden table where a nurse and two medical students were sitting grim-faced, looking like some sort of macabre tribunal. Brooks Brothers shirts were neatly folded in cubbyholes in the wall. They were covered in grime, but you could still make out the reds and oranges and yellows. In the far corner, next to what looked like a blown-out door, was a pile of orange body bags, about twenty of them. Soldiers were standing guard. In the store’s dressing room were stacks of unused body bags.
The group was discussing the protocol for how to handle the bodies. A young female doctor said that she didn’t think anyone should sign any forms, lest someone think that we had certified the contents of the bags, which we were not qualified to do. That, she said, was up to the medical examiner. Someone asked whether a separate body bag was needed for each body part, but no one knew the answer. The leader of the group was a man in his fifties. I looked at his badge. It read “PGY-3.” He was a third-year resident, which meant that I was probably the most experienced doctor in the room, a thought that deeply disturbed me. I had been a cardiology fellow for only a couple of months.
At this point, some National Guardsmen brought in a body bag and laid it on the stretcher. The female doctor unzipped it and inspected the contents. “Holy Mother of God,” she said, and she turned away. In the bag was a left leg and part of a pelvis, to which a penis was still attached. The leg itself hardly seemed injured, but the pelvic stump was beefy red and broken intestines were hanging out of it. A pants pocket was partially covering the pelvis and was emptied of change; this pocket was put in a separate bag. A policeman said that part of the victim’s body had been brought in earlier, along with a cell phone.
That w
as actually good news. If the victim had the numbers of family members on his speed dial, he would be quickly identified. But identification wasn’t my job. Processing was.
After five minutes, the bag was zipped up. The older male doctor, who had been working there for hours, said he had to leave. The other doctor also said she had to get away for about an hour. “Are you a physician?” she asked me. “Yes,” I replied. “Great,” she said. “You can take over.” Then she started giving me instructions on how to catalog the body parts. Basically, I had to call out the contents of each bag to a nurse, who would write them down on a form. That was it.
I was in a fog. Suddenly I was in charge, but I wasn’t a pathologist. I was just improvising. I recalled my friends who had done medical clerkships in Africa. They had told me of the terrible tragedies and deep frustration of not having proper medical supplies. But we were not suffering from a lack of supplies. This was not third-world medicine. It was netherworld medicine, without rules.
Another body bag came in. This one had a spleen, some intestines, part of a liver. After sifting through the bag’s contents, I began to feel ill. I walked past headless mannequins and out into the smoke-filled air.
Our triage center had been set up in a firehouse within yards of the World Trade Center plaza. From here, the destruction was even more profound. Bombed-out cars, coated with an inch of cement dust, lined the muddy streets. Steel beams of the demolished towers stood up in the rubble like butts in an ashtray. Giant hoses and wires coiled from the buildings. Everywhere there were shattered windows and broken glass. The ground was strewn with paper and abandoned shoes, as if people had literally vanished in their tracks. Dr. Abramson, the Israeli echo chief who had accompanied me downtown, gazed at the carnage. “I thought I had seen everything,” he said softly.
Heart--A History Page 18