The next morning, a government car picked me up and took me to the university hospital to perform the reversed gastric tube operation. Dr. Gavriliu was inside the car. The hospital was large and quite modern. I later found out it had been a Catholic hospital originally and then had been taken over by the government. We went directly to an operating room where a patient who had cancer of the esophagus was already anesthetized.
Dr. Gavriliu and I scrubbed our hands and forearms, and a nurse held a sterile rubber glove for me to slip into. As I slid my hand into it, the glove ripped apart. The same thing happened with the second and third gloves I attempted to put on. I was to learn that in poverty-stricken Romania, the medical staff did not have the luxury of using gloves once and then discarding them, as we did in the United States. These gloves had been used, sterilized, and reused again and again. On the next attempt to don the gloves, I gingerly slipped my hands into them, and they remained intact.
Gavriliu and I performed the operation together, which took the whole day. Toward the last few hours, a strange thing happened. The assistants, one by one, walked away from the operating table, leaving Gavriliu and me to finish the operation on our own. I assumed the reason was that the Communists considered all workers equal; meaning that, unlike in the United States, operating-room assistants were not responsible to any surgeon’s authority. I sensed that Gavriliu was angry, having to complete so much of the work himself, although he could do nothing about it.
Figure 10.3. Making headlines behind the Iron Curtain: My collaborating with Dr. Dan Gavriliu in the operating room was covered by the Romanian press. (From “Demonstratie de esofagoplastie dupa procedeul dr. Dan Gavriliu,” Muncitorul Sanitar [Romania], September 29, 1956.)
SECRECY AND A COMMUNIST GOVERNMENT
After the operation, we walked back to the hotel and Dr. Gavriliu stopped me on the street, offering me a quiet caution.
“Do not talk about anything in your hotel room,” he said. “The walls are bugged.” I nodded, both surprised and concerned. I never imagined that I would be the focus of Cold War spying, but it actually made sense. I was one of a very few American doctors—if not the only American doctor—to visit Romania since the start of the Cold War. I began to wonder if the trip had been Dr. Gavriliu’s idea or the government’s.
Jane and I were in Bucharest for one week. As the days progressed, I would hear other people whisper similar warnings to us as we walked outside, away from any hidden microphones. At every function we attended, we noticed a mean-looking guy, always smoking, whose title was “Secretary of the Medical Society.” We later learned that he was really a member of the Bucharest secret police sent to keep an eye on us.
A fine, young medical student was assigned to guide us around Bucharest. When we were walking outside and not within earshot of anyone else, he told us about some of his professors who had been taken away by the secret police and never heard from again. Others were sent to work on the construction of the Moscow Canal only to show up again, years later, emotionally and physically destroyed.
The next day, the medical student did not show up as he had done on other mornings. We asked our handlers that day where he was, and they told us he was visiting his grandmother. We quietly continued our investigation, asking people we felt we could trust where the young man might be and learned that the visiting-the-grandmother line actually meant someone had been picked up by government authorities. Alarmed, we got in touch with the chargé d’affaires of the American legation; unfortunately, he explained, he was not allowed contact with Romanian officials. Instead, he could only advise us.
“Keep asking for the young man,” the chargé d’affaires said. “Tell your contacts that you’d like to see him.” We kept asking, and it worked. The next day, the student was back with us, to our great relief.
One day, while Jane and I were out walking with Dr. Gavriliu, we learned the truth about how our trip came to be. “I did not want you to come to Romania,” I remember Dr. Gavriliu confiding. “The government told me to invite you because they saw us working together as a way to improve our relationship with the United States. They ordered me to send the letter inviting you here. After that, they suspected me of treason because I had made contact with you. Now I am under house arrest.” Later, I suspected that it had not been Dr. Gavriliu who had spotted the abstract about the reversed gastric tube operation in the international medical journal but Romanian government officials.
A few days before Jane and I were to leave, Dr. Gavriliu told me that the Romanian Medical Society would be hosting a reception and dinner in my honor. “Is there anyone you would like to invite?” he asked. I immediately answered that I would like to invite the American chargé d’affaires and his staff, since they had expressed a desire to improve relations with Romania. On our last night, the Americans came to the party and, for the first time, had unofficial contact with Romanians. Subsequently, because of that contact, the American representatives were temporarily allowed to arrange showings of American surgical films to the Romanian doctors once a month.
After we returned back home, Dr. Gavriliu and I kept in contact. He sent me letters updating me on the conditions of patients he and I had operated on. I assumed that his letters were being censored by the authorities, yet I still appreciated what appeared to be genuine appreciation for our relationship.
“When we parted at the aerodrome, I felt a couple of friends [were] leaving us. The thoughts and best wishes of people you knew here accompanied both of you all over your travel,” he wrote in a letter dated November 22, 1956. In asking about whether Jane enjoyed the trip back, Dr. Gavriliu wrote, “It was a pity we did not have the opportunity to dance and let me learn the new [dances]. I love dancing [to] good music.”
Given that Jane and I had been offered the rare opportunity to peak behind the Iron Curtain, our arrival back in the United States generated quite a lot of media interest. When interviewed by the press, I complimented the surgeons and students of Eastern Europe, but I also minced no words in complaining about the conditions under which they had to work and the inability of the people to benefit from medical successes.
“It is remarkable what outstanding work is being done by individual practitioners in Romania under very poor conditions,” I told the Westchester News. “Their operating rooms are very poor, and although the interiors are clean, the hospitals are very old. They are far behind us in the general status of medical care.”2
On December 11, 1956, I gave a talk to a medical organization in Paramus, New Jersey, where I showed movies and slides of the procedures I had performed with Dr. Gavriliu and other medical staff. I explained how the surgeons worked all day and halfway through the night and with inferior equipment, all while being hounded by the government.
“They were beat, but they did this remarkable work,” I said.3
Despite my harsh words, I was invited back to Romania in 1960 to again perform the reversed gastric tube operation with Dr. Gavriliu. By this time, I had published a January 18, 1957, article in Surgery titled “The Use of a Gastric Tube to Replace the Esophagus as Performed by Dr. Dan Gavriliu of Bucharest, Romania.”4 I had also authored a paper that appeared in the medical journal Diseases of the Chest in 1959. In that article, I described how Dr. Gavriliu got in touch with me in 1955 and let me know how he had been performing the reversed gastric tube operation since 1951, how he and I performed the procedure together in Romania in 1956 (which was recorded on film), and how Dr. Gavriliu and I reported the results of the operation at the Meeting of the International Society of Surgery in 1957.5 (In addition, I published numerous other scientific articles between 1959 and 1971 in which I also credited the physician’s work.)
On the second trip to Romania, the operation was again captured on film. Upon my return to the United States, Baxter Laboratories, then the principal manufacturer of intravenous solutions, provided funds for me to edit and distribute a movie, which carried the not-so-glamorous title, “Esophageal Replacement with a
Reversed Gastric Tube.” In 1961, Baxter submitted it to the Fourth International Film Festival of Medical-Scientific Films in Turin, Italy, where it was awarded a Bronze Medallion of Minerva.6
Figure 10.4. A critical voice: When Jane and I returned from Romania, I complained to the American media about healthcare conditions in Eastern Europe. (From Mary Tanenbaum, “County Surgeon Finds Reds Ailing,” Westchester (NY) News, Thursday, January 31, 1957.)
Dr. Dan Gavriliu died in 2012 at the age of 97. Without question, he deserves credit for being the first surgeon to discover and perform the procedure that would become known as the Heimlich-Gavriliu Reversed Gastric Tube operation. It was the first successful replacement of a human organ. I am honored to consider myself a colleague of Dr. Gavriliu’s, one of the world’s great pioneers in thoracic surgery.
Still, I am proud of the fact that I was the first surgeon in the Western world to perform the reversed gastric tube operation. And I am heartened that it became the medical standard to treat dysphagia and is used by surgeons throughout the world.
It had been twenty years since the Chinese soldier in Inner Mongolia had died on my makeshift operating table after receiving a bullet wound to the chest. And yet the memory still haunted me. I could remember seeing his chest filled with blood and air, which pressed on his lung, causing it to collapse. Without the ability to expand, the lung could not take in air.
I continued to ask myself what I could have done to save him. Was it possible that there existed a simple, logical solution to keeping the lung expanded?
The problem of a lung collapsing is not only life threatening for victims of bullet wounds. I have seen it time and again among patients who have undergone chest surgery, such as when a surgeon operates on the esophagus, lung, or heart, or even when a doctor merely inserts a needle into the chest to obtain a lung biopsy. The condition of a lung collapsing is known as pneumothorax. If not treated immediately, the person can no longer breathe, and death quickly follows. In 1962, I wrote about this dilemma in a book called Postoperative Care in Thoracic Surgery.
A major reason why a lung collapses is because there is pressure on it due to surrounding fluid or air or both. Therefore, it’s essential to remove the air and fluid to allow the lung to expand. In the early 1960s, doctors had a rather primitive way to do this. First, they drained the buildup of air and fluid by inserting a tube into the chest and connecting it to a suction machine attached to the wall or floor of the patient’s room. A series of two or three bottles, which usually sat on the floor, collected the buildup.
Figure 11.1. The old way: Before the Heimlich Chest Drain Valve, patients who had undergone chest surgery were hooked up to cumbersome suction devices and collection bottles.
This method was awkward and potentially dangerous. It greatly limited the patient’s movement and proved cumbersome for hospital staff who had to move the patient to another room. Also, there was the chance that the tube draining fluid from the chest could be accidentally yanked out. The situation for soldiers in the field who had received a chest wound was even more precarious. Setting up the ungainly chest-drainage system was simply not feasible, and so, sadly, many soldiers died when shot on the battlefield.
THE ANSWER: A VALVE
I began to investigate what it would take to design a new chest-drainage mechanism that would allow air and fluid to leave the chest so that the lung could expand and let the patient breathe. But this mechanism would have to do something else that was critical: it had to prevent the air and fluid from returning to the chest. If it did get back in, the lung would again collapse. That was what the suction caused by the bottle setup accomplished.
But was suction necessary? I didn’t think so because the air and fluid would naturally leave the body as the lung expanded. The most important thing was to not allow the air and fluid to get back into the chest.
And that’s when it hit me: Why not just use a valve, one that permitted the air and fluid to drain away from the chest and not return? If the right valve was in place, there would be no backup to worry about, and the lung could function normally.
But which valve was the right one? I began to think about all the different kinds of valves that were out there. There was a ball valve in which a metal ball lies on top of the opening of a tube. As fluid or air comes up through the tube, it pushes the ball out of place. When the flow stops, the ball falls right back into place, thereby preventing fluid and air from backing up.
But a ball valve wouldn’t work. If the valve’s opening turned sideways or upside down, the ball would not fall into position to shut off the valve.
What about a flap valve, such as the kind you see in toilets? A flap valve opens and closes on a hinge, cutting off the flow of liquids and air when they reach a certain level. But that, too, posed a problem because, if a blood clot lodged under the lid of the valve, it would stay open, allowing air and fluid to flow back into the chest.
I knew of only one other type of valve, a flutter valve. This is a piece of soft tubing, usually made of rubber or soft plastic. When air or fluid enters one end of the tube, it opens, allowing the air or fluid to pass through. After that, the tube flattens again.
Here’s how I envisioned the flutter valve working to drain air and fluid from a patient’s chest: As the patient inhales, there would be pressure in the chest as the lung expands. This pressure would force fluid, air, or clots out through the drainage tube. Then, when the patient exhales, the pressure in the chest would cease, and the valve tubing would collapse, thereby preventing the air and fluid from backing up.
I wanted to play around with the idea immediately and ran to a nearby five-and-dime store. There, I purchased a Japanese noisemaker that made a sound we used to call a “raspberry” or a “Bronx cheer.” The one I picked up had a little plastic mouthpiece attached to a thin piece of flattened rubber or plastic tubing. Blowing through it made that embarrassing noise. Now that I had something I could practice with, I set to work developing my new, retrofitted valve.
A PATIENT RECEIVES THE CHEST DRAIN VALVE
The idea seemed so logical, I wanted to use the flutter valve on a human. About a week after my five-and-dime purchase, a young man was admitted to the hospital with shortness of breath. A chest x-ray showed that one of his lungs had collapsed and his chest was filled with air, the telltale signs of pneumothorax. After obtaining the patient’s consent to try the chest drain valve, I gave him local anesthesia and then inserted a tube into his chest. But instead of connecting the tube to the suction apparatus, I attached it to my sterilized flutter-valve device.
I sat at the patient’s side for twenty-four hours, observing him carefully. Periodic x-rays showed the flutter valve was working—there was no air trapped in the chest. The valve allowed air to leave the chest while preventing it from getting back in, so the lung could function normally. The patient was breathing and did not have to be tied to a heavy suction apparatus. I felt as though the flutter valve might be the answer I had been seeking.
I took my device to Becton Dickinson and Company in New Jersey, the leading manufacturer of medical equipment. After an extensive series of tests under all kinds of conditions, company researchers determined that the valve stood up. Becton Dickinson made a few dozen devices and called it the Heimlich Chest Drain Valve. I soon started using it on patients who were undergoing chest surgery, including those who had problems relating to the heart, lung, and esophagus. Each time, the chest drain valve worked wonderfully.
THE MILITARY TAKES NOTICE
In January 1966, I spoke at the annual meeting of the American Medical Association in New York City and described a few of the cases where patients had received the chest drain valve and it had worked successfully. After the meeting concluded, four US Navy officers came up to my exhibit. They explained that they were from the National Naval Medical Center (now the Walter Reed National Military Medical Center) in Bethesda, Maryland. The senior officer told me that he was so determined to get Heimlich Chest Drain V
alves to Vietnam that he was going to fly to headquarters that day and procure a navy plane, which he would then fly to New York the next day. He asked me to meet him at a nearby airport with six chest drain valves, which he would then immediately take to Vietnam.
The fact that the military was going to be using my valves filled me with joy. It meant that, for the first time in history, a person shot in the chest on the battlefield had a decent chance of surviving.
Shortly after I gave the officer the six Heimlich Chest Drain Valves, I received a telegram from an executive at Becton Dickinson, saying he had received a letter from US Navy lieutenant named Bradley, who wanted one hundred more valves urgently sent to Vietnam. The lieutenant wrote in his letter that he had dropped off the six valves at a medical unit in Vietnam. He continued, “Yesterday I went back and they had used six of them and think they are great. If you could rush 100 more out to us, I think we could have enough data to make a request to get on the supply table.”1 The telegram also said that a commander named Brodine, who headed a naval research unit in Da Nang, believed that the valves were “urgently needed” in Vietnam and were proving to be “a life saving item, and one that the Navy should be interested in ordering as standard items.”2
The US Air Force also wanted the valves. Becton Dickinson received a letter, dated April 11, 1966, written by a young surgeon who was stationed in Can Tho, Vietnam. As a member of the US Air Force surgical team, Dr. Gerald Baugh treated Vietnamese civilians and soldiers in a building that had once been a hospital but had next to no supplies. According to Dr. Baugh’s letter, the injured were “sent to us by helicopter, truck, even ox-carts from miles around.” He continued:
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