In the bullpen after rounds, Jerry Johnson gulped a quick cup of coffee before setting off to make the same rounds over again, going back to the rooms of everybody DeBakey had seen and answering the questions they were too frightened to ask of DeBakey. Johnson was talking to Santiago, a handsome and intense young surgical fellow from Argentina, saying that he had decided to go into plastic surgery.
“Why?” asked Santiago, who, like most of the foreign surgeons who continually flock to Houston to hover at the elbows of DeBakey and Cooley, was totally committed to the glamour and potential of cardiovascular work.
“Because I don’t want to work around really sick people. I get too involved with them.” Johnson looked out the window into the parking lot. An elderly man was trying to help his wife out of a wheelchair and into his Buick. “I don’t really like them. I can’t get them out of my mind.”
Santiago cut in quickly with his romantically accented English. “But you must leave them at the hospital when you go home at night. You go crazy otherwise.”
DeBakey arrived before sunrise the next day and worked in his locked office until 7: 30 when he suddenly appeared on the third floor surgical suite. He had changed from his street dress—suit custom made by a Beaumont tailor, shirt of a special light cotton made for him in New York, carefully knotted polka-dot bow tie—into his surgical scrub suit, which differed from everyone else’s greens because his was powder blue, his favorite color. The blouse had a thicker layer of absorbent gauze to soak up the blood, which splatters in the best of surgeries. He was in a foul mood, which everyone sensed, probably because he was going to begin the day by amputating Diane Perlman’s leg.
“I wish to God it didn’t have to be done,” he said, as he scrubbed in, washing the lean fingers for ten minutes, then scrubbing his nails with a throw-away plastic sponge. Up until a handful of years ago, reusable brushes and orange nail sticks were used and sterilized after every scrub, but a committee of Texas nurses had introduced the idea of disposable ones.
There are eight operating suites built in a circle around a central glass-walled control room where computers are being installed to monitor patients during their surgeries. When perfected, they will report on all the vital signs of a patient and squawk warnings in advance of a dangerous plunge in blood pressure or of an arrhythmia, the abnormal rhythm that can send the heart into fibrillation and death. DeBakey and his two junior surgeons, Ted Diethrich and George Noon, occupied four of the suites. Other members of the Baylor surgical faculty used the remaining four, turning an average of 50 percent of their fees over to the department. The eight rooms were equipped with the most magnificent of equipment, electronic innards of such sophistication that engineers had become a vital part of surgery. In mask and gown, they entered the chambers almost as frequently as the surgeons.
DeBakey pushed open the swinging doors of Room 4 and saw Mrs. Perlman on the table, already sedated and draped. Only her mottled, pink-streaked leg was exposed; the rest of her body was covered with green sterile cloths. “This is an operation of failure,” said DeBakey. It took but a few minutes to cut through the flesh, and even less to chew the bone through with an electric saw. The severed leg was wrapped in a green plastic sheet and given to an orderly for delivery to pathology. DeBakey left the room and Diethrich sewed up the stump. One of the nurses was recalling another amputation, a woman who demanded that she get her leg back from pathology when the tests were completed. “That leg is still a part of me,” the woman had said, “I’m going to have it buried in the family plot where I will join it some day.”
At midday DeBakey disappeared. Newspapers the next day reported he gave a speech in Kansas City urging more federal money for research. He had embarked on a passionate denunciation of Richard Nixon and his budget allotments. Nixon had become the newest windmill for him to joust. And there were so many others—the American. Medical Association, the local medical society, any organization or individual who differed with his strongly held belief that medicine is a right, not a privilege. He was the most towering figure in Houston medicine, but he was also the most actively disliked. A small percentage of his cases were local referrals. What affection was denied him at home, he could easily find outside its borders. A trophy case in the conference room of Frondren-Brown was filled with gold scalpels and medals and ornate scrolls attesting to his accomplishment, and the case was always lighted, like an eternal flame. “Mike DeBakey,” said one of his most bitter critics, a Baylor faculty member of considerable power, “has an almost pathetic need to recrown himself every day. He will accept the invitation of some girls’ school somewhere in backwoods Pennsylvania and go there and get their medal and fly home all night and charge into surgery. I cannot understand why a man of his power and prestige needs such hosannas.”
In his absence, Ted Diethrich ran the service and at mid-afternoon fairly bounced out of the operating room into the coffee lounge. He had heard from Phoenix that Bill Carroll was responding well to treatment and that his transplanted heart showed no signs of damage from the bar crawl. Moreover, he had just done a surgical “first,” or what he believed to be a “first.”
“It was fantastic! It was the first time anybody replaced a mitral valve and at the same time cleaned out a coronary artery with gas.* I’m not sure I should talk about it until I’m sure the guy makes it. But he looks fantastic!” Ted was only 35 but looked eighteen and if he came into my room and announced he was the one assigned to remove the hangnail, I was not sure I would let him do it. But he is brilliant, already one of the recognized fast guns, and all the other fast guns have made note of him.
Signor Montini’s monitoring scope, electronically measuring his heart rate, had gone all but flat. There had been no improvement in urinary output, his eye pupils settled fixed and dilated. His body had become the texture of cold sponge rubber. He was not so much a human any more as an abstract object committed to the wires and tubes and machines, which covered and wrapped his body. The ventilator that had breathed for him for almost 48 hours was still pushing oxygen impersonally into and out of his lungs, forcing his chest to rise and fall as that of a life-filled man. Dr. Reed, the resident, directed an exquisitely timed and executed attempt to resuscitate the heart. With his palms he slammed into the chest—BAM—BAM—BAM—at intervals of one second. A nurse handed him a hypodermic needle filled with adrenalin, which Reed plunged directly into the heart. The scope began to leap fitfully, only to settle back again. Someone else shot digitoxin to strengthen the heart into an intravenous tube; an inhalation therapist was pumping moist oxygen into the lungs.
After perhaps ten minutes, after countless scores of slams onto the chest, Reed lifted his arms, paused, looked at the scopes with puzzlement, and stopped. Nothing was said, all was lost. Within the brain—deprived now of blood for a quarter of an hour because the heart had stopped pumping it—each cell was shrinking, then turning dark as if stained blue. Each cell was shuddering and breaking up, dissolving, the nucleus disappearing into the cytoplasm, caught up in the dance of death. Millions, billions of cells, each containing DNA, the origin of life, were blinking out. Massive cell death was rushing throughout the body, extinguishing life in the kidney, then the liver, the lesser organs. Oddly, the heart, though stopped and the assassin in this murder, was one of the last to go. A remarkably hardy machine, the heart has been known to leap back into activity after arrests of up to one hour. But by then its owner would be, as Montini would have been, a vegetable; the brain can survive only four or five minutes without life-giving blood.
A nurse drew a lemon-colored curtain around the cubicle to spare other patients the sight of Montini’s bain de mort. An orderly moved in to disconnect the machines and wires and tubes, and when that was done, he scrubbed away the medication and blood from the body. The final act was the classic drawing of the sheet across the face. The orderly pushed the bed across the Intensive Care Unit to an empty corner where a screen was placed about it. There Montini would wait until the trip dow
nstairs to pathology—provided the family gave permission for an autopsy.
Even now there was life of a primitive sort within him. The hair follicles would continue to grow for hours, perhaps days; the nails would remain alive even longer, and his intestines would shift silently and engulf one another. Were it not for embalming fluid and the cold boxes into which the dead are put in morgues and funeral homes, growth would continue for several days.*
I watched the pageant with mute fascination. It was the first occasion I had borne witness to the actual moment of death. I had seen death before, after-the-fact death, that principal currency of journalism. I had, and I would never forget it, seen my first violent death in this very city, fifteen years ago, on my first week’s work for a now defunct newspaper.
Those first dead and those dead since of traffic, riot, and war were figures in an impersonal tableau; I had no prior identification for them, and when I had come upon them, they were only to be counted and tagged and their widows telephoned for color. Signor Montini had lived! He had asked for ice in a hoarse voice, he had raised his hands to look at his nails, he had brought his heart to Houston because DeBakey could repair it, and now he was stiffening and lost.
“What did he die of, exactly?” I asked Reed.
“Pump failure,” he said, but he was busy attending to a woman who was trying to climb from her bed and yank the intravenous tube from her hand.
Because DeBakey was not there, the unwanted task of telling the family fell to George Noon, one of the junior surgeons. With death the machinery of the hospital moves quickly; already the dead man’s brother had been brought to a tastefully done chamber in oriental decor called the Family Room (adjacent to the Intensive Care Unit). A chaplain was beside him, as was a member of the hospital’s social service staff. An interpreter was present; Methodist can summon the speakers of more than 30 languages—and has.
The moment Noon opened the door, Montini’s brother could tell from his face that the day had turned dark.
“Morto?”
A nod.
“No!” A fist slammed into a palm.
* The gasendarterectomy, or “gas” as it is called in the heart center, is a procedure developed in New York in the late 1960s. The surgeon makes an incision in a heart artery and injects whiffs of carbon dioxide gas. This loosens the cholesterol and occlusive matter and enables the surgeon to lift out the entire core thereby restoring blood flow.
* A Baylor pathology professor was conducting an autopsy years ago when a student cried out that he felt a pulse in the cadaver. The professor hurriedly examined the “pulse” and brusquely told the student that the life he thought he felt was contained only in his own fingers.
CHAPTER 2
Sunday was both exodus and genesis, the old patients leaving, the new ones filling their beds. Even though DeBakey had flown first to Rome, where he was to be blessed by the Pope and thence to Brussels, where he would attend a retired king, his service ebbed but slightly. In his absence, the staff admitted new patients and worked them up for DeBakey’s return. Ted Diethrich and George Noon scheduled surgery as well, it being their privilege to serve both as academicians and as private doctors. In most of America’s leading medical schools, the custom is for surgeons to be full-time faculty members, drawing a salary as their only income, allowing them to teach, perform operations, and remain divorced from the competitive world of private practice.
DeBakey, however, has stubbornly kept it both ways. He has never let go of his private practice, one of the largest in the world, even though he is president of Baylor Medical School and simultaneously chairman of its Department of Surgery. For more than two decades he has employed the various medical castes—students, interns, residents, and fellows, plus a full-fledged junior associate or two like Diethrich and Noon—to assist him in running the huge census. The returns seem beneficial to all concerned: the younger men get practical experience from assisting and observing all manner of sophisticated, even avant-garde surgery; DeBakey, on the other hand, fulfills his teaching responsibilities and gets inexpensive help.
During the night a Gypsy prince—or king, his position in the tribal hierarchy seemed to vary depending upon which member of his entourage one talked to—arrived on a stretcher. He was admitted as Thomas Eglund and gave Seattle as an address. He said he had suffered a massive heart attack while on business with his tribe in Kansas and they, alarmed, chartered a plane to fly him to Houston, where he presented himself for treatment “only by the great Professor DeBakey.” No one knew exactly what to do with him, so Prince Thomas was put in a room on the sixth-floor postoperative wing, a heart monitor attached to his chest. There he would wait, under observation, until DeBakey returned. A young man of only 35, the prince was obese; his blubbery body filled the single-size hospital bed and it was important that he lie still because there was no room for him to roll. He had a neat pencil-thin mustache and three rings on his left hand and two on his right, which he refused to put in his drawer.
The floor nurses spent most of the first night chasing his family out of the room. The women wore flowing, pleated skirts that fell almost to their stiletto heels; their golden looped earrings and bracelets clanked as they clattered down the quiet hallways trailing clouds of garlic and olive oil. One woman had her front teeth set with diamonds and she fairly sparkled as she begged permission to sit through the night at the bedside of her ailing kinsman.
Finally the head nurse grew weary of expelling the family. She put up a chain across the floor and threatened to notify the hospital police if they did not stop slipping down the corridors. “Your patient is a sick man and he must rest now,” said a tiny Philippine nurse with a remarkably large voice. “You can visit him in the morning.”
Both Methodist and St. Luke’s had become meccas for prominent Gypsies. And both hospital administrations had grown wary of the tribes’ boisterous cries for the best of everything—the best rooms, the best round-the-clock nurses, the most elaborate tests—and also, particularly if the outcome was unpleasant, their refusal to pay. During one Gypsy’s confinement, while he was in another part of the hospital for x-rays, his relatives took turns climbing into the bed and playing with the automatic controls that made it go up and down. When a nurse demanded that the matriarch remove herself from the bed, she retorted, “We are paying for this bed, and the whole family is entitled to use it.”
On another occasion, an alert member of the Methodist security force spotted one Gypsy nonchalantly pushing another in a wheelchair out the front door. Neither, as it turned out, was sick, but the chair could have been sold for several hundred dollars. Television sets, sheets, boxes of bandages, even an EKG machine have disappeared during Gypsy sicknesses. The most memorable Gypsy assault took place at St. Luke’s, when one of America’s major tribal kings underwent open-heart surgery. During the operation he vomited and a bit of it went to his lungs, followed by an embolism that traveled to his brain. For weeks he lay in extremis while the clans flocked to Houston. They set up tents on the hospital lawn and parking lots; one doctor left work late in the afternoon and discovered a Gypsy family feasting on roast chicken atop his Cadillac. By the time the king had reached his final hours, there were hundreds of mourning kinsmen scattered about the Medical Center, and when he finally expired, the immediate relatives refused to pay the bill because they had not received what they had come for, which was the king’s successful recovery.
When Prince Thomas checked in, Methodist’s Admitting Office demanded a $3,000 deposit. The family balked but came up with $1,000 in wrinkled, carefully counted out small bills and the promise to find the rest.
On a Monday morning, Ted Diethrich set into motion examinations to determine if 43-year-old Arthur Bingham, a Phoenix businessman, could be a candidate for the newest and hottest operation in heart surgery—the coronary artery bypass. This is a delicate procedure in which a vein is borrowed from a patient’s leg and hooked up within the heart to give it a better supply of blood. The operat
ion was devised by cardiologists and surgeons in Cleveland and Minneapolis, but typically the Houston heart men had begun modifying and improving and doing so many that they were becoming recognized as among the world leaders.
At its simplest, the most common acquired heart disease is narrowing of the arteries on the surface of the heart from occlusive matter—largely cholesterol. When this occlusive matter builds up to the point where it completely shuts off blood supply to a portion of the heart, then that portion suffers an infarction—an attack—and dies. Sometimes the heart can survive such an attack and continue to perform its function, although the dead section turns a gray color and is called “ischemic.”
For decades, surgeons have been inventing procedures to get at such occlusions, from reaming arteries out like a Roto-Rooter, to wrapping blood-starved portions of the heart with adhesive, hoping that the abrasion would force new vessels to spring up and serve the heart, to hooking up new sources of blood. None had proved satisfactory, but the search continued. The rewards were obvious, both in lives saved, and—bluntly—in potential patients. Some researchers hold that atherosclerosis is the body’s natural aging process, that the occlusive building begins in late adolescence and can climax fatally at any time thereafter, if not elbowed out by cancer or infection or violence. A now-famous study of a large group of American soldiers killed in the Korean War revealed that up to 65 percent of these strong young men had recognizable atherosclerosis in their coronary arteries. This study exploded the belief that it was a plague of the aged.
Bingham’s Phoenix cardiologist had run tests that indicated serious coronary artery disease and had dispatched him to Houston to see if Diethrich thought surgery was possible. Although DeBakey has built his reputation on the scalpel, he has also brought together all the medical disciplines interested in heart disease—chemists, biologists, radiologists, neurologists (for strokes), and cardiologists, who play the detective role and report to the surgeon what mysteries they have unraveled or suspect. They also recommended for or against surgery, which the surgeon may or may not accept. But in Houston the surgeon is, quite frankly, the Supreme Court.
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