Little Pamela Kroger had been yelling at doctors and nurses all day, but when Cooley walked into her room smiling, she hushed. Even at four, she had respect for his celebrity. “Hello, honey,” he said, able to press his stethoscope against her heart and listen to the hissing irregularities without interruptions. He beckoned for Mrs. Kroger to follow him outside. She had talked to several doctors during the day and she well understood her option: take the child home and wait for her heart to stop, or agree to the nightmare of a man plunging his hands into the child’s heart, in a room where she, the mother, could not go.
“I think we can fix her up,” Cooley began. “But.…”
“I know,” she said. She had been wrestling over what she would say at this moment, and now it was time, and she was nearly mute.
Cooley helped her. “If she was my little girl, I’d have it done. I wouldn’t like it, but I’d agree to it. I just want you to know there is a risk, though.”
Mrs. Kroger stood silent for several moments, not aware that Cooley was anxious to be about his rounds. Finally she nodded her consent, began to cry, ashamed at breaking down in front of this man. She rushed back into her daughter’s room, a hand thrown across her face to conceal the tears from the child.
Outside another room, Cooley told Harold Carstairs’ wife, “This is high-risk surgery. The hole in his heart has been there for a long time, possibly since birth. We can repair that—that’s not the problem. It’s the three or four days later that we worry about.”
“What are the odds?” she asked. Patients and relatives always like to know the odds, as if there was a tote board for all lesions.
Cooley pursed his lips and pulled a figure at random. “About eight to five,” he said and walked away. He muttered to John Russell, his resident, “I hate to make book in front of the patients’ wives.”
One of the Iranian fellows caught Zaorski’s sleeve. “What did he say?” Zaorski explained what odds were and what a bookie was. “He talks so fast and so quiet I can’t understand him,” said the Iranian.
A voluptuous Eurasian mother wearing a mini skirt hesitantly walked up to Cooley, and in struggling English, said, “For you,” shoving a carefully wrapped package into his hands. Cooley thanked her and opened it, discovering a heavy, quite hideous statue of an ancient anonymous doctor or professor. Later, on the floor below, he looked at it again, grimaced, and said, as he handed it to an intern, “I guess I could always put trifocals on it and call it St. Michael.”
“What did he say?” asked one of the foreign doctors.
Zaorski gestured with his head toward Methodist.
On the eve of open-heart surgery, a man lies unfed in his bed and waits for the Nembutal to darken the strange walls. Harold Carstairs was bewildered. A simple man who had worked hard all of his life, he could not understand why he had been chosen to joust with death at the age of 49. He had pitched hay on a farm until he was 21 and thought himself to be a robust youth until the Army rejected him in 1946 because of a heart murmur. A heart murmur! Perhaps he had been born with it, perhaps it had come from an unknown attack of rheumatic fever. It so frightened him that he buried all thoughts of it, and when it threatened him he ran away from it, as a man runs from a criminal past. “A person has to work,” he said. “I got a job on a towboat picking up 85-pound rachets and carrying them around. I worked on the Illinois Central Railroad for ten years and I never once took the physical. I always figured out a way to avoid it. I thought if they heard my heart they would fire me.”
Six years before, a doctor told him to have his heart examined by a specialist. “But he didn’t press me about it, so I didn’t do it.” Not until six months before this Houston night had enough apprehension set in for him to find a heart doctor. He had begun to cough and could not drink enough syrup to make it stop. He felt generally run down and had begun, as he discreetly put it, “to lose my desire.”
Now his apprehension had turned to fright. He clutched his wife’s hand. “I’ve got so much back home,” he said. “I’ve got this wonderful family, the best a man ever had.…” “I never did anything bad to anybody.…” His tears were splashing down his face and, as men do when there is nothing else, he turned to his faith. “I had a vision last night. I saw Dr. Cooley walk in with his young doctors and I swore it was Jesus Christ and his Disciples.”
Super-Jesus!
CHAPTER 6
Dr. Jerry Strong bent over Pamela and blotted her perspiring face. She had been sedated in her room, but the tranquilizers were beginning to wear off as she lay on the stretcher outside Operating Room 1. She was whimpering slightly. Strong said softly, “It’s all right, honey, it’s all right. We’re going to put you to sleep and fix you up in just a minute.” He went into the coffee room and said to no one in particular, “Pulmonary pressure like that kid’s is a bomb with a 72-hour fuse.”
Slender, witty, caustic, and a highly skilled anesthesiologist, Strong reigned as raconteur of the coffee room, the crowded lounge just inside the swinging doors that led to surgery. There were no windows in the lounge and the furniture was cheap, cracking tan plastic; the ashtrays were overflowing, the magazines were out of date. But it served as unofficial headquarters for Cooley’s domain. Throughout the day and half the night it was crowded with surgeons resting before, after, or sometimes during their cases, nurses grabbing a cigarette, medical students cramming or listening to their elders talk of patients and politics. The main attraction was the free hot coffee, and, on days that the drug detail men came around, blueberry cupcakes or oatmeal cookies with a foul-tasting orange ribbon on top. Cooley’s fellows drifted in after each case to dictate surgical reports, and they assembled there each afternoon to discuss the day’s work and await his appearance for rounds.
There was an aura about the two heart teams at the two hospitals which went beyond the marked physical differences in space and resources. (A Cooley staff doctor had complained during the transplant year that he was a man using a 2½-horsepower lawn-mower engine while DeBakey’s people, in their splendiforous center, had a 450-horsepower Cadillac.) Each surgeon dominated his hospital and each used power in his own fashion, but a nurse at St. Luke’s did not even bother to lower her voice in the coffee room when she announced that she did not enjoy scrubbing for Cooley. “I’ve had Dr. Wonderful and his God Squad,” she said. “I’ll take orthopedics.”
Two visiting doctors were in the coffee room with name tags stuck on their scrubs indicating they were from out of state. They had arrived early to watch Pamela’s surgery. They took coffee from the big urn and wandered out to look at the blackboard in the foyer, with the first twelve spaces usually occupied by Cooley cases. A student who had been talking with them remarked on the large number of physicians continually pouring through Houston and crowding Cooley’s—and DeBakey’s—tables.
“We get all the VIP’s down here,” said Dr. Jerry Strong, as he tied on his throwaway sterile mask. “Let’s face it; this is the Big Top.”
At 7:45 A.M., Dr. Domingo Liotta, an Argentine-born surgeon and researcher sliced open Pamela’s emaciated chest. Shortly after 8 A.M., when her ribs were parted and the enlarged heart exposed, Cooley entered the room and, while a nurse dressed him in his sterile gown, asked someone to turn the radio up a little. He says he is not conscious of the music, even though he often whistles or hums along with it, but it is part of his room, as are the cartoons, the occasional nude picture, the inspirational posters that decorate the sterile walls where he spends most of his life with these sayings:
“Ideas won’t keep—something must be done about them.”
“Yesterday is gone, tomorrow may never come, now is the appointed hour.”
“The more you help another, the more you help yourself.”
And, dominating all, a long quotation from Theodore Roosevelt:
“The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood … who knows the great enthusiasms, the great devotions a
nd who spends himself in a worthy cause … who at the end at best knows the triumph of high achievement and at worse fails while daring greatly, so that his place will never be with those cold and timid souls who know neither victory nor defeat.”
Always it is the same. Always there is the one suspended moment when he looks down through the gold Italian half-spectacles taped lightly to his blond, graying sideburns, seeing for the first time the troubled heart beating beneath him. (“Can you remember the first heart you ever saw?” I once asked him. He thought for a moment and finally shook his head. “There’ve been too many,” he answered. I had asked the same question of DeBakey, only he remembered. He said, in fact, he could never forget it. It was in the early 1930s, in the emergency room of Charity Hospital in New Orleans; he had looked down through the rib cage and seen a tiny pulsing pink part of a heart that had been pierced with a knife in a brawl.)
With a slight shift of his shoulder, Cooley was off, hands boldly slipping into the once forbidden chamber, carpentering a new system of circulation within Pamela’s heart. “Some surgeons piddle,” a doctor remarked after watching Cooley operate. “Some surgeons fool around and step back from the table and play with the sucking machine and poke around inside the patient. But not him. He doesn’t waste a breath, not a gesture. He knows exactly where he is going because he has been there before.”
Only twice during the delicate procedure—how simple it looked!—did he speak. Once was in reply to the visiting doctor who asked how often Pamela’s disease—transposition of the great vessels—was encountered. “We used to think it was rare,” he said, “but it is now known to be one of the most common congenital defects. The trouble is, so many kids die when they are a few weeks old.” The second was when he glanced behind him through the glass walls into Room 2, where the next case was being prepared. “What’s that?” he asked. A nurse went to check the schedule sheet posted by the scrub basin. “The VSD,” she said, giving the abbreviation for ventricular septal defect.
That’s not a “what.” That’s not a VSD. That is a human male, one Harold Carstairs from Illinois. Next to his birth, next to his death, this is the biggest moment of his life. Must he be anonymous? Had Cooley connected the cavity before him with the child Pamela he saw yesterday for thirty seconds or the mother he saw for forty? Was it possible to hold so many hearts in his hands and know them?
“Denton Cooley,” said a friend who stood once and watched him through the glass, “is the greatest doctor in the world—from here down.” He made a slashing gesture, a line of demarcation across the wrists.
It was gray and misty with thunder dancing about the city, a condition that seemed compatible with the mood of Marsha Kroger as she waited news of Pamela. Beside her was her divorced husband Gerald, Pamela’s father, a chunky, gentle man with a crew cut and a soft north-Louisiana drawl that welded words together. He had both a book of philosophy and Dr. Zhivago on his lap, but every time footsteps approached, his eyes shot up from the page. Certain people become familiar during the waiting—nurses, orderlies pushing carts, but when a new figure appears, the families are swept by panic. Is the message coming?
“A month after Pamela was born, she turned a bluish color,” recalled Mrs. Kroger. She was a slim woman with an air of efficiency about her. “A strange duskiness set in. Her eyes had always troubled me, a child that sick has haunting eyes. We sat there with our Dr. Spock, trying to be good parents. Our pediatrician didn’t even recognize heart problems. He kept saying she wasn’t feeding properly.
“The thing that began to frighten me was the memory of my twin sisters who died of heart defects a few weeks after they were born. And my grandmother had twin sons, uncles I never knew, who had died of what they called ‘malnutrition’ then, but which was probably heart disease. I felt I was carrying the bad seed and had passed it on to my daughter.… On the day Pamela sank into heart failure, our pediatrician finally decided we should rush her to Houston. Gerald couldn’t get an ambulance.…”
Her ex-husband winced at the recollection. “There was a water festival going on at the lake and all the ambulances in Austin were out there hoping to pick up a drowning.…”
“He finally chartered a plane,” said Mrs. Kroger, picking up the story. “They flew her to Houston and arrived at Texas Children’s with sirens blaring. They did her first catheterization the day Charles Whitman was shooting people from the University of Texas tower. When we got the diagnosis, that the great vessels of the heart were transposed, Gerald fainted.”
Gerald nodded, not embarrassed at the memory. “I was ready to accept one of the minor heart defects, a murmur, even a hole, because I knew Cooley could do them. But this sounded so staggering I thought we would surely lose her.”
“When she got old enough,” said Mrs. Kroger, lighting a new cigarette from the one she had not yet finished, “we told her about her condition. Sometimes she referred to her ‘sick heart’ with a cute look on her face, but she never used it as an excuse. Living with a heart baby was hell. You try to protect her, but you also try to let her lead a normal life. The other day she was on the monkey bars at the park and she froze—she got tired and pale and I could see her anguish.”
Two hours and forty minutes after she had entered the operating room whimpering, time bomb Pamela was ready to leave, her heart reconstructed, her existence for the time dependent upon technology. Jerry Strong supervised her transfer from the table to the rolling stretcher. “Patients not infrequently arrest between here and there,” he said, pointing down the hall toward Recovery. “So I think it’s important to stay with them all the way.” A tube was down her throat and its connection taped across her mouth for the ventilator that would breathe for her until the lungs rallied—if they could. During the transfer, Strong would squeeze the black oxygen bag to feed her with oxygen.
“What are you bringing us?” said one of the Recovery nurses as Strong and an orderly delivered Pamela. “Transposition,” said Strong. A place was made at the end of the room where the children are watched.
Dr. Liotta had come out between surgery and hovered as the nurses hooked up Pamela to the various monitoring machines and wrote her name on the strip of tape at the foot of her bed. Leachman was in Recovery checking on another patient and moved down to Pamela’s bed. “She’ll be all right if the cardiologist takes proper care of her,” said Liotta.
Leachman watched the surgeon return to his quarters. “This is the surgeon’s out, don’t you see,” he said. “He has committed this massive assault on the patient and now he passes the buck to me.”
(Near midnight, Leachman was attending Pamela and he said, not wholly in jest, “Note what physician is still here and what famous surgeon went home hours ago.”)
The general feeling was that Harold Carstairs had small chance of surviving. “I’ll be surprised if he gets off the table,” said one of the surgical fellows, looking at the x-rays that Gwen, the head operating room nurse, had slapped onto the illuminated viewer in the corner of Room 2. The heart was enormous, its shadowy shape almost as big as the chest itself. Strong glanced at it and shook his head, virtually a shudder. But there was no curtain of pessimism in the room, where a Muzak-type station had been switched to one that sent out hard rock, the room where Harold Carstairs was probably going to die. “In medical school,” a cardiologist named Don Rochelle would tell me, “you start out by having enormous empathy for patients and their families. You get involved with all of them. But to work in the cardiovascular field, you have to develop almost a shield around you. When someone dies, they die. You can’t crack up—caths go on, surgery goes on. There’ll be twelve new patients in tomorrow.”
Liotta was first-assisting all day, opening the chests, following Cooley on the sutures, finally closing. The job was passed around on a rotation basis to all twelve of the surgical fellows, plus Liotta, who spent most of his time up in the seventh-floor lab in research but who relished the rare opportunity to cut and sew. When Liotta exposed Carstairs’ he
art, Jerry Strong glanced at it and made an inverted whistle. “Jesus, would you look at that! It’s one of the worst-looking hearts I’ve ever seen. Most of these cases die by the time they’re 35. It’s wall-to-wall heart!”
The huge heart was so flaccid and deteriorated that Cooley had to go at the ventricular septal defect through the tricuspid valve, roughly equivalent to entering a house by crawling under the basement door. During surgery, Jerry Strong pinched Carstairs’ cheeks now and then, bringing a momentary cosmetic flush of pink to the pale skin. Anesthesiologists do this to see if blood is flowing to the patient’s head.
“This is known as the George Lewis technique,” Strong said.
“Is that a professor here?” asked one of the visiting doctors.
“He’s a local undertaker.”
One of the visitors, a short doctor unable to see the field, had navigated his way to the patient’s head-end of the table and was standing on a large, shaky stool. Gwen eyed him nervously and finally asked him to get down, diplomatically finding him a better place. “Someday somebody is going to fall into the patient,” she muttered.
“How old is this patient?” asked the short doctor from his new position.
Cooley shook his head. “Gwen?”
Gwen found the chart with the plastic identification card and discovered from it that Carstairs was 49.
The short doctor shook his head in disbelief, as well he might have.
Carstairs probably was born with the hole in his septum, that partition that separates the two ventricles (lower chambers) of his heart. This had caused the right ventricle to work furiously, pumping blood into the lungs, and at the same time fighting off pressure from the left ventricle. Blood that had returned from the lungs with oxygen had continually mixed with blood that was on its way to the lungs. The ventricular septal defect is the most common congenital heart defect and is almost routinely corrected by the heart surgeons—both Cooley and DeBakey had mortality rates under 10 percent, But Carstairs’ heart was so gross and the tissue around the hole so worn and tired that it would take a large patch to cover it. Would the sutures even hold? Would any other surgeon have even attempted it?
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