Hearts

by Thomas Thompson

  Castle was at that moment accusing the nurses of stealing his suitcase. “It’s right here, Mr. Castle,” said a weary black nurse. “Lemme see it, I don’t believe you,” roared the farmer. He was trying to stand up in bed on shaky old legs and the nurse was torn between fetching his suitcase from the closet and making him lie down. She chose the latter and threatened to tie his arms to the bed unless he behaved. “I’m gonna call the mayor and the sheriff,” he said. “I’m gonna tell somebody how the cow ate the cabbage.” The nurse sighed and went to the closet and pulled out his beat-up cardboard grip. She held it up above her head so Mr. Castle could see it. “Lemme just touch it,” he said. The nurse walked over to his bed. The old man, with surprising strength, snatched it from her and tried to smuggle it under his sheet. The nurse dived after it and put it on his dresser. “I’ll leave it here so you can see it,” she said. “Now, Mr. Castle, stop misbehaving and get some rest. You want to get out of here, don’t you?”

  Quiet and still just long enough for the nurse to leave the room, Mr. Castle jumped up and shouted, “All I want to do is leave and go out to a restaurant and get a real dinner! I promise to come back!”

  “If it wasn’t for that,” whispered Carstairs, jerking his thumb toward the next bed, “I’d be fine. Poor old fellow—I guess he’s lonely. I asked for a private room and they said they’d move me later today.” He touched his hand to his chest, where the incision was held together with sutures and wire brads. “I haven’t breathed so well in years. I think I can actually feel the blood circulating in my body.” His wife took his hand and kissed it and held it tightly against her face. “I can remember the nights when he would fall asleep and gasp for breath,” she said, “and I would lie there with my eyes open until dawn, terrified.”

  Farmer Castle had probably been slightly senile before his surgery, but his postoperative course had confused him even more. It was an infrequent occurrence but one which, until it cleared up within a few days, was disturbing to all concerned. Elderly patients often get “squirrely,” as one anesthesiologist put it, from any drug, even aspirin. Something as powerful as anesthesia can scramble their senses.

  A second potential peril is a tiny bubble of air—an embolism—which can swim to the brain and cause convulsion, twitching, disorientation, even death. When the heart is opened for repair, air floods in. When the surgeon closes the heart, he tries to withdraw all the air. Various surgeons have favorite methods of accomplishing this. Cooley draws air out with a syringe, DeBakey tips the end of the operating table down, others blow carbon dioxide gas all over the field. But sometimes a bubble remains and causes trouble.

  The Recovery Room and Intensive Care Unit are sometimes severe experiences for patients, particularly the elderly ones. “ICU produces psychoses in some people,” said the anesthesiologist. It may well be the loss of the day-night cycle. After surgery, patients wake up in a room that is strange to them, where there are no windows, where the lights are always on, where they do not know the time. It is a world of monitoring machines and beeping noises and crises in the next cubicle.

  There is more drama to be found in St. Luke’s Recovery than the rest of the hospital, a continuing drama of compression and spontaneity, because at any given moment there are up to 24 patients (half on Cooley’s service) crowded three feet from each other. Each patient is in intense pain, each is demanding consolation and attention as he makes the journey from object to being. It takes a special breed of nurse to cope with the extraordinary physical—and emotional—demands of Recovery. The room, originally designed for Central Supply, is low-ceilinged and oppressive and, with patients struggling to climb out of their beds or yank the vital tubes and wires from their bodies, the atmosphere is, at times, that of the battlefield hospital in M.A.S.H. The care dispensed is professional and good, but rationed out by a small, overworked, and sometimes testy staff. When a patient pulled out his nose tube and the male nurse wearily stuck it back in again, the patient yelled, “I’m gonna take it out again, it’s killing me.” “You do that,” snapped the nurse, “and I’ll put in a bigger one.” One disoriented patient spent an entire day fighting everyone until his arms were finally restrained with white furry stays. Seeing a doctor attending the patient in the next bed, the patient used his only available weapon, the right foot, and kicked the doctor in the ribs. The doctor spun around with a fist clenched and fury in his eyes. For one breathless moment the charge nurse thought she was going to see a doctor hit a patient. “I’m sorry,” he said, putting his fist down, “It must be the Ben Taub syndrome.” He referred to his several months in the Emergency Room of the charity hospital, where young doctors, on occasion, have had to knock down mean drunks or else find themselves with a missing tooth.

  The major event of every operating day is at 7 P.M., when the relatives are allowed into Recovery for a few minutes to see the patient after his surgery. There is nothing sicker-looking in medicine than a postoperative major surgery case, with chest painted a ghastly orange, wrapped generously in bandages and tape, covered with wires and tubes through which inch blood and urine. Not infrequently a wife sees a husband and has to be led screaming from the room. About once a week a mother keels over in a faint at first glimpse of her perfectly recovering child. The parents of heart babies have a grueling time. They have not slept at all the night before surgery, have spent ten paralyzing hours in the waiting room, and when at last permitted to see what the surgeon has wrought, cannot cope with the sight.

  Ever since the advent of open-heart surgery in 1955, psychiatrists have been running studies on the attendant emotional problems. The incidence of postoperative psychoses in some groups studied has run as high as 25 percent of all patients. Ideally, each candidate for open-heart surgery should be thoroughly examined and evaluated by a psychiatrist to determine if he is emotionally able to withstand the operation and the hours thereafter. But in Houston, there are too many patients, not enough time. Neither Cooley nor DeBakey feels the occasional psychosis is as important as the principal fact of the case: that the heart needs and will get repair.

  By Sunday night, Recovery was eerily empty. All the patients of the week had progressed from Recovery upstairs to Intensive Care then to their rooms and, hopefully, to discharge in seven or eight days. Ten years ago, heart patients stayed in the hospital from six weeks to two months; in 1970 the average stay was down to ten days. “Denton really cuts ’em up, sews ’em up, and moves ’em out,” said a colleague with a voice sitting on the fence between admiration and derision. The shortened stay could be credited to many things—better pumps, improved anesthesia and its use, the years of experience for all members of the team—but nothing counted as heavily as the dazzling speed and drive of the surgeon-in-chief.

  On Monday morning, the deserted Recovery began filling up—fast. Cooley plunged into a schedule of twelve cases, including two double-valve replacements and two coronary artery bypasses, the operation he was not supposed to like to do. He passed by the schedule board on his way to Room 1, and I stopped him with a question. “Do you ever wonder if the sick people will stop coming? That someday you will have repaired all the bad hearts?”

  “I certainly hope not,” he said. “And so do my creditors.”

  Dr. Shafi, a dark, good-looking Iranian surgeon had ward duty this morning, meaning he would be tending to patients and not participating in surgery. None of the fellows looked forward to ward duty, no more than any of them relished night call. All wanted to spend as much time as possible scrubbed in, standing next to Cooley. All were disappointed when they came to Houston and discovered that they would not be doing any actual heart surgery, only opening, first-assisting, and closing. “Does it ever get boring?” I asked Shafi. He was in the coffee room waiting for the operator to page him and send him off somewhere to diagnose a spiked fever or take out stitches or write prescriptions for patients anxious to be dismissed.

  “Sure,” he said. “But not to D.A.C. He is driven by the numbers. A thousand pump
s in six months … 2,000 in one year. He wants to break his own record. And maybe break”—Shafi threw a thumb in the direction of Methodist—“him.”

  During the coronary operation that took place shortly after lunch—lunch being a term to indicate time, because Cooley does not stop for it, never more than a sandwich on the fly—he began sewing in the artery taken from the thigh, tediously affixing it to the aorta. He looked up and said to the room, “You practice for this procedure by circumcising gnats.”

  Late in the long afternoon—it was going to be well into the night before Cooley finished and could make rounds—some of the fellows were quietly discussing something when I walked into the coffee room. There was stiff silence. They did not want me to hear what they were talking about. Suddenly the conversation shifted to Dr. Tanaka, the stocky, muscled Japanese who had to put up with ribbing almost every day of his year in Houston.

  “Tanaka,” fibbed Shafi, “has a new procedure for opening the chest cavity. He doesn’t use a scalpel. He kicks open the patient with karate.”

  During the laughter, John Zaorski stormed into the coffee lounge. He ripped off his mask and threw it into the garbage can overflowing with coffee cups. He sat down on the couch to dictate an operation summary. “Shit,” he said, before he pressed down the dictation button. “You work for three hours trying to get a guy’s heart started and nothing happens. Nothing!”

  Unknowingly Zaorski had revealed what I was not supposed to hear. Grady Hallman had been doing a coronary in Room 1, and the patient had died on the table. For most of the afternoon, the team—with help from Cooley who had come into the room—struggled to resuscitate him.

  “We couldn’t get him off the pump,” said Zaorski. “Cooley recommended everything in the book, but nothing worked.”

  “Did you shock him?” someone asked.

  “Ten times. Maybe twenty.” Zaorski began the dreary recital of a man’s last hours. A few days later, a stenographer would send the report to the dead man’s home-town doctor. When he finished, Zaorski rubbed his cheeks with his hands for a while. “Thank God it doesn’t happen very often—once a month most, maybe every two months. At some hospitals—every day.”

  The patient was brought on the rolling stretcher to the corridor just inside surgery and a folding green screen was placed around him. People lowered their eyes as they passed by. Cooley went to his office, dictated a letter, and returned to surgery, stopping at the box full of masks for a new one. The death was on his mind. “This time, I wasn’t going to go searching for a donor heart,” he said in a voice curiously flat and one-note. “I decided to let him die in peace.”

  Half an hour later the fellows were joking, not for the fun therein, but in an attempt to erase the defeat. One of the young surgeons suggested: “Write on the chart that Zaorski was first-assisting and was heavy-handed.”

  “Heavy-handed!” Zaorski yelled. “You couldn’t change a tire and you call me heavy-handed!”

  The body was taken downstairs for a post-mortem and picked up by a funeral home, which would handle the lucrative local embalming and arrange for transportation to the man’s home town. “They come right away,” said Zaorski. “They’re anxious to get their hands on the corpse.”

  Time began to blur the faces and fates of the patients, the days and nights welding together. I would store patients in my mind, promising to get back to them, but new ones kept crowding them out and the old ones vanished. By the time I remembered that interesting atrial septal defect—names were lost as well, only the diseases stuck—that interesting ASD was gone, dismissed, well, or dead, on his way home, or already there.

  Carstairs checked out before I could say good-bye; Pamela was leaving on a morning when I was on the children’s heart floor to see somebody else.

  “How do you feel, Pammy?”

  “Fine,” she said shyly, flipping up her nightgown automatically to show her scar, healing well. It would fade into a thin white line within a few months.

  Mrs. Kroger said she was going to have a genetic study done on her family. “And tell my daughters the history of our heart disease. I hope they don’t ever have to go through the hell of this.”

  The skill and achievement of the heart surgeon is most dramatically seen in the juxtaposition of two facts:

  1. Before 1955, when the heart-lung machine was developed, most babies born with serious cardiovascular defects either died at birth or lived a drastically shortened, terror-filled life.

  2. By 1970, only fifteen years later, the heart surgeon could repair and promise normal life to upwards of 80 percent of congenitally damaged hearts. It is an achievement in medicine that ranks with Pasteur, Fleming, and Salk. But there are still the other 20 percent:

  Grady Hallman began a tricky case on a ten-month-old baby girl named Kimberly born with a ventricular septal defect, complicated with subaortic stenosis—a thickening of the lower aorta. This is one of the few congenital defects that must be operated on definitively; there is no palliative operation to tide a baby over until it is older and stronger. “She wouldn’t live to her first birthday without this operation,” said John Zaorski.

  The procedure would not begin for a quarter hour or so; Zaorski and I went to the lounge to have coffee. There were half a dozen conversations going on at once. I stood in the doorway tuning in and out as a man flips a radio dial.

  “God help me to never go through that again,” the resident fresh from DeBakey’s service was saying. “He would stand there at the table and rap me on the knuckles with the needle holder and tell the room, ‘Wants to be a cardiovascular surgeon, wants to be a cardiovascular surgeon, but he performs like a brick layer.’ I didn’t have the courage to tell him I never wanted to be a cardiovascular surgeon.”

  Two doctors were talking of an article in Life magazine that told of a Midwestern town with a new hospital and no doctor to run it, despite the guarantee that such a man could earn at least $40,000 a year. “You can earn $75,000 a year,” said John Russell dryly, “giving flu shots, insurance examinations, and writing excuses for people to stay home from work.”

  “You take these guys out of surgery,” a pediatric surgeon was saying to a girl student, referring to Cooley and DeBakey, “and put them in business or industry, and they’d be Ross Perot or Bernie Cornfeld. Wait, make that Tom Watson or Henry Ford.”

  “Industry?” said the student.

  “You think it’s not an industry? I mean, the by-products are great—people get cured, people get caught, but it’s still an industry.”

  “That’s a helluva case, that baby,” said Zaorski. He had been transferred to another room at the last minute but had watched Hallman begin the ventricular septal defect and subaortic stenosis. “I don’t think the kid’s gonna make it.”

  In Room 1, Hallman was trying to get the baby’s heart to respond. Lola, the scrub nurse, had normally mischievous eyes, but now they were wide and saddened. Hallman fought to activate the heart for more than an hour. He shocked it over and over again. He unclamped the tubes and took the infant off the pump and the heart refused to beat. He put her back on the pump and things seemed to work. But when he shocked her and took her off the pump, the heart refused to beat. Cooley came over from Room 2, where he was doing a valve and said, “Has Nora been told? Better find him, it’s his case.” Nora was Dr. James Nora, a staff pediatric cardiologist.

  “I’ve already told the parents it’s not going very well,” said Cooley, backing out of the room and returning to his valve.

  Another nurse pushed open the doors in the middle of the struggle and said, “Dr. Hallman, the amputation patient in Room 3 is ready.”

  “Go ahead and put him to sleep.” Hallman’s hands were inside the heart of the dying baby.

  “He is asleep.”

  “Then drape him.”

  “He is draped.”

  “Then find Dr. Messmer [Dr. Bruno Messmer, a Swiss surgical fellow] and see if he can start it.”

  Three hours into an operation
that should have taken half that, Hallman lifted his hands with a great slowness from the heart and shook his head. Nothing was said. No pronouncement was made. He only shook his head. There was no point in going further. Nora had come in and seen the futility of it all and went out to find the parents. Hallman left the room; somebody would sew her up. One of the pump technicians bumped into the heart-lung machine and a container of blood flowed sadly across the green tile.

  A chaplain was sent to find the child’s parents. They were led, fearful, to the family room not far from surgery where Nora told them. Sometimes parents rail and scream and attack the surgeon when a child is lost. Parents have lunged at Cooley and beat his breast until their hands are sore, but he never moves. The couple who had brought the child to the hospital, were both twenty-one, both incredibly young. They took the news with dignity. Only Nora’s eyes were clouded and he was rubbing them when he left the room.

  Bill Murrah, the student chaplain from Alabama on a summer internship at St. Luke’s from Union Seminary in New York, leaned against the wall outside. “There’s not much you can tell them,” he said. “They don’t want any religious formulas or quotations from the Bible at a time like this. They just want to know if their baby is alive or dead, and if she is dead, would she have lived without the surgery. They all want to know that, they need desperately to be told ‘NO’ so they won’t feel like accomplices.”