Hearts

by Thomas Thompson

  Lola, the scrub nurse, hurried into the nurse’s locker room to dress and go pick up her four-year-old son who was staying at a nursery near the Medical Center. “All I want to do is hide in the bathroom,” she said. “Nobody’ll ever know I had anything to do with that precious baby’s death. The first patient I ever scrubbed on died … a Fallot.… That’s when I quit. For the first time.” A child’s death sends a shock wave through the women of the heart team.

  One of the motherly-type nurses picked up Kim from the operating table and wrapped her in a pink and yellow blanket and took her out to the surgical corridor, where a rolling baby crib was standing, the same bed in which she had been brought—with her mother leaning over her—to the operating room, the same bed in which two pink diaper pins and a pacifier were waiting for her. The nurse pulled a green sheet across her baby and in a few moments, a coordinating nurse from Texas Children’s gently took her and carried her by hand to the morgue.

  Another child was on a rolling bed in the surgical corridor as the coordinating nurse walked by. She had a curious pinched face and she refused to laugh at Dr. Girgis, the Egyptian-born anesthesiologist who was taking used surgical gloves and blowing them up like balloons and drawing faces on them with his felt pen. He had almost filled up her bed with the cheerful faces but she was not a child who knew how to laugh.

  “We’ll save these for you,” he said. “You can play with them tomorrow.”

  The child told me her name was Joy and that she was the daughter of a truck driver from Oregon. She was eight, she said, but she looked half that. The blueness of her Tetralogy of Fallot made her appear cold.

  There was a depression buried within me, and it had been roused with the baby’s death. I was weary of the hospital and its surgery. My own son, my second son, would be coming from his home in New York to spend the summer with me. Despite his strong body, despite his ability to plant his skis together and take the plus difficiles runs in the French Alps or plow into his older brother in Central Park carrying a football, his heart had something wrong with it. Nine years ago he had been born in this very Houston hospital and the pediatrician had heard a murmur—not a grave murmur—but a worrying, hissing echo that vibrated the tiny chambers. Cardiologists in New York and France had listened to it in the years that followed. They kept saying that he should be examined every year or two, but that his life need not be restricted. “Do not tell him about the murmur,” the doctor in New York had said. “Don’t let him favor it.” I had planned to have him examined by Cooley’s staff, but—had an operation been indicated that afternoon, if there was talk of the knife—I could not have signed the paper to deliver him into a surgeon’s hands. I dressed and left the hospital. I found a movie to erase two hours. I telephoned New York and spoke with my son Scott, who was full of plans for his return to Texas. I hung up and called the hospital; its lure was not to be denied. John Zaorski had night duty again and he was brusque. Things were, he said, frantic.

  I found him in Recovery. “I’ve gotta go tell a man his wife just died,” he said. He was writing a death certificate. In the corner, nurses were pulling drapes around the bed of an elderly woman who had had a double valve replacement the day before. She had arrived at St. Luke’s in grave heart failure, bubbling from the fluids in her lungs and chest. “She was almost dead before the operation,” Zaorski said. “I went down and told her husband about an hour ago that she wasn’t doing well, so he’s prepared.” Death messages were normally given in two stages. If the patient died during surgery, Cooley or a fellow went out and said that the operation was not going well, that serious problems had arisen, that there was little hope—even though the patient was already lost and being sewn up. Then, half an hour, an hour later, the final news was delivered. “It’s easier that way,” said Zaorski. “On us and on them.”

  The neatly dressed old man was in the Family Room. He looked up, unable to control the twitches in his unshaven cheeks. “I’m sorry,” said Zaorski immediately upon entering the room. “We did everything we could. But she’s gone.…”

  Instantly the old man wept, silently, ashamedly. He apologized for his tears. Zaorski intruded tactfully on his grief. “There’s just one more thing,” he said. “We’d like to examine her heart. We can maybe learn better why she died.”

  “I don’t object to that,” said the new widower. “If her death could help anybody else.…”

  On the long walk back to the coffee room, I asked about Joy, the child who had followed the baby into surgery.

  “Who?” asked Zaorski, searching his mental list of the day’s surgery.

  “Joy, the last little girl, the Fallot.”

  “Oh. She died on the table.”

  “Two in one day on the same table?”

  “Yeah. Couldn’t get her off the pump.” Zaorski walked on with his head down. Was his shield cracking, or was he too much of a tyro at the business to have one? “Sometimes,” he said, “this is a lousy service … sometimes it’s worse than a leukemia ward.”

  He telephoned Pathology and reported permission for the woman’s post. “It’s been a rough night,” he said later in the coffee room. “Just before you came, there was a STAT call on sixth-floor ICU.” (STAT is short for the Latin “statum,” which means “immediately” but in hospital code it means “emergency.”) An 86-year-old woman with a pacemaker had arrested and when Zaorski got there the nurse had her on the respirator and somebody else was massaging her chest. Zaorski hooked up the cardiac press and put an endotracheal tube down her throat, the kind with a balloon attached to the end of it. Once the tube gets down, the doctor pumps on the balloon and it stops air from going to the stomach and pushes it directly into the lungs. Zaorski also shot adrenalin into the heart. But the scope stayed flat. Nothing would bring her back.

  “This may be the Tet offensive tonight,” said Zaorski. “They’ll be dropping from the trees.”

  Shirley, the Recovery nurse, rushed in near midnight with her half-smile that concealed worry. She had the chart of a young Italian woman named Vincenza who had appeared at St. Luke’s looking like a concentration-camp survivor. Vincenza had sunken cheeks to which she applied bright, heavy rouge, giving her face the appearance of a death mask. She weighed but 78 pounds and she had Ebstein’s Disease, a rare defect of the tricuspid valve that few surgeons would touch. Cooley had put in a new valve and now Shirley suspected tamponade, bleeding around the heart. There was no urine output to speak of either.

  “All right,” said Zaorski. When Shirley was worried, John followed through. As Zaorski was leaving, a young brunette ward nurse interrupted him. She had an expression of absolute exasperation on her face.

  “It’s Mr. Castle,” she said. The old farmer had been transferred from the semiprivate room, where he had been keeping Carstairs awake, to the ward for disturbed elderly patients down the hall.

  “What’s Mr. Castle doing?”

  “He’s disoriented, climbing out of bed, yelling, disturbing half the floor.”

  “Tell me something new. What did you give him?”

  “Thorazine and Demerol,” said the nurse. “But he’s still very much with us.”

  “How much Demerol?”

  “Thirty-five milligrams.”

  “Give him 50 more.”

  The nurse looked startled. “I don’t want to pile all that Demerol into an 81-year-old man.”

  “Look,” said Zaorski, impatiently. “What’s Demerol going to do at worst—depress the blood pressure, right? You’ve gotta depress him, or he’s gonna kill himself.”

  “Okay.” The nurse gave in.

  “Did you tie him down?”

  “Hours ago.”

  “I’ll be by to see him.”

  Zaorski went into Recovery first, where the emaciated Italian girl, perspiring heavily, was almost lost in the bed. He looked at her x-rays. Shirley slapped them onto the viewer and winced in pain. The nurse had bursitis, aggravated from reaching up so often to put the x-rays in place. Zaorski or
dered digitalis and a plasma-type fluid for Vincenza. “If I give her more blood,” he told Shirley, “it’ll thicken up the blood she already has, and make it even tougher to get it circulating. Which is what she needs.” He did not buy Shirley’s suspicion of tamponade.

  In the disturbed patients ward, Mr. Castle had kicked over his intravenous stand several times and was generally driving the ward nurse up the wall. His favorite trick was to wiggle down to the middle of the bed, drape his legs over the end, and kick, as vigorously as a child learning to swim. The nurse would lug him back to where his head touched the pillow and scold him, and as soon as she turned her back, he would wiggle back again. She had finally tied his hands firmly to the rails with white furry straps that could not cut him.

  “Poor old guy, he’s screwed up. This sometimes happens when the cardiac output fails.” Zaorski watched him struggle against the retaining straps. “He’ll be all right.”

  Within half an hour, Vincenza’s urine tube was beginning to fill, a sure sign that the digitalis and plasma were working and that the heart was pumping strongly enough to support the kidneys. “Score one for our side,” said Zaorski. He noticed that Shirley was still in pain from the bursitis; he persuaded her to take a cortisone shot and permit him to bind her arm to her waist. “Trust Dr. Zaorski,” he said. “Keep it that way and the pain’ll go away in a day or so.”

  Hospitals normally quiet down after midnight but not this night. A fat woman cried out all night with gall bladder pain; Zaorski went to see her twice and agreed that she probably hurt, but not enough to wake up the whole floor. Another Italian, a woman in her mid-twenties named Maria Celestina, was causing her usual trouble. Hers was one of the more interesting cases on Cooley’s service. A pretty, vivacious girl, she had fallen down a well in her village when she was a child and developed a traumatic aneurysm of the thoracic area. Surgeons in Italy had wrapped it with cellophane, but it had grown worse over the years and she had come to Houston. Cooley had excised the aneurysm and replaced it with a Dacron graft. She seemed to be recovering satisfactorily in her room, but she was still a bit goofy and considerably lonely. The only English phrase she felt comfortable with was “Please help me” and she sang it and moaned it with orchestration. What she mainly wanted was company. The fellows had all learned her trick; she would exhort, “Please help me” as one passed by her open door. If he succumbed to the lure and went to see if anything was the matter, she would beckon for him to come close to the bed and try to grab him.

  Maria Celestina started warbling “Please help me” in Puccini fashion close to 3 A.M. but Zaorski was too tired to do anything but slam her door shut, firmly, as he went to see about quieting down Mr. Castle for the fourth time.

  The week was disastrous. “We go through long periods when nothing happens,” said one of the fellows in the coffee room the next morning. “Weeks when everybody gets well, months when nobody dies, nobody even bleeds around a graft, then we get a week like this and I’d like to switch to dermatology.”

  Cooley was doing a routine valve replacement later that day when one of the stunning mysteries of cardiac work occurred. At St. Luke’s it is called “stone heart” for lack of a better name. The patient’s left ventricle suddenly went into a spasm, not unlike a Charley Horse in the leg, and nothing yet known to medicine could bring it back or save the patient. Neither the origin nor the cause is known.

  “It’s almost like witchcraft,” said Jerry Strong. “It could be something muscular, or pollution in the air, or a fall in the stock market for all we know.” Cooley said he has not seen more than a dozen cases in the past decade, and autopsy reveals nothing because the spasm is over by then. “I used to think it might be due to some pump defect, but I’ve dismissed that idea,” he said.

  As he always does when the rarity occurs, Strong injected all manner of medication into the patient’s intravenous, hoping that something or some combination of something would stop the spasm and allow the heart to function. But nothing worked. “When it happens,” Strong said, “they’re dead. Period. I must have dumped twenty different kinds into him. I personally think we ought to put all known medicines into one jug, label it Lazarene, stick it in him, and pray.”

  About 6:30 that night John Zaorski had ducked down to the basement cafeteria and was well into a Salisbury steak when over the chatter of the room he heard a faint page. “Cooley Fellow, Three North, STAT. Cooley Fellow, Three North, STAT.” Some hospitals page Dr. Blue, but the meaning is universal: a heart has arrested and there are but a handful of moments before it becomes permanent death.

  In mid-bite Zaorski dropped his fork, bolted out of the cafeteria, almost bumping into two nurses weaving their way through the crowd. For a big man he could move fast, side-stepping the “CAUTION—Wet Floor” signs, which made the central corridor an obstacle course.

  The patient was a frail, blue old woman who was stretched out on a reclining lounge chair beside her bed. Her mouth was gaping, her eyes were dilated. She was dead. Zaorski picked her up and flung her like a rag doll onto the bed and began the rhythmic pushing on her chest. (The tabloid-familiar custom of slicing into chests and massaging hearts is passé; superior results can be obtained with closed-chest massage.) A young inhalation therapist tore into the room at the same moment and clamped a breathing bag over her mouth. The nurse stood there chattering away, stunned by the whole affair. “She was fine, she was just fine. She had her dinner, she saw the doctor, she was sitting in the chair looking out the window and watching the TV”—the set was still on, droning out a comedy—“I looked in and saw she was gone and I pushed the chair back so she’d lie flat and I sent out a STAT call.”

  Zaorski nodded but was paying little attention. The look on his face revealed frustration; his pushing and the therapist’s squeezing seemed to be having no effect at all, and time was running out. Suddenly, almost magically, the old woman’s chest heaved, she gasped, she choked, and back she came from death. “She’s on her own!” Zaorski cried triumphantly. “Let’s get her into Recovery.” The nurse turned to find a stretcher, but he stopped her. “Let’s just keep her on the bed,” he said, abruptly pushing the end out into the hall. With the therapist on the other end, the procession sped through the surgical waiting room—where the families, startled, were lined up to go in at seven and see the patients—and into Recovery, where a swarm of doctors hooked her up to the machines and monitors.

  Several days later, the woman, a tough, chipper Bostonian, was preparing to leave the hospital and return home. She had no memory of the incident other than waking up in Recovery, a place where she had been ten days previous, after her heart surgery, and a place she had grown to dislike. “I must have fainted,” she said, and the nurse nodded. No one ever remembered those moments on the other side. One woman suffered more than 30 cardiac arrests during her three days in Intensive Care Unit. Flat EKGS, the works. Each time the doctors and nurses would bang on her chest and resuscitate her and each time she would rouse and murmur, “Did I have another one of my sinking spells?” Once she came to just in time to see the nurse preparing to hit her chest and she said, with insult, “And I thought you were my friend.”

  Happily, Maria Celestina quieted down for a while after a quarter of an hour trans-Atlantic telephone conversation with her sister in Italy—a poignant, sobbing, laughing, sometimes hysterical conversation. Everybody on Three North shared her pleasure.

  But sadly, Mr. Castle threw a clot to his brain and died that night in the senile ward. It upset the nurse who had been contending with him. “I wish they had left the old man alone,” she said, moping around the nursing station. She was a young registered nurse who had not experienced the loss of many patients. “He was such a nice old man, he was eighty-one, and he’d never been in a hospital before and I had to help him make a phone call to his family because he’d never even had a telephone in his house. He was telling them to be sure and water his tomato plants.”

  Cooley stayed in his operating rooms fro
m sunrise to sunset, almost as if one death could be assuaged by fixing two more hearts. He betrayed no emotion, no public tears, most likely no private ones. A friend said he was “un-emotional.” He was, surely, affected by the complications and the run of deaths. “There is no more heat anywhere in medicine than in heart surgery,” observed Don Bricker, who had been through the DeBakey program, had operated across from Cooley, and who was now heading surgery at Ben Taub. “There’s simply no area of surgery where you can lose patients on the table as you do in heart work. Gun shots, traffic-crushed victims—these patients may crater on you. But with elective heart surgery, you’re the guy who makes the decision to operate, and when you fix the heart and it doesn’t start up again, then you’re the guy who killed him. When it happens to me, I go out and sit somewhere and weep.”

  Months later, on a Saturday morning in his office, Cooley and I would talk about death. I had never seen a crack in his shield, not even a shadow across his face. How did he hide, or was there anything to hide? “I think I’ve built a shield,” he answered. “One of the big problems, it seems to me, is how the surgeon deals with his disappointments. How to deal with his personal errors, shortcomings, poor judgment, or the complete and total failure which is death. I’ve observed other surgeons who just take it in their stride, the ‘well-we’ve-done-our-best-school.’ I have not been capable of taking it that way. Perhaps you just don’t see it within me. But what can I do? You’ve got to go on, that is the only way to overcome disappointment. Continue your work and realize you are doing good. The tragedy comes when you get two or three bad ones at once and you stop and you start to wondering if you’re doing the world any good at all.…”

  “Do you ever wonder that?”

  He shook his head firmly and negatively.

  At the end of the bad week, someone remarked that it had been reminiscent of the transplant era, of the saddening days when the first batch of Cooley’s transplants, six apparently healthy and rejuvenated people, all started rejecting and dying, and rather than stop, rather than a moratorium, Cooley did more and more. Eight became twelve, fifteen turned into twenty. “His hands had never failed him,” said a friend. “And he couldn’t understand it.”