Fisher, a college dean, was a tall, spare man with china blue eyes and a wide East Texas drawl. He told the investigating doctors that his heart trouble had begun when he was thirteen and running track. “The coach felt the longer and harder we ran,” he said, “the more wind we’d have for the dashes. One day I felt something pull inside my chest.” The Houston cardiologists were more inclined to suspect childhood rheumatic fever than a rare traumatic injury to the heart, but Fisher insisted that as far as he knew he had never had the disease. “My mother took me to a doctor a few months after that day on the track, and he said I had strained my heart and that I should spend the rest of my life in bed. I did no such thing. Believe me, I’ve had a great life! But I always paid extra insurance premiums for a heart murmur.”
In 1940 when he obtained a marriage license and had a physical examination, the doctor diagnosed a “leaky valve.” “He said it was flapping in there like an old barn door,” Fisher said. “At that time the only thing a fellow could do was accept it and live with it. Nobody was cutting into hearts then. To tell the truth I never paid much attention to the damn thing until a couple of years ago when I was helping the workmen move some billiard tables in the student union building and I strained so much I went into my office and lay down. I went to see my doctor who chewed me up and down. ‘You durn fool, you’ve done it again,’ he says to me. ‘I oughta kill you, but I’ll write Denton Cooley.’”
Fisher flew to Houston in the autumn of 1969, where the cardiologists discovered that the valve was leaking so much blood that the heart was functioning at about 30 percent of capacity. Cooley replaced the defective natural valve with a plastic and metal one and sent Fisher home as he had done with hundreds of successful patients before. “I hardly got off the plane before the new one started leaking,” Fisher said. “My arteries and veins stuck out like cords of steel on my arms and legs because the heart was throwing so much pressure on them. My heart had been functioning at that 30 percent capacity so long that when Cooley fixed the valve and sent the heart back up to normal, the valve just couldn’t stand the pressure and tore loose.”
In December, Cooley tried a fascia lata valve, one made from the tough tissue of the patient’s own inner thigh.
It seemed to be holding well until Fisher was released from the hospital and drove to the Houston airport. There he was told that his scheduled flight had been cancelled but if he hurried to a gate at a far-off end of the terminal he could catch another airplane. Fisher picked up his own suitcase and that of a friend and ran down a long, polished corridor. “By the time I stepped off the plane at home,” he said ruefully, “the second valve had torn loose.”
Three months later, when his body was strong enough to accept a third major operation, Cooley sewed in another valve, but the tissue around the valve was becoming so necrotic that it did not hold. Now Cooley was faced with the unpleasant job of trying to make a fourth one stick. “I don’t think anybody’s ever tried four before,” said John Zaorski. “I’ve never seen it in the literature.”
Fisher remained good-natured, unlike some who return to hospitals for a re-do, convinced they were victims of inept medicine. (A few years before, my appendix burst during lunch one afternoon in New York and I was operated on that evening by a well-known and expensive surgeon. In the three months that followed the wound would not heal and I had to return for a second operation to scoop out the silk stitches—which I was “spitting,” they told me—and infection. I was, with no challengers, the supreme grouch of my floor.)
Before his second valve replacement, while being examined by Cooley, Fisher presented the surgeon with a small bottle of glue to make it stick. Cooley had laughed and said he would use it intravenously. Before the third, Fisher asked Cooley what kind of warranty the apparatus carried. And now, as he waited the fourth, Fisher sent his wife out for a zipper.
Tammi, who was only six, had enormous deep-set blue-gray eyes. Her body was tiny from a deformed heart, but she carried it with grace. One moment she would be sitting on her bed playing a card game called “Hate,” the next strolling down the hall watching the other heart kids play. But Tammi would only watch. She held herself aloof and if she was frightened, some check within her held it from sight.
Cooley leaned over her and listened to her heart. He nodded noncommitally and smiled at the beautiful precocious little girl and her parents, a barber and his wife.
Outside he told the entourage of young doctors that Tammi had a bad AV commune, the highest-risk heart surgery. Earlier that summer, Cooley had won one of them—the boy who cried like a cat—and lost one. Few surgeons in the world would bother, or dare, to try. “Most places would send her home to die,” said Dr. Ugo Tessler, an Italian resident who was new to Cooley’s service. (On July 1, most of the foreign doctors had left and a new dozen had come to take their place.)
Tessler walked on, frowning. “She won’t last through surgery.”
“How long can she live without it?” I asked.
“She won’t. She’s going to die.” Tessler’s voice was flat and final.
Cooley was on his way down a flight of stairs, on his way to see Fisher, but Tammi was on his mind.
“I’d like to think that no patient is too sick for surgery,” he said almost to himself. “I’d also like to think that the only ones we turn away here are the ones who don’t need surgery.”
“Will you attempt the operation on Tammi?”
“We’ll see.”
Trying to make Fisher’s fourth valve stay in place, Cooley used a technique of overlapping heart tissue around the mouth of the valve and sewing it doubly tight. He went out after the operation and told Mrs. Fisher, a stylish, attractive woman in a Chanel-type suit, that he felt sure it would hold.
“I’ve heard that before,” she said as he walked away. “I’ve heard everything before.” She was weary and her eyes were red from lack of sleep. She had not, in fact, slept well for nine months of failing valves.
During Fisher’s operation, Tammi was taken for the third heart catheterization of her young life. Five months after she was born, a hometown pediatrician detected a murmur. “I’ve heard these before,” he said. “I can only give you an educated guess, but I don’t think there’s anything to worry about.” But when she was one year old, Tammi fell short of breath, refused to lie down, to stop crying. Her mouth and lips turned blue; cold sweat popped out on her forehead. She was in classic heart failure. Her mother drove the baby in panic to the hospital, where she was slapped into an oxygen tent and put on digitalis to strengthen the tiny heart. When she was three, Tammi was brought to Texas Children’s Hospital in Houston for her first catheterization, which revealed the suspected AV commune. And in the June of her sixth year, the Houston cardiologists catheterized her again. Jim Nora had told Tammi’s mother, “We’ve gone as far as we can without doing something.… She doesn’t have much time left.”
During the next two months the barber and his wife addressed themselves to a cruel dilemma: whether to keep the merry, prankish child at home and seize the time left and crowd it with love—or return her to a hospital where there was the darkest pessimism. “We lived with it for a long time,” the mother said while she waited in the snack bar with a cold cup of coffee, waiting for Tammi to be brought back from the catheterization lab. “Dr. Nora had told us the last time that we needn’t fear anything sudden happening. She wouldn’t go … overnight. But now I know the gradual decline is setting in. I can see her slipping every day. If Dr. Cooley feels there is a chance, only a tiny chance, then we’ll put ourselves in his hands and the Lord’s.”
The night before, after Cooley had dropped by to listen to her heart, I had returned and visited with Tammi. There seemed no sickness about her other than her thinness; she fairly burst with life and humor. “Dr. Cooley’s going to fix your heart up,” her father said, as we played Battle with her well-worn deck of cards.
“Mmmmmmmm,” said Tammi, showing me how she could shuffle, “I think I may
wait. When I’m about nine, I may let him.” She was a princess dispensing favor. She dealt out a hand quickly and began sorting her fate. She looked up and affected a pensive look. “But I would like to beat John in a race,” she said, explaining that John was a very fast child who lived in her neighborhood.
We walked down the hall and stopped to look at a bulletin board outside the nursing station, which was filled with photographs and letters from children who had happily returned home after heart surgery. Tammi’s eyes found and lingered on a picture of a solemn boy with a large incision of his chest. The stitches had not yet been removed.
“Would you look at that,” she said. “They cut that little boy all up.”
On the third postoperative day, Fisher threw a small clot to his brain which, hopefully, only temporarily paralyzed his side. He also developed jaundice and turned a dull yellow. His eyes seemed on fire. Zaorski listened to his heart and shook his head with weariness. I asked what was happening but he said he had to hurry to another case.
Dr. Chuck Mullins, one of the many able pediatric cardiologists, did Tammi’s catheterization with Nora coming into the room now and then. “This kid’s heart seems so malformed that the catheter just flops from side to side,” he said. He was gently moving the catheter at an incision in her arm and watching its passage into the heart over a television screen. The wire moved murkily into the shadow that was the heart. “Her heart is a mess,” he said. “It’s outgrown her body.” The shadow was enormous. It was evil.
Nora had stopped for a cup of coffee just outside the catheterization lab. I asked him what causes congenital defects in children. “There are many reasons,” he answered, “largely unknown ones. The major one is probably the hereditary predisposition. Then there are environmental triggers—bacteria, radiation, insecticides in food, maybe the mother took too many drugs like dexedrine during her pregnancy to keep from getting fat. Women take such incredible things during pregnancies. We’re highly interested in viruses now; we’re studying blood from newborns to see if the baby had an infection in the womb.”
“What about when the mother gets German measles?” I asked.
“That’s the most widely known cause, when a mother has German measles in the first trimester of pregnancy. But it accounts for the smallest percentage of defective hearts, less than 5 percent. If a woman does have German measles during the first ninety days of pregnancy, there is a 60 percent chance the baby will be born with congenital heart disease.”
When the catheterization was over and before Tammi was sent back to her room, Dr. Mullins talked with her mother. He tried to conceal his despair. “There’s really no choice,” he said. “Either you take her home and wait—or you consider surgery, even though the risk is high. Very high. She simply has no heart reserve left. The heart can’t rally on demand and produce more output. You and I can run, climb stairs, rally to fight an infection. But her heart can’t. A cold might be a catastrophe. And I don’t know a way in the world to keep a child of six away from infection.”
The mother seemed confused. “But are you recommending surgery?”
“Dr. Cooley will have to decide and then it will be up to you and your husband. I just wanted you to know what I think.”
Later that afternoon, the fellows in the coffee room were talking of Tammi and Don Bricker heard the conversation.
“She’s going to die,” he said. “I wouldn’t touch her.”
“Then what would you do?” someone asked.
He threw up his hands in surrender. “Give her to Denton.”
The buck stopped at the surgeon’s desk in his tiny cubbyhole overlooking the operating room. The collected wisdom of fifty centuries of medicine was at his finger tips—Tammi’s x-rays, the films of her catheterization, the sheets with the chemical equations, the recommendations, the calculated guesses. But only the man who held the knife could decide whether to bring the child to the operating table that he could see from his desk.
He went to her room as she was eating and asked her parents to follow him into the corridor.
“I think I can help her,” he said. No one had really expected him to turn the child down.
“Would you do it if she was your little girl?” The mother asked.
“If she were mine, I wouldn’t want to. But I’d do it.” I had heard him give the same answer many times, almost automatically. But on this hot summer night the voice lacked its positiveness.
Both parents nodded as one.
When the surgeon went away, Tammi piped up, “Dr. Cooley didn’t say anything to me. I must be too beautiful.”
That night during dinner at his home, John Zaorski talked of Fisher. “I think I heard a leak today,” he said. “I’d guess the valve’s torn loose.” He added that he was not 100 percent certain. But happily, Fisher’s jaundice had cleared up and he was later transferred to a private room. With the yellow cast gone from his body, he was psychologically better and the paralysis from the stroke seemed to be easing. His wife and married daughter were guardedly optimistic.
On the morning of Tammi’s operation, Dr. Mullins passed by surgery. He had wanted to watch the procedure, but he had to catheterize the second of identical six-year-old twin blond girls whose Tetralogy of Fallot had been repaired a year ago. Both twins were spectacular successes and were back only for checkups. “I’m crossing my fingers with Tammi,” he said, “… and saying a few prayers as well. Her heart’s as big as yours or mine.”
What worried Mullins most was the deteriorating mitral valve, one of the many defects that he suspected in her heart. “Denton can probably sew up the holes, but the valve is the problem,” he said. “The surgeon has a completely different thinking on valves than we do. Denton talks about them lasting ten years, but they can also last only five years or five months. The average seems to be about four or five years. I wouldn’t want to face a life of having my chest opened and the surgeon into my heart every four years.… Because once that valve goes out—it’s out. And life depends forever thereafter upon the strength of a piece of metal and plastic.”
Tammi watched Diane, the nurse with the Raggedy Ann doll, explain how she would look after surgery and her face grew unusually solemn. At six could a child really understand that which was going to happen to her?
Sedated with Nembutal and Demerol, Tammi was rolled to surgery at 9:30 A.M. She waited briefly for her turn in Room 2. I leaned over the stretcher. I was masked but she recognized my voice. “I’ll see you in a little while,” I said. “I’ll keep the cards warm.” She bounced her head up and down. “You may have to deal,” she said. “I’m so sleepy.” On the table, she struggled against the black mask that came toward her, sending the vapors of cyclopropane and halothane into her lungs. Quickly she was out. Quickly she was still and silent.
She lay nude on the table while the team performed its preparatory ballet about her. The heart within the tiny body was leaping. “Her head almost vibrates every time the heart beats,” said one of the doctors. “Poor kid.”
Dr. Phil Allmendinger came into the room. A burly, surgical resident from Connecticut, he was spending six months of his third year of residency in Houston beside Cooley. He had arrived on July 1, the change-over date, and in but a few weeks had become overwhelmed by the variety and volume of heart work. “It’s everything I had hoped it would be,” he wrote to a friend in Connecticut. “Already I’ve seen lesions it would take a year to encounter back there.” Allmendinger quickly won the nurses with his decisions in the Recovery Room; the women made immediate and generally accurate evaluations of the new doctors. “Did you come early to get a good seat?” he whispered through his mask. Already the room was crowded. An AV commune would sell out any operating room.
One of the nurses said that Cooley was in a snappish mood. “I saw it the moment he scrubbed in,” she said. Allmendinger knew why. The day before Cooley had lost a difficult aortic aneurysm patient. Also, during the repair of a ventricular septal defect on a two-and-one-half-year-old gir
l from South America, one of the new foreign fellows had, for reasons unknown, taken the clamp off one of the tubes connecting the patient to the pump-oxygenator. Allmendinger, assisting, glanced down and saw a huge air bubble swimming toward the patient. He made a diving grab for the tube to shut off the bubble’s course and put the clamp back on. Cooley saw only the dive and was angry. “Christ, Doctor, everything we do in this operating room has a definite purpose,” he said. “Don’t you know an air bubble like that would go directly to this patient’s brain?”
When Cooley lowered his head and returned his gaze to the field, Allmendinger glanced discreetly toward the fellow who had made the blunder. But the guilty man did not speak up and accept the blame. Rather than squeal on a junior colleague, Allmendinger let it ride. Cooley worked for the rest of the operation in stormy silence.
One of the ward nurses had not helped his disposition on the morning of Tammi’s operation by charging in and complaining that six patients on her floor had been told they could go home but that no one had written the discharge medication and papers. “Nurses stab you in the back this way,” said Allmendinger. “They should complain to you, but they go direct to the chief.” Cooley got on the loudspeaker and acidly told Zaorski, “There are patients stacked up on Three South. Let’s get ’em out of here.” The general gloom that surrounded Tammi’s chances was heavy in the room, and there was a thoracic aneurysm that had to be done after the child. And Hallman was on vacation.
John Russell sliced into Tammi and began peeling back the layers of skin and tissue. The nurse Gwen was hovering behind him preparing the electric saw. “Ready for the saw, Dr. Russell?”
“Just about.”
Gwen waited a moment or two. “Ready now?”
Russell nodded. She handed him the saw and he applied its blade to the child’s chest. “Okay. Hit it.”
The nurse switched on the current and the blade chewed through the breast bone.
“Through?” asked Gwen.
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