A Heart to Serve

by Bill Frist

  Karyn and I leased a house from a Stanford professor who was on sabbatical. Tucked in the hills behind the university, the clay-colored stucco house seemed designed to blend unobtrusively with its surroundings. After living in a small third-floor apartment on Mt. Vernon Street in Boston, we loved that home, complete with a swimming pool and a flower garden in the back. When I wasn’t working, Karyn and I walked and rode bicycles through the picturesque neighborhood.

  When the professor returned, we rented a newer home in Menlo Park. The well-kept neighborhood boasted brightly colored flower beds and enclosed backyards. Karyn loved our new home, as did our young son, Harrison. Was it the warm weather, the more casual approach to life, the better living conditions, or just the healthier lifestyle? The peaceful atmosphere appealed to us, and nine months later, our second son, Jonathan, was born at Stanford Hospital.

  Working with Shumway at Stanford felt like a medical paradise compared to the more traditional, hierarchical surgical experience that was the norm in cardiothoracic surgery at Mass General. Dr. Shumway demanded a team approach, motivating through encouragement rather than denigrating, belittling, or criticizing doctors or nurses. No surgical instruments were ever thrown in Shumway’s operating rooms. Any time things did get tense or an operating team ran into unexpected trouble, Shumway quickly defused the situation with a joke. He imbued confidence in others—his colleagues, his residents, his nurses, the technicians.

  Although he was a brilliant surgeon and technician, Dr. Shumway prided himself on being an even better teacher. Moreover, he enjoyed allowing the younger members in the OR to take the lead. Whether it was Dr. Lower, or Dr. Stinson, or much later, me, Shumway preferred to step back and with precision and confidence guide the doctors he was teaching, frequently referring to himself as “the world’s greatest first assistant.” By the time I arrived at Stanford, Dr. Shumway’s accomplishments were already legendary, yet he seemed as proud of the accomplishments of his trainees as he was of his own. When he introduced me as “a valuable member of the team,” I was thrilled. I later learned that he always introduced newcomers as “a valuable member of the team.” In a world where accomplished senior surgeons are often regarded as untouchable, with huge egos, Dr. Shumway’s attitude was a refreshing anomaly.

  Was this approach transferable to other careers? I had no interest in politics at this time; I was too busy mastering my craft as a heart surgeon. But politicians do have big, self-righteous egos. In years to come, I’d have many opportunities to compare my Senate colleagues and others I met in Washington with Dr. Shumway. For me, he remains a model of unassuming but incredibly powerful personal leadership.

  Most of the residents with Shumway spent three full years in cardiac and vascular surgery before moving up, but I’d already completed my cardiac residency in Boston, so I didn’t go through the Stanford program. As I was the outsider from Boston, the other residents easily could have resented me, but instead they went out of their way to introduce me to the Stanford ways, and to make me feel welcome.

  I spent a few months at the Veterans Administration Hospital, doing more routine heart surgery such as coronary-artery bypass surgery and valve replacements, learning Shumway’s unique methods, and then Dr. Shumway moved me straight into transplantation. Working daily with Drs. Shumway and Stinson, I soon became chief resident in cardiovascular surgery. It was heady stuff, operating every day with surgeons who had made and were continuing to make medical history—pioneers who kept on pioneering.

  A great clinical surgeon must be a great research investigator, Shumway believed. He had all of us work in the laboratory in the basement of the Falk Cardiovascular Research Center as well as clinically in the hospital. We each had our own research project that would address some unknown in the fast-evolving field of transplantation. We were expected to share the results of our investigations with others at national conferences through formal presentations and peer-reviewed papers. Shumway taught us that breakthroughs don’t originate in the operating room. Rather they are the product of countless hours of experimental work in the laboratory. If a new problem arises after the last advance, design a research project and take it yourself to the lab to figure it out. And once you do, be a good enough surgeon to apply your answer clinically in the operating room to better the lives of your patients. A Shumway-trained surgeon does it all—a curious scientist who is equally comfortable in the basement laboratory and in the operating room. Shumway emphasized the value of enlarging one’s comfort zone.

  One of Dr. Shumway’s favorite sayings was, “Cardiac surgery is not hard to do; it’s just hard to get to do.” Indeed, it took four years of college, plus four years of medical school, five years of general surgery practically living night and day at the hospital, a year or two of research, three more years of cardiothoracic surgery—all of that and more, simply to get the opportunity to be the lead surgeon for a heart transplant. But to me, it was worth every minute of the work, every step of the long, long journey. Heart transplantation was adrenaline-producing stuff.

  Dr. Shumway’s philosophy in the OR was, “Keep it simple.” He often reminded his trainees, “The simpler it is, the less room there is for error.” While Shumway expected perfection, he encouraged the doctors he mentored to be honest about missing the mark: “Never be afraid to double-dribble,” he quipped when a surgeon tried to close too much space with one suture. The lighthearted approach in no way minimized the message Shumway emphasized. “Get it right—even if it means taking out a suture and doing it all over again; get it right. Don’t let your pride stand in the way of perfection.” Shumway also taught, “Never lose your temper; if you do, you’ve lost.”

  These are some pretty good rules for heart surgeons. I found them even better for my life in politics.

  The first time I ever cut out a human heart and replaced it with the heart of another person was a night I will never forget, especially with Dr. Norman Shumway, the man who had invented the procedure, cracking jokes across the table from me throughout. It was 3:00 A.M.; the rest of the world was sound asleep. A young girl who would otherwise have been dead in six months now had a chance to live a full life. As I saw that new heart kick into gear and start beating strongly, an amazing sense of elation and relief swept over me. It wasn’t pride; quite the contrary. I was humbled to have the power to protect life, to help restore it or prolong it. Through the miracle of transplantation, aided by the opportunity to be trained by the best, the discovery of modern miracle drugs, and the selfless act of the heart donor, I was blessed with the ability to prolong God’s gift of life. What a privilege—a humbling privilege—to serve others.

  Life at Stanford was good. I was fulfilled in my career; Karyn and the boys were happy, and we couldn’t imagine anything better. And then I received that phone call from Nashville.

  “BILL, THIS IS HARVEY BENDER,” THE VOICE ON THE PHONE SAID. “Ike Robinson and I would really like to talk to you about coming back home.”

  I didn’t really know Dr. Bender very well. I’d spent a couple of months after my first year of med school doing research on heart blood flow in dogs at Vanderbilt, and knew him as the Johns Hopkins–trained head of thoracic surgery there and a well-respected congenital heart surgeon. I also knew that Vanderbilt hoped to develop a state-of-the-art heart transplant facility. Ike Robinson was the vice-chancellor for medical affairs at Vanderbilt.

  “Tell me more,” I ventured.

  Dr. Bender spoke enthusiastically about Vanderbilt’s plans for transplantation, reminding me that they already had one of the busiest kidney transplant programs in the country under the leadership of nephrologist Keith Johnson and surgeon Bob Richie. He wanted to know if I had solidified my own position after my stint at Stanford was completed.

  I told him that indeed I did want someday to return home and that I had a grand dream that included but went well beyond what was being done at Stanford. Shumway had taught me to dream big and then make it happen. My dream was to create a multiorgan
transplant center, housed in one location. We would not just do hearts and kidneys, but would add liver, and pancreas, and bone marrow, and we would soon even do single-lung transplants (though at the time no one had had much success in single-lung transplants; in fact, even the Shumway program had not yet tried to perform them).

  Dr. Bender suggested that Vanderbilt might offer the ideal location for my ambitious new concept. The notion excited me. Certainly, the idea of moving home held a strong attraction for me, especially since Karyn and I would be returning to our southern roots. Mother and Dad were getting older and unlike my elder brothers and sisters, who had all gone away but by then had returned to live in Nashville not far from the family home on Bowling, I had not had the luxury of spending extended periods of time with them since leaving for college.

  Beyond that, however, Vanderbilt was offering me the opportunity to develop a new type of transplant center that was integrated and truly multidisciplinary—to include all organs, with ethicists, social workers, psychiatrists, and scientists all under the same roof. The only institution that had tried anything like this at the time was Pittsburgh, and even they had individual programs separated by organ type. Almost all other existing programs were single-organ centers, and most of them were stovepiped around a single, high-profile surgeon, within a single department. But with my experiences at Stanford, which underscored working as a team, I envisioned the potential synergy of bringing together the expertise of many surgeons and nonsurgical physicians, allowing their rich and diverse ideas to feed into a single, integrated system and stimulate further advances, transplanting all major organs, and bringing in other related specialties, like infectious disease, that were more traditionally housed in separate departments. This was my big dream.

  Shumway had always said focus everything on the patient, so I figured, let’s do just that. Let’s bring the disciplines under one roof around the patient. The casual exchange of ideas among all the disciplines that would ensue with a common location would generate new ideas to be explored and conquered.

  In response to Dr. Bender’s suggestion, I put together a detailed thirty-page blueprint describing how such a program could be achieved. I wrote a business plan for the new endeavor, including the personnel required, the space it would take, and how it might be financed.

  The timing was perfect. Moreover, I was enticed by Vanderbilt’s willingness to allow me to do a small series of transplants on patients who could not afford the high cost of transplantation. I had argued in my business plan that the medical center would have to “invest in” (that is, pay for) five heart transplants and possibly five lung transplants—about one hundred thousand dollars per patient, plus a lifetime of expensive medications. Most insurance companies still regarded this kind of transplant as “experimental.” I knew we could change that by demonstrating the best results in the country. I proposed new billing and reimbursement schemes—billing over a cycle of care. The program would become self-supporting, I said, because I would see that Vanderbilt became the “center of excellence” for transplantation in the South, and thus would be reimbursed by private insurance and Medicare.

  Karyn didn’t flinch when I proposed that we move to Nashville. Instead, she went to work, meeting with Realtors back in Tennessee, finding a comfortable home for our family (thinking it would be the home we would finally settle in for the rest of our lives), negotiating the deal, packing up our belongings in California, and arranging every detail of the cross-country move—all while I lived in the operating room. She literally bought our new home without me ever seeing it. As always, Karyn made the wheels run, allowing me to grow professionally and contribute to my patients.

  Dad had always said, “Good people beget good people.” He used the line in every speech and public gathering. So, like Dr. Shumway, I insisted on handpicking my own team members, and I sought to assemble the best in their fields. When word got around that we were building a team on the Shumway model, we had no shortage of solid applicants.

  I worked seven days a week, month after month, getting the program up and running. My colleague, the smart, low-key, Hopkins-trained Dr. Walter Merrill, and I were constantly dealing with patients, flying off in the middle of the night to hospitals all over the East Coast, sometimes Canada and as far west as Colorado, to personally inspect and then remove the donor hearts. In those days, we had to do all of our own donor “harvests.” The field was so new that a typical heart surgeon had never even seen a heart cut out. And after a patient was successfully transplanted, it was a perpetual battle, fighting against the next round of infections and heart rejections until things settled out. Walter was the consummate partner, always gracious and volunteering to do more than his fair share, never complaining. For more than five years we were at each other’s side daily and all night at least once a week as we built our rapidly growing program.

  Much of the burden of the new program fell naturally to me, since it was I who had the formal training at the most respected heart transplant program in the world. It was exhilarating for our new team but tiring, and it took me away from my family too much. I spent all Christmas Eve and Christmas day in the operating room for two of the first three years of the program. You can’t schedule transplants at your convenience; you do them whenever a donor heart becomes available. And to be honest, giving someone a new life on Christmas Day had special meaning. But the demands on family life were real. Our third son, Bryan, was born in Nashville, but I missed most of his early adventures growing up. Karyn never complained, but she carried a heavy load.

  In addition to transplantation, there was the more routine heart and lung surgery we’d do every day…and the trauma call which would always bring in the unexpected.

  SEPTEMBER 21, 1991, DAWNED A CRISP, CLEAR, EARLY FALL DAY IN Nashville. Karyn and I were watching Harrison play soccer, as Jonathan and Bryan were running up and down the sidelines. Shortly after noon, my beeper began to vibrate and I received a call from Vanderbilt University Medical Center; I knew that either a heart donor had become available for a transplant or a trauma case was on the way in. Either way it was clear I’d have to cut the match short.

  “Dr. Frist, we have a chopper coming in from Fort Campbell. Patient has a potentially fatal gunshot wound to the chest,” the voice on the other end of the line said calmly.

  “What’s the status?” I asked.

  “A chest tube has been placed, but there is continued hemorrhaging. Large bore IVs are in place.”

  I knew what that meant: Emergency surgery was almost certain. “I’m on my way,” I said. “I’ll get to the hospital as quickly as possible.”

  I rushed toward Vanderbilt Hospital to be present in the trauma unit before the helicopter arrived, in the event that we had to go straight to surgery. As I raced across town, I didn’t know any details concerning the patient about to be delivered to the hospital. A gunshot wound, I thought. Shootings are commonly seen in the trauma unit, but they don’t usually present with a chest tube already in place. The patient coming in could be anybody—a civilian, a domestic-violence case, or it might be one of the many young soldiers stationed at Fort Campbell, located on the border of Tennessee and Kentucky, about an hour’s drive northwest of Nashville and home to the 101st Airborne Division.

  I arrived at the hospital, quickly changed into my scrubs, and waited for the helicopter. I didn’t have to wait long. A few minutes later, the military chopper landed at the nearby Nashville Metro Fire Department helipad, and the patient was transferred by ambulance to Vanderbilt’s trauma center, where he was quickly wheeled into the trauma room. A team of trauma surgeons and I went to work.

  While awaiting the patient’s arrival, I had learned that he was indeed a soldier who had been shot during a live-fire training exercise at Fort Campbell. Apparently, another soldier had tripped and accidentally discharged his M-16 a mere forty meters from the patient. The bullet had ripped a hole in the soldier’s chest just over his right breast pocket and exited his back. Bad e
nough for a soldier to accidentally shoot one of his own, but the person he shot was the battalion commander himself. The commander had been observing troop maneuvers when the shot pierced the air, dropping him to the ground. Although he remained conscious, he was bleeding badly.

  A med-evac helicopter on site rushed the soldier to the Fort Campbell Hospital, where the military docs quickly inserted a tube in his chest to evacuate the ongoing bleeding from his lung. Recognizing the bullet had entered close to where the lung connects to the heart and that the bleeding continued after the chest tube was placed, the doctors referred the patient to our Level I trauma team at Vanderbilt for definitive treatment.

  Once we got a look at him in the trauma unit, after a quick evaluation, we made a decision to go straight to the operating room. We needed to perform an emergency thoracotomy to stop the hemorrhaging from the lung. Still conscious, lying flat on his back, with various intravenous tubes hooked to his body, I leaned over the patient slightly and calmly explained the situation. “Colonel, I’m Dr. Frist, a thoracic surgeon here, and I will be taking care of you. What is your name?”

  The soldier replied, “Sir, I’m Lieutenant Colonel David Petraeus, commander of the 3rd Battalion of the 187th Infantry Regiment at Fort Campbell.”

  “Colonel, we’re going to need to take you directly to the operating room to control the bleeding and possibly remove a piece of the lung close to where it connects to the heart.”

  Most patients confronting the potential of going under the knife express some reticence. “Do I really need surgery?” they might ask. “Isn’t there anything else that you can do?”

  Not Petraeus. His eyes locked squarely onto mine as he said, “If we’ve got a problem that needs to be fixed, let’s get on with it. Let’s get it done now.” His straightforward decisiveness surprised me, although I would years later learn that such a call for action and results was a defining characteristic of David Petraeus. Clearly a no-nonsense sort of guy, we went straight to the OR. On the way, he told me how proud he was of the soldiers who had treated him in the field and how he wanted to get back to the base as soon as possible. I told him we had to get him through the surgery first, but you could tell he wasn’t going to stay around long after surgery.