Open Heart

by Jay Neugeboren

  Arthur has sold his two-bedroom apartment in New York and moved into a condominium apartment outside Princeton, New Jersey, one built on land that was formerly an arboretum. He has also bought a smaller, one-bedroom apartment in New York City. He has given up his private practice completely (“If I survived Vietnam,” he says, “I can survive retirement”), and he and his wife Paulette, who has retired from her law firm, intend to divide their time between the Princeton area—they are already enrolled in courses at the university there—and New York City.

  Arthur continues to provide therapy and consultation for former patients—and, several hours a day, for family and friends by the dozens—and he also now puts in one day a week at Gilda’s Club in Manhattan, where he works with individuals diagnosed with cancer, and with those close to them. In the wake of 9/11, and given his extensive experience with trauma victims and people suffering from post-traumatic stress disorders, he has offered his services to various organizations in and around New York City, including the police and the Red Cross.

  But he is not rushing into his new life. “If people make a quick change or transition in situations like this, they usually revert to what’s familiar,” he says on the day movers come to take away his office furniture (he laughs when he tells me that their next stop, after his office, is Woody Allen’s apartment). “That’s why, if somebody is dumped in a relationship, the first person they usually try to connect with is a previous boyfriend or girlfriend—they want to connect with somebody who had once accepted them.

  “But I’d rather stumble and bumble for a while before I move into a new life,” he explains. “I want to do something new, something different. I’ve been talking with a lot of people—in the police department, at the UN, in Princeton, in different charities—some people are urging me to write a book—but I’m in no rush.

  “What I’d like to do, you see, is not be so frightened of the unknown. And most of the world is unknown to me, from astronomy to exotic travel, and I’ve never poked around in them and if I don’t poke around now I’ll die without having done so. So I’m interested in bio-ethics, for example, and, when I fantasize, in contributing to dialogue in and around the operation of a media enterprise—TV, newspapers—but I don’t know if I’m going to be strong enough to do it—to process the world in new ways, to have the life I have while generating a new and different life for myself.

  “I’ve gone through life seeing most things through psychological eyes and in terms of interpersonal relationships, and I don’t want to see the world this way for the rest of my life—through a single prism. Life’s just too various and interesting.”

  In June 2001, I left my position at the University of Massachusetts, rented my Northampton house to a family with two children, and moved back to New York City, where I now live and write full-time.

  Shortly before we head upstairs for sleep, Jerry and I talk again about the time before and after my surgery, and he asks if he ever told me about how my children reacted when I came out of the operating room.

  I say that he didn’t.

  “Well, I brought them to the recovery room,” Jerry says, “and they asked if they could see you, so I think I pulled a little string—I don’t remember exactly—but we got permission to go in and see you. Apparently, however, Aaron is very queazy about these things.”

  I say that ever since he was a small child, Aaron has had a needle phobia—that he has fainted several times in doctors’ offices when he had to receive injections, and that he even fainted once when, for a routine test, a nurse merely pricked his finger to get a few drops of blood.

  “Well, I didn’t know that,” Jerry says, “but he described the same thing, and it wasn’t clear whether he’d be able to do it or not, so I went in and saw you first, and you were completely out of it. But you looked clean and nice. Still, you had tubes coming out here and there, and drains, and this and that.

  “Actually, you looked like hell,” he says, “but very clean— like someone in a casket made to look nice—and quite peaceful, because you were unconscious. So I came out and said, ‘You know, I’m not sure you’re going to be able to do this, Aaron, because your Dad is fine, but he doesn’t look so great. It’s very high-tech stuff, and he’s attached to all these things,’ but Aaron said, ‘I want to go.’

  “So the four of us—actually five, with Seth—all walked in and just stood around your bed, and everybody looked at Dad, and Aaron was a little pale, but he toughed it out. And I think they were reassured because although you were tied into everything like a space cadet, you looked nice and clean, if a little bit dead, and I think they were relieved to see that you were still alive and had made it through the surgery.

  “We walked out of the recovery room and down to the waiting room, and everyone was very complimentary and congratulatory to Aaron, who had really steeled himself for it and pulled together every ounce of his koiyach— his strength—to do it. And I think he felt good about himself.

  “We went home then, and came back the next day, and you were walking already, and advertising your huge incisions, and after that you had a completely remarkable recovery and at every point you kept saying how fortunate you were.

  “Gail and I were grateful—that you were alive, and that we were able to provide a place for your kids. It was very satisfying for us to see them all assembled—to see how important you are in their lives.”

  I nod, but, as on the evening before surgery two years before, find that I can’t speak.

  “And I guess I’m also remembering now that Fred Sachs came to see you.”

  “Yes,” I say. “He stopped by to visit me at least once a day, and on the second day, I think it was, he brought me a book about Brooklyn—it had lots of photos, including some of Erasmus and of other places we remembered.”

  Fred Sachs was associate chief of medicine at Yale, and he had gone to Erasmus with us. At the time of my surgery, Jerry says, Fred was dying from prostate cancer, but he kept the news quiet and never told anybody.

  “Do you remember that he had intended to come to the talk you gave a few weeks before your surgery, for the program in Humanities and Medicine, but he called at the last minute and apologized?” Jerry asks. “So that was the reason he couldn’t come—because he was very sick with the prostate cancer.”

  “When Fred visited with me,” I say, “we talked easily—as if we’d last seen each other a few weeks ago, instead of forty years ago, and he had the sweetest smile and the kindest manner. He was a brilliant and very unassuming guy.”

  “Yes he was,” Jerry says. “Everybody at Yale loved him. He was very smart, very gentle, very modest. He was a good doctor.”

  “When we were growing up, Fred lived around the corner from me, on Linden Boulevard, and we used to walk to and from school together sometimes,” I say. “I sent him a copy of Transforming Madness when it came out a few months after surgery, with a letter in which I said I hoped we’d be able to get together the next time I came down—the three of us—but by the time the letter got to him, he was gone.”

  Jerry makes sure the fire in the fireplace is out, and then we head upstairs to go to sleep. He gives me a hug goodnight, and I find myself thinking that yes, those qualities that lie at the heart of friendship—that allow us to see and appreciate one another for who we are and thereby to more truly know one another—that inspire trust, constancy, kindness, and generosity—these also lie at the heart of what we hope for in our doctors. I comment again on what I’ve been thinking about in recent weeks—the parallels between our lives and the ways in which doctors and scientists have often come upon their insights, diagnoses, and discoveries—and on the contingencies of chance, accident, and sheer good luck that conspired to return my life to me—and I quote Pasteur’s remark, that “where observation is concerned, chance favors only the prepared mind.”*

  Jerry smiles. “What I think, Neugie,” he says, “is that in your case, chance favored the prepared heart.”

  Acknowledgm
ents

  I have benefited enormously from the good sense, expertise, and judgment of friends and colleagues. For early conversations and ongoing encouragement, I am especially grateful to Madeleine Blais, Bob Brick, Jerome Charyn, George Cuomo, Joseph Epstein, Robert Goldstein, Phil Graubart, Sam Tsemberis, and Douglas Whynott. In the course of my research and writing I have had the good fortune to be able to call upon several physicians for information, clarification, and explanations, and am pleased to be able to thank them here. Thanks, then, to Doctors Oscar Garfein, Michael Posner, Sam Rofman, Olav Thorsen, and Gerd-Ragna Bloch Thorsen. For their skills and generosity—for helping to return my life to me—I remain forever in the debts of Doctors Henry Cabin and Sabet Hashim. I am in debt, too, to their staffs, and to the personnel of Yale-New Haven Hospital.

  For helping me check out, and enhance, my understanding of specific matters, I am grateful to Paul Ewald, Henry Harpending, Kim Hill, Magdalena Hurtado, Kenneth Ludmerer, David Mechanic, Renee Pennington, Louise Russell, and Allan Silver. Elise Feeley, reference librarian at the Forbes Library in Northampton, Massachusetts, has been a constant friend and resource. Greg Tulonen, in the early months of research, and James Zarnowiecki, in the final months, have provided excellent bibliographical assistance. Jane Rosenberg, of Eva Productions, has searched out much data for me and brightened many a cloudy day.

  I owe an especial debt to Gerald Grob, who talked with me all through the writing of this book, from its inception to its completion. Along the way, he referred me to sources, corrected errors, read the entire manuscript, and offered numerous and useful suggestions. His generosity and friendship heartened me and sustained me. Doctors Martin Baskin and Rita Charon also read the entire manuscript and provided helpful reactions and comments. For invaluable technical assistance, I am grateful to Kim Florek and Merek Press. I am grateful, too, to Susan Zorn, who performed a masterful job of copyediting.

  My children, Miriam, Aaron, and Eli, have been wonderfully generous in talking with me and bearing with me throughout the writing of this book. Their love, palpable and deep, is an endless source of joy. My brother Robert’s good heart and good will remain an inspiration.

  I am blessed in having Richard Parks for an agent and friend. He has shepherded this book, and this author, through many hills, forests, and valleys. I cherish his friendship, his great good sense, and his indefatigable attention to detail.

  From our earliest discussions, when I did not know whether or not I could or should write this book, my editor, Susan Canavan, has been a dear friend to me and to my writing. Her skills, and her intuitions, are exceptional, and I have depended upon them mightily.

  What to say about Jerry Friedland, Rich Helfant, Arthur Rudy, and Phil Yarnell? They helped save my life, and then they continued, as before, to grace it with their friendship. We were boys together, and now we are men, and to know them, as men, as doctors, and as friends, is, literally—and more and more with the years—to love them. They gave of themselves unconditionally: in hours and hours of conversation, in exchanges of letters, in the reading of drafts of the entire book, and in that ongoing dialogue that is truly life-giving. They did so frankly, warmly, with endless optimism, realism, and good cheer, and without giving any hint, ever, that I was burdening them. The deficiencies of this book are mine. Whatever value it possesses is due largely to them. I trust that Open Heart does honor to them.

  Notes

  1. How Little We Know

  4 He tells me: The medications Dr. Cabin puts me on are Tenormin, a beta-blocker (slows the heart rate and the force of heart contractions, and lowers blood pressure); Vasotec, an ACE (angiotensin-converting enzyme) inhibitor (helps lower blood pressure and makes the heart beat stronger by preventing particular enzymes from narrowing blood vessels); Lescol (lowers cholesterol levels and reduces inflammation); and aspirin (thins the blood, prevents clotting, and also reduces inflammation).

  5 Hundreds of thousands: For a delightful, informative account of bypass surgery, see Joseph Epstein’s “Taking the Bypass: A Healthy Man’s Nightmare,” New Yorker (April 12, 1999), pages 57–63. In 1999, according to the 2002 Heart and Stroke Statistical Update, published by the American Heart Association, 571,000 coronary artery bypass surgical procedures were performed on 355,000 patients in the United States.

  9 Although he describes: Jerome Groopman’s essay “Heart Surgery, Unplugged: Making the Coronary Bypass Safer, Cheaper, and Easier” (New Yorker [January 11, 1999], pages 43–51) is an excellent primer on bypass surgery and its attendant risks. “By now,” Groopman writes, “heart surgeons have mastered the techniques of grafting and suturing, and for those patients who qualify for the operation success rates are excellent—greater than ninety-five percent.”

  Groopman reiterates what Rich has told me—that the majority of serious side effects and fatalities result not from surgery itself but from the heart-lung machine. The problems begin as the cooled blood flows over the machine’s porous membranes: when oxygen bubbles into the blood, it “roughs up” the blood cells. The white cells, which serve to protect against infection, become less effective, and the rate of postoperative infection is relatively high. The roughed-up cells also release inflammatory substances, which irritate the lungs. The blood platelets are damaged by the artificial oxygenation, too, and the patient becomes prone to bleeding. More damage is caused by small clots—composed of blood fats, proteins, platelets, and clumped red blood cells—that form around the oxygen bubbles. When these clots are infused back into the patient, they may block capillaries in sensitive tissues, like those of the brain, the retina, and the lung. Patients on the heart-lung machine have a two-to-four-percent risk of stroke and a twenty-five-percent risk of transitory retinal damage. And from thirty to fifty percent of patients will experience a syndrome [called] “pump head,” in which they suffer significant cognitive deficits: memory loss, inability to concentrate, difficulties in recognizing patterns, and an inability to perform basic calculations. Although the cognitive deficits usually subside over a period of weeks or months, they may delay recovery, and some physicians suspect that they contribute to the clinical depression that often afflicts patients after heart surgery. In addition, patients retain about twenty pounds of fluid as a result of the dilution of their blood in the machine and the trauma of surgery, and this excess fluid puts a further strain on the heart and the lungs. In fact, the very sick or the elderly have been considered ineligible for bypass surgery simply because they are too fragile to withstand the rigors of the heart-lung machine.

  11 And this was ten months: The figure of ninety-eight thousand deaths via medical errors appeared in the New York Times, November 30, 1999 (“Group Asking U.S. for New Vigilance in Patient Safety,” by Robert Pear), and is based on a study done by the National Academy of Science’s Institute of Medicine. Readers should also see “Policing Health Care,” by Lawrence K. Airman, and “Preventing Fatal Medical Errors,” both in the New York Times, December 1, 1999. A follow-up article on deaths due to medical errors, “Getting to the Core of Medical Mistakes,” by Lawrence K. Altman, appeared in the New York Times, February 29, 2000. Beginning in its June 4, 2002, issue (I am writing this in June 2002), the Annals of Internal Medicine is running a series of eight articles that report on medical errors.

  My friends’ insistence that I go to a major hospital is also borne out in a recent study, “Hospital Volume and Surgical Mortality in the United States,” published in the April 11, 2002, issue of the New England Journal of Medicine (NEJM), pages 1128–1137. The study, based on data from 2.5 million procedures—cardiovascular procedures and cancer resections—concluded that “in the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantíy reduce their risk of operative death by selecting a high-volume hospital.” See also the accompanying editorial, “Volume and Outcome—It Is Time to Move Ahead,” in the same issue (pages 1161–1163).
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br />   13 When Rich calls: Here is Dr. Hashim’s description of the surgery, from the “Discharge Summary”:

  On 2/12/99, coronary artery bypass graft surgery times five was performed using left internal mammary artery to the left anterior descending artery, free right internal mammary artery to the ramus intermedius artery, radial artery to the right posterior descending artery, saphenous vein graft to the diagonal artery, saphenous vein graft to the obtuse marginal artery. Total pump time was one hour and 55 minutes. Total crossclamp time was one hour and 11 minutes.

  An intraoperative transesophageal echocardiogram revealed preserved global function with an [sic] left ventricular ejection fraction of 50%, no regional wall motion abnormalities, mild mitral regurgitation, no aortic insufficiency, no tricuspid regurgitation, no shunting, normal pulmonary vein and transmitral flows, no thrombus, no effusion, poorly visualized aortic distal arch. Post pump there were no changes except the ejection fraction was improved to 60%.

  The patient tolerated the procedure well and was weaned from cardiopulmonary bypass without the use of intropic support and transferred to the Cardiothoracic Intensive Care Unit in stable condition where he awoke from anesthesia with no neurological deficits.

  And here is Dr. Cabin’s description of what the cardiac catheterization revealed: “Severe triple vessel coronary disease with an ejection fraction of 30–35%. His right coronary artery and left circumflex coronary arteries were totally occluded and filled via collaterals and he had a 95% stenosis of the proximal LAD [left anterior descending artery].”

  But note that Dr. Hashim’s description of cardiac catheterization is slightly different—a reminder that these numerical figures are not absolute “scientific” realities, but estimates: The patient “underwent cardiac catheterization on 2/11/99. This revealed normal left main. The left anterior descending had 80% stenosis. The circumflex had 95–100%. The right was 100%, left ventricular end-diastolic pressure was 16–20, left ventricular ejection fraction was 30–35%.”