Paneth must have known more than I told him, because it wasn’t long until Silvio disappeared. He was replaced by an American, Steve Rubin. Rubin was an altogether different type. He was smart, decent, and a good doctor. I enjoyed working with him. Rubin had served in Vietnam. His battlefield experience came in handy one night when an elderly woman we’d operated on became confused, opened the window, and jumped out. She landed on one of the spiked railings that are so common in London and was hanging from a leg that had been impaled. Rubin rushed out and performed triage there in the street. After we got her inside, Steve went to the OR and amputated her leg.
I never went home. I slept in a room on the fourth floor, next to the intensive care unit. My life was operating, ward rounds, and more surgery. I was exhausted. I woke up one morning at six a.m. after five uninterrupted hours of sleep and felt refreshed.
One day Rubin called me to say that an old lady on whom we had operated had gone blue and motley. I must not have sounded concerned. “She has skin worse than an alligator!” Rubin said. I was still just listening. “Put it this way,” Rubin finally said, “the anesthetist just intubated her without any sedation.” Intubation—putting a large breathing tube down a patient’s throat—is almost impossible to do on a conscious person.
When I got there, the cardiologists thought the woman had a pulmonary embolism, a blood clot in her lungs. This was serious. Paneth arrived, examined the patient carefully, listened to her chest, and said, “No, an embolus doesn’t sound wheezy.” Instead, Paneth ordered a shot of steroids and a bronchodilator. It was only asthma. The woman got better.
Paneth’s busy practice included heart and lung surgery for adults and children. At least half of his patients were private, paying cases. Many came from other countries. They were treated the same as all the other patients who were done under the health service, except that Paneth always did their surgery.
Pediatric heart surgery was more risky then than it is now. One winter day we operated on a child from Saudi Arabia, a private patient. The surgery wasn’t scheduled for another day or two, but the baby became critical. We couldn’t find the father for permission, so the pediatrician signed off and we went into the OR early in the evening. During the surgery there was a lot of blood—way too much. The scissors must have gone through the back of the aorta, or maybe the pulmonary artery. The child died on the operating table.
I had to find the father and talk to him. He was inconsolable. A day later, we were due to operate on another Saudi baby, but the father came in the night before the surgery and took the child away.
I did my first solo open-heart case on February 1, 1977. The patient had a hole in the entrance chamber of the heart, the same defect that John Lewis repaired in Jacqueline Johnson in 1952, when she was five. Just twenty-four years later, it was now routine. Unlike Lewis, who was racing against the clock, I could put the child on bypass with the heart-lung machine and take my time. I was ready. It occurred to me that I was twenty-nine, and so was Jacqueline Johnson. The operation went smoothly.
I soon felt comfortable doing both heart and lung cases. In most ways, the heart cases were easier. In open-heart surgery, the heart-lung machine was a safety net, giving you time to fix anything that went wrong. Soon I was regularly doing cases alone, lung cases, mainly for cancer, and open-heart cases using the heart-lung machine. It was reassuring to know that Paneth was somewhere nearby, probably having a cup of coffee, in case I got into trouble.
But on one occasion, Paneth went out of town for a week, leaving me with several cases. One was a baby, a girl with a persistent ductus arteriosus. The ductus arteriosus is a short vessel that runs between the aorta and the pulmonary artery that allows the blood to bypass the lungs when you’re in utero and not breathing air. After you’re born, it closes. When it doesn’t close on its own, surgery is usually required. On the day of the surgery, the young mother brought the child to the door of the operating room herself and insisted on talking with me before handing the baby over. I assured her all would be well. A nurse took the baby, and she was put to sleep.
I began the operation. The tissue of the ductus is friable—that is, it’s thin and falls apart easily. Paneth insisted that the ductus should be cut, not tied off or clipped, as many other surgeons did. I clamped off the duct, cut it, and sewed up each end. When I removed the clamp from the aorta, it bled. I put the clamp back on and put another stitch in. When I took the clamp off, the bleeding was even worse.
I froze. Terrible thoughts flooded my brain. The agony of the Saudi father when I’d told him his baby had died. The stone silence in the OR when Kenyon’s patient had bled out before our eyes. The anxious mother holding her child—this child—reluctant to hand her over. How could I go out and tell her I’d killed her baby?
I didn’t dare put the clamp back on. Every time you clamp the vessel, it gets damaged. I put my finger on the aorta, and the bleeding stopped. Unable to move, I told a nurse to go get Mr. Lennox. Stuart Lennox was the only other senior surgeon in the operating complex. He worked with Paneth but was not nearly as good, and they didn’t get on well.
The nurse came back after a minute and said, “Mr. Lennox would like to know what the problem is.”
“Please tell him I’m doing a duct and it’s bleeding.” The nurse went out again. When she came back, she said Mr. Lennox said he would come when he could. I don’t think he was doing anything so important that he couldn’t interrupt it, but he made me wait with my finger in the baby’s chest for at least ten minutes. Finally he barged in, pushed me to the side and looked the situation over for a second. He asked the nurse for a suture, put in a stitch, and walked out.
The bleeding was stopped.
I was furious with myself. I knew I could have done exactly the same thing—and probably better than Lennox had. But I’d let my emotions get in the way. I decided right there that I would never let it happen again. And it never did. Since that day I’ve done pioneering surgeries where the press was literally waiting outside at the doors of the OR and operated on famous people for whom an adverse outcome would have made international news. From that moment, I began to find operating relaxing. I realized I was in control and could take care of any difficulty as well as anybody else. Still, when Paneth got back, I felt that I’d let him down. Apparently Lennox went on at length about how he had to bail out an incompetent registrar. Paneth never said a word about it to me.
I saw patients that year who died with inoperable heart lesions, or diseases of the lung like cystic fibrosis. I was sure some of these people could have been treated with transplants. Lung transplantation wasn’t being done yet, and there was a moratorium on heart transplantation in Britain owing to the many early failures.
Paneth worked mainly in the Brompton’s Elizabeth ward. The head nurse in every ward at the Brompton went by the name of the ward, and so Sister Elizabeth was in charge there. I never knew her real name. I always spent a couple of hours going over all of the patients’ charts before rounds with Paneth, to make sure I could answer his questions. Rounds were every Tuesday, with about twenty junior doctors and nurses trailing Paneth through the ward and crowding in to listen when he explained a case.
Sister Elizabeth was strict—the nurses were all terrified of her. I got on well enough with her, but one day we quarreled. She said nothing afterward. The next Tuesday came, and rounds began. I started discussing the first patient.
“You’re talking about the wrong person, Mr. Jamieson,” said Sister Elizabeth. I stared at the chart. She was right. It was the same at the next patient. I looked like an idiot. It finally dawned on me that Sister Elizabeth had moved all of the patients around randomly after I last left the ward. I never argued with her again.
I still worked in Ken Porter’s lab over at St. Mary’s when I could find time, transplanting hearts in rats. My days and nights were full. Then, in March, I learned Norman Shumway from Stanford would attend a meeting of the British Heart Society, where he was going to give a t
alk. Shumway was the only surgeon in the world doing heart transplants successfully. Knowing how keen I was to work on transplantation, Paneth had written to Shumway to ask if he would take me at Stanford for a year. Now I would have a chance to meet him.
Shumway did not usually take on outsiders. But he had previously made an exception for someone Paneth recommended. I hoped he’d make another for me. Shortly ahead of the meeting, Shumway sent a message saying his daughter had been in a car accident and he couldn’t come. He sent his number two, Ed Stinson, in his place. Stinson’s talk was sensational. Shumway’s group had done some of the first heart transplants in animals in the late 1950s, when everyone said it was impossible. Over the next decade, they had resolved most of the problems involved in transplanting a human heart. After the initial burst of transplant activity following Christiaan Barnard’s first, many surgeons abandoned the operation. Shumway carried on. Now he was doing more than half of all the heart transplants in the world.
In May, Shumway wrote to Paneth saying that he would take me for a year. But I would have to pay my own way. I wondered how much I needed to live on in California. Shumway said his residents at my level earned about $20,000 a year. I doubted I could find that much. I applied for a grant from the British Heart Foundation and started the process of getting a visa for America. It was a busy time. In my first six months working with Paneth, we did 327 cases together, 166 on the heart-lung machine. I did eighty-three on my own, including twenty-two on the heart-lung machine.
In July, everything changed. I rotated off Paneth’s service and went to work for Stuart Lennox. I still covered for Paneth at nights and on weekends, but Lennox became my primary boss. We had fewer cases. Lennox often changed his technique. Every time he went to a meeting or visited another center, usually overseas, he would come back with a different way of doing things. I thought this was a mistake, that it was important to stick to a reliable method that worked well in your hands. Plus, Lennox was sloppy when he tried something new; I never saw him following the recommended procedure precisely. When he got excited in the operating room, which was often, he would scream, “Pass me my whatsit.” With no idea what he was talking about, the nurse would hand him an instrument that seemed right. “No,” he would shout, “Give me the other one.” Sometimes it was difficult not to laugh. Fortunately, as I got to know him, Lennox turned out to be a friendly sort, less intimidating, certainly, than Paneth.
As I was less busy than I had been with Paneth, I asked Lennox if I could put together a team to try heart transplants in dogs. He was hesitant but finally relented. I got a small grant and permission from the Home Office to work on dogs—something that had become a sensitive topic with the emerging animal-rights movement. The work went well. At night the team went home and I dozed on the floor of the laboratory next to the dogs, so that I could check on them from time to time.
Around this time, Christiaan Barnard was in the news again. He had transplanted a baboon heart into a person with heart failure. I was amazed that even someone as reckless at Barnard would not know that the baboon heart would be quickly rejected because of the cross-species reaction. The patient did not survive.
In October that year, Denton Cooley, the renowned Texas heart surgeon, came to visit. He was speaking to the British Heart Society, and I was assigned to meet him at the airport. He was unmistakable when he stepped off the plane, accompanied by his wife, Louise. He was tall, self-assured, and spoke with a Texas twang. I liked him right off.
Cooley did an operation while he was with us, a coronary bypass. I assisted. At first he didn’t seem to be fast, though that was his reputation. But he was fast. There were no wasted moves. He never did anything twice and never checked what he did because he knew it was right. Every move was deliberate and perfect. He was calm and polite, and this mood took over the OR. It was pleasure to watch him at work, and the surgery was over before I knew it.
When I drove Cooley and his wife back to the airport, he told me that it was essential for me go to the United States to see different ways of doing things. I did not know then that our paths would cross many times, and that we would become friends. Twenty years after I dropped him off at the airport, we attended an event together. It was Cooley’s job to introduce me. When he did, he kept it short. “Stuart Jamieson is here with us tonight. He’s the second best heart surgeon in the world.”
In December, the British Heart Foundation gave me a scholarship of $12,000, a little more than half the amount Shumway said that his fellows were paid. I figured I could manage somehow.
Paneth asked me to come to his office late one afternoon. When I went in, he told me to close the door and take a seat. He said that they would appoint someone temporarily to keep my senior registrar job open while I was at Stanford. He said a number of people at the Brompton thought I would make a good replacement for one of the senior surgeons who was retiring soon. I was flattered. The idea that I could become a consultant when I’d just turned thirty was exhilarating.
My year at the Brompton came to an end. I had been in the OR for more than seven hundred cases, about a third of which I had done myself. I had not taken a single day off. And it had been wonderful.
CHAPTER FOURTEEN
THE BEATING HEART
Norman Shumway was in the observation balcony at the University of Minnesota when John Lewis did the first open-heart surgery in 1952. He had done his PhD under Lewis on the effects of hypothermia on the heart. Now that the heart-lung machine could keep the body alive and perfused with blood for two or three hours, cooling the whole body during heart surgery was not necessary. When Shumway moved to Stanford, he performed experiments in dogs to see if cooling only the heart would protect it without a blood supply for an hour or so while he worked on it. With a dog on the heart-lung machine, Shumway removed the heart and then sewed it back in again. This proved to be difficult, because there wasn’t much left to sew it to. So next they transplanted a heart from another dog, leaving connective tissues from the original organ in place to which the new heart could be attached. This led to the early transplant work in the Stanford laboratories. The technique of leaving remnants of the native heart behind to provide a rim of tissue to which the transplant could be sewn became known as the Shumway technique. It would eventually be used in human transplants.
In fact, working on dogs was excellent preparation for working on humans. Dog tissues are more friable and likely to come apart after suturing than human tissues are. If you can operate on a dog, you can operate on a human.
Norman Shumway with his laboratory team. On the left is Ray Stofer, who ran the heart-lung machine. On the right is Richard Lower, who later started a heart transplant program in Richmond, Virginia.
Photograph courtesy of Dr. Shumway
By 1959, Shumway believed their short-term results with transplants in dogs were good enough to present to the American College of Surgeons’ meeting that year in Atlantic City. Dick Lower, a member of Shumway’s team, delivered the paper while Shumway listened. Shumway later said that there was so little interest in their work that Lower had spoken to an audience consisting of “the chairman of the session, myself, and the projectionist.”
But the Shumway group forged ahead, working out the basic principles of heart transplantation. Would a transplanted heart beat in a normal rhythm? Yes, they found. Would it support circulation in the recipient? The answer to that was also yes. And they discovered that if the donor heart was immersed in a cold saline solution, it could be transported to the recipient and still function properly. That left only one problem, but it was the big one: how to prevent rejection of the transplanted heart. Untreated, the animals rejected their hearts in a period of five to ten days.
Shumway’s team tried an array of immunosuppressive drugs, searching for one, or a combination, that would depress the body’s natural defensive response but not so much that the organ recipient was overwhelmed by infection. Here their progress was more halting. They tried azathiaprine—Imuran�
��which had been under investigation as an immune suppressant since the late 1950s. Various steroids were tested. So were radiation and antithymocyte globulin—ATG—a serum created in rabbits that carries antibodies against rejection cells. This was painstaking work, but by the early 1960s they’d had some success. One dog, Ralphie, had lived more than a year after transplantation.
Ralphie. The first living thing to have survived a year after a heart transplant. 1964.
Photograph courtesy of Dr. Shumway
Some of Shumway’s research would have troubled animal rights groups and medical ethicists had word got around. In 1966, Dick Lower transplanted a heart from a human cadaver into a chimpanzee. The heart functioned for a few hours, at which point Lower euthanized the chimp and terminated the experiment. Nothing was said about this, but it was the first heart transplant using a human donor.
By 1967, at least four surgeons in the US were poised to transplant a human heart: Norman Shumway at Stanford; Dick Lower, now working in Virginia; James Hardy at the University of Mississippi; and Adrian Kantrowitz in New York. The shocking news that Christiaan Barnard in South Africa had beaten them all to it had to be discouraging. Dr. Shumway, who as I was soon to learn was unfailingly kind and generous, wrote to Barnard to congratulate him. Had Shumway been able to find a donor a few months earlier, history would have been different.
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