As the operation continued, Najarian came in to watch. I told him about the phone call. He laughed it off and told me not to worry. We started at ten a.m. and were done by three that afternoon. I stayed at the hospital that night to be close by. As I was doing rounds in the intensive care unit, I happened to see Najarian on the evening news. He was talking about Ken Jones’s heart-and-lung transplant, although he played no part in it. I was amused, since he didn’t do heart or lung surgery, let alone do heart and lung transplants.
Jones did well postoperatively but then developed difficulties with bronchospasms. We learned that the donor had a history of asthma, which we had failed to discover during the workup. The asthma in the transplanted lungs went away after a couple of weeks. Since the nerves between the new lungs and the brain were no longer connected, the asthma that occurred after the transplant indicated that local nerves or muscles within the lungs contributed to the condition. The disappearance of the symptoms signaled that the brain was more important in most patients with asthma. Ken was discharged after three weeks. He is still alive and we have grown into our sixties together. Ken is now the world’s longest living lung-transplant patient, and his son now has a family of his own.
The Midwest’s first heart-lung transplant at a press conference six weeks after his May 1986 surgery. I am on the left with Ken Jones, his wife Debbie, and their son. Ken is still alive and well—the longest living lung transplant patient in the world.
Our second heart-and-lung transplant was in a thirty-three-year-old woman from North Dakota named Dee Sellden. Sellden worked in the audit department of the Internal Revenue Service. She had Eisenmenger’s syndrome, irreparable blood-vessel damage in the lungs that resulted from a heart defect that could not be operated on when she was younger. Sellden had been a so-called blue baby. Her congenital heart condition mixed her venous (blue) blood with her oxygenated (red) blood. This caused her skin to turn blue. Replacing both her heart and lungs could fix the problem. Sellden’s donor was a twenty-one-year-old woman from Fargo named Janis Thompson. Thompson was a premed student and cheerleader at North Dakota State University. She had died after striking her head when she fell while practicing a human pyramid.
After she recovered from the surgery, Sellden was pink for the first time in her life. She marveled at the ruddy color of her fingernail beds and lips, which had always been a dusky hue.
Ken and Dee were the start of our new transplant program, which took off. Our fifth heart-and-lung transplant was in an eight-year-old girl named Cindy. Only Denton Cooley had attempted the procedure in such a young patient, and that was years before and it hadn’t worked. But Cindy came through the operation fine, as did all of our other heart-and-lung patients. She left the hospital after three weeks, with her collection of stuffed toys, the youngest surviving heart-and-lung transplant recipient in the world.
As glamorous as the heart-and-lung transplant program was, we did many more heart transplants. We did seventy of them in 1986 and 101 in 1987, making us the busiest heart-transplant program in the world. We achieved another milestone on August 7, 1987, when we became only the third center in the country to be certified to do heart transplants in Medicare patients, which had finally been approved. The other two were Shumway’s program at Stanford and Richard Lower’s in Virginia.
My main focus, however, was general cardiac surgery, which I believed was the key to building up the center. I started bringing people in. Carl White and Bob Wilson came from the University of Iowa, joining the cardiology team as chief of clinical cardiology and chief of the cardiac catheterization laboratory, respectively. They were joined by an enthusiastic new member of the cardiology faculty, Bruce Wilson. Michael Kaye came up from the Mayo Clinic in Rochester to direct our research efforts and help with donor runs. Paneth sent over a surgeon named Bob Bonser for a year. And I promoted a talented young surgeon who’d been training with me, Jolene Kriett, to the surgical staff. Kriett was one of the most naturally gifted surgeons I’d ever seen—everything she did was instinctive and perfect. She was truly that rare person who was born with a knife in her hand. You can tell by the way a surgeon throws a stitch, and whether the next one comes in one fluid motion, whether they’re a natural or not. Jolene was a natural. Matt Paneth used to joke that he could teach a chimpanzee to do heart surgery—and he had done so on several occasions. Jolene had skills you cannot teach.
But at the outset, before I had that kind of help, I did most of the complex cardiac surgery myself. Doing three or four cases a day, I was in the operating room before it got light out and usually left it late at night. I also did operations at other hospitals, sometimes stringing them together one after the other, so that as I finished one patient another one was being opened up on the other side of town. Then it was a mad drive across town. This was before cell phones. The logistics were often daunting.
Two or three times a week, after a long day in the OR, I climbed into the university’s small propeller plane and flew to outlying hospitals and clinics in Minnesota, Iowa, North Dakota, or Wisconsin to meet with doctors and tell them about what we were doing at the university. Sometimes I’d give a talk over dinner, often to only a handful of people. But the referrals to our program grew exponentially, and I kept at it. The hardest thing was the weather, which in the winter was brutal. I had never experienced such cold. I learned for the first time that 40 degrees below zero is the same in Centigrade and Fahrenheit. Also that temperatures like that are painful. I had to wear a scarf over my face so it didn’t hurt when I breathed.
I came back from these trips late at night to face a mountain of paperwork and a long list of phone calls to be returned the next day. I usually slept in my office. The one break I allowed myself was to get back to my ranch in California for a long weekend once a month. It was like being in another country. So many things in Minnesota were foreign to me. I had to learn to keep my car inside the garage at night in the wintertime, otherwise it wouldn’t start in the morning. On one of my first winter mornings, I heard a disconcerting thump-thump coming from the wheels as I drove the first few blocks. It turned out that the tires had frozen and were flattened where they had rested on the pavement. The noise went away once they warmed up.
Returning to Minneapolis on Sunday nights after a trip to the ranch, I felt I almost needed a passport. It was exhausting, but by the end of my first year, the number of open-heart cases done at the university had more than doubled.
On April 10, 1987, just over a year after my arrival, we had the formal opening of the Minnesota Heart and Lung Institute. I invited many distinguished guests. Lillehei was there with his two assistants from the historic first cross-circulation operation. Earl Bakken, the founder of the pacemaker company Medtronic, attended, as did Stan, Phillips’s friend. Together they announced an endowment to provide fellowships for visiting surgeons. Norman Shumway and Matt Paneth were there. Matt, who came over with his wife, Shirley, had not been back to Minneapolis since the midfifties, when he had been a resident with Shumway under Lillehei. I had chosen a motto for our institute—“Anything Is Possible”—and had a plaque made to hang in the lobby, where I passed by it every day. I believed those words, never pausing to consider that “anything” didn’t necessarily mean something good.
We had not yet done a lung transplant without the heart, and few had been done in the world. Joel Cooper in Toronto had pioneered single-lung transplantation and had done a handful successfully. There was almost no experience yet with double-lung transplantation. But I was sure we could do it. We started a waiting list of potential recipients, putting forty-four-year-old Keith Papachek at the head of the line. Papachek had emphysema. His chest was barrel shaped because his lungs were overinflated after years of struggling to breathe.
On New Year’s Eve 1987, I was doing my fourth case of the day, taking a clot out of a heart, when Bob Bonser put his head through the operating room door at 6:40 p.m. and said that it looked like we had a double-lung donor for Keith. The donor, f
rom Indianapolis, had suffered a brain injury and then gone into cardiac arrest. They worked on his heart for an hour with CPR and managed to resuscitate him, but his heart was unsuitable for donation. I told Bonser we could talk when I finished.
As soon as we came off bypass, I found Bob. He told me that we now had another donor, this time a heart donor in Chicago. We had a patient who needed a heart. He’d come in with heart failure after a massive heart attack. To save his life, we had put in a temporary left ventricular assist device, a pump that took over much of the work of the heart. This was early days for that technology, and the patient was one of the first it had been tried in. I was not comfortable leaving him on the machine for any length of time. Now, unexpectedly, we had a heart for him. Things were about to get busy.
The logistics were complicated. Mike Kaye, who usually went on the donor runs, was in the hospital with a detached retina. To complicate matters, teams from other hospitals were in Chicago to harvest the kidneys and liver from that donor and had already started. If we were going to use the heart, we had to leave immediately. We also had to harvest the lungs for Papachek in Indianapolis by four a.m., because the donor’s funeral was scheduled later that day. I left Jolene Kriett to finish the case I had been working on and headed for the airport with Riyad Tarazi, a cardiac surgical fellow who’d come to us from the Cleveland Clinic. As soon as Jo finished the current case, she and Bob Bonser were to start getting the heart patient with the assist device ready for his transplant operation.
Tarazi and I got to the airport at nine thirty p.m., less than three hours after Bonser had stuck his head in the OR to let me know something was up. The Citation jet had its engines running. We climbed in, closed the doors, and were airborne in minutes, headed for Chicago. Life Flights have air clearance that supersedes all other flights except for Air Force One, the president’s plane. On arrival in Chicago, we were met by an ambulance and rushed to the donor hospital with siren blaring and lights flashing. The operation there was uneventful. We cooled the heart, took it out, placed it in a cooler with ice, and were soon at the airport. The New Year had commenced.
We were back in Minneapolis and in the OR by two thirty a.m. I changed into fresh scrubs, relieved Jolene, who’d already taken out the assist device and removed the failing heart. Jolene and Luis Fragomeni, an old friend who’d come to Minnesota as a visiting professor, left for Indianapolis. They were airborne by three a.m. They had planned to grab an hour and a half of sleep on the way, but the heating system on the plane went out shortly after takeoff. Both surgeons were dressed in scrubs with light cotton jackets, and it was bitterly cold. They were still shivering when they reached the donor hospital. As in Chicago, there were other teams there to harvest different organs, and they’d begun. The lungs were exposed, moving rhythmically up and down on the ventilator. Fragomeni checked the blood gases, looked at the condition of the lungs, and told the donor coordinator, “Call Minneapolis and tell them it’s a go.” The call came through to room 14, my operating room, as I was doing the heart transplant.
We had finished the heart transplant by six a.m. At seven, Keith Papachek was wheeled into the operating room and put to sleep. Jolene and Luis were back in the air, accompanied by a cooler that contained a pair of lungs. The clock was ticking, because the lungs were getting no blood. Starting my seventh operation in the past twenty-four hours, I picked up a scalpel and opened Papachek’s chest.
Right away I knew we were in trouble. Papachek’s lungs were stuck to the inside of his chest. It would take a slow and deliberate dissection to avoid subsequent bleeding problems. We put him on bypass so that we could collapse the lungs to make it easier to take them out. I had removed only one when Jolene and Luis arrived in the operating room at nine a.m. The donor lungs had been out of the body for three and a half hours, the outer limit to which we had gone before. I had to make a decision. Should I put them in immediately, which meant taking the other lung out quickly and risking bleeding? Or should I take my time when, in fact, we were already out of time? I thought about all those hours in the lab at Stanford we’d spent working out how to preserve and transport lungs. I decided to go slowly.
When I at last got the other lung out, I immediately started sewing in the new ones. Five and a half hours after they had left the donor’s body, they were in Keith Papachek’s chest. We started ventilating the lungs and shut off the heart-lung machine. Everything looked good. Soon Keith had pink, oxygenated blood running through his arteries, and he was functioning on his new set of lungs. His oxygen levels were normal. We had just completed one of the world’s first double-lung transplants, and in doing it had shattered the record for how long lungs could be preserved outside the body. It had been my longest New Year’s Eve.
Three weeks later, Keith Papachek went home. Remarkably, his chest had returned to its normal size. In medical school we’d been taught that the barrel-chest signature of emphysema was a permanent change in bone structure. But that turned out to be wrong. Once normally functioning lungs were in place, the chest shrank back.
We had accomplished a lot in the nearly two years I had been in Minneapolis. We had started a heart-and-lung transplant program and built up the busiest heart transplant program in the world. But numbers weren’t the best part of the story. By 1988, our one-year survival rate for heart transplants was 97 percent. The new year was off to a great start.
CHAPTER NINETEEN
EXILE
Our clinical practice soared. But I began to understand why so many others had left the University of Minnesota’s cardiac program. The problem wasn’t fierce outside competition at all. It was something that emanated from within. The more I operated, the more I was resented. The general surgery staff whined that I was taking too much operating room time. An even worse transgression was that because I operated seven days a week, I usually missed Najarian’s Saturday morning “grand rounds.” Everyone was expected attend to these sessions and to listen to Najarian holding court. My absence was noted, and word got to me that Najarian was offended. He took it as a personal affront that I was more interested in my patients than in hearing him talk.
All of the key promises made to me when I agreed to take the job had been broken. Before I arrived Najarian had appointed someone who had wanted my job to a full professorship—something I had specifically said would be unacceptable. Naturally, this person fought every new idea and technique I proposed. I never got my research space. I hadn’t even been reimbursed for my moving expenses, and being too busy to complain, I was perceived as weak for letting it go.
But the biggest disappointment was that Najarian did not give me the financial independence he had guaranteed—the one thing that Castaneda had warned me was “fundamental.” Without controlling our own money, we couldn’t reinvest in the program. Instead the money went elsewhere. Whenever I went to see Najarian about it, he told me that we would have financial independence as soon as I “knew the ropes.” Every month we turned checks over to Jim Coggins, Najarian’s financial controller. Every month they got bigger. Soon, we had transferred millions of dollars to Najarian and his group, the Department of Surgery Associates. Ostensibly part of the university, DSA functioned more like a private practice. Coggins was the bagman.
I kept asking Najarian where the money was. He insisted it was in a safe place, and I could tap into it whenever I wanted. He said he knew “to the penny” the amounts he had in all of his department’s accounts. But he never gave me an accounting. Our money disappeared into a black hole. When I hired new faculty, Najarian told me how much I could pay them. I thought the pay was low. When the staff complained, Najarian shrugged and said that I set the salaries.
Then there was the Lillehei matter.
Walt Lillehei had returned from Cornell to St. Paul, Minnesota, in 1975, where he became the director of medical affairs at St. Jude Medical. He’d been through a tumultuous time after being convicted of tax evasion and was no longer licensed to practice medicine in Minnesota. In the el
even years since he’d come back, Lillehei had had no connection to the university. I thought that despite his troubles, this was wrong. Everything I’d done in my career was traceable back to Lillehei. I considered him a legend and believed he still had much to offer. I went to see Najarian to ask if I could make Lillehei an emeritus professor.
Najarian’s office was an imposing place, a glassy aerie high up in the Phillips-Wangensteen Building. The views overlooking the Mississippi were spectacular, and the walls were lined with photographs of Najarian with the many celebrities he’d cajoled into posing with him. Although there was a comfortable sitting area, Najarian always remained imperiously behind his desk when he met with me. It was the kind of throne room that Shumway would have never dreamed of having. As we talked about Lillehei, I could tell this subject was still an open wound. Najarian told me the story about the raid on Lillehei’s lab and the solitary rose. As he talked, huge tears rolled down his cheeks.
Gradually, he composed himself. I argued that Lillehei would help restore prestige to the university, thinking to myself that maybe he’d see this as a credit to himself. I said that there was already money being raised to endow a chair named for Lillehei, a position I would be honored to hold. When I mentioned money, Najarian seemed to lighten up a bit. He told me to go ahead.
I returned along the maze of tunnels to my offices and called Lillehei right away. He was thrilled. I had arranged for his office to be in the institute, and he soon settled in. He was a great asset. Apart from the support and help he gave me, he was an extraordinary teacher and often accompanied us on rounds. He introduced me to Jacqueline Johnson, the first open-heart surgery patient in the world. We were now both thirty-nine.
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