Close to the Sun

by Stuart Jamieson

  I’d only been in town a short time when Moossa invited Daily and me to dinner at his favorite haunt, the Fairbanks Country Club. The purpose was to discuss how we could work together at UCSD—though I had a hunch that wasn’t really what Moossa was hoping for. Daily arrived all swagger, ready for a fight.

  Daily told Moossa that he would leave the university if he was not allowed to do all the children and all the pulmonary thromboendarterectomies while he continued to work at Sharp. In plain language, he wanted nothing to change—and he demanded a written contract to that effect. This would have meant that Daily kept the bulk of the cardiac surgery. This was unacceptable, but I knew that Daily had the backing of many of the cardiologists at the university in addition to Ken Moser and the pulmonary group. I had to decide on the spot how hard to fight.

  I told Moossa I could not agree to Daily’s demand, and that if Moossa accepted Daily’s ultimatum, it would be me who left. Moossa stared at me. I didn’t want to find myself on the street again. But I also didn’t want my first major decision at UCSD to be the wrong one. Moossa turned to Daily.

  “Well, Pat,” he said calmly, “I have to side with Stuart.”

  Daily pushed his chair back, got up from the table without saying a word, and walked out. Moossa and I were left looking at each other over Daily’s half-eaten dinner. I apologized for putting him in a difficult position.

  “On the contrary, Stuart,” he said, “if you had not said that, I would have known I had the wrong man for the job.”

  Daily kept his word and never set foot in the university hospital again. I went to see Moser the next day to tell him that from now on pulmonary hypertension cases were university patients and would be operated on by university faculty. Daily, I said, was no longer on the faculty.

  Moser, who must have already heard this from Daily, didn’t flinch. “Well, Stuart,” he said, “you’ve never done a pulmonary thromboendarterectomy.”

  I said that was true, but that I’d done thousands of open-heart operations and had pioneered new techniques. I was confident I could do the PTE and do it better than Daily. Moser was skeptical. So I proposed a deal. For six months, Moser could send half the pulmonary patients to Daily—on the condition that he sent the other half to me. At the end of that time, he would be free to send the patients to whichever surgeon he felt was better.

  Moser agreed. And at the end of six months, he started sending all of the patients to me.

  That was when Daily made a big mistake. He stormed into Moser’s office, banged on the desk, and insisted that the fifty-fifty sharing arrangement be continued. Nobody threatened Ken Moser. He ordered Daily out of his office and never spoke to him again. Daily subsequently advertised his pulmonary thromboendarterectomy program at Sharp Hospital. But it failed after a handful of cases and was discontinued.

  With Daily gone, I could build the thromboendarterectomy program. I modified the technique and developed new instruments for the operation, which can take all day. The objective is to remove the layer of clot from inside the artery by peeling it from the artery wall with a fine blade. It is delicate work: the artery wall is only as thick as the page on which you’re reading this. Once you establish the plane between the clot and the artery wall, you follow it, working ever deeper until you get it all out. This has to be done under intense magnification, and you can’t have any blood in the operating field. That means the heart can’t be beating and you can’t have the heart-lung machine pumping. You have to shut it all down and drain all the blood from the patient. If you did only that, you would have at most a few minutes to work before you caused brain damage.

  So we used John Lewis’s old method: hypothermia. We put the patient on bypass and then use the heart-lung machine to cool the patient. Then we drain all the blood and hold it in the heart-lung machine while we work. With no blood supply to the brain, or to any of the other organs, you still only have twenty minutes to work, even under hypothermia. So, after twenty minutes, we turn the heart-lung machine back on. After ten minutes we do it all again, draining the blood and continuing the surgery for another twenty minutes. And so on, until we are done and the patient is warmed again.

  This raises an interesting question. What is the status of the patient during the operating phase of the procedure? There is no heartbeat, no blood flow. Brain activity is flatlined. Is the patient dead? I don’t think anyone can answer that. But I do know one thing: after thousands of surgeries during which patients have hovered in this netherworld, none of them has ever awakened and said they saw a bright light, or the pearly gates, or the face of God himself. Not one. If those patients are on the “other side” while we operate, it is a black void.

  We saw a dramatic improvement in PTE outcomes right away. We had been doing one or two PTE cases a month. Now that jumped to two or three a week. By 1998, I had done more than a thousand of these cases, and in 2003 I presented the results of the first fifteen hundred cases at the annual Society of Thoracic Surgeons meeting. At the time, hardly anyone else was doing the operation. Just as with the paper that I had presented to the same conference on combined heart-and-lung transplantation years earlier, this one was named the most significant of the meeting. The honor was especially rewarding, because it was the only time it had been given twice to the same person.

  The society had invited my old Stanford colleague Chris McGregor, now from the Mayo Clinic, to discuss the paper. He congratulated me for developing the “world’s leading pulmonary endarterectomy practice,” and for the team approach we’d taken at UCSD in managing “this demanding disease.” McGregor also pointed to the value of the research efforts in the lab that supported our clinical practice. I was gratified that it was understood that a surgical procedure is of limited value if only one person can do it. Training other members of my team to do the PTE—and welcoming surgical teams from all over the world to train with us—was essential.

  The PTE program at UCSD remains the best in the world. Although it is probably the most difficult of all surgical procedures—it lasts all day and is almost always done on desperately sick patients—our success rate is comparable to that of regular open-heart surgeries, with a mortality rate of only about 2 percent. That includes patients who arrive by helicopters and are being kept alive on ventilators.

  One day early in my tenure at UCSD, just after I’d done the first heart transplant ever performed at the university, the chief cardiologist told me about a patient with heart disease. He had narrowing of the aortic valve and also severe coronary disease. But the cardiologist was hesitant to refer him for surgery, as the patient was in his eighties. Not only that, he was a person of considerable influence at UCSD. An unsuccessful outcome would not be good for our program. I told the cardiologist I didn’t care who it was. Everyone gets the same level of care. Yes, a patient that old was a high-risk candidate for surgery, but without it he would die.

  This elderly patient turned out to be Roger Revelle, a founder of UCSD and a man with an international reputation. The first college at UCSD was named for him. Revelle had also been head of the Scripps Institute of Oceanography and had done pioneering work on the warming of the oceans. He coined the term the greenhouse effect. Revelle was a friend of the former president Ronald Reagan. Just as Stan had been among my most important early cases at Minnesota, an adverse outcome for Revelle could destroy my career at UCSD. He went on the schedule.

  I was in the OR when the cardiologist came in late one afternoon to tell me he had just performed a heart catheterization on Revelle. He said the patient’s condition was “a little rocky.” Asking one of my colleagues to finish up, I left the operating room and went to see him. Revelle was pale and sweating, clammy to the touch, and asleep with labored breathing. His blood pressure was dangerously low. The cardiologist looked grim and suggested that perhaps it was too late for surgery.

  I ordered Revelle straight to the operating room.

  Once he was on the heart-lung machine, I went to work, replacing his aortic val
ve and performing bypasses for all three coronary arteries. The phone in the OR rang. It was the president of the university, asking me to phone him with a report on Revelle’s condition as soon as the operation was over, regardless of the time. I called him back just after midnight to say that Revelle had come through the operation and was recovering.

  The next day there was a long story in the newspaper about Revelle and also our first heart transplant. I was worried about how the coverage would be, since the newspapers in San Diego had picked up on some of the controversy surrounding my hiring. Their initial reporting focused on the salaries members of my team were getting, and on the accusations that had followed me from Minnesota. But I needn’t have worried. I was no longer described as a “controversial” surgeon, but a “pioneering” one. That felt like a win.

  Bill Baxt, the hospital chief of staff, sent me a memo saying, “Congratulations, we are proud to have you here at UCSD.” Moossa, unlike Najarian, who took credit for every success we had, happily acknowledged the progress of the cardiac unit at every step. After we did Southern California’s first combined heart-and-lung transplant the next month, the dean sent over a dozen heart-shaped balloons with a message saying, “The university is proud of you.”

  I had been at UCSD for about a year when one of the cardiologists came to me with an angiogram that showed a patient in severe difficulty. The heart was barely beating, and the coronary vasculature, the blood supply to the heart, was badly compromised. This patient’s left coronary tree, which supplied blood to the main pumping chamber of the heart, was totally blocked. This condition is rare, because a total blockage in this location is almost always fatal. The patient had survived because he was fortunate enough to have an additional blood supply from the right coronary artery, though it, too, was severely diseased. I told the cardiologist that I thought the patient needed a heart transplant.

  “The patient is Kenneth Moser,” he said.

  I was crushed. Ken was not a candidate for a heart transplant. We were not doing people his age at the time. And I doubted he’d submit to the procedure anyway. But without some kind of surgical intervention, Moser would soon be dead. The alternative to a transplant was a risky operation in which some of the dead heart muscle would be cut out in conjunction with a coronary artery bypass.

  I talked it over with Moser. He could have asked any heart surgeon in the world to do it. He asked me.

  The operation went well. Moser recovered and went back to work. A few weeks later, I received a call from his secretary. “I hope I’m not being disloyal,” she said nervously, “but Dr. Moser has started smoking again, and I think you ought to speak to him about it.”

  This was hard to believe. The man in charge of a renowned pulmonary department, who had been the president of the most important pulmonary medical society, the American College of Chest Physicians, smoked! And he continued to smoke after having heart problems that almost killed him. I walked over to his office and sat down. Ken was happy to see me and asked what was on my mind.

  “Ken,” I said, “I’ve come here as your friend, as a colleague, and as your surgeon.”

  “Yes?” he said.

  “I’ve come to talk about your smoking,” I said.

  “Stuart, is there anything else you want to talk about?”

  “No, Ken,” I said, “that’s it.”

  He pointed the way out of his office and said, “There’s the door.” I was beaten.

  More than a year later, Bill Auger, one of Moser’s bright young assistants, showed me a chest X-ray with a large mass visible, a lung cancer. It was Ken’s X-ray. Again, we operated, this time removing part of his lung. He continued to smoke. After he had recovered from his lung operation, I would see him walking toward his car in in the evenings, wheeling a bottle of oxygen with his left hand and holding a cigarette in his right. Ken died on June 9, 1997, a little more than seven years after we first worked together. He was sixty-eight, not young certainly, but not old, either.

  By the time Moser died, we had done a total of 855 PTE operations and were by far the leading PTE program in the world. I worried that Ken’s death, which had affected me deeply, would also have an impact on our practice. He had been our primary referring pulmonologist, bringing us a steady flow of patients, including many from other countries. I should not have worried. Like all great leaders, Ken had trained and gathered around him a group of talented individuals who were up to the task of carrying on. Our team has now done more than four thousand of these operations.

  Being a surgeon does not make you immune to ordinary human emotions. I was home one evening around Christmas—a rarity for me—when the phone rang. A surgeon who was a close friend was on the line. He was out of breath. He told me his mother, who was visiting from Europe, had suffered a cardiac arrest. He was administering CPR on his kitchen floor. I asked him if he’d called 911.

  “No, boss,” he said. “I’m calling you.”

  It’s funny how the mind works in a moment like that, how a brilliant guy like my friend wasn’t thinking straight, even though he’d handled a situation like this many times. When it’s family, it’s different. I told him to hang up and call 911 and then call me back after he did. He called back in a bit and said they were in an ambulance headed to Scripps Memorial, which was not our hospital but was the closest. I said I’d meet him at the emergency room. The surgeon and his mother got there before I did.

  When I came in, the staff looked ashen. They pointed me to a room. When I went in, several doctors and nurses were standing there in shock. My friend had picked up a scalpel and opened his mother’s chest in a desperate attempt to save her. He was doing direct heart massage with his bare hand. I watched for a few minutes, and it was plain that it was hopeless. I walked over and pulled his bloody hand from his mother’s chest and held him by the shoulders.

  “You’ve got to stop now,” I said. “Your mother is dead.”

  We went back to his apartment, where I spent the night with him, talking, trying to help him come to terms with his mother’s sudden death. We were having a brandy when he realized he had to call his father, who was in Europe.

  “What should I tell him?” he asked.

  “Don’t tell him your mother has died,” I said. “He’ll never be able to get on an airplane if you do. Tell him that she’s had a heart attack and is in the hospital and that he should come at once.” I knew the long plane ride from Europe would give him time to prepare for the worst.

  Most of the time, a surgeon’s life is one of daily rewards. I had wanted to fix people when I was young and dreaming of becoming a surgeon. In heart and lung surgery, you do more than just fix people—you restore them to a life they’ve been forced to stop living. They’re not fixed. They’re transformed.

  One day I left the operating room around noon and walked to my office. My secretary told me that someone was waiting inside to see me. When I went in, I found a healthy-looking man accompanied by his son seated on my sofa.

  “You won’t remember me,” the man said as he stood up to shake hands. “I’m Joe.”

  I remembered him perfectly. When I operated on Joe in 1982, he was one of the world’s first heart-and-lung transplants. He had called me earlier that year. He was my age at the time, thirty-four, and had a wife and a five-year-old son. Joe had been told he had only a few months to live. He said he would give anything, pay any price, to live long enough to see his son go to college. He had read about some of our early heart-and-lung transplants in the newspapers and wondered if I could help. He asked about our experience with the operation. I told him we had a lot of experience in monkeys, but not much as yet in humans. He laughed, and said, “Well, I really don’t have much choice, do I?”

  I agreed that he didn’t and asked him to come see us.

  I spent a lot of time with Joe when he got to Stanford. He’d come with his wife and son. After careful consideration, we decided to put him on the list. The time came when we had a suitable donor and did the trans
plant. It was in the night, as usual. Everything went smoothly. After the operation, Joe was in an isolation room that I passed by every day on my way to the OR. I’d pause to look through the big glass doors. Almost without fail, Joe’s son, dressed in a blue sterile gown, with gloves on and wearing a surgical mask that was too big for him, was in bed with him. At the time I thought that if I never did another thing worthwhile, this would be accomplishment enough.

  Joe left the hospital and went back to his life. Years passed. I moved to Minnesota and then back to California. Now, here he was sitting in my office with his grown son. I told Joe I remembered everything about him and his operation, including the date and even what his temperature was on his tenth postoperative day. He laughed.

  “Well, you do remember me,” he said. “I’m here because I’m bringing my son to UCSD to look at the college.”

  So, he’d made it, lived to see the day his son would go to college. He looked fit and happy. Joe was then the longest-living combined heart-and-lung transplant recipient in the world—and surely among the luckiest fathers who ever lived.

  Although conventional heart surgery was going to be the main part of our practice in the new program at UCSD, I wanted to start our transplant programs immediately. Heart transplantation had not yet been done at the university. Double-lung and single-lung transplantation had never been done in Southern California. Ideally, a transplant program is a joint effort between the surgeons and the physicians—pulmonologists for lung transplantation and cardiologists for heart transplantation. Cecilia Smith, a university pulmonologist, was eager to be involved. But we were not so lucky with heart transplantation. We could not generate any enthusiasm from the cardiologists. No one wanted to be included. When we were promised help, Pat Daily’s old friend, the chief of cardiology, was appointed chairman of the search committee to recruit a cardiologist to work with the transplant program. Every person I suggested for the post apparently had a defect of which I was unaware. The committee finally disbanded without interviewing a single candidate. I decided to start the program on my own, without any input from cardiology.