Close to the Sun

by Stuart Jamieson

  This worked fine. It was like Minnesota all over again. We promoted the program. I gave talks at all the neighboring hospitals. My group took the referrals of patients in end-stage heart failure and assessed the candidates. After a slow start, we soon had a number of good candidates for the operation. Within six months of my arrival in San Diego, we were ready to go ahead. We did the medical workups, found money or insurance to cover the cost, did the operations and all the postoperative care, including immunosuppression and the long-term follow-up. We continued to work this way for three years. We became a Medicare-approved center of excellence after two years and started getting paid by the government for transplants. Our results were exceptional, the best in the US and likely the entire world. Of our first fifty transplant patients, only one did not make it.

  Our first heart transplant was done in February 1990 on a Sunday afternoon. Moossa came into the operating room “to lend moral support,” he said. I also heard from Roger Revelle, who was still in the hospital recovering from his surgery. He and his wife, Ellen, who was part of the Scripps family, offered to help with whatever hospital bills the patient could not cover. The operation went well, and the patient was soon discharged. A month later, we did the first combined heart-and-lung transplant at UCSD. Renee Williams, a nurse, had pulmonary hypertension from a congenital heart defect. It wasn’t possible to simply close the hole in her heart now, because her lungs had become irreversibly damaged. The operation took place during the night on March 13, 1990. It was almost four years since I had done the Midwest’s first heart-and-lung transplant. That patient is still doing well more than thirty years later, the longest-living lung transplant in the world.

  In the beginning, not everyone was clear about who would benefit from a heart transplant. I remember getting a call from a nearby hospital about a woman they believed needed one. I’d had a long day in the operating room but walked over to see her in the evening. The patient was a wizened, elderly black woman. She must have been at least eighty. She was sitting up in bed with a skullcap on. What little hair showed beneath it was snowy white. Not only was she well past the age when we would consider doing a transplant, her chart indicated that she was also in the end stages of cirrhosis from alcohol abuse. But I thought that since I’d come over and introduced myself, I should spend a little time explaining what we did. It soon became apparent that no one had brought up the idea of a transplant with her. Which was just as well.

  “Nobody’s cutting on me,” she said. “Don’t want no knife.”

  I couldn’t disagree with that. Realizing she would not be disappointed at not getting a transplant, I went on and explained the procedure to her so she could feel confident in turning it down. She listened patiently. I wasn’t sure she understood what I was talking about. But she did—perfectly.

  “So let me get this right,” she said, “You goin’ to take out my ticker box and replace it with someone else’s ticker box? From someone that’s died?”

  “That’s right,” I said.

  “Well,” she said, poking me in the chest with a bony finger, “tell me this, sonny boy. If it couldn’t keep them alive, how’s it going to keep me alive?”

  I told her she had an excellent point.

  The transplant programs at UCSD continued to grow. In early 1990, we did four transplants in one day—a heart in the early hours of one morning, and then two lungs and a heart simultaneously in the evening, with three operating rooms running at the same time. In between I did three other heart operations. Within a year of our arrival in San Diego, my team had done seventeen lung transplants, and after the first three years, more than one hundred heart, lung, or heart-and-lung transplants with well over a 90 percent survival rate at one year. These patients included the first lung-only transplants in California, as Stanford was still only doing combined heart-and-lung operations. We did the first double-lung transplant the next year, in January 1991. The patient had cystic fibrosis, did well, and was soon out of the hospital.

  I always thought the cystic fibrosis patients were special. A lifetime of struggling to breathe had made them fighters, and they were tremendously grateful for any help that we could give them. I remember one twenty-one-year-old college student named Maria. She came to us desperately ill and wasting away. She weighed only eighty pounds when we did her double-lung transplant. I went to see her before she went home, two weeks after the surgery.

  “Dr. Jamieson, I feel great!” she said.

  I told her I was happy to hear it.

  “No,” she said, “I feel great.”

  Again, I said I was delighted.

  “No,” she said, “you’re not hearing me. For twenty-one years, I have felt sick. I have never felt well. And now, for the very first time in my life, I feel well. I feel normal. I feel great! You don’t know what you do.”

  Maria’s mother, who was sitting by the bed, assured her that we knew. Maybe so, but sometimes it helped when we were reminded. I listened as Maria told me how she would now be able to go to sleep at night without hearing herself wheezing and gurgling, and not be afraid that she’d wake up in the night struggling for air. She was thrilled that she’d be able to get on an airplane, see places like Rome or Paris. Maria said she had something that I realized most of us take for granted: a future.

  A few days after that, I went fishing, though I still carried my beeper. Except for the three months I’d spent in Africa, I had been continuously on call for more than twelve years. Tomorrow was Easter Sunday. When I returned home in the evening, a basket of flowers and an Easter card were waiting for me. “Thank you for our miracle,” the card read. It was signed by Maria and her family.

  In 1992 we did something new. Sam, a young boy with cystic fibrosis, was dying. We couldn’t find a donor because of his small size. He was in the end stages of lung failure. At best he had two weeks to live. I lay awake at night thinking about what we could do to save his life. I had an idea, but it was something that had never been attempted, and it was risky. I told Sam’s parents that if we took a part of each of their lungs, we could replace Sam’s lungs entirely. They agreed without hesitation. We tested their lung functions, and both were good. They could get by just fine with one lobe of their lungs removed. The size and tissue match of each parent was suitable for Sam.

  But I still wasn’t sure it was a good idea. The main problem for me was the issue of informed consent. Any parent would give his or her own life for their child. How objective could they be if I was only asking them to give up a piece of their lungs? What finally convinced me to go ahead was that I believed the risks to the parents were minimal—and more than justified if Sam could live. Not all of my colleagues were as confident. One of them told me I would go down in history as the first surgeon to have a 300 percent mortality for one operation by killing the child and both parents. I was reminded of how Walt Lillehei had been warned he’d have a 200 percent mortality in his first cross-circulation operation. I told my friend that I was sure the operation could be done safely, but I pointed out that a 300 percent mortality in one operation had happened before.

  Robert Liston, a pioneering Scottish surgeon born in 1794, practiced in the days before anesthesia and antibiotics. Survival of surgical patients then depended on speed. The faster the surgery, the less the bleeding and pain, and the smaller the opportunity for the wound to become infected. Nobody understood the concept of sterility then. Liston operated in a frock coat and waterproof boots. He was, to be sure, fast. To save time after making the incision, he would hold the knife between his teeth if he had to then saw through bone. On one occasion, he amputated a patient’s leg in two and a half minutes, but in his haste his knife also amputated the patient’s testicles. In the operation that achieved 300 percent mortality, he amputated the leg of a patient who died afterward from a gangrenous wound infection. Liston’s knife also slashed through the coat tails of a distinguished spectator, who, terrified, had a heart attack and died. The flashing blade also amputated the fingers of his
young assistant, who died afterward from infection.

  I knew I would do better than Liston.

  We worked in three operating rooms and with three teams. We removed part of the father’s right lung and used it to replace Sam’s entire right lung, and then part of the mother’s left lung to replace Sam’s entire left lung. The operation went exactly as planned—everyone survived. But Sam had a difficult postoperative course, in part because each lung rejected at a different rate. It was hard to differentiate between rejection and infection. But Sam gradually improved and ultimately left the hospital with a new lease on life. After a few more of these “living-related” transplants, I stopped doing them, still grappling with the risk to the parent donors. I was mindful of the injunction that is central to the practice of medicine: first, do no harm. I was not satisfied that we could always avoid harming a parent with what was, after all, not a minor procedure but major surgery.

  In early 1994, I got a call from a Dr. Janssen, who wanted to consult with me about a baby with an atrial septal defect, a hole in the entrance chamber of the heart. Janssen wanted to know when it should be closed. I asked him how old the infant was and how much it weighed. He said two months and fifty pounds.

  “Fifty pounds?” I was incredulous.

  “Yes,” he said. “That’s very small for a baby orangutan.”

  Janssen had neglected to say that he was the head veterinarian at the San Diego Zoo. Once I understood, he asked if we could help.

  I went to the zoo and found that they had a state-of-the-art operating room. We tested the orangutan family to see which one would be a suitable blood donor, and later in the summer the whole team went over to the zoo on a Saturday morning to do open-heart surgery on the little ape. It was almost like operating on a human child, except for the heavy chest muscles needed for swinging through the trees, and a large pouch over the airway for the throaty calls orangutans make. The surgery was filmed by a camera crew from the zoo. During the operation we received a call that an infant donor heart was available. We had a baby waiting for a transplant back at UCSD.

  We finished the orangutan by noon and went immediately back to the university hospital, where we transplanted the baby—San Diego’s first heart transplant in an infant. Later that month we did the first lung transplant in a child.

  Neither operation attracted as much attention as the one on the ape. The day after doing it, I left for Costa Rica, where I was giving a talk at a conference. I arrived in the evening tired, sat down in my room, put my feet up, and turned on the television to catch up on the day’s news. And right there on CNN I saw myself operating on the orangutan. Well, I thought, I am famous at last.

  The orangutan grew up. Her name is Karen, and she now has offspring of her own. There’s a plaque at the orangutan exhibit saying that Karen was the first of her endangered species to have open-heart surgery and acknowledging Dr. Jolene Kriett and me for doing the procedure. Naturally we published details of the operation—in the Journal of Zoological and Wildlife Medicine.

  In 1991, we did a lung transplant on a man in his sixties, then the world’s oldest recipient. Manuel Mateos Cándano came from old family in Mexico City, where he was a well-known physician, local mayor, and head of the medical society. He was also a lifelong smoker. By his late fifties, emphysema had forced him to leave the high altitude and smog of Mexico City, where the air pollution was so dense that birds sometimes fell from the sky. He moved first to Acapulco, at sea level, where it was easier to breathe. Cándano was lonely there. He could see no future for himself and often thought of ending it all. Cándano moved again, this time to Tijuana to be closer to medical care in the US. That’s when an old friend told him about the lung transplant program at UCSD.

  Manuel came to my office in a wheelchair and on oxygen. He was pale and gasping for every breath, struggling to stay alive from one moment to the next. I was impressed by his determination and will to live. He was the oldest patient we had accepted, but I said we’d put him on our list. That meant Cándano had to begin active rehabilitation therapy, to try to get his strength back for the operation to come. One day I saw him in the clinic for his eleven a.m. appointment. He told me he’d gotten up at five. When I asked him why so early, he explained that he needed that much time to get ready. Manuel said buttoning one button on his shirt took five minutes, brushing his teeth twenty. He said that back home he was tethered to an oxygen tank with fifty feet of tubing—“like a goat to a post,” he said. Manuel said there were parts of his house he had never seen. I realized then how much a transplant would change his life.

  Months passed. And then we got a call about a donor with good lungs that would be the right fit for Manuel and another patient we had waiting. We decided to use one lung for Manuel and the other for the other patient. We did the operations simultaneously—Jolene did one and I did the other. Both went well. We finished around five a.m., ready to begin yet another full day of surgery.

  Manuel recovered. He threw away his oxygen equipment and went back to Mexico City, a place he never thought he would see again. He returned to his surgical practice with his son as his partner.

  Some years later, I went to Mexico City to give a talk. I met Manuel for lunch. He looked terrific. He invited me to spend a couple of days with him at his ranch. It was a pretty place, nestled in a valley with a river running through it, about two hours north of Mexico City. Butterflies migrate there every year. Manuel kept horses and could ride again. Early one morning, as dawn broke, I got up to enjoy the sunrise. To my surprise Manuel was already up, standing on the porch, looking across the valley to the hills on the other side. I asked what he was doing. “I am looking at my lung,” he said. “I sold that land over there, on the other side of the river, to pay for my lung transplant. That is my new life over there, my lung.”

  Heart transplantation has become almost routine, and lung transplantation is now commonly performed by many groups around the world. It is sometimes difficult to remember the difficulties we encountered in those early days, when we were doing things that many thought were impossible. Experimental work with cyclosporin in our lab at Stanford moved heart transplantation into a new phase, opened the door to lung transplantation, and led us to discover other antirejection drugs. I was fortunate to have been part of that effort.

  Me and Earl Bakken, inventor of the first transistorized pacemaker and founder of Medtronic, at his home in Hawaii. We are holding the first pacemaker—used in a child in 1957. An early draft of Close to the Sun is on his desk.

  What has remained vivid to me are the people we were able to save when they seemed beyond help. The longest-surviving heart, lung, and heart-and-lung transplant patients in the world are people I operated on. Many of them are alive today because we pushed back the limitations on what we could do and for whom we could do it. Over time, transplant patients got older. And younger. And our progress is far from over. Today we perform coronary bypass operations without using the heart-lung machine. We can do complex heart surgeries through small incisions, or replace a heart valve through a catheter that requires no incision at all. In the future we’ll use robots that will allow us to operate remotely—doing heart surgery anywhere in the world without leaving our home hospital. One day we’ll use stem cells to regenerate heart tissue damaged by a heart attack, and we’ll make whole new organs with 3-D printers. As we keep learning, anything really is possible.

  All of this has taken place in a field that did not exist when I was born. The earliest pioneers of open-heart surgery were my mentors and eventually my friends. I have been lucky to be part of something important, to have had a hand in advancing the surgical procedures that have helped so many. I was wise to fly close to the sun.

  I could write a book about my now thirty years at UCSD. But that is another story for another time. In 2011, twenty-two years after I came to San Diego with a promise to build it, the $250 million Cardiovascular Center opened. Mike Kaye and Jolene Kriett have retired. Riyad Tarazi left to head
a heart program in Kuwait. Of our original group at UCSD, only I am still there. Most of my time is spent training the next generation of heart surgeons. I have a fancy title—distinguished professor of surgery and dean for cardiovascular affairs—and I recently traveled to Cape Town to receive a Living Legend award from the World Society of Cardiovascular and Thoracic Surgeons. These honors make me wonder if I am getting old, though being a living legend is preferable to the alternative.

  When I came to UCSD, 250 open heart surgeries a year were being done. I was brought here to build the program. We now do twenty-five hundred heart surgeries a year, making us one of the busiest heart centers in the world. The team consists mainly of people I have trained.

  I still operate, but not as much as before. I have now been involved in more than forty thousand heart surgeries, extending the lives of enough patients to populate a small city. Surgeons I have trained—and who will themselves train their successors—have saved many thousands more lives. My work is alive.

  So am I. Now I contemplate the future and what it holds. I can do whatever I want. I hear there is land for sale in Chobe, and Africa still lives in my blood. I wouldn’t mind renewing my friendship with the elephants. A few of the old ones might remember me.

  POSTSCRIPT

  Richard Atkinson

  Richard Chatham Atkinson earned his bachelor’s degree at the University of Chicago and a PhD in experimental psychology and mathematics at Indiana University. Atkinson joined the faculty at Stanford University in 1956, where he was professor of psychology from 1956 to 1975. He was then nominated by President Jimmy Carter to be the director of the National Science Foundation, a position he served in from 1975 to 1980. He was then appointed chancellor of the University of California, San Diego, and in October 1995 was made the University of California’s seventeenth president. He turned eighty-nine in March 2018.