Open Heart (43 page)

John Gibbon, the man most responsible for the development of the heart-lung machine, did not, like my friends, start out intending to become a doctor.
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Raised in an atmosphere of privilege—French governess, private schools, Princeton education, country properties, European tours—he wanted to become a poet or painter, but enrolled in medical school to appease his father, who was himself a
professor of surgery (the second American to try to suture a wound in the heart). Gibbon's grandfather, great-grandfather, and great-great-grandfather had also been physicians.

Like Rich, Gibbon was bored by the first two years of medical school. He decided to quit, and told his father he would be doing so. Like Rich, however, he finished medical school, and accepted a two-year internship at Pennsylvania Hospital, during which time he assisted in carrying out a hypertension study. This exposure to research excited his imagination, and he next went to Massachusetts General Hospital to continue his studies under the direction of Dr. Edward D. Churchill. It was here that he was assigned to a team that was caring for a woman on the verge of death. As with Rich, what happened next—or rather, in Gibbon's circumstance, what did
not
happen—changed his life, as well as the course of cardiac care.

The woman had had a gall bladder operation and was recovering well until, two weeks after surgery, she developed a pulmonary embolism—a blood clot in her lungs. On October 3, 1930, Gibbon sat by the woman's bedside for seventeen straight hours, checking her pulse rate and monitoring her blood pressure at fifteen-minute intervals. After seventeen hours, the woman lapsed into unconsciousness, and her pulse and breathing stopped. Gibbon called in his mentor, Dr. Edward D. Churchill, who attempted to save the woman's life by surgically removing the clot and closing the artery, which operation he performed in the incredibly swift time of six and a half minutes. Gibbon's mentor, alas, was not as successful as Rich's mentor would be three decades later. Deprived of blood for more than six minutes, the woman's brain died, and then she died too.

The experience so disturbed Gibbon, he later wrote, that while “helplessly watching the patient struggle for life as her blood became darker and her veins more distended,” he began considering the possibility that lives such as this woman's could be saved by a machine that would “do part of the work of the patient's heart and lungs outside the body.”

After completing his fellowship in Boston, Gibbon returned to the University of Pennsylvania Hospital, where for the next three and a half years he operated in the mornings and worked on a heartlung
machine in the afternoons—and at home, at night, and on weekends.

He assembled his first heart-lung machine—the prototype for the one we use now—from a secondhand air pump he bought for a few dollars, and from one-way valves he produced by cutting flaps on the sides of rubber stoppers with a razor blade and inserting glass tubes through their centers, after which he fitted these stoppers into slightly larger tubes. He worked assiduously and obsessively, and he persisted in this work for thirty-three years.

In 1970, he described some of what he had done in order to bring into existence a machine that has, in the last four decades, enabled several million people to survive previously inoperable, intractable, and often fatal conditions.

“My wife and I carried out…slightly bizarre experiments on ourselves and our friends,” he wrote. “We were particularly anxious to learn how slight a shift in body temperature would cause vasoconstriction or vasodilation of the extremities. We got a very sensitive mercury thermometer about three feet long, which would measure temperatures to a hundredth of a degree Centigrade. The bulb of this thermometer would be stuck into my rectum or that of a friend, and the subject would then swallow a stomach tube, down which we poured as much ice-cold water as could be tolerated, measuring the effect on skin temperature of the fingers. I also once got my wife to give me an ice-cold intravenous solution for the same purpose.”

(When I say to Rich that if more than a half century ago Gibbon and his friends had not stuck three-foot thermometers up their asses while chugging down ice-cold water, I probably wouldn't be alive today, he nods. “You got it,” he says.)

In 1952, after practicing open-heart surgery on dogs, Gibbon attempted for the first time to use his heart-lung machine while operating on the hearts of human beings. The results were disastrous. All his patients died, and Gibbon was so discouraged that he never again attempted open-heart surgery. Nor was Gibbon the only one who was discouraged. “Pessimism was rampant,” writes Dr. Walter Lillehai, whose experiments with cross-circulation (a procedure wherein blood is passed not through an oxygenator but through a
human volunteer) became a crucial element in the eventual success of open-heart surgery, “[and] by early 1954 the surgical world had become thoroughly discouraged and disillusioned of the feasibility of open-heart surgery.”
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Although Lillehai believed, in 1954, that “the concept of open-heart correction, however attractive, was doomed,” his success in that same year, using the technique of cross-circulation in repairing the hearts of children afflicted with Fallot's tetralogy (a birth defect afflicting so-called blue babies, and resulting from defects in the blood vessels and walls of the heart chamber), dispelled the notion that open-heart surgery was impracticable. Encouraged by their successes with children, Lillehai and others began working to see what modifications and improvements they could make on Gibbon's pump.

At the same time that Gibbon was attempting to operate on human beings while using his heart-lung machine, other surgeons, intrigued by studies of hibernating animals reported on by a Canadian surgeon named Wilfred Bigelow, were experimenting with a different method of making heart surgery possible: cooling the heart to reduce the body's need for oxygen, thereby allowing surgeons more time for their work.

Within a decade of Gibbon's failures, improvements in Gibbon's machine brought about, for example, by the invention of plastic and the substitution of plastic tubing for glass tubing, combined with techniques for cooling the body, for chemical cardiac arrest, and for ventilating the lungs, made Gibbon's dream of doing the work of the heart and lungs outside the body—and what we know as modern cardiac surgery—a reality.

16

The Prepared Heart

L
ATE
IN
THE
AFTERNOON
of December 26, 2001, my son Eli and I meet at Grand Central Station and take a train north to New Haven in order to spend an evening with Jerry and his family. Jerry, who has just returned from a four-month stay in South Africa, picks us up at the New Haven station.

My journal entry the next morning begins:

In the car, Jerry talks about how sophisticated and “Western” much of South Africa is, and he reminds us that the first heart transplant was performed there by Christiaan Barnard (who was Dr. Lillehai's surgical assistant at the University of Minneapolis Medical School in the late 1950s). Still, most blacks are poor, most whites are rich, and South Africa also has the greatest gaps he has ever seen between
haves and have-nots. “If you could make New York City ninety percent Harlem, and ten percent Upper East Side,” he says, “you would have the picture.”

Violence in South Africa is rampant; a recent incarnation involves the widespread raping of young girls, often nine and ten years old, largely a result, Jerry explains, of the myth that having sexual relations with a virgin will lend one immunity from AIDS. Most white people have taken to hiring their own private security forces, so that even the police force in Durban, where Jerry and Gail were living (Gail stayed for two of the four months), employed a security firm to protect them.

Jerry's daughters, Elisabeth (recently engaged to be married) and Sarah (on semester break from a study-abroad program in Cuba), are at home, and in addition to me and Eli, there are five other guests—Brigette and her four children, ages three to ten. Brigette, Jerry and Gail's babysitter when they lived in Boston, now lives with her husband and children in Brooklyn, a few blocks from Erasmus. “Does the world go round?” Jerry asks.

Dinner is festive—lots of good food, good wine, good talk, and laughter—and during dinner Jerry is gently ebullient and glowingly optimistic—happier and more energized than he has been in years. He talks with enthusiasm about the projects he has begun in South Africa (“I am a guest there,” he says, “and I want to lend my expertise. It is their country, their AIDS problem, and my hope is to be a catalyst—to be able to help them help themselves”), and says he continues to be guided by the saying he took to heart during his previous visit—that the best time to plant a tree is twenty years ago, but that the second best time to plant a tree is now.

The rates of infection are staggering, he tells us, but what he also became aware of soon after his arrival was that a very high percentage of the nursing and hospital staffs are themselves infected, and so he has been working to develop a program in which the first people to be treated when antiretrovirals become available will be hospital staff members. Because the government refuses to acknowledge HIV as the cause of AIDS, and will not pay for antiretrovirals, the program will have to be administered through the private sector, but Jerry has already convinced one hospital to start such a program.
He is confident it will do well—“the antiretrovirals
work!”
he exclaims—and his hope is that success in this hospital will encourage others to initiate similar programs.

“It's estimated that 25% of nursing students and 10–15% of medical students are HIV infected. Can you imagine?” he had written me in early October. “But no encouragement for testing and no antiretrovirals.”

In that same letter he wrote about another project he hoped to initiate: integrating HIV and TB prevention and treatment. “The HIV infection rate is 50% among hospital admissions,” he wrote.

I ask about the HIV/TB project and he says that it too is off the ground, and going well. In addition, believing that the primary cause of HIV infection is unsafe sex (a subject not talked about openly), and that the cause of unsafe sex is usually alcohol or drugs (as happens everywhere else, people get high and don't take precautions), he has initiated several programs in education and prevention. He has been flying to various parts of the KwaZuluNatal province with the Red Cross and other doctors to get these programs started and, also a first for the province, to give seminars on HIV to local health professionals.

“I talk about the prevention and management of opportunistic infections, the construction of multidisciplinary comprehensive programs, and antiretrovirals,” he explained in another letter, “with the hope and expectation that at some time in the not too distant future, they will have them available.”

The overall situation, however, remains grim.

“It's 7
AM
, and Gail and I are home this morning of Yom Kippur,” he wrote two weeks after his arrival. “My work is going too slowly
and I am becoming impatient—but will stay focused and do the best I can. I think things are now getting on track. New figures here estimate that over 4.7 million South Africans are now infected (total population 43 million)—the equivalent of at least 40 million Americans infected in the USA. Most will die.”

Nevertheless, he talks enthusiastically about the possibility of progress in the new South Africa, and uses the same words now that he used when writing to me. “There is,” he says, “both sadness and amazing hopefulness here.”

“The thrill of defeating apartheid has passed and the huge and mundane and seemingly intractable problems left in its wake now must be dealt with—” he wrote on Yom Kippur—

Given the scale of the problems, he says, one cannot think globally. For his part, he hopes to return to South Africa soon (in early January, he will fly there for a week), and he plans to spend at least three months of every year there. “It's really simple, Neugie,” he says quietly. “I could not just watch. I had to go there. I had to do something—to contribute.”

After dinner, and after we have cleaned up the dining room and kitchen, Jerry and I sit in the living room, just the two of us, and Jerry says that if he remembers correctly, this is the first time Eli has stayed over since I was operated on three years ago.