Open Heart (47 page)

11
   
And this was ten months:
The figure of ninety-eight thousand deaths via medical errors appeared in the
New York Times
, November 30, 1999 (“Group Asking U.S. for New Vigilance in Patient Safety,” by Robert Pear), and is based on a study done by the National Academy of Science's Institute of Medicine. Readers should also see “Policing Health Care,” by Lawrence K. Airman, and “Preventing Fatal Medical Errors,” both in the
New York Times
, December 1, 1999. A follow-up article on deaths due to medical errors, “Getting to the Core of Medical Mistakes,” by Lawrence K. Altman, appeared in the
New York Times
, February 29, 2000. Beginning in its June 4, 2002, issue (I am writing this in June 2002), the
Annals of Internal Medicine
is running a series of eight articles that report on medical errors.

My friends' insistence that I go to a major hospital is also borne out in a recent study, “Hospital Volume and Surgical Mortality in the United States,” published in the April 11, 2002, issue of the
New England Journal of Medicine (NEJM
), pages 1128–1137. The study, based on data from 2.5 million procedures—cardiovascular procedures and cancer
resections—concluded that “in the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantíy reduce their risk of operative death by selecting a high-volume hospital.” See also the accompanying editorial, “Volume and Outcome—It Is Time to Move Ahead,” in the same issue (pages 1161–1163).

13
   
When Rich calls:
Here is Dr. Hashim's description of the surgery, from the “Discharge Summary”:

On 2/12/99, coronary artery bypass graft surgery times five was performed using left internal mammary artery to the left anterior descending artery, free right internal mammary artery to the ramus intermedius artery, radial artery to the right posterior descending artery, saphenous vein graft to the diagonal artery, saphenous vein graft to the obtuse marginal artery. Total pump time was one hour and 55 minutes. Total crossclamp time was one hour and 11 minutes.

An intraoperative transesophageal echocardiogram revealed preserved global function with an [sic] left ventricular ejection fraction of 50%, no regional wall motion abnormalities, mild mitral regurgitation, no aortic insufficiency, no tricuspid regurgitation, no shunting, normal pulmonary vein and transmitral flows, no thrombus, no effusion, poorly visualized aortic distal arch. Post pump there were no changes except the ejection fraction was improved to 60%.

The patient tolerated the procedure well and was weaned from cardiopulmonary bypass without the use of intropic support and transferred to the Cardiothoracic Intensive Care Unit in stable condition where he awoke from anesthesia with no neurological deficits.

And here is Dr. Cabin's description of what the cardiac catheterization revealed: “Severe triple vessel coronary disease with an ejection fraction of 30–35%. His right coronary artery and left circumflex coronary arteries were totally occluded and filled via collaterals and he had a 95% stenosis of the proximal LAD [left anterior descending artery].”

But note that Dr. Hashim's description of cardiac catheterization is slightly different—a reminder that these numerical figures are not absolute “scientific” realities, but estimates: The patient “underwent cardiac catheterization on 2/11/99. This revealed normal left main. The left anterior descending had 80% stenosis. The circumflex had 95–100%. The right was 100%, left ventricular end-diastolic pressure was 16–20, left ventricular ejection fraction was 30–35%.”

When Rich returns the postoperative reports to me, he adds a note: “FYI. Looks great—you're going to outlive all your EHHS buddies! Love, Rich.”

25
   
Celebrating:
Compare the chimera of total body transplants to this—sixty-five years ago—from “Lindbergh, Carrel & Pump: They Are Looking for the Fountain of Age,” in the June 13, 1938, issue of
Time:

From this moment [we are] opening to experimental investigation a forbidden field: the living human body [Dr. Carrel says]…organs removed from the human body, in the course of an operation or soon after death, could be revived in the [Charles] Lindbergh pump, and made to function again when perfused with an artificial fluid… When larger apparatus are built, entire human organs, such as pancreas, suprarenal, thyroid, and other glands…would manufacture
in vitro
the substances supplied today to patients by horses or rabbits.

“In effect,”
Time
declares, “Dr. Carrel, with the Lindbergh pump, is looking for the fountain of abundant, replaceable age.”

“It makes an arresting picture,”
Time
concludes, “one that French, Roman Catholic Dr. Carrel is romantic and mystic enough to appreciate—two men, one an ageless seer, the other a young and devoted inventor, sitting on two rocks in the middle of a sea, talking, planning ways to prolong the life and end the ills of mankind.”

Compare also (this time, thirty-eight years ago) a September 24, 1965,
Life
magazine feature,
“Control of Life: Part 3, Manmade and Transplanted Organs Usher In an Era of Rebuilt People,”
in which we find the following statement: “So confident are medical researchers in the feasibility of heart replacement that the U.S. government has launched a crash program to subsidize the development by industry of an implantable heart that could be put into human patients within five years.”

For a sane, fascinating history of the hopes and disasters that accompanied the attempt to build and implant these artificial hearts, see Renée C. Fox and Judith P. Swazey,
Spare Parts: Organ Replacement in American Society
. More often than not, sad to say, the people in whom these experimental machines were placed seemed to be kept alive mainly to keep the machines going.

For an excellent overview of the ethical issues involved, see Stanley J. Reiser's essay, “The Machine as Means and End: The Clinical Introduction of the Artificial Heart,” in
After Barney Clark: Reflections on the Utah Artificial Heart Program
, pages 169–175. “Machines,” Reiser writes, “also can become key agents of a view developed through the Scientific Revolution that nature should be mastered, not lived with. What greater act of domination could we as humans devise than to substitute a machine for the most conspicuous agent of life, the heart?” Reiser alerts us to the dangers of our infatuation with technology: “The ideal
of a value-free science and a compelling desire to apply rapidly what we can produce make for a powerful combination in a modern world in which the capacity to produce innovations may outstrip our capability to wisely integrate them into the fabric of personal life and societal objectives. The creating of technologic means simply comes easier to us than the development of rational and humane ends to apply them” (pages 174–175).

26
   
Consider, though:
The data concerning drug-resistant organisms in hospitals are from Laurie Garrett's
Betrayal of Trust: The Collapse of Global Public Trust
, page 278. Jane E. Brody, in a
New York Times
article, “A World of Food Choices, and a World of Infectious Organisms” (January 30, 2001), states that “the potential for widespread disaster has definitely expanded.” She cites a study from the Centers for Disease Control and Prevention, which found that “food-borne illness accounts for a staggering 76 million illnesses, 323,914 hospitalizations and 5,194 deaths each year in the United States.” In addition, “The disease-control centers estimate that E. coli O157:H7, which was unknown as a cause of food poisoning before 1980, now infects as many as 20,000 Americans a year and kills up to 500.”

27
   
In our time:
The quotation regarding the downgrading of the interaction between patient and doctor is from James LeFanu,
The Rise and Fall of Modern Medicine
, page 223.

27
   
Or consider:
The 15 to 75 percent figure regarding the disparity between television resuscitations and actual resuscitations comes from Dr. Richard Horton, “In the Danger Zone,”
New York Review of Books
(August 10,2000), pages 30–34 [30].

28
   
And though nearly 40 percent:
The figures regarding the percentage of women who fear dying from breast cancer come from “Fearing One Fate, Women Ignore a Killer,” by Benjamin J. Ansell (
New York Times
, January 9, 2001). Readers should also see “Lessons of the Heart: A Devastating Lack of Awareness,” by Denise Grady (
New York Times
, June 24, 2001).

28
   
Despite our sophisticated testing:
For the difficulty of diagnosing heart disease, see especially Chapter 11 of Richard H. Helfant's
The Women's Guide to Fighting Heart Disease
.

28
   
The American Heart Association reports:
AHA 2002 Heart and Stroke Statistical Update, page 11.

29
   
But we now learn:
Stephen Klaidman discusses the absence of ruptured plaque in people who experience heart attacks in
Saving the Heart: The Battle to Conquer Coronary Disease
, page 214.

29
   
In addition, studies:
For basics concerning statins and their relation to heart disease, see the
New York Times
, January 24, 2001, “Heart Study Affirms Value of Statin Drugs.” See also “U.S. Panel Backs Broader Steps
to Reduce Risk of Heart Attacks,” May 16, 2001, by Gina Kolata; and “Cholesterol Fighters Lower Heart Attack Risk, Study Finds,” November 14, 2001, by Lawrence K. Altman. See also “Early Statin Treatment Following Acute Myocardial Infarction and 1-Year Survival,” by Ulf Stenestrand and Lars Wallentin, in the
Journal of the American Medical Association (JAMA
) 285:4 (January 24–31, 2001), pages 430–436; and “Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III),” in
JAMA
285:19 (May 16, 2001), pages 2486–2497.

Concerning statins as the best-selling drugs,
IMS Health's
“Drug Monitor” states, “Top 5 best selling drugs for the 12 months ending March 2002 was
[sic]
again Lipitor, Losec, Zocor, Ogastro, and Norvasc.
Lipitor
continued to show the highest growth in the top five at 29% at constant exchange” (emphasis theirs).

30
   
But the paradoxical finding:
Louise Russell discusses the correlation (and lack of same) between cholesterol and heart disease in
Educated Guesses: Making Policy About Medical Screening Tests
, pages 45–74.

30   
Furthermore, these risk factors:
For an analysis of the “alternative explanation,” see Joseph B. Muhlestein, “Chronic Infection and Coronary Artery Disease,” in
Medical Clinics of North America
84:1 (January 2000), pages 123–148. Readers should also consult P. W. Wilson et al., “Prediction of Coronary Heart Disease Using Risk Factor Categories,”
Circulation
97 (1998), pages 1837–1847.

In an article entitied “C-Reactive Protein, Inflammation, and Coronary Risk,” we find the following: “Despite progress in the prevention of cardiovascular disease, a significant proportion of first cardiovascular events occurs among individuals without traditional risk factors” (David A. Morrow and Paul M. Ridker,
Medical Clinics of North America
84:1 [January 2000]). See also Paul W. Ewald,
Plague Time: How Stealth Infections Cause Cancers, Heart Disease, and Other Deadly Ailments
(page 117): “If all the noninfectious risk factors are combined, they explain only about half the risk of acquiring atherosclerosis. In other words, about half of the people with atherosclerosis acquire it even though they do not have elevated risk factors for the disease. Something big is missing from the picture.”

30
   
In addition, some researchers:
David Weatherall discusses the correlation between low birth weight and the risk of heart disease in
Science and the Quiet Art: The Role of Medical Research in Health Care
, pages 173–174. See also a study by D. J. P. Barker et al, “Fetal Nutrition and Cardiovascular Disease in Adult Life,”
Lancet
341 (1993), pages 938–941.
“in both healthy subjects”:
Information regarding the predictive power
of established risk factors versus exercise capacity comes from Jonathan Myers and Manish Prakash et al., “Exercise Capacity and Mortality Among Men Referred for Exercise Testing,”
NEJM
346:11 (March 13, 2002), pages 793–801.

31
   
But they are:
Klaidman discusses the unreliability of using diagnostic tests such as angiography as treatment guides: “In recent years, however, it has become clear that angiography is not good enough. It does not spot all blockages in the coronary arteries, and more importantly, many of the ones it misses, either because they are relatively small or not in the biggest arterial channels, are more likely to cause heart attacks than most of the ones it identifies” (page 206).

31
   
“Put a patient”:
When, in the spring of 2002, my doctors in New York City—my general practitioner and cardiologist—suggest I go on a low dose of beta-blockers, since statistical studies indicate that they prevent heart attacks in people who have already suffered from heart disease, Rich disagrees. My resting heartbeat is now about 48 to 50 (my blood pressure steady at about 115/75; my cholesterol 148; HDL 43; LDL 75), and the beta-blockers would lower my heart rate even further. Rich sees no need for it: the possible gains are not worth what he sees as the probable risks associated with the long-term use and side effects of any medication. When I call Martin Baskin, my family doctor (an internist), and tell him what Rich has said, he laughs. “Well,” he says, “that's why medicine is an art, and not a science.”