The Heart Healers (4 page)

I spent my cardiology training years in a Boston cardiac catheterization laboratory. Since Greta told me that she cannot recall her catheterization laboratory experience, I will re-create it for her. On her arrival an attendant instructs her to strip off all her clothes, accessories, and undergarments. To cover her otherwise naked body she is offered a flimsy cotton smock, faded and worn from innumerable scalding launderings. The gown, which barely reaches her knees, has ties at the neck and mid-back, leaving a narrow strip of the lower back partially exposed. As Greta would immediately discover, it is impossible to retain any semblance of dignity if she bends over.

When Greta rolls into the cath lab on the gurney, she immediately smells the vague acrid odor of drying disinfectant wafting up from the floor. The lab floor is mopped after every procedure and turnover is rapid. The smell sticks to Greta’s nostrils like sunblock. The cath lab recalls for Greta images from the threateningly immaculate surroundings of a futuristic sci-fi horror flick. It is a cool cavernous windowless bunker, bereft of color or decoration. Every object seems to be either gleaming chrome or white, proclaiming its hypermodern sterility to all who enter. Among the unidentifiable nameless devices on rollers that hug the walls, Greta might recognize a particular one if she watches TV programs like
ER
or
House
. It is the one with paddle electrodes used to revive the dead. Otherwise the vast space seems empty, except for a forbidding, centrally placed rectangular block of metal in the shape of a very narrow single bed. About waist-high, the bed’s surface has the humorless gleam of hard black plastic.

As a nurse softly introduces herself, nameless souls scurry about behind her in the unisex green pajamas of their trade. All about her, Greta is immersed in controlled urgency: needles forced into vials held aloft, a rolling IV stand, skin patches and wires, monitors snapping alive. With so much distracting sensory input, she can grasp only snippets of conversation about her. Then a voice beside her commands, “Hold still, Greta,” and after a 1–2–3 count, four sets of hands grasping the sheet beneath her propel her briefly airborne and quickly deposit her on the hard lonely catheterization table. Suspended above the table are giant circular lights, each with a handle covered by a sterile drape. If Greta squints into the middle of this array, she will see a massive cylinder, heavy enough to eviscerate her, poised high above her chest. The cylinder is the X-ray imager, which will be lowered to almost touch her chest during the procedure. Mounted above the table like appeal court judges, blank-faced monitors stand poised to silently announce their verdict on the rest of Greta’s life. CAD or no CAD? That is the question.

At Greta’s right side is a metal stand with bulky green packages. The opened packages reveal an array of sterile hemostats, forceps, scissors, and scalpels. Gloved hands replace her blanket with strategically placed sterile blue towels folded just so, creating a large open space over her groin. The bared skin is scrubbed using forceps that held gauze soaked in a cold brown disinfectant. Another set of green-gowned latex-gloved hands extend her arm and tape it to a boardlike extension from the table.

As Greta settles on the cath lab table, Jon and his cardiology fellow assistant enter. With just-scrubbed hands and arms, encased in lead vests that overlap knee-length lead aprons, their mandate is to avoid touching nonsterile objects by walking stiffly with their arms tightly flexed at the elbows like religious supplicants. As a nurse holds up a long gown, Jon forces his arms down into its sleeves. The scrub nurse ties the gown in the back, then holds out sterile gloves into which each doctor in turn plunges his well-scrubbed hands. The solemnity of the gowning ceremony, however, is mocked by the hair bonnets and the foolish-looking bags the doctors wear around their shoes. Frightened, depersonalized, immobilized, and now pinned to this long cold rectangle, the image of masked, gowned doctors incongruously dressed in green burkas completes Greta’s vision of the netherworld of the cath lab. A final dislocating incongruity is a faintly audible stanza of Mozart suggesting that her little island was one of peace and tranquility.

Jon’s task is to insert a hollow tube, a catheter, into Greta’s femoral (leg) artery, then thread it back through the aorta (the body’s main artery) until it reaches the origin of the two coronary arteries (which supply the heart with blood). He then injects a dye to create a moving image of each vessel on X-ray film.

All eyes fix on the monitor as Jon injects X-ray dye to outline Greta’s left coronary artery. She notices how suddenly the soft background of noise from nurses and technicians ominously falls silent. The TV monitor displays a severe narrowing in Greta’s left coronary artery near its origin from the aorta. No wonder she is having chest pain with exercise. An obstruction high in the left coronary artery means that all the heart muscle served by that vessel was in jeopardy. A few minutes later when Jon injects her right coronary artery, another obstruction, high in the vessels appears. Staring at the monitor, Jon’s jaw drops. He is looking at the worst of all coronary anatomic conditions: virtually every muscle fiber in the heart of thirty-five-year-old Greta Adams is at risk.

In the room’s sepulchral silence, Greta’s voice whispered. “What do you see?”

Jon leaned close. It was not into her ears his words were whispered, but into her heart. “Greta, you have blocks in both coronary arteries. These types of obstructions are best treated by a cardiac surgeon.”

“When?” was the only word she could croak out.

“This afternoon, Greta. Now.”

Those four words shattered whatever was left of Greta’s fragile façade. It collapsed as suddenly and totally as an Alaskan glacier. Greta sobbed openly. Tears fell into a pool of words Greta’s heart could not express.

Then, the improbable became the impossible. As she lay struggling to close the floodgate of emotion, Greta’s heartbeat became irregular. In less than a minute, her systolic blood pressure, initially in the low normal range of 110, faded as fast as a flame without oxygen. Now it was 90, then 80, 70, 60 … then suddenly the metronomic beep of the ECG monitor stopped altogether. Her heart was in ventricular fibrillation—the dreaded rhythm of sudden death. Ventricular fibrillation (“v fib” in cath lab parlance) is uncoordinated quivering of the muscle of the ventricle, in which the pumping action of the heart is lost. The quivering is due to chaotic ventricular electrical activity in the ventricle, which is readily apparent on the electrocardiogram as small irregular waves. Untreated ventricular fibrillation becomes a “flat-line” if not treated immediately.

Four hours earlier, thirty-five-year-old Greta Adams strode athletically into the hospital with an unknown malady. Two hours later she was diagnosed with a high probability of CAD. In another two hours she was told she had life-threatening CAD. And three minutes after that stunning diagnosis, she was dead. Greta Adams. Energetic wife. Devoted mother. A happy carefree soul had left her family, had passed to the other side with neither a good-bye, nor a word of protest.

What now? A half a century earlier Greta would have been permanently dead. But today although Greta was dead, she was not gone. Unlike Willie the Phillie whose journey ended abruptly on a 1960s Philadelphia morning, Greta’s new life was just beginning. Jon would have to protect her brain from irreversible damage during her cardiac arrest, restore her heartbeat, reopen her closed coronary arteries, keep them open, and prevent further atheroma formation for the rest of her life. How far could Greta tread along this path? As Jon struggles to restore Greta to conscious existence, he will have to use virtually every important cardiovascular advance of the past half century. If she could return to full health Greta Adams’s story would, within the life of just a single person, encapsulate the history of what is assuredly the most chaotic, inspiring, and, yes, greatest medical victory of our times. And so we must track back in our medical tale to the days and hours just before cardiac surgery slipped from the womb into the gloved hands of a young battlefield surgeon in World War II.

2

“WHAT MAN MEANT FOR EVIL, GOD MEANT FOR GOOD”

He who wishes to be a surgeon should go to war.

—HIPPOCRATES, GREEK PHYSICIAN

OUR STORY BEGINS
as the United States mobilizes World War II hospitals throughout Europe and Asia, and surgeon Dwight Harken departs his secure position in the Harvard Department of Surgery to join the U.S. Army Corps group stationed in Luftwaffe-bombed London. Born in Osceola, Iowa, from his early years Dwight Harken had the personality of a man destined to command. With a booming voice, a mane of fiery red hair, and a temper to match, square-jawed Dwight had bulldozed his way to the top of academia, first as a Harvard medical student and later as a young member of the Harvard faculty. As the thirty-five-year-old newly appointed chief of thoracic surgery at the London 160th General Hospital, Harken had never dreamed anything like this as he left Boston: bombs from overhead, fires raging in the streets, and in his operating room, dying soldiers with chests blown wide open, shards of shrapnel scattered throughout their chest cavity, ragged tissue oozing blood. Fresh from university surgical training, Harken now stared down at a patient’s operating field in complete chaos. No careful incision exposed the thoracic cavity; rather ragged irregular fragments of white rib framed gaping wounds like the bloody teeth of a great white shark. The lungs were not smoothly retracted to reveal a beating heart. Rather they were shredded, and with each inspiration they oozed blood that welled up into the surgical field faster than one assistant working with gauze or suction could remove it.

Nothing in Harken’s training had remotely prepared him for this vision of human ruination. Civilian gunshot wounds create a small round bullet-sized entry wound, and a larger exit wound. Shrapnel was devilishly different. The military offered him no pamphlet of surgical management. No sage professor stood over his shoulder to say, “Let’s consider doing it this way.” In a battlefield hospital, each young surgeon was on his own. His decisions had to be instantaneous. Like an implacable drill sergeant, the battlefield operating room made three demands: be decisive, be fast, and have good hands. But there was one other requirement. It was psychological. The effective surgeon had to ignore the psychic trauma of his inexperience in the face of such calamities, of his inability to staunch the constant flow of blood, of his failure to save another wounded young soldier’s life. Self-criticism and second-guessing became deadly academic relics; this was a new place and time. To do his job, to save a life, the battlefield surgeon needed to be supremely confident and never look back.

I first met Dwight Harken some years later when he was a professor and I was beginning my specialty training as a cardiology fellow learning the newly invented technique of coronary angiography at Peter Bent Brigham (now Brigham and Women’s) Hospital in Boston. Years later after I entered academic medicine, we invited Dwight to be a visiting professor at Cedars-Sinai, and on other occasions I felt honored to share the podium with him at national cardiovascular symposia. Dwight Harken was a man you’d never forget. He was the quintessential “can do” American, stepping from the pages of Tom Brokaw’s
The Greatest Generation
. When Harken expressed a strongly held opinion, which was pretty much all the time, his face turned bright crimson, leading some of us at Harvard (behind his back of course) to call him the Great Red Man. By the time I met him he dominated every clinical cardiology conference, and at dinner he dominated every conversation. President Teddy Roosevelt’s daughter’s description of her father seemed to fit Dwight Harken perfectly: He “always wanted to be the corpse at every funeral, the bride at every wedding, and the baby at every christening.”

Like Roosevelt, Dwight Harken was an iconoclast with a font of new ideas, and he expected you to share his enthusiasm. He was unpredictable. He could be deliberately intimidating to young physicians (including me) on hospital rounds. He could shout ferociously at a resident in the operating room, emerge minutes later to be self-deprecating and humble in an interview, and later be hugely entertaining as a cocktail party raconteur. But to me he had one characteristic that overshadowed all others. He had unshakable self-confidence in the operating room. I found myself admiring this man so open with his feelings, an intriguing mix of humility and bombast, sensitivity and arrogance, self-confidence and insecurity.

In his London operating theater Harken confronted dying soldiers with slivers of shrapnel embedded in their beating hearts. Shrapnel is a vicious projectile named after its inventor, eighteenth-century English artillery officer Major General Henry Shrapnel. Placed within the projectile are small balls of lead shot and an explosive charge to scatter the shot and the fragments of the shell casing. Shrapnel’s uniquely grisly contribution to the art of human maiming was that he designed his projectiles to burst apart in the air, raining down tiny missiles to penetrate the faces, brains, and chests of soldiers scattered over a wide swath of land below.

As he examined the metal fragments protruding from his soldiers’ hearts Harken faced a gruesome choice. If he left a fragment of shrapnel inside a heart chamber, the soldier faced two daunting risks. Blood clots could form on the metal surface, break off and travel to other organs; if one of these biologic bullets lodged in the vessels of his patient’s brain it caused a stroke. Equally likely, bacteria could find a home on the metal shards, which served as miniature petri culture dishes, a source to whisk blood-borne infection to every organ throughout the body. This condition, called bacterial endocarditis, was at that time invariably fatal.

Harken’s other option was to yank the shrapnel out of the soldier’s heart. Now he faced an instant torrent of bleeding from the hole he left behind. In the operating room I have seen sudden unexpected arterial bleeding, like Old Faithful, awesome in its power and bone-chilling in its implication. If the hole is in the main pumping chamber, the left ventricle, each contraction of the heart can unleash a narrow geyser of blood that splatters the operating room ceiling. For me the surge of panic that comes with the unanticipated sudden appearance of arterial bleeding is an indelible memory.