The Heart Healers (13 page)

“OK, then, I’ll pay all her hospital fees,” Sam replied. “Can you take care of the doctors’ fees?”

I sat stunned in my office chair. “Have you ever met this little girl, Sam?”

“I know her mother. That’s enough.”

“Do you realize that you are talking about an open-ended cost?”

“It’s not about money,” he said.

“Give me a few minutes to think about this.”

I strolled across the hall to the office of Dr. Alfredo Trento, our multiskilled chief of cardiac surgery. The antithesis of the “surgical personality,” Alfredo rose to greet me with his always-welcoming smile, waved at a sofa next to his desk, and in his charming Northern Italian accent said, “C’mon in, Jim.”

I plunked down in a chair opposite him. Alfredo and I played tennis together on the weekends when we had time. Our kids played on the same high school soccer team. Even so this was not going to be an easy conversation.

“I have a once-in-a-lifetime problem, Alfredo,” I said. “It involves three people. There’s a poor hard-working mother, a very sick child, and a remarkable benefactor. And then there’s you and me,” I added, showing limited math skills. I told the story of the child we had never seen and a mother neither of us knew. Then I showed Alfredo the echoes.

“Here’s the thing, Alfredo,” I said. “If Sam pays the hospital bill, cardiology could do the pre-op evaluation and post-hospital care at no charge. Is it possible for you to do the surgery at no charge?”

I knew how balanced my question sounded but how unfair it really was. My part would be easy. I could admit the patient under my name and handle much of the cardiac evaluation myself. Alfredo’s part was far more complex. He had to convince the physician members of his team and the anesthesiologist to participate. Then he had to perform the surgery and commit his team to handling any postoperative problems.

As with Sam, Alfredo’s response was stunning. There was not even a pause for reflection. “I can do it, Jim.”

I reached across the desk to shake his hand. “Thanks, Alfredo.”

I called Sam to tell him the news.

“I’ll do my part, you do yours, Alfredo does his, and providence will smile on us,” he said.

Where Sam thought the problem was solved, I thought it was just beginning. Unlike our usual patients, Maria was coming with a satchel of unanswered questions. Could the pulmonary stenosis be managed without creating a valve that allowed regurgitation? Would Maria have other cardiac abnormalities unseen on the Polaroids that could complicate surgery, like a displaced coronary artery? Would she have noncardiac abnormalities like scoliosis? Would she have to be treated for other illnesses before she underwent surgery? Was her body strong enough to sustain her during the time her survival would be totally dependent upon a machine? The heart-lung machine would collect deoxygenated blood returning in the body’s veins, add oxygen, and then pump the reoxygenated blood into her arteries, allowing Alfredo to unhurriedly operate on her nonbeating heart. Maria’s life would depend on a heart-lung machine.

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RETURNING TO PHILADELPHIA
after the war, John Gibbon joined the staff of his alma mater, Philadelphia’s Jefferson Medical College. Soon after his return, Mayo Clinic surgeon Clarence Dennis, who shared Gibbon’s vision of building a heart-lung machine, came to visit. It was to be a critical moment in cardiac surgery. Gibbon cheerfully demonstrated his laboratory prototype and then gave its complete specifications to Dennis. Back in Minnesota, Dennis quickly succeeded in building a functioning device. Dennis leapfrogged Gibbon by testing his device in patients. Both patients died, and with these devastating failures, both Dennis and the heart-lung machine seemed destined to become historical footnotes. But then the heart-lung story took an unforeseeable new direction.

Who could have imagined that the final resolution to Gibbon’s apparently insurmountable technical difficulties lay not in his medical domain but in his social life? Gibbon discovered the path that is now the template for all the major technical advances in cardiology. Through his social contacts, Gibbon found a collaborator in industry. Gibbon’s angel was the self-made industrialist Thomas Watson, the chief executive officer of International Business Machines (IBM) and one of America’s richest men. IBM knew cash registers, high speed sorting of punch cards, and primitive computers, but absolutely nothing about oxygenators and pumps. Watson, captivated by Gibbon’s vision, was undeterred. He assigned five IBM engineers to improve Gibbon’s device, and funded its development. He added the critical step of sending engineers to Philadelphia to get hands-on experience with the device in Gibbon’s laboratory. Working with Gibbon, the engineers were able to fairly quickly resolve two of three engineering problems: they diminished pump-induced mechanical damage to the oxygen-carrying red blood cells, and they developed a closed system that prevented blood from clotting. Their first device succeeded in bypassing the circulation in dogs, but it was difficult to argue it was ready for human use. About 10% of the dogs died.

Gibbon and the IBM engineers began to attack the most recalcitrant problem, and the one they knew least about: how to add oxygen to the deoxygenated venous (meaning in the veins) blood before returning it to the body.

In Sweden, surgeon Dr. Viking Björk had just proved that it was possible to add oxygen to red blood cells by whirling a film of blood in a stream of oxygen. Björk’s system was impractical because whirling shattered too many red blood cells. At IBM, engineers came up with a better idea, cascading the blood over a thin slanted sheet of film while exposing it to oxygen, then collecting the oxygenated blood at the base of the film (later inventive genius Walt Lillehei used the same principle, sending clouds of minute oxygen bubbles through deoxygenated blood). With their new method of oxygenation, Gibbon and the engineers kept twelve dogs alive during open heart surgery for more than an hour.

With oxygenation at least partially solved, IBM remodeled the device to make it appropriate for human use. Gibbon’s first patient was a fifteen-month-old baby. Fate decreed that Gibbon would fail. The machine worked, but Gibbon was done in by preoperative misdiagnosis. What he and his cardiologist thought would be a simple atrial septal defect turned out to be far more complex. The atrial septal defect was only one part of the malformation of the baby’s heart. Ironically when Dennis had tried his version of the heart-lung machine, he had been done in by the same mistaken diagnosis. Neither surgeon was able to correct more complex congenital malformations, and both patients died.

In May 1953, Gibbon tried again. This time he operated on Martha Cowley, an eighteen-year-old freshman at Wilkes College in Wilkes-Barre, Pennsylvania, about two and a half hours from Philadelphia. When he opened her heart, Gibbon found he was looking at an atrial septal defect about the size of a half dollar. After his prior misdiagnosis fatality, Gibbon breathed a sigh of relief. This was a simple atrial septal defect, similar in size and complexity to the one Lewis and Lillehei had closed in Minnesota using hypothermia. Unlike the Minnesota surgeons, who had repaired an ASD in six minutes, Gibbon was slow, methodical, and deliberate. Using his heart-lung machine instead of hypothermia, he could take more time. Gibbon kept Martha on the heart-lung machine for twenty-six minutes while he closed the defect. Gibbon declared himself satisfied with his closure. Now history hung in the balance. Would Martha wake up from anesthesia without any brain defect, able to return to her college studies? Martha woke up feeling fine, and recovered quickly from surgery.

Only someone with Gibbon’s personality could have achieved what he did. True, he was not an iconoclast in the mold of Harken, Bailey, or Lillehei, but he shared their persistence in the face of repeated failure, and their immunity to colleagues’ contrary opinions about his work. Gibbon’s nineteen years in pursuit of a single goal stands as a monument to dogged persistence in cardiovascular research.

The postwar surgeons’ serpentine path had entered many blind alleys and bridged a river of children’s blood, but Gibbon had finally broken through. Amazingly, the period from Harken’s D-day shrapnel surgery to Gibbon’s heart-lung machine had been less than a decade, yet as cardiac surgeon Michael DeBakey said, it was “one of the truly great sagas of medical research in the history of medicine.” Two decades later, the heart-lung machine would play a central role in our attack on coronary artery disease, the nation’s number one killer.

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SOME YEARS AGO,
radio news commentator Paul Harvey ended his broadcast with what he called “the Rest of the Story.” He would begin with an intrinsically fascinating story, take a commercial break, then return to relate a dumbfounding final twist that made his tale doubly fascinating. Paul Harvey would revel in telling the Jack Gibbon story. Two months after his success, Gibbon followed up his landmark achievement by using his machine for surgery on two more children with congenital heart disease. Both died. Astonishingly Jack Gibbon, forty-nine years old and at the peak of his career, quit. Flat out quit. He declared a one-year moratorium on use of his device. But in fact he was done. At the end of the year, he gave responsibility for cardiac surgery to a younger colleague. He never again scrubbed, gowned, and gloved for another open heart surgery.

Nowhere in the history of medicine will you find a person who dedicates an entire career to a visionary goal, overcomes seemingly insurmountable obstacles, achieves the goal, and then walks away. Jack Gibbon stands alone.

Two years later Thomas Watson was succeeded by his son as CEO of IBM. Now a dominant company in the emerging computer industry, IBM declared that the heart-lung machine program did not fit its core business, withdrew its team from Philadelphia, and departed from the medical device field.

Having been criticized for all the years he consumed pursuing the heart-lung machine, Gibbon was now condemned by some for abandoning it. Among the critics was Dwight Harken: “All of us who have done firsts and gone on and lost lives and spent a good deal of our own lives to create new things realize what it is like to go through all that. We also know the feeling of triumph as well as the feeling of defeat and we resent it when a man does just one successful case and quits! One patient lives and you can’t just sit down and say, ‘Now I’ve done that, that’s it, that’s my contribution. You are obliged to standardize the technique so as to serve others.’”

Those who knew him, however, knew his decision was quintessential Jack Gibbon. He viewed himself as a scientist and a scholar. He did not even publish a report of the first success with the heart-lung machine until a year later, when he gave an invited lecture at the Mayo Clinic. His report was published in
Minnesota Medicine,
a journal with very limited circulation, rather than in a major medical journal, any one of which would have leaped at the opportunity. Having devoted his professional life to developing the single most important advance in the history of cardiac surgery, Jack Gibbon modestly stepped aside. He had accomplished what he set out to do. But I believe there was another reason. Some, like Harken, Bailey, and Lillehei can tolerate the Pain of the Pioneer, and others cannot. Gibbon could not. I think we can all understand. As his friend George Humphries observed, “The others were taking the risk and killing babies, and he didn’t like that.” Artistic, sensitive, genial, warm-hearted Jack Gibbon could not stand the pain. I think that for Jack Gibbon the balance was clear: he would not put young patients at risk even when it meant ceding recognition at the apogee of his life’s work to others. Gibbon, always the teacher, went on to write a standard textbook on thoracic surgery.

I have found that medical students and most cardiologists do not recognize John Gibbon’s name. As we will see repeatedly in our chronicle, history rewards the person who brings an idea to common use, not the one who has it first. By quitting after one successful use of his device, Gibbon did not pursue the level of surgical immortality that he deserves.
Sic transit gloria mundi
 … thus passes the glory of the world.

The informal partnership between John Gibbon and Thomas Watson of IBM, however, became an enduring template. Collaboration between physician-scientists and industry would drive virtually all the breakthroughs in cardiovascular medicine that followed. As I tell our research fellows, if you want to go fast, go alone, but if you want to go far, go together.

The final irony is that in Gibbon’s time the cardiac risk of smoking was not yet recognized. His heart-lung machine was to become the centerpiece of coronary bypass surgery. But for him it was too late. In 1973, not yet twenty years after his landmark success, lifelong smoker John H. Gibbon suffered a fatal heart attack on the tennis court at the age of sixty-nine.

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GIBBON REFUSED TO
use his device, and IBM proved a corporate dropout. Was the cardiac meteor that had flashed so briefly across the Philadelphia sky extinguished? What happened to the heart-lung machine? It simply reappeared more brightly at the Mayo Clinic, where Clarence Dennis arose like the phoenix from his transient status in the ashes of surgical history to improve Gibbon’s version of the heart-lung machine. Graciously giving credit to the original design that Gibbon had given him years earlier, Dennis and his collaborators called it the “Mayo Gibbon–type oxygenator.”

Mayo Clinic cardiac surgeon Dr. John Kirklin and his colleagues used the device on hundreds of patients over the next several years. Kirklin, rigorously intellectual and aloof, and nicknamed The Iceman by one of his biographers, set up a database for long-term follow-up of his operated patients. Kirklin’s data illuminates the stunning truth of the birth of open heart surgery. In 1955 their mortality rate for cardiac surgery was 50%. A year later it was 20%, and by 1957 it had fallen to 10%. Today it is a few percentage points, with almost all mortality confined to patients who are at very high risk prior to surgery. Tragedy precedes triumph.