The Heart Healers (2 page)
Authors: James Forrester
A minute later an anesthesiologist, panting from running the hallways, shoved aside the surrounding curtains, grasping a breathing tube. I stepped aside as she flexed Willie’s neck back. It took her about a minute to insert a metal flange into his mouth, pass a breathing tube into his trachea, and connect a breathing bag. I resumed pumping. After a few minutes of furious pumping on his chest I was drenched in sweat and near exhaustion. Another trainee replaced me.
Long Coat handed me a large syringe filled with a heart stimulant that we hoped might restore the heartbeat. The syringe was connected to a menacing six inch long needle. “Stick it in the fourth intercostal space,” he said. “Keep going until you are inside the heart.” I shoved the needle deep between Willie’s ribs, almost to the hub, then pulled back on the barrel of the syringe. Blood poured into the syringe. I was inside the heart. I injected the concoction.
Over the next twenty minutes, with the rest of the ward in morbid silence, the slurp of suction tube, loud thumps, and heavy breathing rose above the turmoil from behind Willie’s curtain. Above the cacophony, two terse words repeatedly declared our abject failure. “Still v fib.” We could not resuscitate Willie.
By thirty minutes, the others were wordlessly looking at Long Coat for a decision. He turned to the anesthesiologist.
“What do you think?”
“I think he’s gone,” she said. Her words fell like a guillotine..
He turned to me. “He’s your patient, Doctor. What’s your call?”
His question was like a punch to my solar plexus, unexpected, stunning, painful, taking my breath away. Why me? I was still just a twentysomething kid. An apprentice. This was my friend Willie the Phillie. Was Long Coat being cruel beyond imagination? He knew I wasn’t remotely qualified or prepared, and he yet he seemed to be taunting me by putting this final responsibility for Willie’s death on my shoulders.
Wasn’t this final responsibility clearly his, not mine? Or was he treating me with profound respect, calling me “doctor” before my time, admitting me to the fraternity of shared exhilaration and grief between doctor and patient, letting me know that although we had failed, I had done enough to earn his respect? I will always wonder and never know.
I had never come face-to-face with such a profound, wrenching decision. I felt submerged, unable to breathe. In that moment of total silence, I could only look at my shoes, engulfed in impotent failure. We had done everything to save my thirty-eight-year-old patient, yet in that moment I realized that for people with heart disease, we had almost nothing to offer. Nitroglycerin under the tongue was a mismatch worse than Crimea against the Russians. I raised my eyes to rest them on Willie’s ashen face for a long moment of resignation. In that moment I accepted my responsibility. I was Willie’s friend, but as he said, I was his doctor.
“We should terminate Mr. Loman’s resuscitation. I will record that the patient was pronounced dead at 11:58 a.m.,” I choked out, staring at the wall well above the tattered white curtains.
Long Coat delivered a final insight. “He had coronary disease. It was his time.” His subtext was clear. Willie’s misfortune was that he had coronary disease. With coronary disease, there was nothing a doctor could do.
Routine returned. The anesthesiologist extracted her tube, then sidled around the still closed curtain. The nurses silently, respectfully smoothed and folded Willie’s sheets around him, and over his face. I slipped out from behind the curtain and, avoiding eye contact with my other patients on the ward, trudged to the nurses’ station to make my final entry in Willie’s chart. Trained in medicine’s language of facts devoid of feelings, I wrote, “Cardiorespiratory arrest at 11:27 a.m. Unresponsive to intracardiac medications, intubation, and defibrillation. Pronounced dead at 11:58 a.m.” I called Willie’s next of kin, knowing that on this charity ward, typically no one would come. Watching Willie’s tiny cubicle surrender his lingering identifiers and a gurney wheel his shapeless mass past unshaven men with averted eyes, I felt like a prison warden overseeing the last walk of an innocent man. As I closed his chart, I reread my note: it seemed like I was ushering Willie into eternity with neither a name nor a tear.
My impotent witness to Willie’s sudden death left me staring into an emotional chasm, a doctor’s version of post-traumatic stress syndrome. I felt that although our treatment was bankrupt, we accepted the satisfied conventional wisdom that this was the best cardiology could do. Had he survived his heart attack, my mentors would prescribe a minimum of three weeks of strict bed rest for Willie’s injured heart to heal from injury, after which they would conduct an erudite discussion of when it would be safe for him to dangle his legs over the side of the bed. We needed to discover a better way. Impossibly self-delusional as I may have been, I decided to enter cardiology. And that is why I write today.
When I entered cardiology, we faced a new virulent illness. Epidemics are nothing new. In the early 1300s a new disease appeared in China, joined travelers along the Silk Road to Crimea, then moved on to Europe, carried by Oriental fleas living on black rats, the ubiquitous denizens of merchant ships that plied the Mediterranean Sea. In the half century that followed, the Black Death killed half of Europe’s population, cutting the world population by an estimated seventy-five million people. For seven centuries, the plague stood as mankind’s greatest scourge. At the middle of the twentieth century heart disease erupted in exactly that way, as a scourge before which we stood helpless. Heart disease began to kill five to twenty million people worldwide every single year. In my country, the United States, when I entered medicine, more lives were being lost in a single year than in all of World War II.
If you want to understand this enemy, you have to begin with the normal heart. Its principal function is to deliver life-giving oxygen to all the body’s organs. To do this, the heart consists of four components. Muscle that pumps blood. An electrical system to control the pump’s rate. Valves that control the flow of blood through the heart. And coronary arteries to supply oxygen to the other three components.
A glitch in any one of these four systems gives you heart disease, each with a different constellation of symptoms. Disordered muscle and valve function cause arrhythmias (abnormal heart rhythms), manifest as light-headedness, fainting, and even sudden death. Diseased coronary arteries shows up as angina (chest pain on exertion), heart attack, and sudden death.
I knew all this on that humid Philadelphia morning and still in my own heart I realized that as a doctor, I knew nothing of enduring value to Willie the Phillie. Our medical establishment was largely bereft of effective treatment to reverse his condition. Yet today my heart sends me a different message, one of considerable hope. If I could have shared with Willie what I now know, he would have lived to see his grandchildren graduate.
* * *
FOR MUCH OF
my professional career I served as director of one of the National Heart, Lung, and Blood Institute’s nine multimillion-dollar Centers for Research in Ischemic Heart Disease, and later as director of the division of cardiology at one of the nation’s leading medical centers. So I have been fortunate to have a role in what was and continues to be the most astonishing medical advance of our lifetime. I think I am most proud of my role as a mentor for hundreds of clinician-scientists, challenging them to think differently, to find innovative solutions to all forms of heart disease. A few years ago my efforts were honored when I was selected as the second-ever recipient of the American College of Cardiology’s highest honor, the Lifetime Achievement Award. I know full well that my mentees, my mentors, my colleagues, my profession, and our patients are the ones who really deserve this honor. Our shared achievement is that we have humbled what was the scourge of the twentieth century. As I spin out the story of how our nation’s number one killer, coronary artery disease (CAD), became a preventable disease, I aim to teach you how to prevent or conquer heart disease in your own and your family’s lives.
Since I know personally most of the doctors in this story, I should explain why I dub them “misfits.” It’s fascinating to me how many of them share some unusual personality traits. They reject the common wisdom. They rely on their own intuition. In their private lives they are risk-takers. They ignore the criticism of their peers. They persist in the face of failure. Unlike most of us, they are nonconformists, iconoclasts who refuse to knuckle under to society’s norms, regardless of the potential consequences. Does this tell us something about creativity? I think it does. I concur with Steve Jobs on this:
Here’s to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They’re not fond of rules. And they have no respect for the status quo. You can quote them, disagree with them, glorify or vilify them. About the only thing you can’t do is ignore them. Because they change things. They push the human race forward. And while some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do.
Let me introduce just a few of the misfits we will meet on our journey: we will begin with a bullheaded battlefield surgeon named Dwight Harken. Along the way we will meet cantankerous heart surgeon Charles Bailey, scandalously outspoken cardiologist Mason Sones, utopian maverick Argentine surgeon René Favaloro, life-of-any-party Andreas Gruentzig, establishment-challenging Japanese biochemist Akira Endo. I suspect most readers will not recognize a single name but, today, if a family member, a friend, or you have experienced relief or been cured of heart disease, these men stand unseen behind the doctor responsible for the cure.
* * *
THAT’S THE ESSENCE
of our tale: the past, present, and future of heart disease. But it’s the tree without the branches. The beauty, the fascination of our chronicle, as with all stories, lies in people: the doctors and the patients who live it. Since I know most of the patients and doctors you will meet, I tell both stories from my own personal perspective. To me this drama casts an illuminating oculus on both the progress of science and on the human soul. In living these experiences, I have seen incredible risk-taking, scintillating intuition, perseverance, hubris, bullheadedness, indomitable courage, commitment, selflessness, love, and hope. And so, the story I set out to tell about my experience in medical science becomes a story about all of us. As Ecclesiastes tells us, “The race is not always to the swift, nor the battle to the strong, nor riches to men of understanding, nor favor to men of skill; but time and chance happen to us all.” In the spirit of Ecclesiastes, I offer you a testament to one of the most life-altering, indeed heart-healing, stories of our times.
A shocking occurrence ceases to be shocking when it occurs daily.
—ALEXANDER CHASE, AMERICAN JOURNALIST
EVERY DOCTOR HAS
his favorite organ. Hannibal Lecter prefers the liver; I prefer the heart. Surely it is our body’s hardest worker. Imagine performing 90,000 very forceful push-ups a day, with no time-out for rest. How is it possible, when few of us could clench and unclench our fist at that rate for even an hour? Try doing that for eighty years with not one second off for good behavior. Complex in structure yet simple in function, yet so perfect in performance, the heart is truly Nature’s engineering masterpiece.
Midway in size between a baseball and a softball, its oblong football shape still fits nicely in your hand. Squeeze it. It feels firm and muscular but also hollow. Turn it around in your hands, looking at its surface. Three prominent coronary arteries with lots of branches spread over the heart’s surface before diving into the muscle to supply all the heart cells with blood.
Since it feels hollow, let’s open the heart to see what is inside. In the heart, as in architecture, form follows function. We see four separate chambers. The two chambers on the right (the “right heart”) are responsible for collecting blood from the body and the pumping it to the lungs where oxygen is added. The two chambers on the left (the “left heart”) are responsible for collecting oxygenated blood from the lungs and delivering it to all the organs of the body. The heart’s structure reflects its dual collecting and pumping function. Both the right and left hearts consist of a thin-walled collecting chamber (ancients coined it the “atrium”) and a thicker walled pumping chamber (the “ventricle”).
But why does the heart contract about sixty times a minute when we are resting and as much as 180 times a minute when we exercise? What controls the pump? Specialized cells embedded in the right atrium (the blood-collecting chamber of the right heart) spontaneously emit an electrical impulse at about once per second at rest. The impulse causes the atrial muscle to contract. The contraction forces blood across a one-way valve between the atrium and right ventricle. At the same time, the electrical impulse travels also into the ventricle (the pumping chamber). So about two-tenths of a second after the atrium contracts, the ventricle is shocked into vigorous contraction. What a shrewd innovation by the celestial design committee! When it contracts, the atrium “loads” the ventricular pump with blood, and then two tenths of a second later the ventricle fires off, slamming the one-way valve shut and sending blood rocketing to the lungs. It’s like the ticktock of a grandfather clock: the valve is opened, closed, opened, closed.
Exactly the same process occurs at the same time in the left heart, sending blood to the body’s organs. Repeat that every second, and you have a pumping system that circulates oxygen to body’s organs, and returns the deoxygenated blood to the lungs to be reoxygenated.