Alpha Docs (14 page)

I pull up Richie's record on my computer: late twenties, familial cardiomyopathy. (One of my earlier patients, Malcolm, who was in his thirties, flashes through my mind. This guy is even younger.) There's a family history of heart failure of unknown cause, one of those infamous “idiopathic” cardiomyopathies, the ones that “just happen.” Richie's heart function is so poor that he's at constant risk of sudden cardiac death from bad rhythms. The only thing that may save him is pacing or shocks from the defibrillator in his chest. His eight shocks in an hour are at least six more than the average crisis. He needs to get to a hospital, immediately.

Later I learned why his father seemed so unflustered. He himself had been through this same ordeal a couple of years ago and had gotten a heart transplant. In Mr. Mann's case, he'd had a known cardiomyopathy and developed what's called “VT storm.” VT storm is a recurrent, refractory—as in not yielding to treatment—ventricular tachycardia that can rapidly degenerate into clinical instability and impending cardiopulmonary arrest. Like his son, Mr. Mann had a defibrillator, and then one night, he went into VT storm and received shock after shock. The defibrillator is programmed to deliver lesser jolts or stimulus, called antitachycardial pacing, or ATP, and only if these don't get the heart into normal rhythm does the defibrillator send out the big shocks. The small shocks aren't too uncomfortable. The big shocks are like getting whacked with a baseball bat in the sternum. The whole body jumps off the table. Again and again. As a result, Mr. Mann thought that a few shocks from a defibrillator were pretty routine, until Richie got up to eight shocks an hour. Only then did he think to call the doctor.

I phone Mr. Mann back: “Have you called an ambulance yet?” I don't want the family to panic, but I make it clear that this can't wait. Don't take a leisurely drive down to Hopkins. Go immediately to the nearest ER. I want Richie on IV antiarrhythmic medications to try to quiet his heart down. His father may be unflustered, but Richie is flirting with death.

I leave a message about Richie's condition with Dr. James, the essence of which is, if Richie can be stabilized at the local ER, he should then be transferred to Hopkins tonight. Dr. James, who is at his son's basketball game, calls me back and agrees.

By the time I connect by phone with the hospital where Richie is being treated, they're preparing him for transfer. His defibrillator has shocked him twelve more times, and they're loading him with IV amiodarone to try to electrically stabilize his heart. The amiodarone is calming his heart as much as it can, but that isn't much. The ER docs know that their hospital won't be able to do much more for him and nothing good will happen if Richie stays there. They decide to helicopter him to Hopkins to the cardiac ICU. On the half-hour ride, Richie is shocked every few minutes.

This is the first case I've been a part of where a patient is in this much trouble before he even arrives at the cardiac ICU. I want to be there. There will be another Fellow on duty and a resident, both members of the CICU team. But I got the initial call from Mr. Mann, and I want to see this case through. More than anything, I'm curious. I want to see what this looks like.

I arrive a little after Richie does, at 10:30 p.m. He has his IV medicine, but he's still sore and exhausted. For over six hours, his heart tried to stop beating, and each time, a machine whacked him in the chest. His body and his mind have been through hell. And Richie is no weak-looking character. He's bulky, with a mullet hairstyle, facial stubble, and tattoos—the kind of guy you see on a Harley on I-95 and make sure you don't cut off. But he's also kind and soft-spoken when I talk to him in the cardiac ICU (and one tattoo says
Gramma
). He tells me that the real pain isn't in his chest; it's in his right shoulder. The shocks from the defibrillator have reaggravated an old shoulder injury—each time Richie got shocked, he buckled over and clutched his shoulder. He's had this problem in the past, resulting in a partially torn rotator cuff: an extra pain he didn't need.

I explain to Richie that I'm there on behalf of Dr. James, which reassures him. All of a sudden, he gets shocked again. He'd gone into VT while we were talking. Richie lets out a wild “Yeooow!” that ricochets through the unit as his monitors go off. But the jolt puts him back in normal rhythm, and he's “electrically quiet” after that. The nurses reload him with amiodarone, which helps to calm his heart for now.

I grab a little sleep and see Richie the next morning. Dr. James and I talk to the CICU team about his case. There isn't a lot to do. The medicines are doing what they can. The defibrillator is ready to fire. After years of heart problems, Richie now has a baggy, floppy, weak heart with short circuiting that will only get worse. Richie's arrhythmia is due to the progressive, irreversible decline of his heart. There's no way to definitively fix it, at least not with the heart he has.

All we can do with medication is attempt to quiet things down; the goal, for now, is to buy time. Over the next three days, Richie has a few more VT episodes, more shocks, more bucklings and clutchings. Orthopedists come to look at Richie's shoulder, and fit him for a stabilizing sling so that he can move around in less pain. At the moment, he can just about drag his IV to and from the bathroom. He's considered stable right now, but that only means he's not about to die.

Because of his condition, Richie goes straight to the top of the transplant list. Since Richie has been followed by Dr. James as an outpatient, many of the required steps have been completed, which means we can expedite the rest of the process. Clearly, Richie can't leave the hospital. He can barely get out of bed. All we can do is wait and hope his name comes up soon as a potential recipient of a new heart.

The CICU team checks on Richie throughout the day, as does my group, the heart failure/heart transplant team. The CICU team keeps him alive and stable. My team is there to make sure he remains a good candidate when and if a heart is found. His father visits often too. Some of the nurses remember him from his own transplant. These days, Mr. Mann looks so healthy that his presence lends an irrational optimism to Richie's case.

During the wait, Richie's heart experiences a period of relative quiet. His mother and father wait with him, along with an uncle who also had a heart transplant—there's no denying Richie's genes. His brothers and friends are there around the clock. This was a moment they'd all known might come for the better part of Richie's adult life: the day when he might lie in a cardiac care unit waiting for someone else to die so that he can live. And that day is now.

As it turns out, Richie doesn't have to wait that long for a heart. He has two factors working in his favor: First, his rank is high (a dubious honor given his condition). Second, his blood type is AB positive, which means that Richie is a match with almost any other blood type.

When a member of the CICU team delivers the news to Richie that it looks as if a heart has been found, I'm down the hall with another patient. But when I walk past his room, I see a moment that speaks more than words: Just inside the sliding glass door, Richie's mother sits next to his bed, teary-eyed, holding his hand and stroking his forehead. Just outside of the room, Richie's father is talking to a visitor, outwardly calm, like a veteran whose son is heading off to war. The picture is indelible. It captures fear, hope, and even the difference between mothers and fathers.

A heart's journey can be a story in itself (albeit a fast one, since the donor heart can't be deprived of oxygen for too long). A heart can come from Hopkins's own ER, literally down the hall; or from the Baltimore City Detention Center; or from the scene of a motorcycle accident. There are countless macabre but medically fruitful situations.

Confidentiality is a factor too. Patients are not supposed to know where the heart comes from, or how the donor died. Although patients might be appreciative, they generally can't go find the donor's family and thank them. There's little upside to making a connection between recipient and donor. The doctors may know, but, if so, they keep it to themselves. We try to view the donor as an extension of the organ, and not so much as a person. Otherwise, the emotional and psychological subtleties can be a lot to deal with.

Now that the heart is on its way, medical activity surrounds Richie. Blood is drawn and sent for analysis. Anesthesiologists check him out and explain what they'll be doing. The cardiac surgery and cardiac ICU teams come in. Med students and residents come and go. For the next three hours, while all the prep proceeds, we're aware that the whole event could be called off at any moment, for any number of reasons. New medical information about the donor may come to light; the organ-procuring team may encounter issues with removal; the weather may interfere with the procurement team's ability to travel between the organ site and the hospital; the patient may deteriorate too much, too fast.

The transplant is scheduled for Richie's sixth day in the CICU. An imposing, grown man who, because of his heart condition, has had to live with his parents and cannot get or hold a regular job is about to receive a new heart. This operation could change his life forever, if he survives it.

That afternoon, after all the protocols are met, Richie is wheeled into surgery. The operation will take almost five hours. Whenever I walk past the waiting room, I see his family pacing, drinking coffee, and quietly trying to reassure one another. But for most of that five-hour stretch, I'm in the operating room theater, watching as a team of surgeons performs a riveting—albeit slightly gruesome—ballet. Each surgeon has a highly specific job, and all of their steps are orchestrated precisely. They open Richie up, saw his sternum down the middle, and spread the rib cage to either side. Then Richie is put on a cardiopulmonary bypass machine, which allows his major arteries and veins to be cannulated (insertion of tubes to divert blood flow), and subsequently drained completely. His blood now runs through the bypass machine, allowing this car-size contraption to act as his heart and lungs during the operation. The size of this machine is its own testament to the power of the human heart. It astounds me that we are born with a fist-size muscle that requires a device that large to stand in for it.

Once Richie is connected to the bypass machine, his own heart is removed. It's a dramatic, frankly solemn, sight. For heart doctors, it is an unforgettable visual justification of all that we do. I spend a moment taking it in.

Next, the donor heart is formally implanted; all the veins and arteries are sewn together, after which they're checked and double-checked by team members. And then, carefully, gingerly, the surgeons detach Richie from the bypass machine. When they make that switch, his new heart is supposed to take over. His blood is supposed to start being pushed through his body, but by someone else's heart. If the heart doesn't start immediately, the only possible recourse is to jolt it electrically. But you can't put the old heart back in. The new heart has to work. Everyone—no matter how many times they've seen it or done it—holds their breath.

With all eyes fixated on the new heart, we wait. There's no switch to turn it on. At this point, we're relying on biology and nature, on the heart's ability to recognize connections and to decide that it's going to start beating again…if it's going to. It beats once. That single thump is miraculous to me and, I think, to everyone in that room, no exceptions. My naïve, inexperienced expectation is that the donor heart will now start beating regularly immediately. No. It has to work its way there. After the first beat, there's at least a ten-second pause, which can feel like ten minutes. And then, eventually, a second beat. Slowly, steadily, over the next thirty seconds, the beats become more frequent, more organized, more forceful, more reliable. After what seems like an eternity, this new heart is beating regularly. It has decided to start working again, this time in an entirely different body.

That evening, nearly six hours later, Richie lies in the cardiac surgery ICU. This is a postsurgical ICU, so it's run by the surgeons, and it's all about monitoring the recovery after the physical trauma of having your chest cracked and your heart patched, bypassed, or replaced. Richie has an endotracheal tube down his throat, which, along with all the IVs and monitors around him, gives him a strangely mechanical look. He's still full of anesthetics, and he will likely need a machine to help him breathe for another twenty-four hours, during which time the anesthesiologists will guide him from deep sleep to full consciousness. His family looks in on him, and their relief and anxiety are palpable. You made it, their expressions seem to say. Now wake up, please wake up.

When Richie finally opens his eyes, the breathing tube prevents him from talking. He has a zipper scar up the middle of his torso, a bit longer than a typical bypass scar, and he has drains coming out of him to get rid of any excess fluids and/or detect bleeding. But now he could easily be mistaken for any other patient with a serious heart issue, not the borderline marvel that he is. But unlike other heart patients, he didn't come to Hopkins for a pacemaker implant or a valve replacement or bypass surgery. He came for a new heart, one of only a handful per year. Ten days ago, Richie was barely alive. And now he's in the process of recovering with somebody else's heart. In medical parlance, pretty f—ing amazing.

A few days later, after being freed from the breathing machine and now fully awake, Richie is moved out of the cardiac surgery ICU to Nelson 6, the cardiac surgery general ward. I see him every day, usually twice, on my rounds. His father, the transplant vet, visits him daily, as does his mother. As the days go by, I see Richie's brothers and friends less and less—a sure sign that their confidence in his survival is rising.

One day, his brother catches me in the hall and asks how I think Richie is doing. It's an interesting question. Richie has been battered, beaten, and sliced open, and he's trying to get used to an alien organ. But his condition is nothing short of amazing compared to what might have happened with no transplant—in which case, he'd likely have died in days or weeks. The period of greatest danger is up to and through surgery and immediately following. Some patients don't get off the operating table, but Richie did. Days, weeks, and months later, the outlook becomes measurably better. I give his brother the standard medical answer: “Under the circumstances, just as we would hope at this point.”