Extreme Medicine (9 page)

That radiation, passing with ease through soft tissue, attenuated by denser bone and metal fragments, falling finally upon a fluorescent plate, revealed a bullet in the region of the heart's left ventricle. It was moving synchronously with the heartbeat in a disturbing whirling motion. The bullet appeared to be lodged in the wall of the soldier's heart, its waist apparently plugging the muscle of the left ventricle, its tip inside the ventricle, wriggling with the flow of blood.

Grey Turner considered his options. If the bullet migrated farther, it could lead to an embolus, showering fragments of clotted blood or infected material into the soldier's circulation and blocking distant arteries, with unpredictable consequences. Or perhaps its dislodgement might lead to rapid and fatal hemorrhage. Even if it were to remain stable in situ, the presence of the bullet would surely be a source of disastrous infection. In Grey Turner's eyes, there was little option but to intervene surgically.

The operation proceeded under a primitive anesthetic cocktail of alcohol, chloroform, and ether. Grey Turner made his first incision, shaped like a letter C the size of a man's palm, in the skin on the left side of the soldier's chest. Through this he removed the soldier's sixth rib and then divided the three ribs above it, allowing him to open the chest wall outward like the rear cover of a book. He retracted the lungs, gently pulling them out of the way, and finally gained access to the injured heart. There he carefully opened the pericardium.

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T
HE BEATING HEART DOES NOT SIMPLY
expand and contract. To witness it in life is to understand surgeons' traditional reluctance to interfere. There is an element of torsion in the way that it moves—waves spreading across its muscle from base to apex. Even in health, its cadence constantly changes, accelerating and slowing periodically but with a clear, intrinsic, and vital rhythm. It exhibits a physical dynamism like no other organ in the human body, and thus it is inescapably the engine of life, even as it lies on the table before you.

There is anatomical complexity too: Tributary veins flow into the vena cava, the last great vessel of the returning circulation. The point of entry, the atrium of the right side of the heart, is but the first of four chambers. The second, separated from it by a fibrous three-leafed valve, is the right ventricle, thicker walled than the atrium above, able to provide a volume of blood with enough energy to send it through the pulmonary artery, its pulmonary valve, and out to circulate through the blood vessels of the lungs.

That outflow divides and fragments into a plethora of smaller and smaller vessels, until finally they form the many millions of fine capillaries, vessels sometimes smaller in diameter than the red blood cells that must traverse them.

Here those red blood cells, the all-essential vehicles of oxygen delivery, must distort as they squeeze through the capillaries, snaking around the alveolar air sacs, grabbing oxygen and giving up carbon dioxide as they go.

Then there's the return journey. Capillaries become venules, venules become veins until they merge to comprise the pulmonary vein, returning the circulating blood once more to the heart. Here a third chamber, the left atrium, receives blood from the pulmonary vein, freshly laden with oxygen from its voyage through the lungs.

The left atrium provides just enough impetus to push the blood through a valve shaped like a bishop's miter—the mitral valve—whereupon it enters a fourth and final chamber: the left ventricle. This structure, with its muscular wall, must develop enough force to accelerate the blood of a single heartbeat out through the aorta and past the aortic valve to circulate throughout the body.

Through this network of vessels, into these chambers, over these surfaces, blood must flow endlessly, never faltering, never forming eddies or clotting, from moment to moment across the entire span of a human life. And in 1917, somewhere in this complex mass of mobile, twisting tissue lies a bullet that Major George Grey Turner must find.

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G
REY
T
URNER BEGINS HIS SEARCH.
He finds a scar covering an entry wound in the wall of the left ventricle. There is no doubt that the bullet lies within. He carefully cups the heart in his hands, trying to feel for the missile. The heart, he notes, develops the hardness of a stone while contracting, making it impossible to feel anything within. In the cycle of each heartbeat he has less than a second when the muscle is relaxed enough for him to locate the bullet. But even this proves impossible; the bullet is too deeply seated. Instead, he punctures the heart carefully but repeatedly in the area around the scar, remarking upon how solid its substance feels and noting that these needle wounds bleed but stop quickly of their own accord. In his written record of the operation, Grey Turner narrates his exploration like a mountaineer describing a new route. These are discoveries, territories uncharted. But the bullet remains elusive.

Unwilling to give up, Grey Turner pares the rib stumps back to give himself more room. He rotates the heart to examine its posterior aspect, whereupon—to his horror—it stops. Grey Turner massages the now flaccid heart, squeezing it in his hands, hoping in some way to resuscitate it back to life. He rotates it back to its proper position, continuing to squeeze it in his hands, and finally it begins to beat again. But the bullet is still nowhere to be found.

After an hour and a half of searching in vain, Grey Turner decides to fall back upon the most fundamental of the general principles in surgery:
primum non nocere,
“first, do no harm.” To any practitioner of medicine, knowing when to stop is at least as important as having the courage to proceed. Admitting defeat, he withdraws and closes the chest, leaving the bullet lodged in the officer's beating heart.

Grey Turner's instincts to withdraw were correct. The projectile was left in place, and the patient duly recovered from his surgery. In fact, the soldier in question recovered fully and was even sought out and found by Grey Turner twenty-three years after that abortive operation, in 1940, alive and well. His only complaint was of occasional fatigue, but that, Grey Turner explained, the patient had attributed to his exertions in “the current war.”

—

G
REY
T
URNER
was not the only surgeon of the Great War to attempt cardiac surgery. Elsewhere there were reports of surgeries to remove missiles from hearts—some successful—but these were few and far between and not enough to convince the wider surgical fraternity that the heart could be reliably interfered with. The received wisdom of the time stood. The heart was perceived as all but inoperable.

But World War II saw the further mechanization of combat; the practice of war became still more efficient, and the specter of wounded hearts returned. Shell fragments and bullets found their way into chests in greater numbers, and casualties with wounded hearts once more began to arrive at military hospitals.

Dwight Harken had visited London as a civilian and had worked alongside the renowned British surgeon Arthur Tudor Edwards. In 1942, Harken returned as a thirty-three-year-old U.S. Army captain and an aspiring thoracic surgeon, assigned to a post in Brigadier General Paul Hawley's office in Grosvenor Square, tasked with assisting the U.S. Army in organizing and coordinating medical logistics.

Harken hailed from the small town of Osceola in Iowa. Graduating near the top of his class, he won the opportunity to attend Harvard Medical School. Harken remained at Harvard as a graduate, spending part of his surgical residency in Boston and later New York before winning a grant from the New York Academy of Medicine to develop his interests abroad in a location and specialty of his choosing. Ambitious but not wishing to compete with the likes of Allen Whipple, Edward Delos Churchill, and Elliott Carr Cutler—titans of general surgery—Harken decided to take a gamble and specialize in the newly emerging field of thoracic surgery. This was a bold move in an era that valued the gifted generalist more highly than the narrowly skilled specialist. Nevertheless, Harken chose to travel to England and take up a visiting fellow's post at the Royal Brompton Hospital with Arthur Tudor Edwards.

Tudor Edwards was one of the few thoracic surgeons, if not the only one, in the world at the time of Harken's secondment. His caseload was principally concerned with the treatment of tuberculosis. Assisting in the operating room, Harken marveled at Tudor Edwards's skills as a technician, watching keenly as he carefully explored the contents of his patients' chests and pared back tuberculous tumors, liberating blood vessels and elements of the branching bronchial tree from their encasement.

Yet Harken couldn't help but wonder why, when confronted with the diseased heart, which was in his eyes a mechanical entity, Tudor Edwards and his colleagues remained reluctant to operate, despite the pioneering work of Grey Turner's generation. So when the outbreak of the Second World War interrupted his apprenticeship with Tudor Edwards, Harken returned to Boston to begin his own experimentation.

—

B
ACTERIAL ENDOCARDITIS, AN INFECTION
of the inner surfaces of the heart and its valves, was an almost invariably fatal affliction in Harken's time. In the absence of antibiotic therapy, the bacterial infection would disintegrate the heart's internal structures. Worse, the pumping action of the heart would seed infection and emboli throughout the body. Harken sought to combat this formidable enemy. In theory, surgical removal of the focus of infection would arrest the process and give the afflicted patient the opportunity to survive. But at a time when the world remained reluctant to enter the cavities of the heart, Harken's hypothesis needed the support of hard evidence before he could attempt it in human patients.

He began by working on dogs. He operated on canine hearts and attached metal clips to the surface of their mitral valves. He found that this intrusion always led to infection and the onset of bacterial endocarditis. This approach provided a model of the disease he sought to treat, allowing him to simulate naturally occurring bacterial endocarditis in dogs, and it also gave Harken confidence that the cavities of the living, beating mammalian heart could be entered and repaired without immediate fatality.

However, Harken's work was once again interrupted by the events of war, as he was returned to England in 1943 and posted at Grosvenor Square under the command of General Paul R. Hawley, chief surgeon in the European theater of war. Here, anticipating a flood of casualties with penetrating chest wounds, he and Tudor Edwards campaigned successfully for the establishment of specialist thoracic units.

In the first half of 1944, presumably in preparation for the imminent Allied invasion of Europe, several specialist thoracic units were set up throughout England. In May 1944, Dwight Harken was released from his office post in Grosvenor Square and, to his delight, made director of the 15th Thoracic Center at the 160th U.S. General Hospital in Cirencester—a thousand-bed facility complete with a nearby runway to receive casualties from the battlefront. For Harken, this was a happy release from the burden of his administrative role at Grosvenor Square, letting him return to the operating room and resume his passion for surgery.

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T
HE
U
.
S
.
A
RMY HOSPITAL WAS BUILT
on the grounds of Stowell Park in Northleach, England. It amounted to little more than a cluster of corrugated-steel Nissen huts housing patient wards and surgical teams.

The month of May 1944 failed to provide much in the way of casualties to occupy Harken and his team. He spent the time productively nevertheless, preparing and training his clinical staff in the new art of thoracic surgery.

They would not have long to wait to put theory into full practice; June 6, 1944—D-Day—was suddenly upon them. The hospital received a tidal wave of casualties, delivered by air from the European theater, first from the invasion and then a later surge after the Battle of the Bulge. Confronted by casualties arriving with missiles lodged in their hearts, Harken consulted George Grey Turner for guidance on whether or not to attempt their removal. Grey Turner gave Harken his blessing, stating that there were many good clinical reasons to remove such foreign bodies but that the neuroses that might result from a patient's knowledge that he “harbors an unwelcome visitor in one of the citadels of his well-being” might give cause enough. The challenge that Harken had so meticulously prepared for had finally arrived.

—

O
NE OF
H
ARKEN'S GREAT SKILLS LAY
in understanding that the technical ability of the surgeon had to be matched with an equally capable operating team. These surgeries, particularly those involving foreign bodies in the cavities of the heart, often demanded considerable intraoperative resuscitation. While Harken navigated his way through the anatomy, his anesthetist would be responsible for actively resuscitating the patient: providing massive transfusions and balancing efficient pain relief against the hazards of bleeding out, hypothermia, and shock. For the anesthetist in these cases, it was like flying a plane on fire, hoping to hold it in the air long enough for the surgeon to be able to douse the flames.

Rates of blood loss of up to a quart and a half per minute were recorded, a torrent that could empty the patient's heart and blood vessels and precipitate cardiac arrest in a matter of seconds. That phenomenon—shock caused by hemorrhage—came to be better understood later in the century as the compromise of the heart and circulation by rapid blood loss and the consequent failure to meet the metabolic demands of the body's vital organs. Left unabated, this process leads inexorably to death, and though the physiology of shock and its consequences hadn't been fully grasped by the time World War II arrived, Harken's team had intuitively come to understand the great value of massive whole blood transfusion in keeping patients alive.