Authors: James Forrester
The Heart Healers (14 page)
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A FEW WEEKS
after my last conversation with Sam, Maria and her mother appeared in the lobby of my office. She was small for a twelve-year-old. In a new flowered dress, brown skin, and black hair, she was endearing. A small silver cross dangled from a silver chain around her neck. Eyes downcast, she stood very close to her mother.
A few minutes later in the examining room, Maria still did not look at me directly. I paused to see my examining room as she saw it: narrow, white walls without windows; its only decoration a blood pressure manometer mounted on the wall. Two inexpensive chairs, a small metal desk, and an odd three-piece examining table completed the space in which there was no locus of warmth, comfort, or safety. The examining table was so high she would have to use a stool to reach it.
I got another chair for her mother, and asked both of them to sit close to me in a small circle. I rested my hand on her mother’s arm and told her I would like to look at her hands. Then I did the same with Maria, gently opening her closed little fist. Her fingernails had the dusky blue color of tetralogy. Next I told her mother I would like to listen to her heart. I positioned my stethoscope over the mother’s heart and listened. Then, with the stethoscope still over her mother’s heart, I motioned for Maria to listen to her mom’s heartbeat. Her face lit up and she smiled. Young cardiologists sometimes argue that you don’t need a stethoscope anymore because you get everything you need to know from the ECG and echo. What’s more, the information is far more accurate. But they overlook a critical point: the stethoscope is a metaphor for caring communication, a symbol of the connection between me and my vulnerable patient.
Before having her climb on the examining table, I did a quick sleight-of-hand trick I had done with kids around the world, asking which hand held an object. Kids always choose the wrong hand, and Maria did, too. A smile. I did the trick again. She chose the other hand, and was right. A big smile of triumph. Now she could look at me. I saw that although Maria had been shy, she did not seem fearful. Maria had already passed through that stage. She had accepted that in this hospital her life lay in the balance. So what I saw was hope. Immense bravery speaking to me from the brown eyes of a frail little girl standing alone in a joyless room, a foreign land, trusting her life to strangers she could barely understand. She touched her cross as I boosted her onto the examining table.
On the exam table, I could feel the outward heaving movement of her hypertrophied right ventricle. She had the typical heart murmurs associated with tetralogy. Alfredo came in. He focused on the chest wall, listened to her heart, and carefully checked the pulses of the vessels to be used during the heart-lung bypass. Imaging of Maria’s heart showed no additional congenital abnormalities. Dr. Larry Czer, a member of my cardiology staff who specialized in all of Alfredo’s pre- and postoperative care, gave the green light for her open heart surgery. Maria’s impossible dream was about to begin.
I slipped in and out of the operating room on the day of surgery. Maria’s tiny body was enveloped in a cocoon of four surgeons and an anesthesiologist, backed by what seemed like a second layer of heart-lung machine technicians and scrub nurses. At Alfredo’s command, Maria’s heart was stopped, and she was “on bypass,” her life held in the balance by the heart-lung machine. Alfredo cut open Maria’s heart, entering it through the right atrium, so that he could preserve the pulmonary valve and avoid damaging the right ventricle. He easily closed the ventricular septal defect with a patch. Next he turned his attention to the narrowed pulmonary valve. He enlarged the valve’s area. Finally he made sure that all blood from the left ventricle would be pumped only into her aorta. The whole procedure took a couple of hours. At the end of the procedure, with the heart-lung machine now turned off and Maria’s own heart beating again, Alfredo used echocardiography to check on his repair. The echo showed excellent pulmonary valve function. The pressure in the right ventricle had already fallen dramatically, the two cardinal signs that his fix was going to work.
With Alfredo still in the operating suite, I went to the family waiting area to give her mother the news. She crossed herself as I approached, looking for some sign of good or bad news. Twenty feet away, I gave the universal two thumbs-up sign. Her eyes grew temporarily glassy, but she didn’t cry.
On the day following surgery, Maria already looked much healthier. Her blue lips were now pink. Although it is difficult to listen for murmurs immediately after surgery, I heard no murmur of pulmonary insufficiency (backflow across the pulmonary valve). This was the most common complication of tetralogy surgery, created if the surgeon overshoots the mark in correcting the pulmonary valve stenosis. Late on post-op day one, Maria could sit up in bed. The next day she sat in a chair. Soon she walked to the window of her room. In the second post-op week she was ready for discharge.
A few months later I received a letter postmarked El Salvador. It was very neatly written in Spanish.
Dear Dr. Forrester,
Thank you for your kindness and understanding in helping me with the surgery by Dr. Trento. I know that saved my life because I feel strong and healthy now. May God bless you and your family.
Sincerely,
Maria de Silva.
Over the years I lost touch with Sam Bachner. Halfway through writing this book, I called Sam’s office to ask if he knew anything about that twelve-year-old child from a decade and a half ago. His secretary set up an appointment for me to call him back.
When I called back a couple of days later, we reminisced for a few minutes.
Then Sam said, “Would you like to talk to Maria?”
Baffled, I wondered if Sam had lost a little over the years. We were both getting older. After a long embarrassed pause, I said, “In El Salvador?”
“No, right now. She’s here with me.”
The voice of a young woman floated up softly from my speaker phone. “Hello, Dr. Forrester, it’s Maria.” Accustomed as I am to speechifying, for several moments I found myself without words. Staring at the phone in disbelief. Dumbfounded. Sensing my confusion, her voice filled the uncomfortable void, “I want thank you again for your kindness so many years ago.”
Her words recalled a child’s letter from years ago, buried emotions now almost two decades old. As that poignant moment passed, I pictured devilish Sam Bachner beaming at the profoundly moving surprise he had dropped in the lap of his old friend. It was time for me to have Maria to tell me the Rest of her Story.
“After the surgery, it took a while for me to recover my strength, so I stayed with my mom at Mr. Bachner’s house. But of course after a few months I had to return to my country. When I got home, I felt strong for the first time ever in my life. So I focused on my schoolwork. I was a really good student, good enough to go to college. I graduated with a degree in business.”
I beamed as I replied, “I feel just like a proud parent. What a wonderful story.”
“But it’s not the end of my story, Dr. Forrester. After college, I married my sweetheart, and now we have two children.”
“Two kids … how lucky can I be to have called just when you came back to LA for a vacation. That’s a pretty crazy coincidence,” I said.
“Well, not exactly. I came back to be with my mom … it’s pretty amazing, but she still works for Mr. Bachner. It’s been twenty-three years now.”
“Sam’s a mighty fine boss,” I offered.
“He sure is. I am one of his business managers.”
I slapped my forehead. “You’re kidding” was all I could say. All I could think was thank goodness I was sitting down when I called Sam. My most astonishing phone call ever lasted a quite a while longer as the three of us chatted until finally it was time to say warm good-byes.
When I hung up I leaned back in my chair, closed my eyes, and mused how one life saved created two new ones. I recalled a phrase I had spoken at my mentor’s eulogy: “A teacher affects eternity; he never knows where his influence ends.” I saw that Maria’s life reflected that idea. She was saved by the intuition of Dwight Harken, the inventiveness of Walt Lillehei, and the persistence of John Gibbon years before Alfredo Trento’s magical cardiac reconstruction. And, of course, by her own Don Quixote, Sam Bachner. So different in pedigree, personality, and era, these men shared a uniquely American trait: each had dreamed an Impossible Dream.
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TODAY CHILDREN DESTINED
to die from a cardiac malformation often have a diagnosis made by echocardiography and have surgical correction while they are still neonates. Given the river of blood with which cardiac surgery began, the mortality rate for congenital heart surgery is now astonishingly low. It has plummeted from 50% in Walt Lillehei’s early years to about 2% today. In major centers, the mortality rate for the simplest heart defects is 0%.
John Gibbon’s invention had created an outcome far beyond the most fevered imagination of Aristotle, or even Billroth, and Paget, the surgeons who proclaimed the heart was off-limits. Mankind had replaced the function of the heart and lungs given him by nature with a machine so powerful that cardiovascular medicine emerged from its Dark Ages, poised for its own industrial revolution.
In the event of my Demise when my heart can beat no more, I Hope I Die For A Principle or A Belief that I have Lived 4.
—TUPAK SHAKUR, AMERICAN RAP SINGER AND POET
THE SUCCESS OF
cardiac surgery brought three devastating complications that often caused death on the table: ventricular fibrillation, complete heart block, and preoperative misdiagnosis. To advance cardiac surgery to the next level, we had to find a way to cope with these misadventures. But when we did, the solutions created an entirely unanticipated, electrifying spin-off: our first breakthrough in the treatment of CAD.
Cardiac surgery’s single most terrifying complication was the sudden onset of ventricular fibrillation, the devastating disorder of heart rhythm that caused Willie the Phillie’s sudden death. Ventricular fibrillation, which claimed many of Harken and Bailey’s early patients, is the heart’s electrical system’s descent into complete chaos. The simultaneous, synchronized forceful contraction of every ventricular muscle fiber is replaced by tiny wormlike writhing of the muscle fibers, with the result that there is absolutely no forward movement of blood. A person with no blood flow loses consciousness in about five seconds, and is irretrievably brain-dead in about four minutes.
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IN ENGLAND ON
March 17, 2012, in the forty-first minute of the first half, twenty-three-year-old world-class English center midfielder Fabrice Muamba heard his goalie yell for him to pull back to a more defensive position. Congo-born Muamba was a rising English soccer star. He had represented England on its under-21 team, had played briefly for the Arsenal, then moved to Birmingham City where fans voted him the Young Player of the Year. Sold to Bolton for $10 million, he was named as the
Bolton News
Player of the Season in 2010. At just age twenty-one Muamba had signed a new four-year contract. He was now a force on the Bolton Wanderers as they played a nationally televised match against the Tottenham Hotspur before a packed stadium of 30,000 fans in Tottenham. His goalie’s voice was the last one he heard that day. With no one near him, Muamba spun and fell face forward on the field. Initial derisive catcalls disappeared as the first players to reach him tried to roll him onto his back and waved frantically for help. Trainers and doctors from both clubs ran out. Someone started cardiac resuscitation. Within seconds, a defibrillator appeared at Muamba’s side. The drama escalated further when a fan pushed past guards and raced onto the field. The fan was consultant cardiologist Dr. Andrew Deaner. The stadium fell as silent as a grave as Deaner demanded to take over. Two defibrillator shocks were administered. Players from both teams wept privately; several knelt and prayed.
After six minutes of futile attempts to resuscitate Muamba on the pitch, he was lifted to a gurney and wheeled toward the emergency exit ramp. As he disappeared onto the ramp, every voice in the stadium chanted “Fa-BRICE Mu-AMBA.” At the end of the ramp the caterwauling wail of a departing ambulance announced another battle with heart disease. Dr. Deaner accompanied him to the ambulance. In the ambulance he insisted that Muamba be sped to his coronary care unit at the famed London Chest Hospital. Realizing it would be impossible for the teams to continue, referee Howard Webb canceled the game. Bolton’s next game, three days later, was also canceled.
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SUDDEN UNEXPECTED DEATH.
What can one do when faced with such a shocking event? One such moment occurred in 1947 as Cleveland’s endlessly innovative surgeon Dr. Claude Beck was operating on a fourteen-year-old boy with a severe congenital inward depression of the breastbone. The proper name of the condition is pectus excavatum, but medicine has nicknamed it “funnel chest.” The boy’s sternum squashed his heart against the vertebrae like a punching bag. After restoring the normal chest configuration, Beck began to close his surgical incision. Suddenly the boy’s pulse disappeared. In a single glance Beck knew he was looking at tragedy. The child’s heart was in ventricular fibrillation. Since the invention of anesthesia a century earlier, surgeons were intimately familiar with ventricular fibrillation, the leading cause of death on the operating table. In surgical suites throughout the world “v fib” meant the operation was finished. Ventricular fibrillation meant death. There was no way to bring the patient back to life.
But on that morning Claude Beck had a hunch. He had no painstaking prior research, no study design, no testable scientific hypothesis. He just had an intuition. He immediately began manually squeezing the teenager’s heart at sixty squeezes per minute to maintain his circulation. That would keep him alive, but for what purpose? Every person in his operating room, his hospital, his profession knew that no surgeon in the world could bring back the heartbeat during ventricular fibrillation. Nowhere but in Cleveland, Beck was thinking.
