Heart: An American Medical Odyssey (12 page)

After checking out of the hospital, I issued a press release on July 9 indicating that I planned to attend the Republican National Convention in New Orleans in August. I made it clear that my recent stay in the hospital would not alter my political plans. The heart attack did not force me to make a single major change in my professional schedule, but it did require me to back out of a wilderness pack trip with Jim Baker. We had planned it for July while the Democrats were holding their national convention, but given my health situation, I couldn’t justify a weeklong horseback trip into the Yellowstone backcountry. (When I told Jim I couldn’t make it, he quickly found a replacement: George H. W. Bush.) I returned to work in the House of Representatives on July 22.

After further tests showed there clearly had been some progression in my coronary artery disease, Dr. Ross raised with me the possibility of undergoing bypass surgery. He didn’t present it as necessary to save my life, but thought it was advisable because of my lifestyle. I noticed I was having some difficulty traveling through airports carrying luggage. I found it necessary to stop and rest occasionally. I clearly lacked the stamina I’d once had. Having open heart surgery wasn’t something I looked forward to, but if I wanted to continue my career in the Congress and continue my skiing and pack trips in Wyoming and all of the other activities I loved, it was necessary.

My confidence in the outcome grew when I learned that Dr. Ben Aaron, the surgeon who had saved President Reagan’s life in March 1981, would perform the operation. On August 9 I announced that I would undergo bypass on August 19, after the GOP convention. “While for me the bypass surgery is optional,” the statement said, “I have decided to do it now so that in the future, I can lead the same kind of active life I have in the past.”

My August 9 statement also noted that my dad had just undergone coronary bypass surgery in our hometown of Casper. Since my first heart attack ten years before, I had been asked frequently if there was any history of heart disease in my family. I always answered that Mom’s dad had died of a heart attack at age sixty-six, but that as far as we knew, there was no history of heart disease on Dad’s side of the family. Dad never talked about his health, and as far as I knew, he had rarely if ever seen a doctor since he had been discharged from the Navy at the end of World War II.

In early August 1988, Mom had finally persuaded him that he needed to have a doctor take a look at him, so he made an appointment. During that appointment, the doctor discovered that his condition was so serious that they took him directly into surgery and performed a six-way bypass on him. When they opened him up, they found he also had a large aneurysm in his aorta and evidence that he had experienced two previous heart attacks that he never told anyone about. The doctors didn’t believe he would survive the bypass and aneurysm repair if they did both at the same time, so they completed the bypass and sent him home to recover for eight weeks, then brought him back in to repair his aorta. He lived another ten years. Now I knew I had a history of heart disease on both sides of my family.

In Wyoming, I had primary opposition for the GOP nomination for Congress but won comfortably with 87 percent of the vote. That same day, I convened a meeting of the Convention Rules Committee and successfully passed the rules change that would allow all Republican members of Congress to have floor access at national conventions. Since George Bush had already sewn up the GOP nomination for
president, the only excitement focused on his choice of Senator Dan Quayle for vice president.

For me, one of the most memorable moments of the convention was the private talk I had with Larry King, then a correspondent for CNN. Larry and I sat on the steps going up to the CNN broadcast booth during one of the regular convention sessions and talked about my scheduled coronary bypass surgery. Larry had recently undergone a similar procedure, and I had a lot of questions. He walked me through his experience and was very helpful.

On Wednesday night of the convention, George Bush was officially nominated for president. The following day, I flew back to Washington and checked into George Washington University Hospital. That evening, George Bush gave his acceptance speech and delivered the memorable line: “Read my lips, no new taxes.” What was memorable for me was that I watched his speech flat on my back in a hospital bed while a male nurse shaved the hair off my body to prep me for surgery the next morning.

Since this was my first open heart surgery, I was introduced to a number of technologies and procedures I had never before experienced. I was told at the outset that the anesthesia would have the effect over time of diminishing my memory of the operation. That was probably true, but I still have a recollection of certain aspects of the procedure twenty-five years later. I have a memory of being aware during part of the operation of what was going on around me. When I asked, the doctors explained they really had no idea what goes on inside an unconscious patient’s brain.

This was also my first experience with being on a respirator. When I came out from under the anesthetic, I discovered I was breathing with the aid of a machine that had been inserted into my throat, and I couldn’t speak. The discomfort I felt was more psychological than it was physical. I felt the same way about the catheter that had been placed in my bladder. The idea of being dependent on these devices bothered me.

On the second day of my recovery, my chest and back felt as if I’d been hit by a truck. Obviously the anesthetic had worn off by then,
and I was feeling the effects of having my chest opened wide and my rib cage separated to get at my heart. For two or three days, it was very hard to find a comfortable position in the bed. In my subsequent open heart surgeries I didn’t experience that kind of discomfort, no doubt in part because there have been significant improvements in pain management. Other things have changed too. Lynne had purchased a CD player for me that allowed me to listen to music through a pair of earphones. In 1988 it played only one CD at a time.

After I checked out of the hospital on August 26, I spent several weeks getting my strength back. I had time to reflect on the fact that my dad and I both had bypass surgery within a few weeks of each other. He was seventy-three and I was forty-seven.

In October I returned to Wyoming in time to do some campaigning and easily won reelection with 67 percent of the vote. On December 5, my Republican colleagues unanimously elected me House GOP whip.

Four months after my surgery, I was skiing at Vail and Beaver Creek in Colorado, something I could never have done without the bypass.

An assignment to Dr. Robert Wallace’s service was a lucky break for me as a third-year medical student: I had the opportunity to learn from a famous heart surgeon and decide once and for all if surgery was for me.

Dr. Wallace had come to Georgetown from the Mayo Clinic where he had trained under the legendary John Kirklin, one of the pioneers of cardiac surgery. In 1968, Wallace became the first surgeon in the United States to perform the Rastelli procedure to correct transposition of the great arteries, a devastating congenital heart defect, where the aorta and pulmonary arteries arise from the wrong chambers of the heart. Dr. Wallace was old school, and rounds began in the ICU way before sunrise and moved forward at a rapid pace before concluding in time for the first OR case of the day. There was talk that he didn’t approve
of students or residents with facial hair, a perhaps apocryphal story recounting a patient’s fatal infection and the beard Wallace had allowed the patient to keep at the time of his operation. On rounds the day before, I thought I saw Wallace take note of my well-groomed whiskers, the last vestige of my college years.

“Don’t worry about it,” one of the residents said.

Not reassured and not taking any chances, I wore a surgical hood for my first case, a kind of OR trapper’s hat replete with ear flaps. Now with my mask in place and revealing less of my face than a typical mummy, I tried to make myself invisible as Wallace entered the operating room. After donning his gown and gloves and moving quickly to the table, ignoring a series of “Good morning, Dr. Wallace” salutations, the chief leaned toward me, his head lamp and loupes (magnifying OR lenses) inches from my head, and fumed, “Step away from the table and cover your face! There’s no place for a beard if you want to be a surgeon.”

An inauspicious beginning.

•  •  •

The British often refer to an operating room as an operating theater. It is part anachronistic description of the old tiered galleries from which young physicians once observed surgical procedures and part apt depiction of a highly choreographed space in which only dramas are staged.

You enter the cardiac OR through a door adjacent to a deep, stainless-steel sink and notice the discarded antiseptic scrub brushes littering the base. When you push through the door, you immediately notice that the room is very bright, and very cold, and filled with a lot of people. At the head of the table, separated from the surgical field by a sterile drape suspended between two poles, is the anesthesiologist who has inserted an endotracheal tube, which protrudes from the patient’s mouth like a fat transparent cigar. The tube is mated via lengthy corrugated hose to a large machine that provides a mixture of vaporized anesthesia, nitrous oxide, and oxygen, keeping the patient asleep and ventilated.
You gingerly slide next to the anesthesiologist, moving into the small space amid an organized jumble of IV tubing, pressure lines, and a rolling forest of infusion pumps. From this vantage point, the patient’s only visible body part is his head, and you watch as the anesthesiologist slips a transesophageal echo probe into the patient’s mouth. Unlike the endotracheal tube positioned in the airway, this much longer ultrasound transducer is destined for the esophagus, which lies behind the heart; it provides inside-out surveillance of cardiac function during the operation.

At the table you count four gowned participants. A surgeon’s assistant beside one leg has inserted an endoscope under the skin and is working to remove an eighteen-inch-long segment of vein through a one-inch incision below the knee, a bit of magic that eliminates the long scars and swollen legs common to bypass surgery patients a decade ago. A scrub nurse positioned near the waist presides over a broad back table filled with a gleaming menagerie of elegant stainless-steel instruments. Across the room, the perfusionist sits behind the heart-lung machine, its pump temporarily idle. You step onto a small platform and peer over the screen to watch the surgeon and first assistant open the chest with a sternal saw, a pneumatic-powered tool with a jagged reciprocating blade that slices effortlessly through the hard breastbone with a loud and angry growl, reminding you more of wood shop than science lab. An adjustable metal retractor is then wiggled into the breach and the chest is winched open revealing the beating heart still shrouded in its translucent pericardial sac.

•  •  •

In 1896, the English surgeon Stephen Paget published a textbook of thoracic surgery and began the chapter titled “Wounds of the Heart” with the following passage:

Surgery of the heart has probably reached the limits set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart.

Paget’s assessment reflects a view universally held by surgeons of his day.
Thirty years earlier, during the American Civil War, there were sixty thousand limb amputations but not a single repair of a wound to the heart. From the time of Hippocrates, until the eve of the twentieth century, the heart was thought untouchable.

In September 1896, the same year that Paget’s textbook was published, a twenty-two-year-old gardener was taken to the State Hospital in Frankfurt, Germany, after being stabbed over the heart. Two days after admission, the patient’s condition deteriorated, prompting an evaluation by Dr. Ludwig Rehn, a prominent surgeon, who diagnosed a rapidly increasing hemothorax (collection of blood in the chest). To determine what was bleeding, Rehn opened the patient’s chest and, ominously, found blood exiting from a tear in the pericardial sac. He then took the unusual step of opening the pericardium. As cardiac surgery was thought to be undoable and even an attempt unethical, there was usually little reason to enter the protective fibrous shell that encases the heart. Rehn later noted,
“The sight of the heart beating in the opened pericardial sac was extraordinary.” A 1.5 centimeter gash in the right ventricle was clearly visible, dark blood pouring from the wound with every cardiac contraction. Knowing that his patient was going to bleed to death, Rehn attempted to close the hole, explaining in his report, “Though one would have liked to have had time to carefully consider the problem, it demanded an immediate solution.” Timing his movements to the end of diastole, when the heart rises and briefly pauses after it fills with blood, Rehn succeeded in placing three silk sutures through the right ventricular wall, completely sealing the wound. The patient survived his ordeal after a lengthy hospitalization, becoming the first recipient of successful cardiac surgery.

In a review of Rehn’s landmark operation and the cases that followed, published in 1902 in the
Boston Medical and Surgical Journal
(the forerunner to the
New England Journal of Medicine
), Dr. Harry Sherman wrote:

The road to the heart is only 2 or 3 cm in a direct line, but it has taken surgery nearly 2,400 years to travel it . . . During most of this time surgery stood still.

In the years that followed Ludwig Rehn’s taboo-breaking first cardiac operation, surgeons around the world became increasingly intrepid, frequently without success, in their attempts to repair a heart stricken with a congenital or acquired malady. All were hindered by a common problem: how do you keep a patient alive while you work on his or her heart?

Early in 1931, Dr. John Heysham Gibbon, a twenty-seven-year-old surgical research fellow at Harvard, watched as a middle-aged woman recovering from gallbladder surgery lost consciousness and died from a massive pulmonary embolus. He later wrote: