Knocking on Heaven's Door: The Path to a Better Way of Death (13 page)

with a direct injection of potassium chloride, one of three drugs

conventionally used to execute convicts in the death chamber.

While a newly invented heart-lung machine (essentially a sophis-

ticated pump that ran the blood through coils of glass and plas-

tic tubing to an oxygenating aerator) did the work of the child’s

heart and lungs, Lillehei stitched up the hole between the cham-

bers. Then the child’s body was warmed in a trough filled with

warm water, and the heart was restarted with a single shock from

another new electrical device called a defibrillator. The luckiest

children went on to live long, normal lives.

Often, though, Lillehei’s surgical suturing damaged the tiny

hearts’ delicate nerves and conduction system so that they could

no longer maintain normal beats. In one particularly bad run

of surgical experimentation, seven in a row of Lillehei’s “blue

babies” died this way. Some of the families were too poor to pay

for a gravestone. Lillehei was desperate. He turned to a young

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inventor named Earl Bakken, who had recently cofounded with

his brother-in-law a small business called Medtronic to repair

electronic machines for the research labs of local hospitals,

including the University of Minnesota Medical School. Earl

Bakken had been fascinated with electricity since seeing the

movie
Frankenstein
when he was a child growing up poor in

rural Minnesota. In the early thirties, around the same time that

my naughty father was nearly blowing his fingers off in South

Africa with homemade bombs, Bakken was tinkering in his

family’s basement workshop in Minnesota, cobbling together a

functioning telephone system, a crude rotary mower, a robot

that smoked cigarettes, firecrackers he could set off by remote

control, and a rudimentary but nastily effective taser.

In January 1958, in a converted garage in Minneapolis heated

by a potbellied stove—six years after the Grass Physiological Stim-

ulator pulled R.A. back from the brink of death at Beth Israel Hos-

pital in Boston—Bakken cobbled together the world’s first fully

portable electronic pacemaker. The main components were an

off-the-shelf nine-volt rechargeable nickel-cadmium battery, two

dials, a red light that blinked on and off, and two simple transistors

that delivered a timed electrical pulse. Etched on newly invented

silicon wafers, the transistors were based on a blueprint for an

electronic metronome that Bakken found in
Popular Electronics
.

His pacemaker, a giant advance over the Grass Physiologic Stimu-

lator, was the love child of two postwar technological revolutions,

one in cardiac surgery and another in miniaturizing electronics.

The first patient to get Bakken’s Medtronic 5800 was a six-

year-old girl with a congenital heart defect who had just under-

gone open-heart surgery. It hung from her neck like a heavy,

old-fashioned press camera, with two wires inserted close to

her heart through her chest wall. The wires repeatedly cued her

heartbeat with a tiny electrical spark until it recovered enough

to resume beating on its own. Compared with the massive,

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katy butler

full-body shocks of the Stimulator, the Medtronic 5800 was a

breakthrough. But its wiring caused susceptibility to infection

where it entered the body. Like the Stimulator, it was still a

“bridge” technology—a clumsy device suitable mostly for help-

ing patients to climb over a period of temporary organ failure.

In the fall of 1958, at the Karolinska Institute just north of

Stockholm, an inventor named Rune Elmqvist and a surgeon

named Åke Senning took the next leap. After months of experi-

ments on dogs, the pair embedded a pacemaker and all of its

wiring completely inside the human body for the first time.

Their first patient was Arne Larsson, a desperately ill forty-

three-year-old owner of a Swedish marine electronics firm.

He’d been an avid ice-skater, golfer, and businessman until a

viral infection, perhaps hepatitis contracted from eating tainted

oysters, severely damaged his heart and liver. His heart kept

up a slow and irregular twenty-eight beats per minute, and he

fainted multiple times a day. His doctors thought his death was

imminent. After repeated entreaties from Larsson’s wife Else-

Marie, the doctor and the inventor set aside their canine experi-

ments long enough to try to save the man’s life, though they felt

the experiment was premature.

Elmqvist, the director of research for a budding Swedish elec-

tronics firm called Elema-Schönander, cleaned out a Kiwi shoe

polish tin and, using the tin as a mold, wedged in two small,

rechargeable nickel-cadmium batteries, miscellaneous wiring,

and two standard circuits etched on wafers of silicon. He filled

the tin with medical-grade epoxy resin. Once the resin hardened,

he pulled the contraption out of the tin. It looked like something

from a garage workshop: a small, translucent hockey puck filled

with coiled wires, a battery, and electronic odds and ends, trailing

two stainless steel wires encapsulated in polyethylene sleeves.

In one of the institute’s operating rooms, Senning opened Lars-

son’s chest and sewed the two wires along the outer surface of

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his heart. The puck-shaped generator was tucked into a pocket of

skin in Larsson’s abdomen. Larsson came out from surgery with

a normal heartbeat. About six hours later, acid from the battery

leaked into the casing and shorted out the pacemaker. Larsson

went back into surgery and was given another one, which lasted

a few weeks, only to be replaced by still another, this one longer

lasting. With little further ado, Arne Larsson went back to skiing,

playing golf, and running his electronics business.

The pace of medical lifesaving, meanwhile, was moving so

quickly on so many fronts simultaneously that it soon required

a new kind of hospital room: the intensive care unit (ICU). In

Kansas City, Kansas, in 1961, a Dr. Robert Potter took over an

open ward formerly used to nurse the county’s impoverished

elderly and set up eleven cubicles equipped with all the lat-

est machinery and electronic monitors. Staffed by nurses and

doctors fully trained in the lifesaving new practice of CPR, the

intensive care unit put all the new machines in one place.

Primitive respirators based on the design of vacuum clean-

ers used flexible plastic hoses to funnel blasts of air down the

throats and into the failing lungs of people temporarily too sick or

paralyzed to breathe on their own. The nation’s first “crash carts,”

manufactured in Potter’s father’s sheet metal shop, held all the

new equipment, all the better to rush it to the bedside. There

were endotracheal tubes to attach the new respirators to the

throats of patients; “ambu-bags” that doctors could inflate and

deflate by hand to temporarily deliver air; metal external defibril-

lator paddles to jolt the heart back to life; and a bed board to slip

under the body, providing the firm surface needed for an external

heart massage so vigorous that it often cracked ribs.

Patients poured in. In 1969 in Miami, a man who’d dropped

dead of a heart attack was successfully resuscitated for the first

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time by a combination of outside-the-hospital defibrillation and

CPR. Victims of car accidents on the new federal superhighways

were soon being sped to freshly built emergency rooms and ICUs

throughout the United States, ferried in ambulances manned by

newly-certified emergency medical technicians, dispatched via the

brand-new 911 system, established nationally in 1971. The driving

force behind it all was President Lyndon B. Johnson, who’d barely

survived a heart attack himself in 1955 in Middleburg, Virginia, and

had been rushed to a naval hospital in a hearse doing double duty as

an ambulance. Johnson’s war on sudden death was a success.

The 911 system and the new ICUs saved the lives of many

hardy people in their primes who’d suffered a heart attack, over-

dosed on drugs, been in a head-on collision, or been stabbed,

shot, drowned, or accidentally poisoned. At the same time, the

units obliterated Western death rituals, reshaped the architec-

ture of the hospital, transformed the meaning of the body, and

brutally deformed the way families, doctors, nurses—and even

the dying themselves—behaved at the deathbed.

In the nineteenth century, dying usually meant waiting. In “The

Sisters,” set in 1895, James Joyce described such a vigil for a

sixty-five-year-old priest dying in a poor Dublin parish in 1895:

There was no hope for him this time: it was the third stroke.

Night after night I had passed the house (it was vacation

time) and studied the lighted square of window: and night

after night I had found it lighted in the same way, faintly and

evenly. If he was dead, I thought, I would see the reflection

of candles on the darkened blind for I knew that two candles

must be set at the head of a corpse. He had often said to me, “I

am not long for this world,” and I had thought his words idle.

Now I knew they were true.

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A fellow priest received the dying man’s final confession,

anointed his forehead with oil, and spoke the litany of ancient

Latin phrases marking the universal passage from life to death.

When it was over, the priest’s two sisters washed their brother’s

body and dressed him for his coffin.

In the metallic, machine-filled ICU, where death was fought

to a standstill and its arrival regarded as an emblem of medical

failure, such sacred rites of passage all but disappeared. Nurses

often looked first at the monitors and then at the patient. The

dying person was no longer in charge of his or her own death:

doctors were the new authorities, and they popped in and out on

rounds. There were technical specialists to treat each discrete

bodily organ but nobody to minister to the emotional or spiri-

tual needs of the dying person or the family. Latin liturgy gave

way to talk of blood gases. Busyness supplanted waiting. Family

members who once kept the death vigil, wiped the brows of the

dying, changed their bedclothes, and listened to their last words

were restricted to visiting hours. Months after the experience,

family members, especially those who took part in decisions to

remove people they loved from life support, experienced high

rates of anxiety, depression, and symptoms of posttraumatic

stress. Often there were no “last words” because the mouths

of the dying were stopped by the tubes of respirators and their

minds sunk in chemical twilights to keep them from tearing out

the lines that bound them to earth.

The new machines ushered in a transformation in the meaning

of the body. It was no longer the temple of the soul but a hous-

ing for organs to be removed, rejiggered, and replaced like spare

parts. The heart—the mystical seat of wisdom, love, and cour-

age, the telltale heart that could harden, break, soften, knock,

and open; the heart that knew what the mind could not compre-

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hend—was now a pump. The lungs were a bellows, the kidneys

a sieve. Once, the dying person had been the main actor in the

play of death. Now, the hero was the doctor.

As the up-to-the-minute machines spread to newly prosper-

ous countries around the world, they transformed not only the

meaning of the aging and dying body but its look as well. “The

number of plump corpses has been on the rise recently,” wrote

Shinmon Aoki in
Coffinman,
a memoir of his work as a Japanese

Buddhist mortician in the 1980s:

These plumped-up, celadon-colored bodies take on the

appearance of water-filled plastic bags. When I first started

out washing and coffining corpses early in 1965, the majority

of cases were home deaths. I’d go to a farming home in the

foothills to find a corpse with a withered frame like a dead

tree. . . . They looked like dried-up shells, the chrysalis from

which the cicada had fled.

Along with the economic advances in our country, though,

we no longer see these corpses that look like dead trees. . . .

The corpses that leave the hospital are all plumped up, both

arms blackened painfully by needle marks made at transfu-

sion, some with catheters and tubes still dangling from throat