CHAPTER 6

Dr. Jerry Strong bent over Pamela and blotted her perspiring face. She had been sedated in her room, but the tranquilizers were beginning to wear off as she lay on the stretcher outside Operating Room 1. She was whimpering slightly. Strong said softly, “It’s all right, honey, it’s all right. We’re going to put you to sleep and fix you up in just a minute.” He went into the coffee room and said to no one in particular, “Pulmonary pressure like that kid’s is a bomb with a 72-hour fuse.”

Slender, witty, caustic, and a highly skilled anesthesiologist, Strong reigned as raconteur of the coffee room, the crowded lounge just inside the swinging doors that led to surgery. There were no windows in the lounge and the furniture was cheap, cracking tan plastic; the ashtrays were overflowing, the magazines were out of date. But it served as unofficial headquarters for Cooley’s domain. Throughout the day and half the night it was crowded with surgeons resting before, after, or sometimes during their cases, nurses grabbing a cigarette, medical students cramming or listening to their elders talk of patients and politics. The main attraction was the free hot coffee, and, on days that the drug detail men came around, blueberry cupcakes or oatmeal cookies with a foul-tasting orange ribbon on top. Cooley’s fellows drifted in after each case to dictate surgical reports, and they assembled there each afternoon to discuss the day’s work and await his appearance for rounds.

There was an aura about the two heart teams at the two hospitals which went beyond the marked physical differences in space and resources. (A Cooley staff doctor had complained during the transplant year that he was a man using a 2½-horsepower lawn-mower engine while DeBakey’s people, in their splendiforous center, had a 450-horsepower Cadillac.) Each surgeon dominated his hospital and each used power in his own fashion, but a nurse at St. Luke’s did not even bother to lower her voice in the coffee room when she announced that she did not enjoy scrubbing for Cooley. “I’ve had Dr. Wonderful and his God Squad,” she said. “I’ll take orthopedics.”

Two visiting doctors were in the coffee room with name tags stuck on their scrubs indicating they were from out of state. They had arrived early to watch Pamela’s surgery. They took coffee from the big urn and wandered out to look at the blackboard in the foyer, with the first twelve spaces usually occupied by Cooley cases. A student who had been talking with them remarked on the large number of physicians continually pouring through Houston and crowding Cooley’s—and DeBakey’s—tables.

“We get all the VIP’s down here,” said Dr. Jerry Strong, as he tied on his throwaway sterile mask. “Let’s face it; this is the Big Top.”

At 7:45 A.M., Dr. Domingo Liotta, an Argentine-born surgeon and researcher sliced open Pamela’s emaciated chest. Shortly after 8 A.M., when her ribs were parted and the enlarged heart exposed, Cooley entered the room and, while a nurse dressed him in his sterile gown, asked someone to turn the radio up a little. He says he is not conscious of the music, even though he often whistles or hums along with it, but it is part of his room, as are the cartoons, the occasional nude picture, the inspirational posters that decorate the sterile walls where he spends most of his life with these sayings:

“Ideas won’t keep—something must be done about them.”

“Yesterday is gone, tomorrow may never come, now is the appointed hour.”

“The more you help another, the more you help yourself.”

And, dominating all, a long quotation from Theodore Roosevelt:

“The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood … who knows the great enthusiasms, the great devotions and who spends himself in a worthy cause … who at the end at best knows the triumph of high achievement and at worse fails while daring greatly, so that his place will never be with those cold and timid souls who know neither victory nor defeat.”

Always it is the same. Always there is the one suspended moment when he looks down through the gold Italian half-spectacles taped lightly to his blond, graying sideburns, seeing for the first time the troubled heart beating beneath him. (“Can you remember the first heart you ever saw?” I once asked him. He thought for a moment and finally shook his head. “There’ve been too many,” he answered. I had asked the same question of DeBakey, only he remembered. He said, in fact, he could never forget it. It was in the early 1930s, in the emergency room of Charity Hospital in New Orleans; he had looked down through the rib cage and seen a tiny pulsing pink part of a heart that had been pierced with a knife in a brawl.)

With a slight shift of his shoulder, Cooley was off, hands boldly slipping into the once forbidden chamber, carpentering a new system of circulation within Pamela’s heart. “Some surgeons piddle,” a doctor remarked after watching Cooley operate. “Some surgeons fool around and step back from the table and play with the sucking machine and poke around inside the patient. But not him. He doesn’t waste a breath, not a gesture. He knows exactly where he is going because he has been there before.”

Only twice during the delicate procedure—how simple it looked!—did he speak. Once was in reply to the visiting doctor who asked how often Pamela’s disease—transposition of the great vessels—was encountered. “We used to think it was rare,” he said, “but it is now known to be one of the most common congenital defects. The trouble is, so many kids die when they are a few weeks old.” The second was when he glanced behind him through the glass walls into Room 2, where the next case was being prepared. “What’s that?” he asked. A nurse went to check the schedule sheet posted by the scrub basin. “The VSD,” she said, giving the abbreviation for ventricular septal defect.

That’s not a “what.” That’s not a VSD. That is a human male, one Harold Carstairs from Illinois. Next to his birth, next to his death, this is the biggest moment of his life. Must he be anonymous? Had Cooley connected the cavity before him with the child Pamela he saw yesterday for thirty seconds or the mother he saw for forty? Was it possible to hold so many hearts in his hands and know them?

“Denton Cooley,” said a friend who stood once and watched him through the glass, “is the greatest doctor in the world—from here down.” He made a slashing gesture, a line of demarcation across the wrists.

It was gray and misty with thunder dancing about the city, a condition that seemed compatible with the mood of Marsha Kroger as she waited news of Pamela. Beside her was her divorced husband Gerald, Pamela’s father, a chunky, gentle man with a crew cut and a soft north-Louisiana drawl that welded words together. He had both a book of philosophy and Dr. Zhivago on his lap, but every time footsteps approached, his eyes shot up from the page. Certain people become familiar during the waiting—nurses, orderlies pushing carts, but when a new figure appears, the families are swept by panic. Is the message coming?

“A month after Pamela was born, she turned a bluish color,” recalled Mrs. Kroger. She was a slim woman with an air of efficiency about her. “A strange duskiness set in. Her eyes had always troubled me, a child that sick has haunting eyes. We sat there with our Dr. Spock, trying to be good parents. Our pediatrician didn’t even recognize heart problems. He kept saying she wasn’t feeding properly.

“The thing that began to frighten me was the memory of my twin sisters who died of heart defects a few weeks after they were born. And my grandmother had twin sons, uncles I never knew, who had died of what they called ‘malnutrition’ then, but which was probably heart disease. I felt I was carrying the bad seed and had passed it on to my daughter.… On the day Pamela sank into heart failure, our pediatrician finally decided we should rush her to Houston. Gerald couldn’t get an ambulance.…”

Her ex-husband winced at the recollection. “There was a water festival going on at the lake and all the ambulances in Austin were out there hoping to pick up a drowning.…”

“He finally chartered a plane,” said Mrs. Kroger, picking up the story. “They flew her to Houston and arrived at Texas Children’s with sirens blaring. They did her first catheterization the day Charles Whitman was shooting people from the University of Texas tower. When we got the diagnosis, that the great vessels of the heart were transposed, Gerald fainted.”

Gerald nodded, not embarrassed at the memory. “I was ready to accept one of the minor heart defects, a murmur, even a hole, because I knew Cooley could do them. But this sounded so staggering I thought we would surely lose her.”

“When she got old enough,” said Mrs. Kroger, lighting a new cigarette from the one she had not yet finished, “we told her about her condition. Sometimes she referred to her ‘sick heart’ with a cute look on her face, but she never used it as an excuse. Living with a heart baby was hell. You try to protect her, but you also try to let her lead a normal life. The other day she was on the monkey bars at the park and she froze—she got tired and pale and I could see her anguish.”

Two hours and forty minutes after she had entered the operating room whimpering, time bomb Pamela was ready to leave, her heart reconstructed, her existence for the time dependent upon technology. Jerry Strong supervised her transfer from the table to the rolling stretcher. “Patients not infrequently arrest between here and there,” he said, pointing down the hall toward Recovery. “So I think it’s important to stay with them all the way.” A tube was down her throat and its connection taped across her mouth for the ventilator that would breathe for her until the lungs rallied—if they could. During the transfer, Strong would squeeze the black oxygen bag to feed her with oxygen.

“What are you bringing us?” said one of the Recovery nurses as Strong and an orderly delivered Pamela. “Transposition,” said Strong. A place was made at the end of the room where the children are watched.

Dr. Liotta had come out between surgery and hovered as the nurses hooked up Pamela to the various monitoring machines and wrote her name on the strip of tape at the foot of her bed. Leachman was in Recovery checking on another patient and moved down to Pamela’s bed. “She’ll be all right if the cardiologist takes proper care of her,” said Liotta.

Leachman watched the surgeon return to his quarters. “This is the surgeon’s out, don’t you see,” he said. “He has committed this massive assault on the patient and now he passes the buck to me.”

(Near midnight, Leachman was attending Pamela and he said, not wholly in jest, “Note what physician is still here and what famous surgeon went home hours ago.”)

The general feeling was that Harold Carstairs had small chance of surviving. “I’ll be surprised if he gets off the table,” said one of the surgical fellows, looking at the x-rays that Gwen, the head operating room nurse, had slapped onto the illuminated viewer in the corner of Room 2. The heart was enormous, its shadowy shape almost as big as the chest itself. Strong glanced at it and shook his head, virtually a shudder. But there was no curtain of pessimism in the room, where a Muzak-type station had been switched to one that sent out hard rock, the room where Harold Carstairs was probably going to die. “In medical school,” a cardiologist named Don Rochelle would tell me, “you start out by having enormous empathy for patients and their families. You get involved with all of them. But to work in the cardiovascular field, you have to develop almost a shield around you. When someone dies, they die. You can’t crack up—caths go on, surgery goes on. There’ll be twelve new patients in tomorrow.”

Liotta was first-assisting all day, opening the chests, following Cooley on the sutures, finally closing. The job was passed around on a rotation basis to all twelve of the surgical fellows, plus Liotta, who spent most of his time up in the seventh-floor lab in research but who relished the rare opportunity to cut and sew. When Liotta exposed Carstairs’ heart, Jerry Strong glanced at it and made an inverted whistle. “Jesus, would you look at that! It’s one of the worst-looking hearts I’ve ever seen. Most of these cases die by the time they’re 35. It’s wall-to-wall heart!”

The huge heart was so flaccid and deteriorated that Cooley had to go at the ventricular septal defect through the tricuspid valve, roughly equivalent to entering a house by crawling under the basement door. During surgery, Jerry Strong pinched Carstairs’ cheeks now and then, bringing a momentary cosmetic flush of pink to the pale skin. Anesthesiologists do this to see if blood is flowing to the patient’s head.

“This is known as the George Lewis technique,” Strong said.

“Is that a professor here?” asked one of the visiting doctors.

“He’s a local undertaker.”

One of the visitors, a short doctor unable to see the field, had navigated his way to the patient’s head-end of the table and was standing on a large, shaky stool. Gwen eyed him nervously and finally asked him to get down, diplomatically finding him a better place. “Someday somebody is going to fall into the patient,” she muttered.

“How old is this patient?” asked the short doctor from his new position.

Cooley shook his head. “Gwen?”

Gwen found the chart with the plastic identification card and discovered from it that Carstairs was 49.

The short doctor shook his head in disbelief, as well he might have.

Carstairs probably was born with the hole in his septum, that partition that separates the two ventricles (lower chambers) of his heart. This had caused the right ventricle to work furiously, pumping blood into the lungs, and at the same time fighting off pressure from the left ventricle. Blood that had returned from the lungs with oxygen had continually mixed with blood that was on its way to the lungs. The ventricular septal defect is the most common congenital heart defect and is almost routinely corrected by the heart surgeons—both Cooley and DeBakey had mortality rates under 10 percent, But Carstairs’ heart was so gross and the tissue around the hole so worn and tired that it would take a large patch to cover it. Would the sutures even hold? Would any other surgeon have even attempted it?

Gwen handed, without being asked, a Dacron patch to Cooley, which he accepted and with his scissors trimmed down to a circular affair, larger than a quarter and smaller than a half-dollar. Deftly he sewed it into the septum, closing off the hole. He worked calmly, dispassionately. Disasters have happened—they happen in any surgery—but none has ever broken his calm. A clamp can slip off an aorta and blood can erupt to the ceiling like a geyser. Cooley sews through the blood. Once an assisting surgeon was opening the chest with an electric saw and he cut too far, slicing into the heart. He cried out in horror. Cooley hurried into the room, quietly sewed up the unintended wound, and turned to the defect for which he had been engaged.

When he was done with Carstairs’ patch Cooley said, almost in a whisper, “Let’s see what happens.” Carstairs was taken off the pump and the life-sustaining responsibility given back to his own system. The heart fibrillated slightly, enough to cause Cooley to put him back on the pump for another few moments. A jolt of electricity started up the heart the second time. It beat regularly and normally.

Jerry Strong raised his eyebrows as a compliment to Cooley’s surgery, also indicating that there was considerable road to travel before the reconstruction could be considered successful.

Three hours after Pamela’s surgery, her blood pressure was up to 82/50, a good sign. She was trembling, moving her arms about, and fighting the mouthpiece as the anesthesia began to slip from her system.

After six more operations, Cooley finished at 5 P.M., made brief rounds, visiting those patients whom John Russell had scheduled for the next day. A mother whose child was recovering nicely asked if he would pose for a photograph. Not only would he, he swooped up the child, instructed the woman to move across the room with her back to the afternoon sun, and held still for one Polaroid and two 35mm slides. A second woman watching expressed disappointment that she had not brought her camera. Did Cooley have any pictures of himself? His office would give her one. Cooley hands out handsome line drawings from a Karsh portrait. DeBakey has a stack of glossies he autographs and distributes to those who ask. It occurred to me that there are two professions where the participant stands directly under a spotlight—acting and surgery—while doing their principal work.

I had an appointment to eat dinner at a Mexican restaurant with two medical student friends, and as I dressed, another student was combing his hair in the locker room. He had been working in Cooley’s surgery that day, doing the scut work of holding retractors until the fingers ache and pinpoints of pain invade them.

“Some day,” I said. “Eight cases.”

“That’s too many,” said the student. “Personally I think the surgeon should do fewer cases and have more rapport with the patient. Some surgeons actually work up the patient preoperatively, do the operation, and stay with him until he is out of danger.”

But who could do as many sophisticated cases as Cooley can do? “Shouldn’t his skill be used on as many patients as possible?”

The student shook his head. He had long sideburns and the beginnings of a mustache. Jerry Strong had commented that very day how hip the medical students were starting to look. “Wait till the AMA gets ahold of them,” Strong had said.

“There might be other Cooleys around if somebody gave them the chance,” the youth said. “But of course I’m still a student, and I’m still idealistic.”

Medical students know of all the places where dinner is cheap and filling. This being Wednesday it was half-price night at a Mexican restaurant where for 99 cents one got a taco, a combination plate of enchiladas, beans, rice, tamales, a basket full of toasted tortillas, and heartburn (a misnomer, it should be called esophagus burn, because the heart is not involved). Jerry Naifeh and Bob Viles, both second-year students and aspiring surgeons—in their classes, when a theoretical case would be presented and the instructor would ask for possible medical solutions, Jerry and Bob would usually cry, “Cut! Cut!”—were talking about DeBakey’s announced scheme to reduce the number of years a doctor must spend in medical school and residency before he can begin practicing. As it then stood, a heart surgeon had to spend thirteen or fourteen years after he finished college, making him almost 35 by the time he had fulfilled his military obligations. The training period was four years in medical school, one year in internship, four years in a residency, three years in a surgical specialty, and one year as a fellow.

DeBakey had recently proposed cutting one year out of medical school—“the second’s a waste of time, anyway,” said Jerry—and shortening the residency from four years to three. In a nation critically short of doctors, it seemed a valid idea. Most doctors think they are over-trained anyway.

“The Professor’s always looking out for the students,” said Jerry. “He’s almost a God to us.”

It was not always thus. Less than a handful of years ago DeBakey was so caught up in his myriad duties that students complained they never saw him or had access to him. At the annual senior dinner, the class voted DeBakey their “Chicken” award, given by graduating students to the faculty member who had contributed least to their medical education. Stung, DeBakey instituted a series of Saturday-morning breakfasts at which all seniors were invited for free bacon and eggs and an ask-me-anything hour.

Jerry suggested that DeBakey erupts at people in his operating room to weed out those emotionally unfit to become surgeons. “He really psyches you out if you let him,” said Jerry. “You make mistakes, you forget everything when he goes on a rampage. There was this woman resident who really got it. He used to scream at her, ‘No, deah, no! You’ll never learn! You’re psychologically defeated!’” (The woman is now a successful Houston surgeon.)

Hans Paessler joined us, weary after three afternoon cases with Ted Diethrich and an hour in the lab inducing heart attacks in pigs. Hans looked like a ski instructor with wide shoulders and strong arms. He was spending his year in Houston not only observing DeBakey and Diethrich but wheeling his yellow Fiat convertible about the southwestern part of the city in heavy pursuit of beautiful and preferably rich girls. “I have a date this weekend with a former Miss Playmate,” said Hans. “She works at the Shamrock Hilton as a hostess.”

“As a what?” said Jerry.

“She greets visiting dignitaries,” said Hans. “She is … she has.” Hans was searching in vain for English dimensional terminology. He settled for extending his hands a considerable distance in front of his chest.

“Medicine is business in Houston,” Hans said, taking a sip of Lone Star beer and frowning, mentally comparing it with the brew of Munich. “The patient is the customer. I’ve never seen a place like this. Doctors are so nice to each other! The reason is they worry constantly about getting referrals. I asked a cardiologist the other day why he was always smiling, always so polite to everybody, and he said, ‘Because you never can tell who’s going to give me a referral some day.’”

In his country, Hans said, surgeons do not operate on the very elderly. “We send an 85-year-old woman with an aneurysm back to her cabbage patch and let her live out her life. Here, DeBakey will operate on her. It’s incredible!”

I drove back quickly to St. Luke’s, where I wanted to follow the progress of Pamela and Carstairs through the most critical night of their lives. John Zaorski was on night duty, looking after all of Cooley’s patients. Zaorski, a stocky, crew-cut reserve major in the Air Force and a former sugeon with the military in Korea, was on the last leg of his medical education. At 35, he was anxious to get into private practice. The nursing staff considered him one of the best of the fellows—“They like me because at least I speak English,” said John, who spoke in a rat-a-tat Joisey accent. He was coming out of a woman’s room on Three South when I found him. “That’s an interesting lady, you should talk to her,” he said. “She’s a Jehovah’s Witness.” The patient inside was Mrs. Grieg from Colorado, who had survived open-heart surgery without blood transfusion.

Cooley is one of the few surgeons in the world who will attempt surgery on Witnesses, having vowed to observe their prohibition against accepting blood. He has done some 100 cases, using only saline solution to replenish body fluids, and his mortality rate is about the same, in some series slightly lower, than with non-Witness patients. The feat is astonishing, considering that almost every surgery, even minor surgery, requires blood, if not during the actual operation, then certainly in the postoperative period.

The ban on blood for Witnesses is strictly observed; there is no cheating in Recovery when a pressure nose dives and the obvious treatment would be “give blood.” Dr. Grady Hallman once noticed an order for blood written on a Witness chart and he quickly found the charge nurse and demanded an explanation. The nurse said that there had been an error, which had been caught, and that the blood had not been administered, only ordered.

Mrs. Grieg was a retired hairdresser, a neat, thin, prim woman, nine days postoperative. Her heart was tolerating the new plastic mitral valve that Cooley had put in. She was reading her Bible and she found a verse from Leviticus that is the foundation of their belief.

“‘Ye shall not eat blood.…’ We interpret that as meaning that we cannot use blood, either.… ‘It shall be poured out onto the ground.’” A bony, liver-spotted finger flew across the pages into the New Testament. “And St. Paul told us, right here, ‘Ye shall abstain from blood.’ Both the Old and the New Testament support our faith.”

“Are there many dissenters to this principle within your sect?”

“Our organization has no splits. There are no rebels. We know only that it takes courage and we accept the risk. We believe that this is what God wants us to do, else he would not have given it to us in His Word. We cannot violate His Scriptures. When I entered the hospital, I signed a paper stating that, if I got anemia or postoperative complications, I would not hold the hospital or Dr. Cooley responsible. We think God is with us, He is in this room, He is listening to this conversation. We will remain alive only as long as He has need for us here.”

Mrs. Grieg left the hospital the next day, looking serene and handing me some pamphlets to study.

Shortly after 10 P.M., Carstairs’ potassium level dropped sharply, causing concern to Shirley Fife, the efficient Recovery Room nurse who was working a double shift, already having put in eight daytime hours in Leachman’s cath lab. She took Carstairs’ chart and hurried into the coffee room, where Zaorski was slumped for a few minutes rest. There had been few problems this night and on his last tour of the hospital, the nursing stations reported that everyone was either resting well, or better still, not complaining.

“This can be dangerous,” Zaorski said, scanning the chart. “The danger is that the patient can go into arrhythmia, irregular heart beats; they can kill you. His potassium level is, let’s see, 2.9. Normal is an even four. Potassium’s an electrolyte, one of the chemical agents that controls the heart beat. Cooley foresaw this, because he hooked up Carstairs with pacemaker wires in case we needed to slap one on and speed up his beat.”

Zaorski ordered potassium to be injected into Carstairs’ intravenous tube and no sooner had he returned to his coffee than did Shirley hurry in, this time with Pamela’s chart in hand. The child’s potassium level also had plunged. “Give her some, too, as long as you’re at it,” said Zaorski.

In the hours after heart surgery, six danger signs watched for are:

1. Tamponade—bleeding around the heart. This can precipitate a fatal drop in blood pressure and must be corrected by emergency surgery. “This is usually the only thing we’d call Cooley for at home,” said Zaorski. “This or a death.”

2. Lung malfunction. The lungs can develop resistance to the new pressure system created by revised blood circulation within the heart.

3. Heart block. When the surgeon sews a patch into the heart, such as Carstairs’ VSD repair, he must avoid hitting a vital clump of nerves called the Bundle of His. If a single suture is placed one millimeter over and into this clump, it can destroy the heart’s natural pacing system and the patient must be hooked up to a pacemaker.

4. Low urine output, indicative that the kidneys are not being well nourished with blood pumped from the heart.

5. Arrhythmias.

6. Bleeding around the graft.

Shirley hauled Zaorski back into Recovery for the third time in less than half an hour. Pamela’s intravenous tube had come out. “She probably pulled it out, she’s been squirming and fighting everything,” Shirley said. Zaorski sighed and tried for ten minutes to work an intravenous needle into Pamela’s veins, but the child had been catheterized so often that her veins had thrombosed; they simply would not accept another needle.

“Gimme a cutdown,” said Zaorski, requesting a sterile pack with instruments for cutting into the foot and finding a vein to hook up the intravenous.

The charge nurse, busy down the line turning a patient, called back, “You’ve got to get her parents’ permission.”

“For a cutdown?” Zaorski’s voice was incredulous. A “cutdown” has long been a procedure of most routine nature.

“It’s considered minor surgery now, and the hospital requires you to get the parents’ signatures.”

“Well, for Christ’s sake that’s a new one on me. What do you recommend? It’s past midnight, visiting hours in most hospitals are over. You have any idea what motel I go to to find her parents? Or what their names are?”

The charge nurse shook her head. Zaorski asked me to scout the Texas Children’s surgical waiting room; he, in the meantime, would look through St. Luke’s lobby. I ran down the hall and into the dark foyer. An elderly man in cowboy boots was sleeping on a cot he had brought; he sat up with a startled look on his battered face. A woman trying to stretch across two folding chairs stood up quickly and searched for her eyeglasses. Neither belonged to Pamela. I apologized and raced back to Recovery. Zaorski had drawn a blank as well.

“The rule is,” the nurse said, “that if the parents cannot be found and if the surgeon considers the procedure necessary, then he can go ahead.”

Zaorski nodded. She could have saved us both a foot race.

“You just go ahead and start,” said the nurse. “I’ll phone around and try to find her parents. If I can’t, then you can sign the paper saying it was necessary, in your opinion.”

“Be sure and write down that we tried to find the parents,” said Zaorski.

“Trust me.”

“I trust everybody. I just wanna cut the deck.”

Zaorski put on sterile gloves and cut into Pamela’s foot, complaining the whole time about the constantly multiplying rules that hospitals are initiating to protect themselves against lawsuits.

“It’s getting ridiculous. We might as well have a lawyer standing beside us. So’s malpractice insurance. I understand it costs $9,000 a year premium in Los Angeles. Plastic guys get socked the worst. Patients scream, ‘Look what you did to my nose, you bastard,’ and sue you for $12 million.”

When there was a period of almost an hour without a page or a summons from Shirley, Zaorski relaxed with a couple of other doctors on night duty. They were talking about Cooley, his skill, his money—a continuing topic of conversation among the younger men.

One doctor began doing mental arithmetic and announced that Cooley was potentially the highest-paid doctor in the world. “Look at it this way,” he said, scribbling with his ball-point pen on the leg of his scrub suit. “He does 1,000 pump cases a year at $1,500 each, that’s $1.5 million. Plus another half million, easy, from his vessel work. That’s $2 million if he collects from everybody.”

Zaorski disagreed. “But he knocks a lot of fees off. I saw him throw six unpaid bills in the wastebasket at one sitting.”

“He’s gotta be worth $10 million, easily.”

“In medical school,” Zaorski said, “we learned that a good surgeon can make up to $75,000 a year in a small town and maybe $100,000 to $300,000 in the city.”

“Why is Cooley so good?” I asked, blinded by the tally sheet on the doctor’s pants.

“Speed’s the main thing,” said Zaorski. “It’s so important in these cases. If you keep a patient on the pump too long, his blood loses the ability to clot and he can become acidotic—that’s an abundance of lactic acid. Just before a patient dies, he fills up with this stuff. Speed is the difference between success and failure in open-heart work. Cooley even got down to where he could do a heart transplant in 36 minutes.”

“But they’re all dead,” said the doctor standing at the coffee pot.

“Yeah,” said Zaorski. “That’s right. Transplants are a stupid way of doing things.”