CHAPTER 7

Seventy-two hours after surgery, Pamela was sitting up, sipping a Coke, brushing her hair, and tearing into get-well cards. The bluish cast to her skin was gone, the sadness had slipped from her eyes, and though she was still pale, there was a general aliveness about her that had not been there before Cooley rearranged her heart. Leachman listened to her heart and she accepted his stethoscope without protest. “You must be sick, Pammy, you’re so quiet,” he said, nodding encouragingly at her mother. “There’s still a lot of getting-used-to necessary for the lungs,” he said later. “It’ll be a few months before those hissing noises go away, but I believe she’s going to be fine.”

Carstairs went from Recovery to the sixth-floor Intensive Care Unit, where his vital signs were observed for 36 hours, then on to a semiprivate room, where his roommate was disturbing him more than the postoperative pain. The man in the next bed was an 81-year-old farmer, Leroy Castle, who had had a variety of surgery, some vessel work, his gall bladder removed. From a town so small it was not even on the map, he was confused by the hospital and fought off the sedatives given him. When awake he talked constantly in a booming hog-calling voice and was visited frequently by eight large relatives, all of whom talked louder than he did, and all at once. “I thought it was bad in ICU when a man died in the next bed,” said Carstairs. “They pulled the curtains around his cubicle, but I knew what was happening. This is worse. I can’t get any rest.”

Castle was at that moment accusing the nurses of stealing his suitcase. “It’s right here, Mr. Castle,” said a weary black nurse. “Lemme see it, I don’t believe you,” roared the farmer. He was trying to stand up in bed on shaky old legs and the nurse was torn between fetching his suitcase from the closet and making him lie down. She chose the latter and threatened to tie his arms to the bed unless he behaved. “I’m gonna call the mayor and the sheriff,” he said. “I’m gonna tell somebody how the cow ate the cabbage.” The nurse sighed and went to the closet and pulled out his beat-up cardboard grip. She held it up above her head so Mr. Castle could see it. “Lemme just touch it,” he said. The nurse walked over to his bed. The old man, with surprising strength, snatched it from her and tried to smuggle it under his sheet. The nurse dived after it and put it on his dresser. “I’ll leave it here so you can see it,” she said. “Now, Mr. Castle, stop misbehaving and get some rest. You want to get out of here, don’t you?”

Quiet and still just long enough for the nurse to leave the room, Mr. Castle jumped up and shouted, “All I want to do is leave and go out to a restaurant and get a real dinner! I promise to come back!”

“If it wasn’t for that,” whispered Carstairs, jerking his thumb toward the next bed, “I’d be fine. Poor old fellow—I guess he’s lonely. I asked for a private room and they said they’d move me later today.” He touched his hand to his chest, where the incision was held together with sutures and wire brads. “I haven’t breathed so well in years. I think I can actually feel the blood circulating in my body.” His wife took his hand and kissed it and held it tightly against her face. “I can remember the nights when he would fall asleep and gasp for breath,” she said, “and I would lie there with my eyes open until dawn, terrified.”

Farmer Castle had probably been slightly senile before his surgery, but his postoperative course had confused him even more. It was an infrequent occurrence but one which, until it cleared up within a few days, was disturbing to all concerned. Elderly patients often get “squirrely,” as one anesthesiologist put it, from any drug, even aspirin. Something as powerful as anesthesia can scramble their senses.

A second potential peril is a tiny bubble of air—an embolism—which can swim to the brain and cause convulsion, twitching, disorientation, even death. When the heart is opened for repair, air floods in. When the surgeon closes the heart, he tries to withdraw all the air. Various surgeons have favorite methods of accomplishing this. Cooley draws air out with a syringe, DeBakey tips the end of the operating table down, others blow carbon dioxide gas all over the field. But sometimes a bubble remains and causes trouble.

The Recovery Room and Intensive Care Unit are sometimes severe experiences for patients, particularly the elderly ones. “ICU produces psychoses in some people,” said the anesthesiologist. It may well be the loss of the day-night cycle. After surgery, patients wake up in a room that is strange to them, where there are no windows, where the lights are always on, where they do not know the time. It is a world of monitoring machines and beeping noises and crises in the next cubicle.

There is more drama to be found in St. Luke’s Recovery than the rest of the hospital, a continuing drama of compression and spontaneity, because at any given moment there are up to 24 patients (half on Cooley’s service) crowded three feet from each other. Each patient is in intense pain, each is demanding consolation and attention as he makes the journey from object to being. It takes a special breed of nurse to cope with the extraordinary physical—and emotional—demands of Recovery. The room, originally designed for Central Supply, is low-ceilinged and oppressive and, with patients struggling to climb out of their beds or yank the vital tubes and wires from their bodies, the atmosphere is, at times, that of the battlefield hospital in M.A.S.H. The care dispensed is professional and good, but rationed out by a small, overworked, and sometimes testy staff. When a patient pulled out his nose tube and the male nurse wearily stuck it back in again, the patient yelled, “I’m gonna take it out again, it’s killing me.” “You do that,” snapped the nurse, “and I’ll put in a bigger one.” One disoriented patient spent an entire day fighting everyone until his arms were finally restrained with white furry stays. Seeing a doctor attending the patient in the next bed, the patient used his only available weapon, the right foot, and kicked the doctor in the ribs. The doctor spun around with a fist clenched and fury in his eyes. For one breathless moment the charge nurse thought she was going to see a doctor hit a patient. “I’m sorry,” he said, putting his fist down, “It must be the Ben Taub syndrome.” He referred to his several months in the Emergency Room of the charity hospital, where young doctors, on occasion, have had to knock down mean drunks or else find themselves with a missing tooth.

The major event of every operating day is at 7 P.M., when the relatives are allowed into Recovery for a few minutes to see the patient after his surgery. There is nothing sicker-looking in medicine than a postoperative major surgery case, with chest painted a ghastly orange, wrapped generously in bandages and tape, covered with wires and tubes through which inch blood and urine. Not infrequently a wife sees a husband and has to be led screaming from the room. About once a week a mother keels over in a faint at first glimpse of her perfectly recovering child. The parents of heart babies have a grueling time. They have not slept at all the night before surgery, have spent ten paralyzing hours in the waiting room, and when at last permitted to see what the surgeon has wrought, cannot cope with the sight.

Ever since the advent of open-heart surgery in 1955, psychiatrists have been running studies on the attendant emotional problems. The incidence of postoperative psychoses in some groups studied has run as high as 25 percent of all patients. Ideally, each candidate for open-heart surgery should be thoroughly examined and evaluated by a psychiatrist to determine if he is emotionally able to withstand the operation and the hours thereafter. But in Houston, there are too many patients, not enough time. Neither Cooley nor DeBakey feels the occasional psychosis is as important as the principal fact of the case: that the heart needs and will get repair.

By Sunday night, Recovery was eerily empty. All the patients of the week had progressed from Recovery upstairs to Intensive Care then to their rooms and, hopefully, to discharge in seven or eight days. Ten years ago, heart patients stayed in the hospital from six weeks to two months; in 1970 the average stay was down to ten days. “Denton really cuts ’em up, sews ’em up, and moves ’em out,” said a colleague with a voice sitting on the fence between admiration and derision. The shortened stay could be credited to many things—better pumps, improved anesthesia and its use, the years of experience for all members of the team—but nothing counted as heavily as the dazzling speed and drive of the surgeon-in-chief.

On Monday morning, the deserted Recovery began filling up—fast. Cooley plunged into a schedule of twelve cases, including two double-valve replacements and two coronary artery bypasses, the operation he was not supposed to like to do. He passed by the schedule board on his way to Room 1, and I stopped him with a question. “Do you ever wonder if the sick people will stop coming? That someday you will have repaired all the bad hearts?”

“I certainly hope not,” he said. “And so do my creditors.”

Dr. Shafi, a dark, good-looking Iranian surgeon had ward duty this morning, meaning he would be tending to patients and not participating in surgery. None of the fellows looked forward to ward duty, no more than any of them relished night call. All wanted to spend as much time as possible scrubbed in, standing next to Cooley. All were disappointed when they came to Houston and discovered that they would not be doing any actual heart surgery, only opening, first-assisting, and closing. “Does it ever get boring?” I asked Shafi. He was in the coffee room waiting for the operator to page him and send him off somewhere to diagnose a spiked fever or take out stitches or write prescriptions for patients anxious to be dismissed.

“Sure,” he said. “But not to D.A.C. He is driven by the numbers. A thousand pumps in six months … 2,000 in one year. He wants to break his own record. And maybe break”—Shafi threw a thumb in the direction of Methodist—“him.”

During the coronary operation that took place shortly after lunch—lunch being a term to indicate time, because Cooley does not stop for it, never more than a sandwich on the fly—he began sewing in the artery taken from the thigh, tediously affixing it to the aorta. He looked up and said to the room, “You practice for this procedure by circumcising gnats.”

Late in the long afternoon—it was going to be well into the night before Cooley finished and could make rounds—some of the fellows were quietly discussing something when I walked into the coffee room. There was stiff silence. They did not want me to hear what they were talking about. Suddenly the conversation shifted to Dr. Tanaka, the stocky, muscled Japanese who had to put up with ribbing almost every day of his year in Houston.

“Tanaka,” fibbed Shafi, “has a new procedure for opening the chest cavity. He doesn’t use a scalpel. He kicks open the patient with karate.”

During the laughter, John Zaorski stormed into the coffee lounge. He ripped off his mask and threw it into the garbage can overflowing with coffee cups. He sat down on the couch to dictate an operation summary. “Shit,” he said, before he pressed down the dictation button. “You work for three hours trying to get a guy’s heart started and nothing happens. Nothing!”

Unknowingly Zaorski had revealed what I was not supposed to hear. Grady Hallman had been doing a coronary in Room 1, and the patient had died on the table. For most of the afternoon, the team—with help from Cooley who had come into the room—struggled to resuscitate him.

“We couldn’t get him off the pump,” said Zaorski. “Cooley recommended everything in the book, but nothing worked.”

“Did you shock him?” someone asked.

“Ten times. Maybe twenty.” Zaorski began the dreary recital of a man’s last hours. A few days later, a stenographer would send the report to the dead man’s home-town doctor. When he finished, Zaorski rubbed his cheeks with his hands for a while. “Thank God it doesn’t happen very often—once a month most, maybe every two months. At some hospitals—every day.”

The patient was brought on the rolling stretcher to the corridor just inside surgery and a folding green screen was placed around him. People lowered their eyes as they passed by. Cooley went to his office, dictated a letter, and returned to surgery, stopping at the box full of masks for a new one. The death was on his mind. “This time, I wasn’t going to go searching for a donor heart,” he said in a voice curiously flat and one-note. “I decided to let him die in peace.”

Half an hour later the fellows were joking, not for the fun therein, but in an attempt to erase the defeat. One of the young surgeons suggested: “Write on the chart that Zaorski was first-assisting and was heavy-handed.”

“Heavy-handed!” Zaorski yelled. “You couldn’t change a tire and you call me heavy-handed!”

The body was taken downstairs for a post-mortem and picked up by a funeral home, which would handle the lucrative local embalming and arrange for transportation to the man’s home town. “They come right away,” said Zaorski. “They’re anxious to get their hands on the corpse.”

Time began to blur the faces and fates of the patients, the days and nights welding together. I would store patients in my mind, promising to get back to them, but new ones kept crowding them out and the old ones vanished. By the time I remembered that interesting atrial septal defect—names were lost as well, only the diseases stuck—that interesting ASD was gone, dismissed, well, or dead, on his way home, or already there.

Carstairs checked out before I could say good-bye; Pamela was leaving on a morning when I was on the children’s heart floor to see somebody else.

“How do you feel, Pammy?”

“Fine,” she said shyly, flipping up her nightgown automatically to show her scar, healing well. It would fade into a thin white line within a few months.

Mrs. Kroger said she was going to have a genetic study done on her family. “And tell my daughters the history of our heart disease. I hope they don’t ever have to go through the hell of this.”

The skill and achievement of the heart surgeon is most dramatically seen in the juxtaposition of two facts:

1. Before 1955, when the heart-lung machine was developed, most babies born with serious cardiovascular defects either died at birth or lived a drastically shortened, terror-filled life.

2. By 1970, only fifteen years later, the heart surgeon could repair and promise normal life to upwards of 80 percent of congenitally damaged hearts. It is an achievement in medicine that ranks with Pasteur, Fleming, and Salk. But there are still the other 20 percent:

Grady Hallman began a tricky case on a ten-month-old baby girl named Kimberly born with a ventricular septal defect, complicated with subaortic stenosis—a thickening of the lower aorta. This is one of the few congenital defects that must be operated on definitively; there is no palliative operation to tide a baby over until it is older and stronger. “She wouldn’t live to her first birthday without this operation,” said John Zaorski.

The procedure would not begin for a quarter hour or so; Zaorski and I went to the lounge to have coffee. There were half a dozen conversations going on at once. I stood in the doorway tuning in and out as a man flips a radio dial.

“God help me to never go through that again,” the resident fresh from DeBakey’s service was saying. “He would stand there at the table and rap me on the knuckles with the needle holder and tell the room, ‘Wants to be a cardiovascular surgeon, wants to be a cardiovascular surgeon, but he performs like a brick layer.’ I didn’t have the courage to tell him I never wanted to be a cardiovascular surgeon.”

Two doctors were talking of an article in Life magazine that told of a Midwestern town with a new hospital and no doctor to run it, despite the guarantee that such a man could earn at least $40,000 a year. “You can earn $75,000 a year,” said John Russell dryly, “giving flu shots, insurance examinations, and writing excuses for people to stay home from work.”

“You take these guys out of surgery,” a pediatric surgeon was saying to a girl student, referring to Cooley and DeBakey, “and put them in business or industry, and they’d be Ross Perot or Bernie Cornfeld. Wait, make that Tom Watson or Henry Ford.”

“Industry?” said the student.

“You think it’s not an industry? I mean, the by-products are great—people get cured, people get caught, but it’s still an industry.”

“That’s a helluva case, that baby,” said Zaorski. He had been transferred to another room at the last minute but had watched Hallman begin the ventricular septal defect and subaortic stenosis. “I don’t think the kid’s gonna make it.”

In Room 1, Hallman was trying to get the baby’s heart to respond. Lola, the scrub nurse, had normally mischievous eyes, but now they were wide and saddened. Hallman fought to activate the heart for more than an hour. He shocked it over and over again. He unclamped the tubes and took the infant off the pump and the heart refused to beat. He put her back on the pump and things seemed to work. But when he shocked her and took her off the pump, the heart refused to beat. Cooley came over from Room 2, where he was doing a valve and said, “Has Nora been told? Better find him, it’s his case.” Nora was Dr. James Nora, a staff pediatric cardiologist.

“I’ve already told the parents it’s not going very well,” said Cooley, backing out of the room and returning to his valve.

Another nurse pushed open the doors in the middle of the struggle and said, “Dr. Hallman, the amputation patient in Room 3 is ready.”

“Go ahead and put him to sleep.” Hallman’s hands were inside the heart of the dying baby.

“He is asleep.”

“Then drape him.”

“He is draped.”

“Then find Dr. Messmer [Dr. Bruno Messmer, a Swiss surgical fellow] and see if he can start it.”

Three hours into an operation that should have taken half that, Hallman lifted his hands with a great slowness from the heart and shook his head. Nothing was said. No pronouncement was made. He only shook his head. There was no point in going further. Nora had come in and seen the futility of it all and went out to find the parents. Hallman left the room; somebody would sew her up. One of the pump technicians bumped into the heart-lung machine and a container of blood flowed sadly across the green tile.

A chaplain was sent to find the child’s parents. They were led, fearful, to the family room not far from surgery where Nora told them. Sometimes parents rail and scream and attack the surgeon when a child is lost. Parents have lunged at Cooley and beat his breast until their hands are sore, but he never moves. The couple who had brought the child to the hospital, were both twenty-one, both incredibly young. They took the news with dignity. Only Nora’s eyes were clouded and he was rubbing them when he left the room.

Bill Murrah, the student chaplain from Alabama on a summer internship at St. Luke’s from Union Seminary in New York, leaned against the wall outside. “There’s not much you can tell them,” he said. “They don’t want any religious formulas or quotations from the Bible at a time like this. They just want to know if their baby is alive or dead, and if she is dead, would she have lived without the surgery. They all want to know that, they need desperately to be told ‘NO’ so they won’t feel like accomplices.”

Lola, the scrub nurse, hurried into the nurse’s locker room to dress and go pick up her four-year-old son who was staying at a nursery near the Medical Center. “All I want to do is hide in the bathroom,” she said. “Nobody’ll ever know I had anything to do with that precious baby’s death. The first patient I ever scrubbed on died … a Fallot.… That’s when I quit. For the first time.” A child’s death sends a shock wave through the women of the heart team.

One of the motherly-type nurses picked up Kim from the operating table and wrapped her in a pink and yellow blanket and took her out to the surgical corridor, where a rolling baby crib was standing, the same bed in which she had been brought—with her mother leaning over her—to the operating room, the same bed in which two pink diaper pins and a pacifier were waiting for her. The nurse pulled a green sheet across her baby and in a few moments, a coordinating nurse from Texas Children’s gently took her and carried her by hand to the morgue.

Another child was on a rolling bed in the surgical corridor as the coordinating nurse walked by. She had a curious pinched face and she refused to laugh at Dr. Girgis, the Egyptian-born anesthesiologist who was taking used surgical gloves and blowing them up like balloons and drawing faces on them with his felt pen. He had almost filled up her bed with the cheerful faces but she was not a child who knew how to laugh.

“We’ll save these for you,” he said. “You can play with them tomorrow.”

The child told me her name was Joy and that she was the daughter of a truck driver from Oregon. She was eight, she said, but she looked half that. The blueness of her Tetralogy of Fallot made her appear cold.

There was a depression buried within me, and it had been roused with the baby’s death. I was weary of the hospital and its surgery. My own son, my second son, would be coming from his home in New York to spend the summer with me. Despite his strong body, despite his ability to plant his skis together and take the plus difficiles runs in the French Alps or plow into his older brother in Central Park carrying a football, his heart had something wrong with it. Nine years ago he had been born in this very Houston hospital and the pediatrician had heard a murmur—not a grave murmur—but a worrying, hissing echo that vibrated the tiny chambers. Cardiologists in New York and France had listened to it in the years that followed. They kept saying that he should be examined every year or two, but that his life need not be restricted. “Do not tell him about the murmur,” the doctor in New York had said. “Don’t let him favor it.” I had planned to have him examined by Cooley’s staff, but—had an operation been indicated that afternoon, if there was talk of the knife—I could not have signed the paper to deliver him into a surgeon’s hands. I dressed and left the hospital. I found a movie to erase two hours. I telephoned New York and spoke with my son Scott, who was full of plans for his return to Texas. I hung up and called the hospital; its lure was not to be denied. John Zaorski had night duty again and he was brusque. Things were, he said, frantic.

I found him in Recovery. “I’ve gotta go tell a man his wife just died,” he said. He was writing a death certificate. In the corner, nurses were pulling drapes around the bed of an elderly woman who had had a double valve replacement the day before. She had arrived at St. Luke’s in grave heart failure, bubbling from the fluids in her lungs and chest. “She was almost dead before the operation,” Zaorski said. “I went down and told her husband about an hour ago that she wasn’t doing well, so he’s prepared.” Death messages were normally given in two stages. If the patient died during surgery, Cooley or a fellow went out and said that the operation was not going well, that serious problems had arisen, that there was little hope—even though the patient was already lost and being sewn up. Then, half an hour, an hour later, the final news was delivered. “It’s easier that way,” said Zaorski. “On us and on them.”

The neatly dressed old man was in the Family Room. He looked up, unable to control the twitches in his unshaven cheeks. “I’m sorry,” said Zaorski immediately upon entering the room. “We did everything we could. But she’s gone.…”

Instantly the old man wept, silently, ashamedly. He apologized for his tears. Zaorski intruded tactfully on his grief. “There’s just one more thing,” he said. “We’d like to examine her heart. We can maybe learn better why she died.”

“I don’t object to that,” said the new widower. “If her death could help anybody else.…”

On the long walk back to the coffee room, I asked about Joy, the child who had followed the baby into surgery.

“Who?” asked Zaorski, searching his mental list of the day’s surgery.

“Joy, the last little girl, the Fallot.”

“Oh. She died on the table.”

“Two in one day on the same table?”

“Yeah. Couldn’t get her off the pump.” Zaorski walked on with his head down. Was his shield cracking, or was he too much of a tyro at the business to have one? “Sometimes,” he said, “this is a lousy service … sometimes it’s worse than a leukemia ward.”

He telephoned Pathology and reported permission for the woman’s post. “It’s been a rough night,” he said later in the coffee room. “Just before you came, there was a STAT call on sixth-floor ICU.” (STAT is short for the Latin “statum,” which means “immediately” but in hospital code it means “emergency.”) An 86-year-old woman with a pacemaker had arrested and when Zaorski got there the nurse had her on the respirator and somebody else was massaging her chest. Zaorski hooked up the cardiac press and put an endotracheal tube down her throat, the kind with a balloon attached to the end of it. Once the tube gets down, the doctor pumps on the balloon and it stops air from going to the stomach and pushes it directly into the lungs. Zaorski also shot adrenalin into the heart. But the scope stayed flat. Nothing would bring her back.

“This may be the Tet offensive tonight,” said Zaorski. “They’ll be dropping from the trees.”

Shirley, the Recovery nurse, rushed in near midnight with her half-smile that concealed worry. She had the chart of a young Italian woman named Vincenza who had appeared at St. Luke’s looking like a concentration-camp survivor. Vincenza had sunken cheeks to which she applied bright, heavy rouge, giving her face the appearance of a death mask. She weighed but 78 pounds and she had Ebstein’s Disease, a rare defect of the tricuspid valve that few surgeons would touch. Cooley had put in a new valve and now Shirley suspected tamponade, bleeding around the heart. There was no urine output to speak of either.

“All right,” said Zaorski. When Shirley was worried, John followed through. As Zaorski was leaving, a young brunette ward nurse interrupted him. She had an expression of absolute exasperation on her face.

“It’s Mr. Castle,” she said. The old farmer had been transferred from the semiprivate room, where he had been keeping Carstairs awake, to the ward for disturbed elderly patients down the hall.

“What’s Mr. Castle doing?”

“He’s disoriented, climbing out of bed, yelling, disturbing half the floor.”

“Tell me something new. What did you give him?”

“Thorazine and Demerol,” said the nurse. “But he’s still very much with us.”

“How much Demerol?”

“Thirty-five milligrams.”

“Give him 50 more.”

The nurse looked startled. “I don’t want to pile all that Demerol into an 81-year-old man.”

“Look,” said Zaorski, impatiently. “What’s Demerol going to do at worst—depress the blood pressure, right? You’ve gotta depress him, or he’s gonna kill himself.”

“Okay.” The nurse gave in.

“Did you tie him down?”

“Hours ago.”

“I’ll be by to see him.”

Zaorski went into Recovery first, where the emaciated Italian girl, perspiring heavily, was almost lost in the bed. He looked at her x-rays. Shirley slapped them onto the viewer and winced in pain. The nurse had bursitis, aggravated from reaching up so often to put the x-rays in place. Zaorski ordered digitalis and a plasma-type fluid for Vincenza. “If I give her more blood,” he told Shirley, “it’ll thicken up the blood she already has, and make it even tougher to get it circulating. Which is what she needs.” He did not buy Shirley’s suspicion of tamponade.

In the disturbed patients ward, Mr. Castle had kicked over his intravenous stand several times and was generally driving the ward nurse up the wall. His favorite trick was to wiggle down to the middle of the bed, drape his legs over the end, and kick, as vigorously as a child learning to swim. The nurse would lug him back to where his head touched the pillow and scold him, and as soon as she turned her back, he would wiggle back again. She had finally tied his hands firmly to the rails with white furry straps that could not cut him.

“Poor old guy, he’s screwed up. This sometimes happens when the cardiac output fails.” Zaorski watched him struggle against the retaining straps. “He’ll be all right.”

Within half an hour, Vincenza’s urine tube was beginning to fill, a sure sign that the digitalis and plasma were working and that the heart was pumping strongly enough to support the kidneys. “Score one for our side,” said Zaorski. He noticed that Shirley was still in pain from the bursitis; he persuaded her to take a cortisone shot and permit him to bind her arm to her waist. “Trust Dr. Zaorski,” he said. “Keep it that way and the pain’ll go away in a day or so.”

Hospitals normally quiet down after midnight but not this night. A fat woman cried out all night with gall bladder pain; Zaorski went to see her twice and agreed that she probably hurt, but not enough to wake up the whole floor. Another Italian, a woman in her mid-twenties named Maria Celestina, was causing her usual trouble. Hers was one of the more interesting cases on Cooley’s service. A pretty, vivacious girl, she had fallen down a well in her village when she was a child and developed a traumatic aneurysm of the thoracic area. Surgeons in Italy had wrapped it with cellophane, but it had grown worse over the years and she had come to Houston. Cooley had excised the aneurysm and replaced it with a Dacron graft. She seemed to be recovering satisfactorily in her room, but she was still a bit goofy and considerably lonely. The only English phrase she felt comfortable with was “Please help me” and she sang it and moaned it with orchestration. What she mainly wanted was company. The fellows had all learned her trick; she would exhort, “Please help me” as one passed by her open door. If he succumbed to the lure and went to see if anything was the matter, she would beckon for him to come close to the bed and try to grab him.

Maria Celestina started warbling “Please help me” in Puccini fashion close to 3 A.M. but Zaorski was too tired to do anything but slam her door shut, firmly, as he went to see about quieting down Mr. Castle for the fourth time.

The week was disastrous. “We go through long periods when nothing happens,” said one of the fellows in the coffee room the next morning. “Weeks when everybody gets well, months when nobody dies, nobody even bleeds around a graft, then we get a week like this and I’d like to switch to dermatology.”

Cooley was doing a routine valve replacement later that day when one of the stunning mysteries of cardiac work occurred. At St. Luke’s it is called “stone heart” for lack of a better name. The patient’s left ventricle suddenly went into a spasm, not unlike a Charley Horse in the leg, and nothing yet known to medicine could bring it back or save the patient. Neither the origin nor the cause is known.

“It’s almost like witchcraft,” said Jerry Strong. “It could be something muscular, or pollution in the air, or a fall in the stock market for all we know.” Cooley said he has not seen more than a dozen cases in the past decade, and autopsy reveals nothing because the spasm is over by then. “I used to think it might be due to some pump defect, but I’ve dismissed that idea,” he said.

As he always does when the rarity occurs, Strong injected all manner of medication into the patient’s intravenous, hoping that something or some combination of something would stop the spasm and allow the heart to function. But nothing worked. “When it happens,” Strong said, “they’re dead. Period. I must have dumped twenty different kinds into him. I personally think we ought to put all known medicines into one jug, label it Lazarene, stick it in him, and pray.”

About 6:30 that night John Zaorski had ducked down to the basement cafeteria and was well into a Salisbury steak when over the chatter of the room he heard a faint page. “Cooley Fellow, Three North, STAT. Cooley Fellow, Three North, STAT.” Some hospitals page Dr. Blue, but the meaning is universal: a heart has arrested and there are but a handful of moments before it becomes permanent death.

In mid-bite Zaorski dropped his fork, bolted out of the cafeteria, almost bumping into two nurses weaving their way through the crowd. For a big man he could move fast, side-stepping the “CAUTION—Wet Floor” signs, which made the central corridor an obstacle course.

The patient was a frail, blue old woman who was stretched out on a reclining lounge chair beside her bed. Her mouth was gaping, her eyes were dilated. She was dead. Zaorski picked her up and flung her like a rag doll onto the bed and began the rhythmic pushing on her chest. (The tabloid-familiar custom of slicing into chests and massaging hearts is passé; superior results can be obtained with closed-chest massage.) A young inhalation therapist tore into the room at the same moment and clamped a breathing bag over her mouth. The nurse stood there chattering away, stunned by the whole affair. “She was fine, she was just fine. She had her dinner, she saw the doctor, she was sitting in the chair looking out the window and watching the TV”—the set was still on, droning out a comedy—“I looked in and saw she was gone and I pushed the chair back so she’d lie flat and I sent out a STAT call.”

Zaorski nodded but was paying little attention. The look on his face revealed frustration; his pushing and the therapist’s squeezing seemed to be having no effect at all, and time was running out. Suddenly, almost magically, the old woman’s chest heaved, she gasped, she choked, and back she came from death. “She’s on her own!” Zaorski cried triumphantly. “Let’s get her into Recovery.” The nurse turned to find a stretcher, but he stopped her. “Let’s just keep her on the bed,” he said, abruptly pushing the end out into the hall. With the therapist on the other end, the procession sped through the surgical waiting room—where the families, startled, were lined up to go in at seven and see the patients—and into Recovery, where a swarm of doctors hooked her up to the machines and monitors.

Several days later, the woman, a tough, chipper Bostonian, was preparing to leave the hospital and return home. She had no memory of the incident other than waking up in Recovery, a place where she had been ten days previous, after her heart surgery, and a place she had grown to dislike. “I must have fainted,” she said, and the nurse nodded. No one ever remembered those moments on the other side. One woman suffered more than 30 cardiac arrests during her three days in Intensive Care Unit. Flat EKGS, the works. Each time the doctors and nurses would bang on her chest and resuscitate her and each time she would rouse and murmur, “Did I have another one of my sinking spells?” Once she came to just in time to see the nurse preparing to hit her chest and she said, with insult, “And I thought you were my friend.”

Happily, Maria Celestina quieted down for a while after a quarter of an hour trans-Atlantic telephone conversation with her sister in Italy—a poignant, sobbing, laughing, sometimes hysterical conversation. Everybody on Three North shared her pleasure.

But sadly, Mr. Castle threw a clot to his brain and died that night in the senile ward. It upset the nurse who had been contending with him. “I wish they had left the old man alone,” she said, moping around the nursing station. She was a young registered nurse who had not experienced the loss of many patients. “He was such a nice old man, he was eighty-one, and he’d never been in a hospital before and I had to help him make a phone call to his family because he’d never even had a telephone in his house. He was telling them to be sure and water his tomato plants.”

Cooley stayed in his operating rooms from sunrise to sunset, almost as if one death could be assuaged by fixing two more hearts. He betrayed no emotion, no public tears, most likely no private ones. A friend said he was “un-emotional.” He was, surely, affected by the complications and the run of deaths. “There is no more heat anywhere in medicine than in heart surgery,” observed Don Bricker, who had been through the DeBakey program, had operated across from Cooley, and who was now heading surgery at Ben Taub. “There’s simply no area of surgery where you can lose patients on the table as you do in heart work. Gun shots, traffic-crushed victims—these patients may crater on you. But with elective heart surgery, you’re the guy who makes the decision to operate, and when you fix the heart and it doesn’t start up again, then you’re the guy who killed him. When it happens to me, I go out and sit somewhere and weep.”

Months later, on a Saturday morning in his office, Cooley and I would talk about death. I had never seen a crack in his shield, not even a shadow across his face. How did he hide, or was there anything to hide? “I think I’ve built a shield,” he answered. “One of the big problems, it seems to me, is how the surgeon deals with his disappointments. How to deal with his personal errors, shortcomings, poor judgment, or the complete and total failure which is death. I’ve observed other surgeons who just take it in their stride, the ‘well-we’ve-done-our-best-school.’ I have not been capable of taking it that way. Perhaps you just don’t see it within me. But what can I do? You’ve got to go on, that is the only way to overcome disappointment. Continue your work and realize you are doing good. The tragedy comes when you get two or three bad ones at once and you stop and you start to wondering if you’re doing the world any good at all.…”

“Do you ever wonder that?”

He shook his head firmly and negatively.

At the end of the bad week, someone remarked that it had been reminiscent of the transplant era, of the saddening days when the first batch of Cooley’s transplants, six apparently healthy and rejuvenated people, all started rejecting and dying, and rather than stop, rather than a moratorium, Cooley did more and more. Eight became twelve, fifteen turned into twenty. “His hands had never failed him,” said a friend. “And he couldn’t understand it.”

But any confidence misplaced or temporarily lost during the transplant year had long since come back. Cooley seems to feel that if he cannot help a patient in the operating room, if his hands cannot find and hold the spark of life, then it simply cannot be done. “Denton knows when he has done a good operation,” observed a senior member of his team. “But he doesn’t go to all extremes to keep them alive in Recovery or ICU. If they don’t get better due to their new hemodynamic situation, then …”—the doctor made a hopeless gesture with his upturned hands. “Mike DeBakey, conversely, will go to hell and back to keep the patient alive. If he dies a month later at home—well, the operation was a success.…”

At the Saturday morning pathology conference, Cooley talked briefly and dispassionately of the ten-month-old baby Kimberly’s death. One case a week is selected for extensive discussion. “It was a most confusing heart,” he said. “She had such complete heart block afterward that even a pacemaker wouldn’t drive it, and we ended up with a fiasco on our hands.” Dr. Rosenberg, the pathologist, took the infant’s heart out of a plastic container and put it on a sheet of wrapping paper to give his theories. “The septum was closed, there was a grotesque left ventricle. And note this unusually deep cleft in the mitral valve, which is rapidly becoming our most frequent rarity.”