Tuesday, July 2, 9:45 a.m.
After more than two hours in operating room #4, one of Bellevue’s newest hybrid ORs, Mitt could not believe how much more interesting his second day was from his first right from the get-go. During much of his first day of surgery, particularly the first several hours, he’d seen little of the operative procedure since his line of sight had been blocked by Dr. Geraldo Rodriguez’s torso. On today’s open-heart surgery case, which was a mitral valve replacement on Ella Thompson, there had been no such problem, even though Dr. Rodriguez was again the first assistant. And good visibility wasn’t the only beneficial change for Mitt. Yesterday he’d spent the entire case using both hands to pull up and back on a retractor, which had not been easy, especially for eight hours.
On today’s case very little retraction had been needed because the cardiothoracic attending surgeon, Dr. Pamela Harington, who was the associate chief of the department, had employed an instrument called a sternal retractor. After using a vibrating bone saw to cut through the sternum vertically, she’d put in the sternal retractor and cranked it open, which fully exposed the fatty pericardium as well as sizable portions of both alternately inflating lungs. Mitt had been spellbound, especially watching the opening of the pericardium to expose the beating heart. As a medical student, Mitt had never seen an open-heart surgical case, although from a technical perspective he knew a considerable amount about the heart-lung machine that made it all possible. He’d been directly exposed to an extracorporeal membrane oxygenation machine, which operated under similar technological principals, during his third-year internal medicine rotation.
To make the situation even more engaging and personal for Mitt, Dr. Harington had taken an early and strong interest in his participation when she’d been told by Dr. Rodriguez at the beginning of the case that it was only Mitt’s second full day as a resident. That fact had clearly caught her fancy, as she was quick to say that she, too, had done her surgical training at NYU and mostly at Bellevue, although she’d gone on to do a fellowship at the Cleveland Clinic. It was obvious to Mitt that while she was thinking of him, she was mostly waxing nostalgic.
“You must be thrilled, Dr. Fuller,” she added now as she looked across at Mitt during an unexpected delay in the procedure caused by the perfusionist, who wasn’t quite prepared to go on bypass. He was still busily in the process of priming the heart-lung machine when Dr. Harington announced she was ready to insert the cannulas to divert the blood away from the heart. Mitt was on the opposite side from Dr. Harington, once again nestled between Geraldo and the anesthesia screen but with a completely open view of the operative site. “I remember my first few days as a resident as if they were yesterday,” Dr. Harington continued. “I hope you are aware just how extraordinary and exciting a journey you’re beginning. Although I’m sure you had to have worked hard to get here, you are a lucky, lucky man. All I can say is, enjoy it!”
Mitt nodded as if agreeing, but after the previous day and night, he wasn’t sure that enjoy was the right verb. He was thinking survive might be more applicable. Nor did he feel all that lucky. Although he was presently fascinated by the operation, he was exhausted mentally and physically after only one day and one night. The worrisome question of how he’d be feeling after a week or a month dogged him.
Despite how bad he felt physically, he’d somehow gotten through rounds at 6:30 a.m., during which he was introduced to the rest of the surgical residents. Andrea had been particularly eager to learn how his evening had gone, but there hadn’t been time for him to explain in any detail. All he said was that he’d fill her in later. During rounds he’d managed to briefly present his three cases, including Ella Thompson, whose surgery he was now witnessing, along with those of Roberto Silva and Bianca Perez, whose surgeries were to follow Ella Thompson’s in the same OR.
During rounds, Andrea had presented her cases as well, but no one had told her beforehand to be succinct. Instead, Dr. Kumar had interrupted her first two presentations to speed things up and encourage her to concentrate on just the important facts. By her third, she’d finally gotten the message.
All in all, the morning rounds had gone smoothly, with just a few minutes spent on each case. If there were clinical management problems, like a postoperative fever or lack of bowel sounds after abdominal surgery, the whole group lingered a little longer until a consensus was reached.
At the very end of rounds, there’d also been a brief discussion of the Benito Suárez calamity, but the conversation mostly revolved around the details of the patient’s aortic pathology, the difficulties that such pathology caused in suturing the graft, and the associated genetics. To Mitt’s chagrin, little was mentioned about the clinical catastrophe that had taken place and whether there was anything that he could have done when he first arrived on the scene to avert what had ultimately happened.
When rounds broke up, Dr. Van Dyke did take Mitt aside to commiserate briefly with him about the Suárez experience. Mitt appreciated her concern and could tell she was genuinely sensitive to his mindset. As a result, he was tempted to bring up his weird olfactory and visual hallucinations to get them off his chest, so to speak, and maybe find out if she had ever had a similar experience. But then at the last moment, he changed his mind. He’d not had time to adequately think through the experiences himself, and besides, he was worried that it might make her question whether he had what it took to be a surgical resident.
Mitt truly didn’t know what to make of the experiences, and they seemed crazy in the light of day. He’d always thought of himself as being reasonably creative, but conjuring up out of the blue horrific smells and a mysterious child seemed beyond his capabilities. Actually, now that it was daylight, it was even difficult for him to recall exactly how bad the smell had been and what the child had looked like, both of which lent support to the idea that it had been some aberrant, brief waking-nightmare.
After the rapid rounds, those who were scheduled for 7:30 surgical cases went to the elevators to go down to the eleventh floor, including Mitt and Andrea. As their elevator descended, he at least had an opportunity to tell her exactly how exhausted he was and that he hoped her on-call night would be a hell of a lot easier. Her response was to ask to hear more, specifically about the Suárez case.
“Let’s just say it was the worst clinical experience of my life,” Mitt had said, knowing that he wouldn’t have time to elaborate before Ella Thompson’s surgery. At that exact moment, the elevator door had slid open on the eleventh floor, and everyone, including Mitt and Andrea, piled out en masse and headed for their respective ORs.
“While we’re waiting to go on bypass, Dr. Fuller, let me share something with you,” Dr. Harington suddenly announced with obvious pride, breaking into Mitt’s brief reverie. “I happen to be an armchair devotee of Bellevue Hospital history. Maybe that’s not quite strong enough. Maybe a ‘connoisseur’ or ‘aficionado’ of Bellevue’s intriguing history is more accurate. To be honest, I can’t get enough of it. It’s a fascinating three-hundred-year saga with an astounding list of medical firsts. Let me ask you: Are you aware of the extraordinary history of this hospital, Dr. Fuller?”
“Yes, to an extent.” Mitt had no idea where this new discourse was heading, especially in the middle of an open-heart surgery case while waiting for the perfusion machine to be ready.
“One of the most interesting aspects, as you might imagine, is that there’s an extraordinary cast of characters involved, any one of whose life stories would make for a great Hollywood movie.”
“I’m sure,” Mitt said, wanting to be agreeable.
“Why I bring it up is that I recall there were actually a number of Dr. Fullers who served as Bellevue attendings over the years and who were, in their lifetimes, very well-known characters. Are you aware? Could these Fullers have been any relation?”
Mitt tried to look into the depths of Dr. Harington’s eyes to get some sense of where she was going with this unexpected topic. Yet it was almost impossible to tell because she was wearing a pair of surgical magnifying eyeglasses with a built-in bright light such that when he looked directly at her, all he saw was a glare. He had very mixed feelings about being associated with past medical and, in particular, surgical greats, which was why he’d never mentioned it during his application process. But at the moment, he didn’t see any way to skirt the issue. “Yes,” he said after a brief pause. “I am related.”
“Oh, my goodness gracious,” Dr. Harington said with obvious pleasure. “Oh, wow! I can’t believe it! That’s fantastic. As I particularly recall, there were three Fuller nineteenth-century surgeons. Are you related to all three?”
“I am,” Mitt said reluctantly.
“Oh my goodness! Isn’t this rather incredible, Dr. Rodriguez? We have a direct descendant of three historic Bellevue surgeons currently on our residency staff and helping us on this case. I think that’s outstanding.”
“Amazing,” Dr. Rodriguez agreed.
“I’m also related to Samuel Fuller,” Mitt said, attempting to divert attention away from his association with surgery at Bellevue. “He was the physician in the Plymouth Colony.”
“Interesting, no doubt,” Dr. Harington said. “But I’m more impressed with your connections to the Bellevue Fullers. I remember reading that Dr. Homer Fuller had been clocked doing a mid-thigh amputation in nine seconds. That’s skin to skin including sawing through the femur. Can you believe that? I can’t!”
“That’s incredible,” Dr. Rodriguez agreed.
“How close a relative was Homer Fuller?” Dr. Harington asked.
“He was my paternal great-great-great-great-grandfather,” Mitt said. “He was born in 1801.”
“My word! I think this is beyond fascinating,” Dr. Harington carried on. “I really do. Your relative must have been an amazing individual, although quite religious, I understand. Maybe even a bit over the top. But despite that, he and Dr. David Hosack, another famous Bellevue surgeon, were part of a team that took grave-robbing for dissection corpses to new heights, which, by the way, put Bellevue on the anatomical map. Wow! I mean, we’re talking about a very colorful history here. The downside was that Homer Fuller, who was some thirty years younger than David Hosack but significantly more religious, ended up being the leader of the anti-anesthesia group here at Bellevue.”
“Good grief,” Dr. Rodriguez said. “He was against anesthesia?”
“Yes, as crazy as it sounds today. He believed that the pain that patients experienced was God’s work and shouldn’t be interfered with, or something weird like that. Anyway, for a while here at Bellevue there was a ‘pro-anesthesia’ faction and one that was against, led by Homer Fuller. Luckily pro-anesthesia won out, for obvious reasons, yet as I understand it, Homer kept doing his lightning-fast surgery without anesthesia long after it was generally accepted by most everyone else.”
“Homer Fuller kept doing surgery without anesthesia?” Mitt questioned incredulously. He’d never heard anything along those lines, or even close. All he’d ever heard about his medical ancestors was unadulterated praise. It was a source of significant familial pride.
“Yes, it seems so,” Dr. Harington said. “That’s what I read, and I have a reference to an obscure, unpublished article that talks about this, if you’re ever interested to learn more. In the 1970s, an NYU bioethicist named Robert Pendleton, who was as fascinated by Bellevue Hospital history as I am, somehow came across some revealing primary sources. Unfortunately, his untimely death from a heart attack intervened and his work was never published. As great as the Fuller surgeons clearly were in terms of operative skill, they did seem to have a penchant for being on the wrong side of what we now know were major medical advances.”
“What do you mean?” Mitt asked, taken aback.
“Another Fuller named Dr. Otto Fuller was responsible for a number of important technical surgical advances and was also, strangely enough, on the wrong side of another major advance that was as important in many ways as the introduction of anesthesia. It was the antiseptic movement, which, at the time, was being championed by none other than Dr. William Halsted. I’m assuming you are also related to Dr. Otto Fuller?”
“Yes,” Mitt admitted. “He was my great-great-great-grandfather, born in 1835.” He’d heard so much about his Bellevue relatives, Mitt had all their associated dates committed to memory.
“My gosh, such fascinating history,” Dr. Harington said with an appreciative shake of her head. “Back then, before the Joseph Lister antiseptic crusade took over the world’s surgical centers, around half the surgical patients died of sepsis, including here at Bellevue. Since we’re so accustomed to strictly adhering to aseptic technique nowadays and take bacteriology for granted, it’s difficult for us to realize there was a long time before it was accepted. Back then, surgeons didn’t even wash their hands or their instruments or change their clothes before doing surgery, and sometimes they went from doing autopsies directly to the operating room or the delivery room without any preparation in terms of cleanliness whatsoever. It truly boggles the mind.
“What about Dr. Benjamin Fuller and Dr. Clarence Fuller?” Dr. Harington questioned after a short pause. “Are they also direct ancestors?”
“Yes,” Mitt answered. He was almost reluctant to admit it after hearing what she’d said about Homer and Otto.
“Two more high-powered Bellevue physicians,” Dr. Harington said. “Dr. Benjamin Fuller was the second surgeon in the world to perform a mitral valve fracture in 1925, the same valve we’re going to replace today, which they couldn’t do back then. Were you aware of that?”
“I was,” Mitt said, feeling a bit of relief to be reminded of something positive.
“He was a pioneer, for sure,” Dr. Harington said. “And extremely technically talented. But, like his two forebearers, he had his downside. He was a rabid opponent of the concept of informed consent, which was becoming a significant issue at the time. He felt strongly that charity patients, which is what Bellevue has always handled as a public hospital—and still does—had a moral or religious obligation to offer their bodies for medical research as their side of the bargain. From his perspective, since they got free care, he felt they were obligated to contribute, even had a moral responsibility to do so. The trouble was back then there was no limitation to what a surgeon could try, even on a whim, and a few of them tried rather strange therapies, like injecting tobacco juice.”
“Tobacco juice?” Dr. Rodriguez questioned with astonishment. “Why tobacco juice?”
“Heaven only knows,” Dr. Harington said. “It’s part of the reason Bellevue history is so fascinating. Of course, I’m talking about a long time ago, back when bleeding and purging were the primary treatment options.”
“I had never heard anything about Dr. Benjamin Fuller being against informed consent,” Mitt said when Dr. Harington paused.
“I don’t imagine you would have,” she said. “Especially because he had so many positive attributes. What about Dr. Clarence Fuller? I imagine he’s held in high regard in your family, with his contributions of putting Bellevue Hospital psychiatry on the world map.”
“I heard a lot of positive things about Clarence when I was growing up,” Mitt said. “I’ve even read a number of his papers predating behavioral therapy,” he added. He was tempted to say he’d briefly thought of psychiatry as a potential specialty but held himself in check.
“Yes, he certainly contributed early on to behavioral therapy,” Dr. Harington said. “As well as to psychotherapy. But he had a downside, too. He had been a strong, early advocate of lobotomies and was responsible for many of those done here at Bellevue before the procedure totally fell out of favor and he tried to distance himself from it. As I learned also from Robert Pendleton’s papers, he even did a huge number on children because at the time he was competing for the top job as division chief. His main competitor was Dr. Lauretta Bender, a big advocate of electroconvulsive therapy, which was getting her a lot of press. He even advocated lobotomies for behavioral problems of childhood, insisting it was far more effective than ECT, which often had to be repeated up to twenty times to get a lasting effect.”
“Okay, ready to commence bypass!” the perfusionist suddenly called out, breaking into Dr. Harington’s monologue. “Sorry to keep you all waiting. We’re good to go.”
“All right!” Dr. Harington said, and clapped her gloved hands excitedly. “Okay! Let’s get this show on the road!” She leaned over toward the anesthesiologist, asking if the patient was adequately heparinized.
“She is indeed,” the anesthesiologist replied, flashing a thumbs-up.
Mitt took a deep breath and changed his posture, moving most of his weight from one leg to the other. He was shocked to hear that his illustrious surgical forebearers had been on the wrong side of history in relation to anesthesia, antisepsis, and even informed consent. Up until then, he’d only heard how great they’d been, without having any idea their greatness was restricted to technical ability. As for Dr. Clarence Fuller, Mitt had never heard of his supposed support of lobotomy.
“I assume you know what we are doing here,” Dr. Harington said to Mitt as she got ready to implant the cannulas, which had already been prepared. The closed-circuit tubing had been severed and the appropriate tips connected.
“Generally, yes,” Mitt responded, trying to deal with the disconcerting revelations about his ancestors as well as his exhaustion. He’d read about open-heart surgery as a medical student and had a reasonable understanding of the basics but had never actually seen it done.
As the case proceeded, Mitt became progressively more enthralled. To his delight, Dr. Harington explained step by step how the patient’s blood was rerouted away from the heart, how the heart was then cooled to four degrees centigrade by the cardioplegia solution introduced through the coronary arteries, and finally how the patient herself was cooled but to a much lesser degree by the heart-lung machine to lower her metabolic demands.
Even though he was participating only by intermittently helping to maintain the necessary operative field exposure, Mitt was truly taken in by the whole process and for a time forgot how tired he was. He was especially interested in the opening of the left atrium and seeing the damaged mitral valve before it was removed. He then studiously observed exactly how the pig replacement valve was painstakingly positioned and sewed into place.
Mitt also couldn’t help but notice that as all of this was happening, the atmosphere in the operating room was congenial, particularly compared with the day before. An instrument, which Mitt was told was a pair of DeBakey forceps, named after the famous cardiac surgeon Michael DeBakey, somehow managed to leave the instrument tray and hit Dr. Harington’s right elbow as she was about to place another suture on the replacement valve, similar to the incident with Dr. Washington.
“So sorry,” the scrub nurse said apologetically as she quickly took the forceps from Dr. Harington’s hand. “How on earth did that happen?”
“I’m sure it was my fault for blocking your view of the operative field,” Dr. Harington said. “You were probably trying to see over my arm. I know it makes it difficult for you to predict what I’ll be needing if you can’t see.”
Another incident occurred when Dr. Harington and Dr. Rodriguez were exchanging a needle holder, since placement of a specific group of sutures was going to be easier from Dr. Rodriguez’s side. In the process the needle holder dropped. Once again, no ill feelings or attempts to cast blame on the other person.
“Sorry,” Dr. Harington said, immediately taking responsibility. “My fault.”
“Don’t be silly,” Dr. Rodriguez said. “I wasn’t watching like I should have.”
Curiously enough, Mitt had been watching, and he had to blink several times, as it had appeared to him that the needle holder had somehow levitated out of Dr. Harington’s hand. Knowing that was impossible, he attributed the impression to his exhaustion, just as he had attributed last night’s weird hallucinations. As a medical student, Mitt had been tired before, but he’d never been as tired as he currently was. Nor as anxious.
In due course all the sutures attaching the pig replacement mitral valve had been carefully placed, snugged up, and tied. Then there was the closing of the left atrium, which was carried out comparatively quickly. “How long have we been on bypass?” Dr. Harington asked the anesthesiologist as she straightened up when all was done.
“Forty-eight minutes total,” the anesthesiologist said.
“Not bad,” Dr. Harington commented to no one in particular. “Okay! Let’s start the weaning process and get the patient off the heart-lung machine. Are we good to go, team?”
“Good to go,” the anesthesiologist and perfusionist said in unison.
“All vital signs good and stable,” the anesthesiologist added. He switched on the ventilator with 100 percent oxygen, and the lungs began their rhythmical inflating and deflating.
“Excellent,” Dr. Harington said. And then to the perfusionist she said: “Discontinue the cardioplegia solution, while I begin to unclamp the aorta.”
When the clamp was off the aorta, she looked across at Mitt. “What I’m doing now allows normal blood to begin flowing through the heart, rinsing out the cardioplegic solution. That’s going to warm the heart up rapidly and get it to begin beating again on its own.”
Mitt nodded. It was fascinating to get to watch the whole process in real time. As impressive as it all was, he began to wonder if he shouldn’t at least consider a future in cardiovascular surgery as a subspecialty despite the previous day’s disaster.
A few minutes later silence fell as everyone watched the heart, waiting for it to begin beating. Unfortunately, long minutes passed but the heart remained motionless. “Hmmm,” Dr. Harington voiced under her breath, more to herself than anyone else. “I don’t like this. What the hell is going on here?”
Over the next three quarters of an hour, Mitt sensed the atmosphere in the operating room progress from congenial to tense. Ella Thompson’s heart was refusing to cooperate. Instead of immediately returning to its normal beating, it remained stubbornly quiescent. With increasing frustration, Dr. Harington tried a series of shocks using sterile paddles supplied by the circulating nurse. Unfortunately, none of the shocks worked, and the ceiling-mounted heart monitor continued to trace a totally flat line.
Following the unsuccessful shocks, Dr. Harington tried an internal pacemaker at the recommendation of a Cardiology consult conducted over the intercom system. But there was no response whatsoever, even over an extended period. The anesthesiologist sent off an emergency blood electrolyte sample, but the results came back normal.
“Was there anything at all from your end that might have suggested there’d be a problem?” Dr. Harington asked the perfusionist.
“Nothing,” the perfusionist responded. “Not a hiccup. Everything has been rock stable and normal.”
“My word,” Dr. Harington said with obvious despair. “Who would have guessed? Certainly not me. I suppose this ticker was a lot sicker than any of us imagined. But I’m truly amazed. There’d been no hint.”
Mitt sensed where the conversation was going and experienced a rising sense of dismay. The previous evening when he’d done Ella’s history and physical, he’d felt an emotional attachment to the woman, such that the idea that she was now—less than twenty-four hours later—on the brink of death seemed like an impossible transition. It made him feel complicit, as if he were somehow responsible. He’d had several brushes with death as a medical student, but each of those patients had been in extremis when Mitt had been assigned. The deaths had never involved a functioning, seemingly happy, family-oriented, and connected human being, who had lots of grandchildren and even more great-grandchildren.
“What about using ECMO?” Mitt blurted out without much thought. “Couldn’t an extracorporeal membrane oxygenation machine tide her over until her own heart comes back online?” The idea of just giving up seemed totally unreasonable.
Dr. Rodriguez chortled but then admonished himself for doing so. “Sorry,” he said. “I don’t mean to laugh, but using ECMO at this stage would just be putting off the inevitable and ultimately be a disservice to the family and the patient. The heart’s been at body temperature and fully oxygenated for more than an hour. If it was going to restart, it would have done so before now. This is real life. You win some and you lose some.”
Mitt felt a pang of panic. He didn’t want to stop trying. “Isn’t there something else we can do?” There was a sense of desperation in his voice. “What about some kind of ventricular assist device or even a heart transplant?”
“First of all, you can’t assist a ventricle that’s not beating,” Dr. Harington said, sensing and appreciating Mitt’s anguish. “And second, do you have any idea of how many patients are currently waiting for a transplantable heart who are considerably younger than Ms. Thompson? Let me tell you: more than seven thousand. No, she’s not a candidate for a heart transplant. As hard as it might be, we have to accept our limitations as physicians and surgeons. We’ve tried our best, and for some as-of-yet-unknown reason, it wasn’t enough in this case.”
After her minor soliloquy, Dr. Harington abruptly stepped back from the operating table. Reaching behind her neck, she undid her gown, then pulled it off. Next she stripped off her surgical gloves as she turned to face the circulation nurse. “Inform the front desk we’ve had a fatality in here. They’ll know what to do. Meanwhile, everyone just leave everything as is other than turning off the heart-lung machine, stopping the IV, and stopping the ventilator. Don’t disconnect anything! Even leave the drapes in place! Everything!” With that said, she left.
A few minutes later Mitt stumbled into the surgical lounge in a kind of exhausted daze, feeling shell-shocked. He couldn’t believe it. His first two surgical cases as a resident had resulted in death. Although he hardly felt directly responsible, he did feel complicit. It wasn’t a good feeling.
“Dr. Fuller,” a voice called out. Mitt turned around to see Dr. Rodriguez coming directly toward him. With his surgical mask dangling below his chin, Mitt got a good look at his full face with its three- or four-day beard. He was a heavyset man with full, round facial features. “Hearing about your night with the Benito Suárez debacle, you must be drained. Is that a fair assumption?”
“Pretty close,” Mitt responded, worried he was going to be asked to do something menial.
“As you know, the Roberto Silva pancreatectomy will be in the same OR we’ve been in for Thompson’s valve replacement. Obviously, there’s going to be a delay with what’s happened and the need to involve the medical examiner’s office. Why don’t you beat it back to the on-call room and get a little shut-eye? I’ll give you a shout when Silva’s case is about to start, and you can pop back here and join in. What do you say?”
“I’d say that was a great idea,” Mitt admitted. He was taken aback by the fourth-year resident’s solicitude. It was unexpected but certainly appreciated. “To be truthful, I am really wrung out.”
“I’m not surprised. Go get some rest!”