Super Medicine
At the Texas Medical Center doctors can rebuild your heart, give you new limbs, treat your cancer, save your children from affliction, and maybe even bring you back from the dead.
(Page 10 of 12)
The Heart Institute was created by and around one man, Denton Cooley, whose bronze bust stands in the lobby. Cooley began planning the institute in 1962, when his departure from DeBakey’s cardiovascular service was complete, and it was formally dedicated ten years later. It is an institution carefully designed to be an efficient setting for the world’s largest cardiovascular surgery service, as well as a pleasant place for the surgeons there to spend the great majority of their time. What Cooley wants out of life is to live in a world where he can operate as much as possibly, under optimum conditions, and to be recognized as the greatest heart surgeon there is. He wants to operate faster and better and more than anyone else, and to take on the cases that make other surgeons throw up their hands. Like DeBakey, he is a prominent citizen of Houston and the world, with the emphasis more on Houston than in DeBakey’s case. He is constantly in the local society columns, and is a member of the local business establishment in a way DeBakey isn’t. If he seems today happier than DeBakey, part of the reason is that DeBakey wanted more, wanted to be a major figure in medical politics as well as a surgeon. Cooley, wanting only to operate, could build an institution around himself, exactly to his specifications, and be happy as a clam. DeBakey, wanting to change the world as well, had to move in an arena so big that he couldn’t possible control all its elements and so had to be always wary and sometimes disappointed. Even Cooley, because of his departure from Methodist and Baylor and his subsequent fame—is one of DeBakey’s disappointments, but DeBakey, precisely because he is so difficult and vain and competitive, may have helped, in a sense, to spur Cooley on to become what he is today. And Cooley, perhaps, has done the same for DeBakey.
The Heart Institute has eight operating rooms and does between 25 and 30 operations a day. In a single year 5000 adults and 1000 children will undergo open-heart surgery there, and another 1000 adults will undergo vascular surgery. About 200 of the 7000 will die during surgery or just afterward. All of these patients come to the Heart Institute because of Cooley’s reputation, but he doesn’t do all the operations himself. Residents and fellows open and close all of Cooley’s patients, and Cooley’s associates do some of the institute’s operations, sometimes to his specifications, sometimes on their own. But Cooley himself has certainly done, and continues to do, more heart surgery than anyone else in the world.
His bread-and-butter operation these days is the coronary artery bypass, an operation popularized in Cleveland in the sixties but now done in greater volume—3000 a year—at the Heart Institute than anything else. The aim of a bypass operation is to route blood around occluded arteries inside the heart, thus relieving angina pain and possibly preventing heart attacks. This is done by removing a length of vein from the leg and attaching one end of it to a coronary artery and the other to the aorta, so that blood will flow through the bypass rather than the artery for that distance. The vein used for the bypass is roughly the size and consistency of a large fishing worm, so sewing it into the heart taxes the eyesight and the hands to their limits. “Bypasses are Chinese water torture,” says one heart surgeon. “They’re lucrative and a good operation, but you start to see ‘em in your sleep.”
They’re also controversial, especially since the publication in 1977 of two studies claiming that the bypass does not prolong life or prevent heart attacks. The august New England Journal of Medicine, which is to medical journals what the New York Times is to newspapers, has warned that the operation is being performed on people who don’t really need it but who believe—without any evidence—that it will make them live longer. The journal said America’s bypass bill is nearly a billion dollars a year (each year about 3000 bypass operations are done at the Texas Heart Institute at a cost of $10,000 to $12,000—with the surgeon’s fee $4000 to $5000 of that—for an annual bypass income of $30 million), and that “the enormous funds already being devoted to this procedure divert support available for other, perhaps more necessary, aspects of medical care.” Virtually everyone at the Medical Center, of course, hotly denies these charges.
The reason people come to the Heart Institute in such numbers for bypasses—which are now available all over the country—is that when you know your chest is going to be opened up and your heart stopped, you want to get the very best care. Most people think the best care means the best surgeon—for pre- and postoperative care, you could stay in your hometown and be ministered to by a less busy organization. Dr. William A. Nolen, a Minnesota surgeon who had a bypass operation and wrote a book about it, decided not to go to the Texas Heart Institute when a friend told him, “Bill, if you think the Mayo Clinic is impersonal, wait till you see Cooley’s operation. It makes the Mayo Clinic look like the warmest, most sociable place on earth.” There are certain operations—on children’s heart defects, or on cases everyone else has given up on—where the reasons for choosing Cooley over anyone else are compelling. For bypasses, they are not; he has an efficient operation, great hands, and a very low death rate, but so do surgeons at a dozen other places. But in matters of this importance, it reassures people to know they’ll be opened up by the best pair of hands in the business, even if the difference between the best pair of hands and the seventeenth-best pair is insignificant.
For people in Houston the advantages are overwhelming because the Heart Institute is right there. The operation has become a sort of status symbol in Houston, and the city is full of men who are proud that they have had their chests sawed open and veins sewed onto their hearts by Denton Cooley, and then been put together again with wire and thread. Most of them say they never felt better, but some of them report one strange side effect of the operation. For about a year afterward, for no reason at all, there will be odd moments when these vigorous and successful men will suddenly burst into tears.
In midafternoon on a Wednesday in December, Cooley strolled into Operating Room 3 of the Heart Institute to do a bypass. By the time he got there, his associates had already opened up the patient’s right leg, pulled out part of the saphenous vein, and put it in a little cup of saline solution. They had sawed open the chest and pried the rib cage apart with a heavy metal retractor. They had cut open the pericardium (the sac around the heart) and routed the patient’s blood via large plastic tubes through a machine that temporarily takes over the work of the heart and lungs so that the heart can be stopped for the operation. Then they had draped the patient, so that all of him that was visible was the heart itself and the top of his head—his eyelids taped shut, electrodes attached to his forehead, his toupee in perfect array.
Cooley walked over to the right side of the operating table and the nurse handed him a scalpel. A big man, he was wearing glasses with what looked like tiny telescopes attached to each lens, and attached to his head was a flexible plastic tube through which shone a bright beam of light. He rested one hand on the heart and with the scalpel began to probe the yellowish surface of the heart for the artery. Completely steady and at ease, he drew the scalpel across the heart, making tiny pokes here and there, until there was a small ooze of blood. He had found the artery.
“Eureka,” he said. “I have found it.” He looked around the table at the assembled surgeons, nurses residents, and technicians. “Now who was it that first said that?” He spoke in a sort of Texas-accented W.C. Fields mumble that indicated he was preparing for a little operating room jiving.
“Archimedes,” someone said.
“That’s right,” said Cooley. “It was Archimedes, an ancient Greek.” He cut a small incision along the artery, making the hole where he would attach the bypass. “Now, Archimedes sat down in his bathtub one day and saw that he was displacing water with his body.”
He picked up the saphenous vein, cut it to shape, and began to sew it to the artery. He used a fine thread attached to a tiny crescent-shaped hook. With a needle holder in one hand he would push the hook through the vein and then through the coronary artery and then he would grab the hook with the forceps in the other hand and draw the thread through, completing the stitch.
“Archimedes felt that as much as he weighed was how much the water he displaced weighed. This was an important discovery. I have some friends who are architects, and they tell me when you build a building first you have to figure out how much that building is going to weigh. Then you dig up that much dirt.” He sewed through the last gap between the vein and the heart and drew them together. “You have to weigh the dirt to make sure it’s exactly the same as what the building’s going to weigh. It’s very scientific, you see. And that”—here he looked up from the heart and glanced around at his audience—“that, my friends, is the principle of real estate in Houston, Texas.”
The next case in that room, and the last case of the day, was a man with an aneurysm in the upper part of his aorta, perhaps the most difficult problem in heart surgery. He was 49 years old, obese, and hypertensive, and he had suffered from terrible chest pains for three years. The mood in the operating room changed completely. Cooley worked in total silence for two and a half hours; the room and the observation dome above were crowded with residents eager to see something this spectacularly difficult attempted.
Cooley cut open the blown-up part of the aorta and removed a mass of clotted matter the size of an orange, so big that it was difficult to imagine that there could have been extra room for it in a human chest. Then he began laboriously replacing most of the man’s aorta with an inch-thick, foot-long Dacron tube.
The great problem in the operation would be time. The heart-lung machine, which reroutes, pumps, and oxygenates the blood while the heart is still and thus makes open-heart surgery possible, can be dangerous if used too long. After too much time on the machine, the blood, already thinned with an anticoagulant called heparin, can refuse to clot. Any of several organs can fail. The safe time to be on the machine is generally thought to be one hour, though Cooley had had this patient’s body temperature lowered to 68 degrees in order to make it safe to be on the machine longer.
My Library
