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.
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The first case was a carotid artery, and Norman began to cut away the fat and muscle to expose the occluded blood vessel. “We’re going to take out the eggs, the restaurants, the late nights, the cigarettes, the bad women,” he said, trimming back the flesh around the vessel. “I can feel the cholesterol in there. It’s like a rock. If your artery clogs up like this you’ll get a stroke.” Now he had a four-inch stretch of artery exposed. “This is more a preventive operation than a curative one. They did the first one in France in ’forty-eight. I think DeBakey introduced it here in ’fifty-one or ’fifty-two. Anyway, he and Cooley popularized it.”
Cooley ambled in, cut open the artery, and took out a glob of yellowish material that felt like a piece of rubber. He cut a small piece of Dacron and began to patch up the incision.
“Dr. Cooley,” said Norman. “Who was it that first did this operation?”
“Denton A. Cooley,” Cooley said.
Up in his office after the operation, Norman said, “Was it Cooley or DeBakey? Who knows? It was probably one of their assistants. It doesn’t matter; they popularized it. This medical center was nothing in 1948. And you couldn’t have picked two better types to build it up. They’re cut from the same cloth. They’re robber barons, megalomaniacs, great talents. I’ve known Cooley since I was a boy. I first heard of him when I was an intern, in ’fifty-four. Since he started, he’s been the hottest thing coming down the pike. He is bloody good. He’s smooth, he’s slick, he’s a gifted person. He and DeBakey are not ordinary people. There’s something in these guys. They’d pay you to let them operate on you, if they had to. Look what they’ve accomplished—my God!”
Norman walked out to the coffee machine and poured himself a cup. He also cut a big chunk from a fruitcake that was sitting there and stashed it behind his desk for later consumption; he hardly eats, and when he does it is in the office, because he considers even the hospital cafeteria a waste of time. As he was settling back again, there was a call from the operating suite: Dr. Cooley felt things were going too slowly, so could Norman get back downstairs?
In Room 3, a large, white-haired man, a bypass case, was spread out on the table. A junior surgeon was down at the foot of the table tugging out the saphenous vein. Norman positioned himself near the head, sliced down the chest with a scalpel, and picked up the electric saw.
“This guy is D.A.C.’s neighbor,” Norman said. “River Oaks. Fat, too. We’ve got a millionaire on the table.”
Cooley walked in. “What’s this guy do, doctor?” Norman said.
“Plaintiff’s lawyer.”
“Oh, yeah? What kind of work?”
“Oh,” Cooley said innocently, “you know, medical.”
“He sues doctors?” said Norman. “Turn off the machine!”
When Cooley had done three of the five bypasses on the man’s coronary arteries, Norman had to dash out to give a speech to a group of cardiologists-in-training in the Texas Children’s auditorium. He ran to his office, where an assistant showed him, at an approximate rate of two per second, the slides he was to talk about. Then he gathered them up, dashed downstairs, pocketed a sandwich that was sitting on the table outside the lecture hall, and whizzed through an hour’s talk about the progress on the ALVAD.
Back in his office, Norman carefully avoided a group of visiting dignitaries in town for the convention of the American Association for the Advancement of Science. A Texas Heart Institute fellow from India, about to return home, came in to say good-bye. His mastery of English was not complete, so he just wrung Norman’s hand and murmured over and over, “Great man, great man.” Later there was an interviewer from the Canadian Radio Network and then a group of four scholars from Stanford who were doing research on ethical and political issues in medicine and were interested in the ALVAD.
Norman is Cooley’s emissary to the medical ethics world, which views Cooley himself with great suspicion because he doesn’t play by everyone else’s rules. One of Norman’s jobs is to make sure the ALVAD is developed in a way that doesn’t horrify the respectable medical establishment, and with the Stanford group he took great pains to explain the detail with which every step of the ALVAD’S trials was being recorded, the care taken to get informed consent from the patients, the closeness of the Heart Institute’s cooperation with the government, the discretion with which the project team was handling the press.
“Before December 23, 1975,” he told the group, “we had no idea what would happen in man. None. Zero. We had done five hundred calves. We still didn’t know. And each time we did a patient we learned. We reported everything.” He went on to describe their progress, ending with an account of the Valentine’s Day transplant.
“That sounds like the old Cooley,” one of the visitors said sarcastically.
“Oh, no,” said Norman, “that was done under the auspices of the National Heart, Lung, and Blood Institute. We did complete reports. I’m basically a company man.” A sign of the cooperation is that the government foots the bill for ALVAD implants, at $25,000 to $30,000 a case.
An intriguing question is what happens if Norman is right about ALVAD and it does work. Does the government make it available to everyone whose life it could save, adding perhaps billions of dollars to the national budget to keep a small, old, very sick minority of the population alive a few more years? Or should it be available only to those who can afford it, with the thousands of others who could have benefited by it dying for lack of funds? Norman is as aware of this dilemma as anyone, and he accepted an article for Cardiovascular Diseases that speculated about a national health agency in the year 2002 passing out perfected ALVADS to a computer-selected random minority of those people who needed them rather than funding every case.
I asked Norman what his own solution to this hypothetical ALVAD dilemma would be, and he said he didn’t know. “Should I be doing what I’m doing—developing something that may or may not work—or should I be working in Ben Taub?” he said. “That’s a tough one. I guess it comes down to where I am best used. Should health be a right or a privilege? I know what it is: it’s a privilege.” He pulled his surgeon’s cap down over his forehead and leaned forward confidentially. “It probably should be a right.”
“You know,” he said, changing the subject slightly, “it’s very rewarding taking care of patients. One time I was up in Washington at a conference and there was an engineer from Switzerland there who had banged his finger. There I was—the great researcher, hearts, philosophy, papers, right?—and I said, ‘Wait a minute.’ I took off my registration nameplate. I heated the pin on the back with a lighter. For ten minutes I spun the pin on his fingernail, and I opened up his subcuticular hematoma. His pain went away immediately. He felt good. I felt good.”
Like so many of the doctors who work at the Texas Medical Center, John Norman is a man of extraordinary intelligence and capacity for productive work, dazzlingly skilled, his heart firmly fixed in the right place. What has primarily motivated him in life is a strong desire for this country’s highest nonmonetary rewards—prestige, recognition, being the best. Working at Ben Taub or fixing someone’s painful finger does not seem to him to be the fulfillment of all his talent and promise and expertise—it may be health care but it isn’t medicine. So he works on an expensive, experimental replacement part for the human heart. It’s path-breaking work, and he says that in a few years the ALVAD will be perfected. And when it is, I asked him, what happens them? He shrugged. “Our society probably won’t be able to afford it. Think of what the money for one ALVAD could do if you spent it in Fifth Ward.”
Norman’s last case on that day was a replacement of an artificial valve in a woman’s heart. After her first valve replacement the woman had stopped taking her anticoagulant pills, and as a result the valve had clogged up and she had had two strokes. When Cooley came into the room he cut open her heart and took out the old valve, a hard plastic-and-wire affair that was filled with clotted blood.
The schedule was running smoothly again, and Cooley was in a good mood. “Did you know, Jack,” he said to Norman, “that I applied to Harvard Medical School?”
“No kidding. What happened?”
“They turned me down. You know why?”
“Why?”
“On my application, I said I liked girls. When they turned me down I said, ‘Hey, wait a minute, I could also learn to like boys.’ But they said, ‘Sorry, you have to have it from birth.’”
Cooley picked up the new valve, which was more technologically advanced than the old one, a soft, floppy disc the size of a half dollar, made from a cow’s pericardium.
“You know,” said Norman, across the heart, by way of conversation, “in two weeks I’m going on a site visit for NIH.”
“Jack,” Cooley said, “you got to stand up to the government. That’s what they want. Now myself, I’m going on a cruise.” This was in reference to the Heart Institute’s symposium, “Advances in Cardiovascular Medicine and Surgery,” to be held the next week aboard the Stella Solaris as it cruised from Galveston to Cozumel to Montego Bay, laden with doctors and Houston executives. “With my friends and neighbors…white flannel trousers…with cameras at the ready…” While he talked, Cooley was running stitches from the inside of the heart through the edge of the new valve, building an intricate cylinder of threads, in the middle of which the valve was suspended.
“Did you see the folks from the American Association for the Advancement of Science convention?” said Norman. “They were here today, looking around.”
“Ah, good. Did we discuss algorithms with them? You know, we’re at the forefront of the advancement of science. We’re the nose cone of the advancement of science….” Cooley got a dreamy look in his eyes at this talk of intellectual matters. He was finished sewing the valve by now, and looked at it suspended there in the threads for a moment. “Ah,” he said, assuming another of his voices, this one an excruciating pidgin French. “Ah, littérature.”
“Literature,” said Norman.
“Ah,” said Cooley, still in his French accent, “Massachusetts.”
“Massachusetts.” Here was Norman called on once again to defend the East, private schools, big government, and play-by-the-rules medicine. “Ah, Texas,” he said. “The lonely frontier.”
Cooley chuckled and pushed the new valve into the heart.
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