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 5 of 12)
DeBakey still does delicate surgery, still flies all over the world, still testifies in Washington and lobbies in Austin, has a young wife, and a one-year-old baby, wields enormous power, has both achieved more and been recognized more than most people ever dream of. He even gets along with the private medical community now. But he is also inescapably 70 years old and that can’t make him happy — what other explanation can there be for the dyed hair and the platform heels? His mentor, Alton Ochsner, retired from surgery at 70. His rival, Cooley, is only 58. DeBakey can’t operate for too many more years; even ten years ago, when Thomas Thompson wrote Hearts, the talk was that he was not as good as he used to be. Nowadays, one hears passionate defenses and denunciations of his ability. After watching him work, I would feel confident about having him operate on me. But no surgeon can go on forever. DeBakey has built his whole life on never slowing down, never letting anyone surpass him, and soon he will have to.
Very quietly, the Baylor trustees DeBakey selected ten years ago have set up a search committee to look for his successor as the medical school’s president. Late last year they gave him a new title in addition to president and chief executive officer: chancellor. This was publicly presented as just another honor. In fact, it was designed to be a title DeBakey could retain after his retirement, which, it is said, will be announced later this year. To be sure, he will continue to be extremely active in the affairs of the school, and for that reason it is unlikely that the board will confer presidency on a strong-minded outsider. Whoever becomes president, DeBakey is certain to go out in a new shower of accolades. But it is impossible to believe that that will finally make him content.
BREAD AND BUTTER
On a Monday afternoon not long ago, Ernest Salazar checked into the Neurosensory Center for an ear operation. He was a prototypical Texas Medical Center patient. He had come there for an advanced surgical procedure, to be performed by an academic doctor in an expensive specialty wing. What gets the glory at the Texas Medical Center is the spectacular rate of growth, the research, the towering figures, the heart transplants; but the bread and butter of the place is provided by people like Salazar. Operations like his are what the Texas Medical Center does all day.
A friendly, calm man of 39 who works as a business analyst for Gulf Oil in Houston, Salazar has always been in excellent health except for his ears. From early childhood he had painful infections that eventually ate away his eardrums, impaired his hearing, and made it impossible for him to go swimming. As he grew up the infection subsided and he came to accept his bad ears as his fate. But four years ago, when he moved to Houston from Ohio, the pain flared up again and he decided to have something done. His wife’s doctor recommended that he see an old acquaintance of hers from medical school, Dr. Bobby Alford, chairman of the department of otorhinolaryngology (ear, nose, and throat) at Baylor College of Medicine. Salazar had contacted a doctor downtown on his own, but he decided to go to Alford instead. “Baylor, head of department — it sounded pretty good to me,” he says.
He came to be very happy with his decision. In 1975 and 1976 Alford operated on Salazar, once on each ear, building him a new set of eardrums and rearranging his middle ears to improve his hearing. As a result of these operations he was no longer in pain, he was able to swim, and he could hear better, though still not perfectly. Now he was ready to start the second phase of his treatment. Alford wanted to operate once more on each ear, in order to check its progress and to try to further improve Salazar’s hearing. Alford had told Salazar that while the first series of operations had been absolutely necessary, the second series was elective, but Salazar had been enthusiastic about going ahead with them. The next morning, then, he would have his third ear operation, the second on his left ear.
Thirty years ago, an Ernest Salazar could almost certainly not have had that operation. Thirty years ago there was no Texas Medical Center and few places in the country specialized in advanced ear surgery. Thirty years ago the microsurgical techniques used on Salazar’s ears didn’t exist. Perhaps more important, thirty years ago a middle-class person like Salazar couldn’t have afforded this sort of elective operation.
Like most salaried Americans today, Salazar had a group medical insurance policy at work that would cover the lion’s share of the cost. In 1940, 10 per cent of Americans had some form of medical insurance; today, over 80 per cent. The growth of health insurance is one of the developments that made the Texas Medical Center possible. “If I had to pay for it out of my own pocket,” said Salazar the evening before the operation, “I’d have to think twice about having this operation.” As it was, the operation, which wasn’t strictly necessary and might not accomplish anything, had a direct cost to the patient so low as to make it worthwhile. In a country with a socialized medicine system like England, Salazar wouldn’t have had to pay a penny for such an operation, but on the other hand he would have had to wait months for it if he could get it at all. Health insurance means that in this country we have a sort of socialized medicine for the middle class, which means more medical procedures are performed than if there were no insurance. That’s one reason our health bills — and inflation — are so high.
On the morning of the operation, Tuesday, a nurse awakened Ernest Salazar at six and gave him a Valium tablet, followed by a shot of morphine. Feeling drowsy, he put on a light gown and was wheeled into the surgical suite. In the operating room the anesthesiologist inserted a needle attached to a small plastic tube into his arm and said he was going to drip sodium pentothal through it. That was the last thing Salazar remembered.
A little before nine, Alford came into the operating room. Salazar was completely covered with sterile surgical drapes, except for his left ear. Alford sat down on a stool next to the operating table, pulled over a high-powered microscope, and peered down Salazar’s ear canal. He could see the eardrum he had built, a pearly-gray sheet of muscle that had grown in perfectly. Then he pulled back Salazar’s ear, took a scalpel, and began to cut.
He made a semicircular incision about four inches long just behind the ear, carefully deepening the cut and stopping the flow of blood with an electric instrument called a Bovie, which looks like a soldering iron and cauterizes the blood vessels. Presently Alford reached the ear canal with his scalpel. He took a plastic cord and ran it through his incision, into the ear canal, and out the ear. Then he tied back the ear like a flap, leaving it looking only precariously attached to the head, and peered into Salazar’s middle ear through the microscope.
Under high magnification, Salazar’s middle ear was a beautiful sight. Against a background of luminescent china-white bone, delicately filigreed with tiny red blood vessels, there stood little white projections that looked like a strange kind of plant life. Alford poked around with long-handled, needlelike probes and pondered his next move.
In the middle ear there are three minuscule bones — the malleus, the incus, and the stapes — which through vibration transmit sound waves from the eardrum to the inner ear. Alford could see that there was no infection there, which was good, and he could also see why Salazar’s hearing was imperfect. In the earlier operation Alford had removed Salazar’s diseased malleus and rearranged his middle ear so that vibrations would be transmitted directly from the incus to the stapes. But in the intervening time an infinitesimal space had opened up between the two bones. What Alford had to do was improvise a way of closing that gap.
He asked the nurse to bring him an incus from a freezer in the operating suite where such spare parts are kept, and turned his attention to Salazar’s mastoid bone. With a drill, he slowly cut a small chip of bone out of the mastoid, taking care to avoid hitting the facial nerve. When he was finished he drew out the chip with a tweezers. It was about twice the size of one of those “tiny time pills” that come in cold capsules, and the spare incus was just a little bigger. Then Alford swung the microscope back to the middle ear and dropped the bone chip into the gap he was trying to close. There was still a little space left, so he dropped the spare incus in too. To hold everything in place, he stuffed the cavity with small puffs of a special plastic that dissolves in a few days, untied the flapped-back ear, sewed it up, and packed the ear canal with cotton wadding. The operation was over at 11:15 a.m.
At 3:30 p.m. Salazar woke up in his room, feeling woozy, a big bandage on his ear. He dozed off and on for the rest of the day, and the next day he went home. Five weeks later Salazar went back to the Neurosensory Center, his bandage off and the packing removed, for a hearing test. As it turned out, his hearing had improved so slightly that he couldn’t notice any difference. His out-of-pocket expense for the operation had been $102, with the insurance company picking up the rest. The hospital’s bill had been $1098.89; the anesthesiologist’s, $304; and Alford’s, $710, for a total cost of $2112.89.
“I guess what I got out of it was that he was able to examine the ear and see if there was infection,” Salazar said. “And I’m very happy about that. I’ve got no complaints. I’ve got to look at the whole program. When I came to Dr. Alford, I was in pain. I couldn’t swim. How could I complain?”
THE MAKING OF A DOCTOR
At about nine o’clock on a Friday night in December, a man named Ernie Smith wandered into the emergency room of Ben Taub General Hospital. He walked up to the triage desk, where nurses decide which patients will be treated immediately and which will have to sit in the waiting room until there is a free moment for them. Because Ernie’s head and face were almost completely covered with blood, the triage nurse sent him in for treatment. Over the loudspeaker, someone said, “B Team, patient check,” and Dr. Roxann Rokey resignedly walked over to take a look.
Ernie was not only bloody but also filthy, dressed in tattered clothes, and very drunk. He was a big white man in early middle age, and for all his problems he had a rakehell, devil-may-care insouciance about him. Rokey considered him for a moment, then pushed his nose with her finger. It was soft and squishy. “Does your nose usually look like that?” she asked him.
My Library
