Wednesday, January 1, 2020

Surgical notes #1—1988: A new heart beats the odds

Saint Catherine of Siena Exchanging Her Heart with Christ
by Giovanni di Paolo (Metropolitan Museum of Art)

     Happy New Year! 
     One rule of mine is not to dwell too long on any topic. So having written four columns on spine surgery in July, and a big sleep apnea piece earlier this month, the prudent strategy would be to avoid first person accounts of medical procedures for a while. 
      But the spine surgery series did really well—Apple News picked it up—and my boss barked, "Steinberg! Can't you get your hip replaced or something?" 
     Well, okay chief, if you insist...
     Kidding.  He didn't say that. What happened is, my professional discretion might have said one thing, but my body had other ideas. The right hip has been deteriorating for years; some days it felt like somebody has jammed a pine cone in there. I've been using a cane for three months. Lately it has been getting even worse. So I went under the knife at Northwestern Monday. Nothing as complicated as the summertime laminoplasty. Just a quick hip replacement, which I'm told is a very simple, routine procedure nowadays. I should be home Tuesday afternoon.
     I will write about it, eventually. Over 300,000 Americans had hip replacement surgeries last year, so it's not as if this is some esoteric topic.
     Still, I want to give myself a few days to let the drugs wear off, the cobwebs clear and to learn how to sit again. I've written about a good many surgeries over the years, and thought I would share a few while waiting for Mother Nature to sign off on my recovery. How long? We'll see. This story was a favorite of mine. I can still see myself flipping through two notebooks, seeing the scribbled words "baby chick" and wondering: why did I write that?

     Dr. Bryan Foy gently scoops up the human heart and holds it, as he would a newborn chick, with one hand cupped underneath, one hand over the top.
     It is 1:24 a.m. at Illinois Masonic Medical Center, 836 W. Wellington. Foy turns, takes a step, and places the heart in a metal bowl of frozen slush. Taking a pair of long tweezers, he peers into the various orifices of the heart. It looks good.
     Meanwhile, at Loyola University Medical Center in Maywood, other surgeons are waiting to remove the Jarvik-7 artificial heart that has kept Peter Reali, a 55-year-old machinery repairman from Brookfield, alive for the past 34 days.
     Loyola receives a phone call from the operating room at Illinois Masonic. The donor heart is out. Foy and the transplant team are heading for the helicopter and the seven-minute trip back to Loyola.
     Heart transplants, once rare and experimental, are becoming more common. When Loyola began transplanting hearts in the spring of 1984, there were 14 transplant centers in the country. Now there are more than 100, including seven in Illinois. Loyola has given hearts to more than 120 people—100 of whom are still alive.
     One of them is Peter Reali, who had never been in a hospital when he had his heart attack last April. Two weeks later, his heart stopped four times, to be restarted by electric shock. Doctors decided his heart was about to give out, and placed him on the Jarvik until a donor heart could be found.
     During tense weeks of waiting, the irony that his life could only be saved by someone else's accidental death was not lost on Reali.
     "It don't seem right, waiting for somebody to die," he said, the Jarvik ticking loudly at the foot of his bed. "But you still want to live. There's no other way to do it. You can't go to a used heart store."
     Hopes were high around Memorial Day. Most heart donors come from trauma victims; motorcycle accidents are so frequently a source of donated hearts that doctors dub them "donorcycles."
     On May 31, an ex-con was shot in the head and taken to Illinois Masonic, where he was pronounced brain dead. His family agreed to donate his organs.
     Two other heart patients in the state besides Reali had blood types and body sizes that made them eligible for the heart. Their doctors conferred, and Dr. Roque Pifarre, the chairman of the department of cardiovascular surgery at Loyola, convinced them the heart should go to Reali.
     An hour before the transplant is to begin, the Loyola surgical team assembles at Loyola: surgeon Foy; Ravi Kamath, his assistant; Kathleen Siebold, procurement coordinator, and Hazem Tillawi, a profusionist (person who floods the donor heart with cold fluids to keep it viable). Together, they wait for a helicopter to take them to Illinois Masonic to pick up the heart.
     To cover their apprehension, the team members joke among them selves. Foy speculates on the possible effect that the heart of a felon might have on Reali.
     "If Mr. Reali wakes up and has an irresistible desire to steal objects and carry a baseball bat, we'll know why," he says.
     At 11:39 p.m., a Long Ranger II helicopter looms from the east, a cluster of multicolored lights against a black sky. The group moves quickly to the chopper and climbs in for the quick ride to a landing zone near the hospital.
     At precisely midnight, they enter a large surgical theater, brimming with shining instruments. In the center, stretched out on a table, is the gunshot victim, both arms straight out. His chest heaves up and down as the respirator breathes for him. Someone covers his face with a towel.
     His chest is scrubbed with a yellow antiseptic and a thin plastic film placed over it. At 12:18 a.m., Foy takes a small electric saw and cuts into the chest. The air is filled with the smell of burning flesh.
     While another team digs into the glistening intestines, isolating the kidneys, Foy carefully cuts the connective tissue around the heart, until it is isolated, a beige and purplish muscle the size of a fist, beating furiously.
     The pace picks up as both teams prepare to remove the heart and kidneys. At one point, eight pairs of hands are frantically working inside the chest.
     At 1:20, the heart is stopped, the aorta clamps off and Foy makes the final cuts to remove the heart. The kidneys are close behind.
     After checking the heart, Foy places it in the freezing saline solution and seals it in a round Tupperware container. The container is placed in a red and white Igloo Playmate cooler, and the team hurries back to the helicopter.
     Tillawi carries the heart, never losing contact with it. When changing his scrub suit, he keeps his foot pressed against the cooler side, like a baseball player leading off from a base. There is no joking now, just silent concentration of the unfinished business ahead.
     By the time the team returns to Loyola, the head of the cardiac unit, Pifarre, assisted by Dr. Henry Sullivan and cardiologist Dr. Mark Zucker, have removed the Jarvik. It sits on a table, looking very much like the tail light assembly from an old Buick. Reali is kept alive on a heart-lung machine, which circulates and oxygenates his blood.
     By 2:17 a.m., the donor heart is placed in Reali. Sullivan and Pifarre settle down to the task of hooking it up.
     Using pink thread and a tiny, curved needle, Sullivan attaches the loose arteries, a task that requires amazing dexterity because he holds the needle and thread with long tongs.
     "That's a nice fit," he says.
     At 2:24 a.m., more icy saline slush is poured over the heart, using a tool resembling a turkey baster. Ten minutes later, Sullivan looks up, gives a half-sigh, half-groan, and returns to work. It is the greatest display of fatigue or emotion any of the five surgeons display throughout the six-hour operation.
     Fourteen people hurry about the crowded operating room. A medical photographer snaps pictures. The blood suctioned out of Reali is "cleaned," impurities removed using a centerfuge, then put back into Reali. About 40 percent of his blood can be recovered this way.
     A sign of just how routine heart transplants are comes shortly after 3 a.m., when Sullivan jolts the new heart with a pair of small electric paddles.
     There is no commotion, no cheering. Just a pause as everyone in the room looks up at the crazy jumping of purple and green lines on the heart monitor hanging from the ceiling. The heart is alive and beating, after a fashion. The heart machine still continues to do most of the work, to reduce the strain on the heart. The work of the lungs is still done by a device resembling an oversized blender.
     For the next two hours, Pifarre stands over the heart, watching it, changing the level of fluids to alter blood pressure, reducing the work done by the heart machine, occasionally poking an inquisitive finger against the heart.
     "The heart is starting to take over on its own a bit," says Michael Wallock, a profusionist. "There's some nice ejection now."
     Ten minutes later there is trouble: irregular heartbeats. Pifarre looks for bleeding in the new sutures, and Zucker stares into the open chest, his hands on his hips, like a golfer considering a putt.
     At 4:05 a.m. the heart machine is shut down. The heart is beating on its own. At 4:16, nurse Elissa Bailey leans on a table and momentarily dozes, then snaps her attention back on the operation. A little before 5 a.m., Pifarre goes to tell Reali's wife, Dorothy, how the operation is going. Orderlies begin cleaning up the operating room. Three large hampers are filled with garbage—wrappers, towels, empty supply packages, gauze.
     At 5:10, the geared chest spreader is taken off. "Do you have a sterile peanut butter and jelly sandwich back there?" Foy asks, as he scrapes the chest bone in preparation for closing the chest.
     Heavy steel wires are threaded into the sides of the chest. Pifarre and Foy pull hard on the thick wire to draw both sides of the rib cage together.
     "He seems to tolerate it well," Pifarre says.
     "There was a little drop," Foy says, looking at the blood pressure monitor. "But nothing sustained or dramatic."
     The wire is bent and twisted along a 12-inch incision, then snipped off with wire cutters. The skin is closed, using surgical staples. Just after 6 a.m., the blue paper coverings are torn away from Reali, and he becomes a person again instead of just a draped chest.
     "Well, here's Peter," Pifarre announces, pulling open Reali's eyelid.
     "OK buddy, don't give up," Foy says. "Whatever you do. Not now."
     Reali is rolled to his room at 6:20 a.m., the surgeons accompanying him, supervising the tangle of tubes and wires.
     The next morning he is brought out of the anesthesia; his first thoughts are that he doesn't hear the Jarvik ticking, which he interprets to mean that either the transplant worked or he is in heaven.
     "I looked down there, and there was no machine powering me," he says, recalling the moment. "It was nice."
     Two weeks later, Peter Reali walks out of the hospital, with his wife and family. He returns weekly, to check for signs of rejection - the body's immune system battling the foreign heart tissue—a major obstacle in heart transplants. But, for now, Reali is doing well and is optimistic.
     "I feel good," he says. "Being home feels good. I go for walks; it's beautiful. My knees are a little mushy, but I go just a little bit farther every day. In a way, I'm glad it happened. It's something I won't forget."

      —Originally published in the Sun-Times, July 17, 1988


  1. Wow. More than 30 years ago. Nice little drama. With a happy ending. Hope the hip turned out as well.


  2. After finishing I realized just how Great the writing was. To be transported into that surgery and feel the tension and immediacy was encompassing. I did not contemplate the writing until I had finished.

  3. A wonderful exposition made real by mention of some of the ordinary implements involved. One jumped out at me. My aged mother once said the most useful invention of her long life was Tupperware.

  4. Glad you are home and recuperating. Love how you write — whether about sleep apnea, Trump, or a heart transplant. Happy New Year. Enjoy your vacation.

  5. Great article! Looks like Mr. Reali is still with us, which is nice to see. Hope you’re doing well.

  6. I second all of the sentiments expressed here. Having had a hip replacement in 2014, I understand what you will be going though. Good luck.

  7. great medical writing bro! loved every word. spellbound! refuah shelemah!

  8. Great story about real heroes. Try to imagine the courage it takes to undertake a transplant or brain surgery. Even a hip replacement. Follow the instructions of your rehab team, Neil. They worked hard to attain their skills, harder than you need to recover maximum mobility. Kitty is also counting on you.

  9. Compelling; thanks for re-posting. And love the di Paolo painting.

  10. God, Neil--when it rains...Get well fast!!!


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