Open Heart

For Arthur, Jerry, Phil, and Rich

Two are better than one; because they have a good reward for their labor.

For if they fall, the one will lift up his fellow; but woe to him that is alone when he falleth; for he hath not another to help him up.

Again, if two lie together, then they have heat: but how can one be warm alone? And if one prevail against him, two shall withstand him; and a threefold cord is not quickly broken.

—
ECCLESIASTES
IV:9–12

1 How Little We Know

2 All the Time in the World

3 The Consolation of Diagnosis

4 It's Not Viral, Goddamnit!

5 Coronary Artery Bypass Graft Times Five

6 The Ponce de León Thing

7 Listen to the Patient

8 They Saved My Life But…

9 One Year Later

10 In Friends We Trust

11 So Why Did I Become a Doctor?

12 A Safe Place

13 It's Not the Disease

14 The Patient's Story

15 Natural Selection

16 The Prepared Heart

ACKNOWLEDGMENTS

NOTES

BIBLIOGRAPHY

INDEX

1

How Little We Know

O
N
AN UNSEASONABLY MILD
, sunny afternoon in early February 1999, I drive down from my home in Northampton, Massachusetts, to Guilford, Connecticut, 120 miles away, to spend an evening with my friend Jerry Friedland and his wife, Gail. Jerry is director of the AIDS programs at Yale-New Haven Hospital and the Yale School of Medicine, and he and I have known each other for nearly fifty years—since the fall of 1952, when we were both sophomores at Erasmus Hall High School in Brooklyn.

Early the next morning I leave my car at Jerry's house and we head in to Yale-New Haven Hospital together. As I have also been doing for the past dozen or so years with another high school friend, Phil Yarnell, a neurologist living in Denver, Colorado, I take a break once or twice a year from my own work—my writing and teaching—to spend a day with Jerry at his work.

This time, however, I am traveling with Jerry to New Haven not to spend a day with him at the hospital and in his AIDS clinic, but because he has helped arrange an appointment for me with Dr. Henry Cabin, chief of cardiology at the hospital, to see what's going on in my heart. Dr. Cabin, who will take an angiogram of my coronary arteries (injecting radio-opaque dye that makes blockages visible when x-ray pictures are taken), has told me that this is ordinarily an outpatient procedure. Even if he finds significant blockages and decides to perform angioplasty (threading balloons into one or more
of my coronary arteries through a catheter to open the arteries), I should be able to drive back to Massachusetts following the procedure. Still, Jerry has insisted that I return home with him afterward and stay another night so I can rest up, and so we can have more time together.

Being with Jerry while he works with patients, staff, and medical students and talking with him about his work have given me great pleasure through the years—have inspired me, really. Jerry is one of my oldest and dearest friends; he is also a doctor whose work with AIDS patients and AIDS research has been literally life-changing and life-saving for thousands of people.

When we spend time together between my visits to Yale-New Haven, we continue the dialogues begun there—discussing patients I've met and how they're doing, talking about his AIDS research and his public health projects, and—as in my ongoing talks with Phil—moving from the particular to the abstract and back again while speculating on the causes, prevention, diagnosis, and treatment of disease in general—about where, in things medical, we've been, about where we are, and about where we might be going.

Also, a true joy, knowing each other as we do across most of our lives, our talks have meandered—inevitably, always—along more personal paths as, without needing to impress or dissemble, we've tried, in matters having to do with things more private—family and friends, above all—to understand just who
we've
been, who we are, and where we might, in the years ahead, be going. When we are together, the time between visits—whether days, months, or years—disappears. Our conversations, at sixty, are as warm and stimulating—as rich, delightful, and filled with laughter—as were our conversations nearly a half century ago when we were teenagers taking walks together along Flatbush Avenue in Brooklyn.

At the hospital, Jerry walks me through admissions, and, although he regularly puts in seventy-to-eighty-hour workweeks (Gail maintains this is a very low estimate), he seems to have nothing else to do but to be with me, and he stays with me until I am in the room where the angiography is to be performed. Later on he will recall how astonished he was to find that when I undressed to ready myself for the procedure, I had to roll up my clothes and place them
on the floor in a corner of the room. If I hadn't been his friend, he said, he might not have noticed, and this was a reminder to him of how different things often seem, and are, from a patient's perspective.

When I wake from anesthesia a few hours later, I'm lying on a gurney, and Dr. Cabin is smiling down at me. Although Dr. Cabin is a decade or so younger than we are, he too grew up in Brooklyn, where both his parents were high school teachers, and this, along with his warm, direct manner, puts me at ease. He has straight dark brown hair, is about five-foot-nine—two inches taller than me—and is fit and athletic-looking. I look up at him, my head a bit woozy, and he looks familiar suddenly, like one of the guys I played schoolyard ball with in Brooklyn.

“Let me show you what we found,” he says.

He points to a monitor hanging above me and explains that what I am seeing is film from the x-rays taken of my heart. The lines of colored fluid moving downward and outlining my coronary arteries—bourbon-colored squiggles, in my memory—come from the dye injected through a catheter he had inserted into the femoral artery in my groin.

On the screen I watch blood begin to flow into each of my three major coronary arteries, then stop. Dr. Cabin points to the spot where only a small amount of fluid continues to leak downward and says the angiogram tells us that only one of my three major coronary arteries is working and that no more than 10 percent of that artery is functional. Two of my three major coronary arteries (the right coronary artery and the circumflex artery) are 100 percent blocked, the third (the left anterior descending artery) 90 percent.

Dr. Cabin estimates my ejection fraction, which measures the heart's ability to pump blood and which is the best general indicator of the heart's overall functioning, at 30 to 35 percent; in a healthy heart, it would be between 50 and 70 percent.

“You've been going on nothing,” Dr. Cabin says to me, and then: “We're going to try to get you into surgery tomorrow morning.”

“Great,” I say without missing a beat, and it is only later that Jerry makes me aware that my reaction—Hey, this is good news, so let's go for it and do whatever we have to—is not typical. At the same
time, I am, if optimistically, in a daze. I hear everything Dr. Cabin says to me but still seem to believe that in an hour or so I'll walk out of the hospital with Jerry, get into his car, and drive back to Guilford. Instead of spending an evening with Jerry, however, I may instead—the possibility seems an ordinary piece of information—get to spend my last evening on earth alone in a hospital room in New Haven.

Dr. Cabin tells me that because the arterial occlusions are so massive, I am going to need a quadruple coronary bypass. (Like a bypass that reroutes cars and trucks around an avenue clogged with traffic, a coronary bypass graft, stitched in above and below an obstructed artery, reroutes blood through an unclogged artery and around the obstructed artery.) He tells me that he is putting me on several medications to minimize the possibility of a heart attack, that he has already conferred with Jerry about surgery, and that he has put a call in to Dr. Sabet Hashim, the man he and Jerry consider the best cardiovascular surgeon at Yale.
^*
If Dr. Hashim cannot arrange to operate the following morning, a Friday, I will stay in the hospital over the weekend so that Dr. Cabin and his staff can keep an eye on me. The slightest exertion—or no exertion at all—might cause some arterial plaque to flake off, or to rupture, and block the narrow portion of my one coronary artery that is still working.

Open-heart surgery (or, more accurately, open-
chest
surgery) is, I know, a major event, a procedure that seems as astonishingly primitive as it is technically remarkable: They will crack open my chest then slice open an arm and a leg to harvest a vein and an artery that, after they shut down my heart for several hours while recycling my blood through a heart-lung machine, they will stitch into my heart before reattaching major incoming and outgoing arteries, jump-starting my heart with electricity, and stapling and sewing my chest closed. Even though I will be virtually dead for several hours—my body temperature lowered to 80 degrees (as with hibernating animals, cooling reduces the body's need for oxygen, thereby giving the surgeon extra time for suturing) while a team of doctors and technicians retrofit me with new interior plumbing made up of spare parts taken from within my own body—the procedure itself, for all the drama and miracle of the fact that one can perform it on living human
beings, has become commonplace. Hundreds of thousands of bypasses are performed each year (more than a half million in the United States), and—given my state of health—the possibility of failure, error, or distressing side effects seems minimal.
^*

Dr. Cabin talks with me about the surgery, and I ask if he was surprised to discover that my arteries are nearly 100 percent blocked.

“No. Little in my line of work surprises me,” he says, and he adds—something he will repeat when I see him for a six-week checkup following surgery—“But you
are
totally anomalous.”

True enough, I think, for despite the extent of the blockage, I have had few of the symptoms that usually accompany severe coronary disease: no chest pain or discomfort (no heaviness, pressure, tightness, or squeezing sensation), and no arm pain, dizziness, nausea, palpitations, faintness, or unusual fatigue. Luckier still, especially given the magnitude of the blockage, I do not seem, on the evidence of an echocardiogram, to have had a heart attack.

Nor do I seem to have had any of the classic risk factors for coronary disease. Until a week or so before surgery, I was swimming a mile a day, and at a good pace, as I had been doing for the previous twenty-five years, while also regularly playing tennis and half- and full-court basketball (sometimes with teenagers). I had never been a smoker, my cholesterol was normal, and so was my blood pressure. My resting pulse was fifty-eight. By all accounts I was in excellent physical shape and, at five-foot-seven and 150 pounds, I weighed perhaps 5 pounds more than I had forty-four years before when I was a senior in high school.

Genetics and family history? My mother was still alive at the age of eighty-seven, most of my thirteen aunts and uncles had lived well into their eighties, and some had survived into their nineties. My father, who died of emphysema at the age of seventy-two, had had a heart attack when he was fifty-nine, but he never exercised, had been overweight, and had smoked three packs of Chesterfields a day throughout his adult life.

About an hour after my talk with Dr. Cabin, when I've been moved to a hospital room and am lying in bed—the first time I've been hospitalized since I was operated on for Hodgkin's disease at the age of eighteen, forty-two years earlier—Jerry comes by to visit.

“Hey Neugie,” he says, using the nickname all my old friends use. “How're you feeling?”