Fenway Park – Second Time – Part II

For those who missed it a year ago…  FENWAY PARK & CARDIAC KARMA – PART II

Andrew was taken by air-ambulance to Dallas, and admitted to Children’s the next day. He and his mother had 13 years to understand his life, and his heart, and the difficult and unforgiving path which life had laid out for him to get him to this point. Dr. G. had less than a day to take it all in, analyze the salient points, and make decisions which could, in the very real sense of both words, involve life and death. She’s the coordinator of the heart transplant program at Children’s, and she became involved in Andrew’s case because transplant was one of the first, and most likely, options for a kid in his situation. Her decision making process began in the Echo lab. After seeing the extent of the problem on the computer screen, she went to meet Andrew, who was already being treated with intravenous medication to slow both his heart rate and function in an effort to keep him stable. At this point, the choices for Andrew were slim. As the I.V. medication was not giving him a significant lift, the only remaining options were the implantation of a machine to aid his heart function, called a Left Ventricular Assist Device (LVAD), or a heart transplant. The LVAD option is not a pleasant one. It involves combining the left ventricle with a large, complex external device to improve ventricular function. A vigorous teen-ager like Andrew would not have enjoyed life on a pump. The transplant option is a difficult one, as well. A heart transplant is not the panacea many people think it to be. For the rest of the patient’s life daily medication is required, to make certain the body does not reject the new heart as a foreign organ. But there is more to it than just lifelong medication. The process of cutting open the chest, through the muscle wall, through the breastbone, placing the patient on the heart-lung bypass machine to sustain life while the heart is removed and replaced, is a crushing physical challenge for any person to undergo. There are psychological scars involved for transplant patients which are just as real, and often more prominent, than the physical scars. Whether it is the length of time the patient is on anesthesia, or simply the emotional baggage involved in major surgery, not everybody bounces back from it into a completely normal life. Add to that the problems a young teen faces just dealing with all his raging hormones, and the picture becomes quite complex.

“The first thing we consider when we look at a kid for transplantation is that there has to be a need for it. Not everybody who comes in with heart failure gets on the list. If you have a malignancy, an active cancer, if you have a systemic disease that will affect the new heart, if you don’t have a supportive family and, unfortunately, if you don’t have certain financial viability, these are some of the first contraindications. Potential transplant candidates are worked up for cardiology, surgery, financial structure, neurology, and psychological evaluation, as well as other sub-specialties. Then we all come together as a team and make our transplant assessment. I did my surgical transplant assessment and I thought he was a great candidate because he was otherwise a healthy kid,” Dr. G. noted, “very active, came from a very supportive family. So he was worked up, and he was listed for transplantation.”

At that point, Andrew and his family were given a pager and told to always keep it close at hand. The moment a donor heart was located, everything in his life would have to stop, and no matter where he was in the hospital or what he was doing, he would begin the final prep for surgery to replace his heart with that of someone else. Someone who had not died yet.

Dr. G at a Red Sox game in her home town of Boston.

Dr. G at a Red Sox game in her home town of Boston.

Fenway Park – Second Time

For those of you who missed in the first time around, which was quite a while ago, here is one of the more fascinating out-of-the-OR stories from Dr. Guleserian’s career.  This is part one.  It will continue in subsequent posts.  Please feel free to share it in any way you like.

Dr. G at a Red Sox game in her home town of Boston.

Dr. G at a Red Sox game in her home town of Boston.

FENWAY PARK AND CARDIAC KARMA

by Mark Oristano

The cool night air was to be expected in October’s New England, and where there were trees to be seen, the leaves had already assumed their annual, golden hue. But inside Fenway Park in Boston green remained the dominant color, the brilliant Irish tint of the grass set against the faded green of the towering left field wall, the famous Green Monster. The chill at Fenway was of no concern to Andrew Madden as he held the baseball loosely in his right hand and kicked at the rubber on the pitcher’s mound, nor was he disturbed by the roar of 36,370 fans in the stands, ready for game two of the 2007 World Series between their Red Sox and the Colorado Rockies. Andrew might have wondered if he was trying to pitch again too soon. He wasn’t recuperating from a sore muscle, or even a torn rotator cuff. No player in baseball history had ever come back from the surgery Andrew Madden had recently undergone and taken to the mound again. The crowd went silent. Pumped by the sport-specific adrenaline that only his first World Series game could provide, Andrew wound up and let loose with a screwball, designed to break in toward a right-hand hitter. But no there was no one in the batter’s box. Andrew’s pitch bounced harmlessly in the dirt in front of the catcher, who scooped it into his mitt with a practiced ease, trotted out toward the smiling pitcher, and handed him the ball. The 36,370 broke into a full-throated roar. Andrew had never heard such a sound before, had never imagined hearing it; not on this field; not in this way.

Only 21 days earlier, 13-year old Andrew Madden lay unconscious on the table in OR 5 at Children’s Medical Center of Dallas, draped in sterile blue cloths, his chest cut open and his blood circulating from his body through a heart-lung bypass machine which oxygenated the blood to feed tissues and organs while his own heart was being cut out. The young heart, critically weakened by Idiopathic Dilated Cardiomyopathy, was replaced with the healthy heart of a recently deceased 26-year old mother. Because she was young and slender, and because she had the same blood type, her heart was perfect for Andrew. She had died in childbirth earlier that day. Now, even while her family grieved, she was giving birth again.

It was the beginning of Andrew’s comeback, the completion of a heart journey which had taken him from Dallas to Boston. The surgeon performing the operation, Dr. Kristine Guleserian, was Andrew’s friend and fellow Red Sox fanatic. Dr. G took the journey in reverse, from Boston to Dallas, where her path intersected with Andrew’s in August of 2007.

The first day I shadowed Dr. Kristine Guleserian around Children’s Medical Center of Dallas was both an education, and a physical challenge. Even though I’m 13 inches taller than she, Dr. G. walks faster than I can keep up with when she’s at full speed. She is generally at full speed. She burst out of her office at the moment our two o’clock appointment was to begin, throwing on her long, white lab coat as she hurried toward the door.

“Come on, let’s go. You wanted to see my life? This is it.”

I ran after her on her way to the Echocardiography Lab as she went to examine a high-end ultrasound view of one of the hearts on which she would soon operate. She is one of only nine women in the country practicing congenital cardiothoracic surgery, operating on the tiny hearts of newborns only days old, as well as the more mature hearts of youngsters and teens. Her first view of a case often comes in the cramped confines of the Echo Lab, a dark room lit mostly by the glow of the computer monitors on every desk and wall. Two cardiologists, also women, sat at one end of the room staring at a monitor, and Dr. G sat with them. An Echo is black-and-white, and to the layman, it looks likes nothing so much as a pie-shaped, blurry, moving x-ray. To the six trained eyes around me, however, it was an intimate, personal portrait defining a cardiac road map. A nine-year old boy had a problem with his left ventricle, the chamber of the heart that pumps oxygenated blood to the aorta for its trip through the body, and the cardiologists wanted Dr. G’s opinion as to possible surgical intervention. She was Socratic, as I would later observe her to be when teaching residents on rounds, asking questions she likely already knew the answers to; never instructing, merely stating, “Well, I might do…” so-and-so.

Along with the fuzzy black-and-white image, an Echo also has audio, the swooshing sound of the blood as it moves through the four chambers of the heart. It’s the sound a doctor hears with a stethoscope, amplified in this room through speakers, a throbbing, rhythmic drumbeat which would be the envy of any percussionist, and after a short time, in a small, hot room, it becomes hypnotic. As this was my first exposure to the complex jargon of cardiac anatomy being used in its element, I found myself numbly trying to comprehend the words, and then falling victim to the relaxing, repetitive rhythm of the heart valves and the coursing blood. This was a heart in distress, but the sounds it made were incredibly soothing. The snap back to reality came when I caught my eyes closing and I sat up, reminding myself that this was not a TV show. These people were discussing cutting open the chest of a young child, so they could carve into his heart. In 15 minutes the case had been discussed and a course of action decided upon. It’s in this same room where Kris first met Andrew Madden. Many doctors will refer to a patient as simply that, “the Patient.” But Dr. G. will use terms such as “this little guy,” or “this doll,” and, most often, the child’s actual name. There are parts of America’s complicated, convoluted, and contradictory health care system that work — those parts guided by people who care about their patients as human beings and not as, “the appendectomy in 240.” The first time Dr. G. glanced at Andrew Madden’s echo she saw amid the fuzzy black-and-white blob what the layman might call an enlarged heart. To Dr. G., it was clearly Idiopathic Dilated Cardiomyopathy.

“Dilated cardiomyopathy is a process by which the heart muscle, over time, dilates, or gets larger,” Dr. G. explained during a rare break in a crowded day. “The first word of the diagnosis is ‘Idiopathic,’ meaning we don’t know why it happens. When you’re born with it, as Andrew was, some people get better. But, some people get worse and some people sort of stay the same over time. About a third, a third and a third.”

The primary danger with cardiomyopathy is that the heart function becomes less efficient as the heart grows in size. Eventually, the pumping action becomes so weak that the patient is in danger of total heart failure. Not long after he was born, it was obvious Andrew was not getting enough oxygen to his body, and his heart function was inefficient, but the problem was mild enough that, with medication, he could live a normal, healthy life, which he did for thirteen years. Growing up in Odessa, in west Texas, where a good part of life is as it used to be decades ago, with kids playing baseball all day, and making sure to add “Sir” and “Ma’am” to the end of a sentence when speaking to a grownup, Andrew was as normal a kid as he could be. Little League baseball, basketball, school. It was on the local par-3 golf course where Andrew’s life all but hooked into the woods for good.

“It was mid-August,” his mother, Laurie Wemmer, recalled, “and he was trying out a new set of golf clubs. I was with him. All of a sudden, he fell to his knees and began gasping for air. He was showing all the signs of heart failure. He had reached the point where his heart was barely pumping.”

OR Tackle Box

OR Tackle BoxNo, nobody’s going fishing after surgery.  Yes, that is a tackle box.  It’s on the anesthesiologist table in the OR and it has all kinds of things in it that they use to put the patient to sleep, and make sure that sleep stays at the proper level.  (It’s not so odd to see a tackle box used for something other than fishing.  Many of my fellow stage actors use them for makeup cases.)

Half a Heart

WARNING — GRAPHIC IMAGE

 

During a special surgery to install a new form of ventricular assist device (VAD), the patient’s heart had to be transected.  What you see here is the half of the heart that was removed so that the machine, a bridge to transplant, could be put into place.

Half of a heart, removed for insertion of a Ventricular Assist Device.

Half of a heart, removed for insertion of a Ventricular Assist Device.

Art from the O.R.

I have come to be fascinated by the strangely beautiful art that is evident in an operating room.  It must have something to do with being surrounded by a group of people who are extreme experts at what they do.  Maybe it’s the lighting, which changes often depending on what needs to be viewed.  Maybe it’s the intricate dance of hands. But something about it is fascinating to capture.  Of course, there is also the realization that a life is at stake, which certainly adds to the drama.  But every time I’m in the OR, I find something new to aim at.

Surgeons Hands at Work

Whiteboard Diagrams Keep Everybody on Target

Surgeons_story_white_boardBefore the surgery gets underway, the surgeon will often draw a diagram on the whiteboard in the OR.  Sometimes it’s to let a non-medical person (like a photographer) in on what’s going to be happening.  Sometimes it’s just to plant a reminder in everybody’s head as to what’s going on.

Regardless, I think one key to being a good heart surgeon is the ability to do proper whiteboard renderings.

Watching the Monitor in OR

Cutting into a valve in real time.

Cutting into a valve in real time.

There are monitors throughout the OR for everybody to get a view of what’s going on.  The view comes from the loupes that Dr. Guleserian wears to magnify her field of vision during surgery.  A fiber-optic camera is connected to the glasses frame of the loupes so that the camera sees exactly what she is looking at.

At this point in this operation, she’s sewing a valve together after some resection inside to aid in proper blood flow for a young patient.

 

Close Quarters in Surgery

Surgical work is up close and personal.

Surgical work is up close and personal.

When you work in the OR, it gets close and personal.  Head to head, as it were.

Especially when you’re working with tiny children that Dr. Guleserian and her colleagues treat.  Some of them are, literally, less than a day old, needing emergency heart surgery from the very start of their lives.  Those hearts aren’t even the size of a ping pong ball. (Your heart, by the way, is about the size of your fist, in case you were wondering.)