1
Where the hell is my heart? Erin McGrath wondered as she burst through the swinging door and into the operating room.
Inside OR 22, the usual controlled chaos reigned. The staff buzzed with activity. The anesthesiologist, a taciturn South African named Peter Proust, hovered beside a bank of high-tech monitors as he mixed the cocktail of drugs required to achieve the delicate balance between putting the patient to sleep and keeping her brain and other organs viable during the three-hour transplant surgery.
Wearing green hospital scrubs, but not yet gowned, Erin strode up to the stretcher beside the operating table. Her patient, Kristen Hill, lay still on the gurney. Kristen's pale face was covered with a bulky breathing mask to optimize the oxygen delivered to her fluid-logged lungs. On the right side of her neck, several intravenous lines converged at the plastic hub connecting to a central line that tunneled through the skin and into her jugular vein.
Erin felt a deep affinity for the young woman who, like her, was a mother of fraternal twins. Life had dealt Kristen one blow after another. Abandoned by her husband when her twins were only toddlers, forced to support the family on a minimum-wage income, and now incapacitated by a failing heart, somehow the twenty-six-year-old remained perpetually hopeful. Underneath the clear plastic mask, Kristen wore the same accepting expression as usual. But despite the oxygen, her lips were bluer than ever. She appeared to deteriorate by the minute.
Where's the damn chopper with my heart? Erin thought again as she reached the bedside.
Kristen's own heart was shot. The once-powerful pump had turned into a mass of engorged useless tissue after a virus had suddenly attacked it. The illness had begun innocuously enough, as little more than the same cold that had hit her children. But the virus unexpectedly turned on Kristen's heart, causing myocarditis. Within days, it had destroyed the muscle that constituted the cardiac wall. Despite the maximal medication and all other interventions Erin had tried, Kristen's shattered heart couldn't keep up with the circulatory demands of her body.
Erin rubbed her patient's elbow. "How are you holding up, Kristen?"
"Okay." She mustered a grin through her mask. "Dr. McGrath, I thought I'd be asleep by now."
"Not much longer," Erin said, hoping she was speaking the truth.
The call from the national organ donor registry had woken Erin at five A.M. from a very light sleep. The day before, because of Kristen's drastic deterioration, the heart surgeon had put out a plea through the transplant network for any viable heart within a thousand-mile radius of the Alfredson Medical Center. That evening, on a rainy highway outside of Billings, Montana, a twenty-two-year-old biker hit an oil slick and lost control of his motorcycle. Slamming into the guardrail, the biker was thrown thirty feet and smashed headfirst into the mountainside. His helmet was no match for the wall of rock. Brain-dead at the hospital, he turned out to be a close enough tissue match to Kristen Hill for organ donation. By seven A.M., the transplant team had harvested the biker's heart, finding it in healthy condition and miraculously unscathed from the accident.
As soon as Erin heard the news, she had ordered Kristen transferred into the operating room to prep for the imminent transplant. Everything looked promising. And then a sudden storm blew in from the east and grounded the Alfredson's transport helicopter.
Erin viewed her patient with an apologetic smile. "Kristen, the heart is still not here."
Panting heavily, Kristen nodded. "It'll get here soon, huh?"
"Very." The chopper was in flight and expected to arrive at any moment, but Erin knew that wasn't the problem. "The donor organ has been outside the body—or ‘on ice'—for almost four hours now."
"That's too long?"
Erin squeezed Kristen's hand. "Generally, we accept five hours as the upper limit of cold ischemia, the time a nonbeating heart can be outside of a body and still usable in transplant."
"So you still have an hour," Kristen encouraged.
"But it will take longer than that to open your chest and implant the new heart."
The first flicker of despair crept into Kristen's features. "What happens after five hours?"
Erin frowned. "It gets dicey. The donor heart can become irreversibly damaged from lack of blood and oxygen. It often doesn't pump well after transplant. Sometimes, we can't even get it restarted once we've implanted it."
Kristen's face tensed with resolve. "Dr. McGrath, you don't know when another heart will become available, do you?"
Erin shook her head grimly. "No."
"Look at me." Kristen sputtered a moist cough, as if for effect. "We both know I can't wait much longer."
Erin nodded.
"I am willing to take my chances on this heart. Today. Right now."
Erin leaned closer. "Kristen, you do understand that once we begin, there's no turning back? If the new heart doesn't take . . ."
Kristen swallowed. "I understand, Dr. McGrath. I still want you to try."
Erin let go of her patient's hand. "Okay, Kristen. As long as the heart arrives in the next fifteen minutes, we'll go for it."
Erin looked over and saw that the anesthesiologist was eyeing her dubiously. "Fifteen minutes, Peter," she said. "Not a second more."
With a minimal shrug of his shoulders, Proust turned back to the syringes and vials laid out in front of him.
Erin looked over at the charge nurse. "Joanne, let's get Kristen on the table and prepped for surgery."
The heavyset nurse turned and nodded to another nurse. Together, they headed for Kristen's stretcher. The wall phone behind Proust rang shrilly. The anesthesiologist grabbed it. "OR twenty-two," he said in his terse Afrikaner inflection. He hung the phone up without saying another word into the receiver. "It's here," he announced matter-of-factly.
Erin turned back to her patient. "Kristen, this is the point of no return, you understand?"
Her lips broke into a brave smile. "I just want to see Katie and Alex through grade school. That's all."
"Fair enough." Erin swallowed, thinking of her own twins, who were in their last year of grade school. "I'm going to go scrub now."
Even before reaching the swinging door, Erin felt the first twinges in her belly. No! She wanted to scream. Not now, of all times.
Erin stood at the metallic sink outside the OR, scrubbing her hands as she struggled to hold back the surging anxiety. It's not real, Erin, it's not real . . ., she repeated over and over in her head. But the mantra didn't deter the sense of suffocation from growing, as though a pair of strong hands was squeezing her throat. Her fingers began to tingle with needles and pins—a telltale sign of hyperventilation.
The first panic attack had struck out of the blue three months earlier. Late one night, Erin was wheeling her garbage can down her driveway when she was overcome by a horrible sensation, as though someone had suddenly tightened a bag over her head. She wanted to run, but she couldn't breathe well enough to move. So she stood beside the garbage can, gripping its handle and trembling like a leaf. Though vaguely aware that she was suffering a panic attack, Erin still expected to die at any moment. Nauseous from anxiety and the smell of decaying fruit and vegetables, she spent ten of the most distressing minutes of her life frozen in the driveway before she was able to pull herself together enough to even go inside.
Since the first panic attack, Erin had experienced six or seven more. None of them came with any warning. She had not told anyone about the attacks, not even her husband. Instead, she had started herself on an antidepressant that was supposed to suppress the episodes. It hadn't. And today, for the first time, she was experiencing what she had dreaded most: a panic attack at work.
Fingers shaking under the warm soapy suds, Erin fought to slow her breathing and focus her racing thoughts. Thanks to the storm in Montana, too much time had already been lost. Every second she wasted at the sink trying to calm herself would lessen the chance of the donor heart working. She considered calling a colleague in to take over the operation, but the only other cardiac surgeons in the building were already scrubbed into surgery. By the time one of them could respond, the donor heart would be as useless as ice cream that had been left out of the freezer too long.
Erin turned off the tap with her knee. Her chest thudding, she studied her fingers and noticed that the shake had lessened to a subtle tremor. The needles-and-pins sensation had dissipated, too. She took a few controlled breaths and then, holding her sterile hands in the air, backed through the swinging door and into the operating room.
Erin was relieved that her mask shielded her face from the others, but she avoided all eye contact, not wanting them to see the remnants of panic in her eyes.
"She's under," Proust said with his typical economy of words.
Erin glanced over to see Kristen Hill unconscious on the table with an endotracheal breathing tube poking between her lips and connecting to a respirator. One of the surgical assistants had already sterilized and draped her chest, exposing a ten-by-ten-inch surgical field centered on the sternum, or breastbone. Kristen looked peaceful, which helped calm Erin slightly, but she still started at the sudden noisy whir of the bone saw when her assistant tested its blade.
Erin slipped her arms through the gown held open for her. The same nurse held out sterile gloves. Erin had breezed through this step innumerable times without a second thought, but now she concentrated on getting her fingers safely into the gloves as though it were as delicate an undertaking as sewing in a new heart valve. She breathed a small sigh of relief when she slipped into the gloves without complication.
Erin walked over to join the assistant on the near side of the OR table. She had a quick glimpse of Kristen's exposed chest. Get it together, woman! she commanded herself. She turned to the tall surgical resident, Dr. David Robards, who had prepared the bone saw. "Okay, David," she said, testing her voice. "Open the chest."
He nodded enthusiastically. The scrub nurse passed him a large scalpel that he immediately applied to the skin overlying the sternum. He drew down like an engraver, splitting the skin from the base of Kristen's throat to her belly. Dr. Karen Woo, the elfin second surgical assistant standing on a step across from him, followed the separating skin wound with a sponge to dab at the blood. She used a handheld electric coagulator, which resembled a high-tech pen, to burn the bleeding vessels closed.
Satisfied with the incision, Erin nodded to Robards. He raised the saw and it buzzed to life in his hand. Robards applied it to the incision, cutting through the sternum that he had just exposed. The acrid smell of burning bone, a vivid reminder that her hands-on role was rapidly approaching, launched Erin's heart racing anew.
Robards traded the saw for bone spreaders, which looked like giant tweezers. He inserted the teeth of the tool into the gap he had created in the sternum and spread the handles. The chest cracked open with a familiar crunch.
Erin took a deep breath and stole a glimpse at her hands, which were no longer trembling. No room for error now.
Without a word, Robards moved out of the way and Erin stepped into his spot. Everyone understood it was her surgery from now until the time came to close the chest again. She shut her eyes for only a moment and then plunged her hand through the open chest wound. Her fingers slid underneath the thin-layered pericardium, the fibrous tissue that covers and protects the heart. Enveloping the organ, she squeezed the heart gently and felt it beat sluggishly in her hand. With the tips of her fingers, she explored the anatomy of the great vessels—the aorta, pulmonary artery, and vena cava veins that connect the heart to all of the other blood vessels in the body—as she mentally walked through the next steps of the surgery. "Forceps and scalpel," she said to the OR nurse, who was already holding them out for her.
Erin withdrew her hand from inside Kristen's chest and reached for the tools. "Headlight," she said, and someone switched on her fiber-optic headlamp. She looked down and shone the bright beam inside the wound to better illuminate the chest cavity. Her own heart thudded in her ears, but her hand was steady as she reached out with the forceps and grasped the pericardium with the metallic teeth. She raised the tissue, tenting it away from the heart, and sliced down vertically with the scalpel. She slid the pericardium away, as though removing bubble wrap, and exposed Kristen's globular pinkish red heart.
"How are we doing for time, Peter?" she asked.
"Fifteen minutes," he grunted. "Or four hours and ten minutes of cold ischemia."
Desperate to get the donor heart implanted within the five-hour window, Erin knew she needed to speed up. Not too fast, though; rushing surgery only guaranteed mistakes. "Okay, I need the first cannula. Let's prep for CPB," she said, referring to cardiopulmonary bypass.
Someone wheeled the freezer-size heart-lung machine—an external pump and oxygenator that allows the heart to be disconnected from the human circuit by providing artificial blood circulation for the body—closer to the table, while the scrub nurse handed Erin the tools she needed. As her focus became absolute, Erin's anxiety receded from her consciousness. She freed the superior vena cava, the largest vein in the body. Making a small nick in its side, she slid a garden hose–like tube, or cannula, into position, and then tied it into place. Feeling the pressure of time as viscerally as footsteps behind her in a dark lane, Erin rapidly repeated the procedure with each of the three other great vessels. She calmed a little more after each cannula had been secured.
Accepting the clamps offered by the scrub nurse, she fastened off the great vessels, one by one, as near to their insertion into the heart as possible, thus separating the heart from the rest of Kristen's blood vessels. Under the watchful eye of the perfusionist, or bypass technician, the heart-lung machine whirred to life as its transparent tubing turned red with the blood it mechanically pumped in the place of the patient's own heart.
A nurse dabbed at Erin's sweaty brow. She glanced over to the perfusionist, who nodded his approval that the bypass machine was functioning well. "Time to remove the organ," Erin said.
Robards grabbed the syringe full of potassium chloride and injected it into the cannula that Erin had inserted directly into the left ventricle of Kristen's heart. It pumped away for several more beats and then quivered to a halt.
Erin reached inside the chest cavity and wrapped her fingers around the now-still heart. "Scalpel," she called.
She sliced through the vessels beyond the clamps, separating Kristen's heart from her body. Pulling the organ free of the chest, Erin was reminded again of an Aztec priest yanking the heart out of a victim and offering it up as a sacrifice to the gods. With her blood-soaked glove, she deposited the organ into a waiting basin. "Time?" she called out to Peter.
"Four hours, twenty-five minutes," he replied, giving only the cold ischemia time.
Thirty-five minutes to implant the new heart! She had never done the procedure in anywhere near that short a window. She wondered if anyone had. The tingling started in her fingers again, but she willed herself calm. One step at a time, Erin!
"The donor heart, please," Erin said.
A second nurse opened a metallic chest near the table. She withdrew the heart from the ice bath and carried it in both hands to Erin with the reverence of someone holding a holy relic. Erin grabbed it in her right hand. The heart felt unnaturally cool through her glove. Although taken from an adult male, it was still smaller than the badly damaged swollen organ Erin had just excised from Kristen's chest. On inspection, the donor heart looked to be in excellent condition, but she knew that her eyes could not discern the whole story. Besides, she was way beyond the point of turning back.
Slowly rotating the donor heart 360 degrees, Erin mentally aligned it with Kristen's great vessels that she needed to attach. "Suture and needle driver, please."
Erin gently lowered the donor heart into Kristen's chest. She lined up the edge of the donor and recipient pulmonary artery and stitched in the first suture of Kristen's new heart.
Working rapidly, Erin attached the rest of the great vessels to the new heart. The challenging fastidious work was the perfect antidote to her irrational anxiety. She deliberately avoided asking about the time until she tied off the last suture, securing Kristen's largest vessel, the aorta, to her new heart.
As soon as her assistant cut the last stitch, Erin turned urgently to Proust. "Time?"
"Five hours and sixteen minutes," he muttered.
Better than I expected, but still too long! "Let's unclamp now," she snapped.
One at a time, she removed the clamps from the great vessels, allowing Kristen's blood to pass into her new heart for the first time. Each time, Erin stopped and watched intently for any sign of bleeding at the suture lines but was relieved to remove the last clamp without spotting any leaks from the blood vessels.
The new heart lay utterly still inside Kristen's chest.
"Okay. Let's restart it. Paddles, please."
Someone passed Erin the set of internal defibrillator paddles, which resembled a pair of electrified salad spoons. She slid one of the sterile paddles underneath the heart and cupped the other paddle on top, as if squeezing it between tongs. "Okay, charge to ten joules."
A high-pitched buzzing sound cut the room's somber silence. "Charged," a nurse called.
Like everyone else, Erin watched the squiggly horizontal blue line on the cardiac monitor above the OR table. The reading showed ventricular fibrillation—the transplanted heart's erratic, but expected, rhythm. She simultaneously depressed the two little red buttons on the handles. The paddles vibrated almost imperceptibly as they released their shock.
A solitary spike from the shock shot up the monitor like a line across a page, but the squiggly fibrillation pattern held firm.
"Dial up to twenty joules," Erin said, as calmly as possible.
She shocked the heart again but the ventricular fibrillation held fast.
The anesthesiologist shook his head gravely. Fingers crept tighter around Erin's neck. "Recharge!" she barked.
Erin shocked three more times in succession, but she didn't need to look at the monitor to know that the donor heart had not responded. It flopped between her paddles as unresponsively as a thick steak lifted by a pair of tongs.
Erin dropped the paddles on the nearest tray and then turned to the anesthesiologist. "Peter, run an isoproteronol drip," she told him. "I need a milligram of epinephrine and a cardiac needle."
Reaching for the syringe held out by the nurse, Erin noticed her own hand had begun to tremble again. "Come on, Kristen," she muttered under her breath as she poked the long needle through the thick ventricular wall of Kristen's nonfunctioning new heart and squirted the medication directly into its major chamber.
Erin wrapped her other hand around the transplanted heart and gave it several pumps in open cardiac massage to try to coax it into activity. She glanced over to the monitor. It still squiggled away in fibrillation.
The imaginary ligature tightened around Erin's neck. "Another syringe of epinephrine," she croaked. "And have an external ventricular assist device on standby to implant."
Proust glanced at her, his eyes rife with doubt. Erin knew he was right. Kristen Hill was running out of time. The bypass machine was still filling in for the work of her heart, but with or without mechanical assistance, the chances of the donor heart restarting were diminishing by the second.
Erin's own heartbeat crashed like cymbals in her ears. As she pulled her fingers out of Kristen's chest cavity, the rough tremor was visible to all. Her tiny female assistant eyed her with silent concern, but Erin ignored her. She shot her hands out for the defibrillator paddles on the tray. She almost dropped one of them as she fumbled to position it behind the nonresponsive heart.
"Come on, Kristen," Erin muttered under her breath. She glanced at the nurse. "Okay, charge to twenty joules."
Erin shocked the heart again. No response. She repeated two more times, but the wavy line on the monitor refused to budge from its deadly fibrillation pattern. She exchanged the paddles for another syringe of epinephrine. She almost missed the chamber as she jabbed it into the heart and injected again.
"Listen, Erin." Proust's tone was uncharacteristically sympathetic. "We're at well over five hours of cold ischemia. How long will we continue?"
"She deserves longer," Erin said, in a whimpering voice that surprised even her.
Proust shrugged and turned back to the respirator.
"I need syringes of vasopressin and dopamine." Erin cited two other drugs meant to stimulate the heart.
She reached for the paddles again and repositioned them inside the open chest. She applied three consecutive or "stacked" shocks. Barely glancing at the monitor, she dumped the paddles back on the tray and grabbed for the new syringe that the nurse was holding out to her.
"We got something," Proust muttered as he pointed to the monitor.
Erin looked up and saw the change. At regular intervals, a wide blip interrupted the line that had otherwise flattened. She leaned forward and shone her bright headlight onto the donor heart. It took her a second to realize that its walls were now quivering slightly. Holding her breath, she watched as the flicker grew stronger. Soon the heart began to visibly beat.
"Yippee!" Woo whooped, and a wave of relieved laughter spread through the OR.
Erin backpedaled away from the table. She felt as though she might faint. But her sudden light-headedness and cold sweat were a small price to pay for the torrent of relief washing over her.
