Fred Dickey's Island of Human Drama
'I can distinctly remember every single person we’ve lost'
'I can distinctly remember every single person we’ve lost'
In this 2015 file photo, doctors prepare to transplant a heart at Sharp Memorial Hospital in the Serra Mesa neighborhood of San Diego. (Nelvin C. Cepeda / Union-Tribune)
By Fred Dickey San Diego Union-Tribune Newspaper 4/17/17
This is how it sometimes happens.
Little more than a year ago, 43-year-old Kim Gregory from Lake Elsinore arrived at a Sharp hospital, where she would probably die. Her life clock was nearing 11:59.
She had been sent there from Scripps Clinic to either get a heart transplant or for whatever desperate measures Sharp specialists could use to keep her alive.
That job fell to 36-year-old Dr. Hirsch Mehta and the transplant team at Sharp Memorial Hospital.
He describes her crisis. “She had a genetic cardiomyopathy, meaning she was born with a heart that never really worked well. It got her through young adulthood, but now it’s just not doing its job.
“Tom Heywood (M.D.), my former mentor at Scripps, sent her over to me.” He interrupts himself to say, “I don’t have enough great things to say about Tom.
“Anyway — god! She’s a wreck. We put her in ICU, listed her for transplant and — tick-tock, tick-tock — every day she’s getting worse.
“One afternoon, when I went back and saw her, she looked absolutely horrible. I mean, she probably — if she didn’t die that night, she certainly was going to die the next day, and I knew it. I didn’t say it to her, but she knew something was dreadfully wrong.
“I told the nurse, ‘This is my cell number. You call me when something happens. I know something’s going to happen.’
“We’ve put her on complete heart bypass. She’s waiting for a transplant and has been for a couple weeks. I don’t even get to the parking lot when I get a phone call.
“We have a heart! Fantastic! I walk back and let Kim know. Two hours later, she’s in the operating room getting a new heart.”
She was near death. Why wouldn’t you tell her that?
“You know, I don’t know. I don’t think she knew she was going to die.”
(When later told that, Kim gasped and said, “Oh, my god!”)
Mehta says, “I came to work the next day, she was asleep. The day after, she was awake, feeling fine. Four days later, she was out of the ICU. Twelve days later, she was home.”
Kim is currently finalizing plans for her wedding. Mehta will be invited.
Kim was lucky, she got a heart. Others languish in hospital beds or wheelchairs hoping each faint heartbeat will be followed by another. They are victims of indifference.
Not indifference by the transplant team, which starts each day by checking the availability of donor hearts. No, the indifference is the public’s that will take a perfectly usable heart from a deceased person that could keep another alive and either burn it or bury it.
Mehta and the team have to stand by empty operating rooms and see patients die because there are no hearts to give them.
As to why people are reluctant to cooperate on donations, he says, “I mean, there may be some cultural or religious issues. There might be fear or lack of education. I don’t know. It’s a question that we struggle with, because there are great numbers of people who die every year waiting for a heart that never comes.”
Here’s what it comes down to: Last year, the Sharp team performed 13 transplants. Mehta estimates that, were sufficient hearts available, at least 25 transplants could have been done.
That translates to several humans who could be walking, loving and laughing today but aren’t.
Many former patients rest in Mehta’s memory bank, but one in particular surfaces when donor availability is mentioned.
In a recent year, a San Diego man under 30 came to the emergency room with what seemed like a cold.
It wasn’t. A virus had invaded his heart, Mehta says. “His heart function was 20 percent. He was sent to us where we stabilized him and put him on medication. He was sent home with a return date, but came back in four days. He was in complete shock.
“We put artificial pumps in his leg and monitoring devices through his neck. Then, 24 hours later he got even worse. We put him on full heart-lung support bypass. We listed him for transplant that day.” He pauses for emphasis. “That day! He’s in the ICU waiting for a donor heart, just waiting. We waited, and we waited, and we waited. Two and half weeks went by, and we kept waiting.”
He explains that the heart-lung machine is meant only as a temporary fix. It will do the job for a short while, but as time accumulates, things are bound to happen, and they are not good things.
“His organs are deteriorating. Kidney and liver function get worse, He goes on dialysis. He starts bleeding internally. The machine can’t do everything.”
Three and a half weeks later, he went into multi-organ failure. Kidneys dead. Liver not working. Lungs filled with fluid. Small clot in the brain — probably a small stroke.
Mehta says, “We had to tell his family that their young brother and son, who a month ago felt fine, that there was nothing left to do for him.”
No more waiting.
“We turned the machine off and he died within five minutes.”
With the sobbing family gathered bedside, a technician had to walk to the young man’s bed and turn the dials, listen to the machine whirr to a stop and go silent. Then step back, fumble for something to say and quietly steal away, leaving the family to their grief.
That evening, Mehta went home to dinner with little appetite, then forced a happy face and asked his wife how her day went.
“When I come home every day, at whatever time that may be, and the door opens, I hope my wife can’t tell if I’ve had a great day or a horrible day. I hope she doesn’t see it on my face.
When we put our daughter to bed and we have our moments as a couple and not as parents, then I open up to her.”
Mehta says, “I can’t for the life of me remember all the people we’ve saved. But I can distinctly remember every single person we’ve lost.”
He derives a sense of mission from his religion. “The Hinduism I practice is where I try to fulfill my responsibilities and give as much as I can. Serve my patients, serve those around me. Serve.”
The physicians on the transplant team don’t always treat each other like Rotarians at the social hour. These are experts at the top of the heap. In dealing with most people about medical matters, their opinions and statements are accepted with a snap-to “Yes, doctor!” But they don’t say that to each other.
A patient-care conference can become a knowledge-ego clash at the summit. And Mehta is not a shy man.
He nods agreement. “Absolutely, it can get heated. I mean, we have four members of our team who have practiced for 30 years, and I’ll go at it with them. I will. They don’t always like it.
“You know how it goes: ‘I’ve been doing this since you were in diapers.’ And they’re right, they have been.”
But you have the benefit of the latest, most advanced instruction.
“That’s true, but these are some of the people who wrote the book of instruction.
“We may have different views, but then we’ll decide as a group what’s better and what’s not better. The culture is positive when I, a young cardiologist, can go toe to toe with a surgeon who’s written books on how this should be done. No matter what we decide, there’s great value in having open and frank discussion.
“We will disagree, we will fight and we will argue, but we never lose respect for each other. Every time we disagree, later that day I’m going to go to them for advice.
“Our wives are friends. Our children play together. They are just as much a part of my extended family as my own extended family.”
I have the impression the optimal heart would come from a healthy young person who died accidentally. But is there an age limit on getting or giving a heart?
Mehta answers, “Well, to be a recipient, biologic age and physiologic age can be very different. We’ve seen people 65 who have a medical age of 85. They won’t get a heart. However, we’ve seen people 65 who, except for their heart, have a medical age of 55. They’d probably be just fine for transplant.”
Likewise, what age heart will you accept to be transplanted?
“A healthy person 55 who died, say, in an auto accident, who has no artery disease and the pump is working fine, who doesn’t need any blood-pressure support, that person is probably an adequate donor for a 30-year-old.
“However, a 25-year-old who has abused methamphetamines and who has drugs in their system at the time of death, we won’t take that heart for anybody.”
Mehta talks about a case of about three years ago that comes to his mind, and I suspect isn’t buried very deep.
“There was a woman about 70 who came to us from the emergency room with chest pain. She needed to get her heart looked at. I talked to her and to her family. It started out routine, but the examination showed she had horrible disease. All of her arteries were loaded with plaque. She needed at least four or five bypasses. Her carotid arteries were blocked. Her leg arteries were blocked.”
When Mehta and his team tried to put a large IV into her heart, the needle punctured the lung. That’s what is called a “complication.” It’s a medical term that says stuff happens.
The risk of that occurring is dicey enough that patients are warned of it in advance. In what Mehta and his colleagues do, the adjective “minor” is a seldom used modifier.
Mehta says, “We treated the lung puncture and the minute we got that under control, her arteries became compromised, which put stress on her heart. She ended up developing an infection and then she lost blood flow to a leg, and then she was having acid build-up. One thing just spiraled into another, into another, into another. She also had eight or 10 other undiagnosed medical problems.”
The woman was placed in a medically induced coma, and family members were presented with options such as multiple bypass surgery, amputation of the leg and a permanent breathing tube.
The family declined on the basis of the woman’s known wishes. She was allowed to die.
“It ended up a tragedy for the family and a grave disappointment for all of us who worked on her.”
We love happy endings and dignified doctors with a touch of gray at the temples and a stethoscope draped around the collar of a white coat. Because we’re of that romantic image, it is easy to overlook the gut-wrenching tension and fear of failure that can create that gray hair.
Medicine at the rarified heights where transplant teams practice is performed without a net. Transferring a beating heart 2,000 miles and putting it in another person is not treating the common cold.
These doctors are not in the motor pool, they’re medical commandos, and they will suffer losses. And when they succeed, as they do to an amazing extent, any celebration is cut short because here comes another failing heart.
Mehta’s reward? He gets invited to Kim Gregory’s wedding, which is especially nice because he knows her heart.
Fred Dickey’s home page is freddickey.net
He believes every life is an adventure and welcomes ideas at [email protected]