24 hours at Johns Hopkins

“Because your whole world can change in 24 hours.” – The Paper (1994)

Tuesday, November 28, 1944: Sometime during the evening of the 28th, Dr. Alfred Blalock places a telephone call to the Surgical Laboratory at Johns Hopkins Hospital. His Surgical Assistant, Vivien Thomas, has recently developed a surgical correction for the heart defect known as Tetralogy of Fallot, also known as Blue Baby Syndrome. The two men have planned for Thomas to teach Blalock the steps needed to successfully complete the surgery during an operation on a dog. Blalock has done the operation only once and many more teaching sessions are needed.

Blalock is calling with grim news: Earlier he had asked Thomas about the possibility of operating on 19 month old infant Eileen Saxon. Weighing only nine pounds and often cyanotic, the dusky blue color that gives this malady its name, she is deteriorating rapidly. At the moment she is so cyanotic that she is purple and is struggling for every breath. Dr. Blalock tells Thomas to meet with Elizabeth Sherwood, the operating room supervisor, first thing in the morning. Thomas has invented several surgical tools specifically for this operation and he is to make sure that they are available.

Thomas is stunned and reminds Blalock that he doesn’t know the operation very well. “But if you don’t get ahead of yourself, break it down into smaller and smaller steps as you work, it can be done.” It is one of the familiar sayings Thomas uses when he is teaching proper surgical procedure and for a moment, Blalock feels as if he is the assistant.

After Blalock hangs up, Dr. Helen Taussig orders him home. Blalock protests, but she reminds him that he plans to operate in the morning – an operation that could very well be emergency surgery. The hospital has his telephone number should he be needed during the night. At roughly the same time, Thomas and Blalock leave for their respective homes. Segregation is still prevalent at the time and Thomas leaves by a back entrance; neither man knows the other one has left.

Dr. Taussig spends the night on the ward; Eileen’s parents are also there. Although they don’t know it, this is an ominous sign: in the 1940’s, visiting hours rules were strictly enforced unless a patient was seriously ill.

Wednesday, November 29, 1944: Too nervous to drive, Blalock asks his wife Mary to take him to the hospital. She lets him out of the car in front of the towering Johns Hopkins dome. Dr. Blalock enters the building, walks through the rotunda (rubbing the toe of the Statue of Christ for luck, an old Hopkins tradition) and turns left. From here he exits the building through a side door, walks approximately 50 yards, and into the Harriet Lane Home for Invalid Children. Vivien Thomas enters the Hopkins complex from a side entrance and goes immediately to Elizabeth Sherwood’s office. Miss Sherwood knows nothing about Dr. Blalock’s plan to operate but immediately shows Thomas the selection of items that will be available to Dr. Blalock. Thomas adds custom-made clamps and needles to the collection. These needles are no more than 1/2 inch long. Thomas insists that the clamps and needles not become part of the general operating room supplies – they have been custom made for this operation only.

Blalock and Taussig examine the child and confer. Eileen has not improved during the night, and Taussig concedes that there is nothing else that she can do. She leaves the meeting as Thomas arrives, perhaps to return to Eileen’s bedside or for a quick trip to the Cafeteria. Blalock and Thomas discuss the upcoming operation. They go over some of the more critical steps, and also discuss “routine” points such as where the incision should be made. Thomas informs him that Miss Sherwood has promised that the large operative theatre will be available but needs to know when the operation will begin. Blalock decides that the operation will take place after the morning rounds, unless events dictate otherwise. He leaves to confer with Eileen’s parents and to conduct Rounds. Thomas did not normally participate in Rounds so he would have gone to the Surgical Lab, although he may have gone to his office. He calls Miss Sherwood and informs her of Blalock’s decision.

The operative team convenes in the Scrub Room annex connected to Room 706. Although first chosen at random, the majority of Hopkins’ early heart surgeries will take place here and the room will come to be known as “The Heart Room.” Dr. William Longmire and Dr. Denton Cooley will assist. An unknown person sets up a movie camera pointed at the operating room table; this film still exists in the Johns Hopkins Hospital Archives.

Blalock continues to discuss the upcoming operation with Thomas as he prepares for surgery. Thomas is not scrubbed in and has no intention to – he is not allowed on the Operating Room floor. He will be seated in the raised seats of the theatre, however. Helen Taussig will be in the Operating Room, even though she is not a surgeon. She’ll spend most of her time at the head of the table, monitoring the patient.

A few minutes before Eileen arrives, Blalock quietly asks his scrub nurse to find Thomas and help him get scrubbed in. As expected, Thomas is seated in the bleachers above the OR. Blalock also orders a milk crate and has it placed behind him. Thomas stands on the crate, peering over Blalock’s shoulder at the operative field.

The operation begins with a curving incision near the 4th rib on the child’s left side. With Thomas guiding him, Blalock gently works past the lung and cuts a path to the heart. The heart is small, dark, and obviously struggling. William Longmire later said “I remember watching him open the patient and just thinking it was impossible.”

Blalock works patiently, finding the Left Subclavian Artery and the left branch of the Pulmonary Artery. He places a clamp on the Subclavian to cut off blood flow – using one of the clamps designed by Vivien Thomas for this procedure – and cuts it. He then places two similar clamps on the left branch of the Pulmonary Artery. Making a small opening in the Pulmonary Artery, Blalock uses the tiny needles Thomas has prepared to sew the Subclavian Artery into the Pulmonary Artery. After double checking his work, Blalock removes the clamps. He is unable to feel blood flowing through the new connection.

Legend has it that Helen Taussig said “Al, the child’s lips are a lovely pink color!” The Johns Hopkins online exhibit about the operation states that the anesthesiologist said “The boy’s a lovely color now!” at a later date, during the third operation. Blalock’s operative notes comment that the circulation in the nail beds of Eileen’s left hand “appeared to be fairly good.”

The difficult segments are complete but the operation is far from over. Sulfanilamide (an antibiotic) is introduced into the incision and Blalock begins to close. He sews the soft tissue closed with silk sutures and is finally done. The operation has taken about ninety minutes. (CLICK HERE to perform the Blalock-Taussig Procedure yourself. Read Blalock’s operative notes here:  PAGE 1 PAGE 2)

Eileen is moved to the Recovery Room, where Dr. Henry Bahnson is responsible for her care. As one might expect, Blalock and Taussig look in on her often.  Bahnson’s opinion is that the little girl is still very blue but improves over time. Eileen’s mother comments “When I saw Eileen for the first time, it was like a miracle… I was beside myself with happiness.” Very little is known of Thomas’ movements after the operation. He is seen in Recovery and also in his Lab.

As the sun sets on the city of Baltimore, Eileen remains in critical condition but she is stable. The operation is a success, but in a few months it will fail and she will need another Blalock-Taussig Procedure, this time on her right side. She will die just before her 3rd  birthday.  The doctors determine that the surgery is more suited to an older child whose blood vessels have had a chance to grow. In early 1945 Blalock and Taussig co-authored a medical journal article about the first three procedures. Hundreds of patients would flock to Johns Hopkins Hospital to receive the life-saving surgery, even though the odds were long: an article in the February 17, 1947 issue of The American Weekly noted that 14 of the first 70 patients had died.

But parents noted that 56 of them had lived and were growing up, something that had never happened before. The era of Congenital Cardiac Surgery has begun.

Don’t let the Water get in the Boat

I was back at the University of Alabama at Birmingham (UAB) in May of 1988, getting ready for one last heart operation. My Cardiologist had sat down with my parents and I at an earlier appointment and discussed possibly performing a version of the Fontan Procedure (See “A Final Note:” at the end of this post!) on me. It was really a two stage operation, but my first two surgeries roughly equaled the first part of the Fontan, so I would only need the second part of the operation. I would never be normal, my Cardiologist told me, but this final operation would bring me as close to being heart healthy as I would ever get.

This was the first time that everything hinged on my decision. I had been underage for my previous surgeries, so the responsibility had fallen to my parents. Since I had just turned 21, this time the Go/No Go was my decision. After steeling myself to the thought of all the pain and recovery time that would be involved, I decided to have it. All of the testing and X-rays had given my surgeon the information he needed to devise a plan he was confident in, and he and his team met with me the night before.

“Any questions?” he asked.

“Just don’t start without me,” I joked.

Dr. Albert Pacifico had been my heart surgeon the first time I had been a patient at UAB in 1977. Pacifico is known for two things: being good, and working fast. He averages eight heart operations a day, when the typical surgeon performs two a week. As far as Cardiac Surgery is concerned, he’s the superstar.

The next day, the crap hit the fan. As soon as the surgical team opened my chest, things began to spin out of control. Opening my rib cage tore some scar tissue that had became attached to the back of my rib cage, and I began to bleed profusely. Dr. Pacifico was world renowned and had probably performed more heart operations than anyone alive, and he needed every bit of that skill to get the bleeding under control. “Imagine your chest cavity is a boat, and your blood is water,” he later said as an explanation. “You never want to get too much water in the boat.”

“Shoot, doc,” I groaned. Talking after surgery isn’t the easiest thing to do. “You should have woken me up. I would have bailed out the boat while you fixed the leak.”

The leak was starting to get ahead of him; every time he sealed one bleeder another would pop open. I was bleeding out faster than the surgical team could put it back in.

As he always did, the surgeon came down to a Conference Room where the families of his patients had been summoned. He normally called out a name, and the family members would group around him as he consulted an index card and summarized the operation. (This was a long time before Health Record Privacy became such an important issue.)

“I will speak to you two last,” he told my parents. My mother gasped and began to cry.

The Patient Representative stepped forward. “That’s not the way we handle that,” she said, placing enough emphasis on the word so there was no doubt what THAT was.

The news still wasn’t good. The bleeding had been stopped, but I had required 20+ units of blood. A lot of water had gotten into the boat. I was in recovery, but I wasn’t recovering. I wasn’t going downhill, either; so you could say I was just holding my own. And then he said the phrase that has come out of every surgeon’s mouth:

“We’ll know more in a few hours.”

The waiting room was huge. UAB had designed a building that contained all of its surgical suites and all of the recovery areas, which meant the entire ground floor was a unit’s waiting room. The surgical unit waiting area was over there, while ICU was here, and surgical recovery over there, but if you took out the walls you would have one large room.

So the families sat and waited, talked, and followed each other’s progress. A good report cheered everyone, while bad news made the room grow somber. A young lady – my father thought she was a teenager, but he later learned she was an adult who ran a hairdressing shop in a nearby suburb – heard about me and gathered her friends. “We need to pray for this young man,” she said.

At about the same moment, my surgeon sat by my bedside in Recovery and studied my chart. He was by himself, which was quite unusual. Pacifico was usually at the head of a five to ten person entourage. And he had been reading for an hour, which was also quite unusual for him. Finally he snapped the chart shut and ordered a change in my medications, and from that point on I began to improve.

A miracle? The skill of an experienced, trained surgeon? “Yes” is the answer to both questions. I believe God still works miracles, and I also believe that He does a lot of them without any fanfare. Heart Surgery is a modern miracle, but what about the guy who invented the Band-Aid? His little idea has probably saved just as many lives, and possibly more.

This story doesn’t end here. A few years later, my cardiologist commented, “It’s probably a good thing that there was so much trouble when we tried to perform that Fontan on you. We’re learning that it’s not working as well as we hoped, and some of those who have had it are actually worse off than they were before.”

The hero you find may not be the hero you are looking for.

A Final Note: As I mentioned, these events occurred in 1988. The Fontan Procedure that was to be performed on me (And that eventually showed poor outcomes) is not the Fontan that is being performed today. The operation has undergone several revisions and is now much more effective.