Celebrate Red and Blue Day

“What sort of day was it? A day like all days, filled with those events that alter and illuminate our times…” – You Are There, 1953

November 29, 1944: Dr. Alfred Blalock took one final look into the incision. It looked right… he had been operating for years, surgery shouldn’t make him nervous anymore. But this operation did. He had completed this same surgery on a dog only once, and no one had ever tried it on a human before. Let this work…

“Watch for bleeding,” his assistant reminded him as he started to remove the clamp. Blalock nodded, ready to drop the clamp back into place if the new connection leaked. But not too hard, too much pressure and you crush the Pulmonary Artery; do that and you kill the patient.

His partner, Dr. Helen Taussig, stood near the head of the table. Heart surgery had been her idea, she had just as much riding on this operation as he did. Probably more – she had assured both him and the child’s parents that the theory behind this operation was sound. The little girl’s heart defect caused Cyanosis – she was literally suffocating from lack of oxygen. Taussig’s theory was to reroute a blood vessel to the lung and increase the amount of oxygenated blood available. Blalock’s assistant, Vivien Thomas, had designed the operation and tested it. All three of them had their reputations on the line.

And the irony of it all was if things went bad, he’d probably be the one to suffer least. Blalock was the Chief of Surgery, after all. Taussig was an almost deaf female doctor (who ever heard of such a thing?) and Thomas was a Black man who official job description wasn’t supposed to bring him anywhere near a scalpel, much less doing experimental surgery. If things went wrong, they would be the ones hung out to dry.

So let’s not allow things to go wrong, Blalock thought as he inspected his work again. “I’m removing the clamps,” he finally said.

Reaching into the open wound, he gently touched the new connection. “I can’t feel any flow,” Blalock said, disappointed. After a long pause, Taussig spoke.

“Al, the baby’s lips are a glorious pink color.” Stunned, the surgeon watched as the child’s blue lips slowly turned pink.

Before that day in 1944 heart defects were almost always fatal, usually during the first year of life. Occasionally a child was lucky enough to survive to late childhood or the early teens, but that was only under the best of circumstances. And that “lucky” child had no strength, no energy, and very little Quality of Life. Even after that first surgery (the Blalock-Taussig Shunt)  there was still only one operation, designed to relieve the effects of one heart defect. The odds weren’t good, but CHDers now had a chance. And sometimes one chance is all you need.

CHD Survivors, our families, and our friends celebrate November 29 as Red and Blue Day. Participating in Red and Blue Day is simple – just dress in red and blue clothing. You don’t have to donate any money (though if you choose to, your favorite CHD Support Group would be an excellent choice!) and you don’t have to volunteer to do anything. Simple as can be. If anyone compliments you on your good taste or your color scheme, just be prepared to explain why you chose those colors.

A Heart Defect is an Invisible Disability… many of us don’t even look like we have a health problem. Some of us are Cyanotic, but you have to look really close (and know what you are looking for) to see it. But November 29 is OUR DAY, so wear Red and Blue… and let’s stand out!

Partners of the Heart

In honor of Red and Blue Day, what follows is a reprint of an article I wrote for the November 2009 issue of The Right Heart Times, the newsletter of the CHD support group Hypoplastic Right Hearts:

The Blalock-Taussig Shunt (Shunt means “detour”) was the brainchild of one of the most unusual people in medicine: Dr. Helen Taussig. Despite being Dyslexic and slowly losing her hearing after becoming a doctor, Taussig had overcome both disabilities to become the head of the Cardiac unit at the Harriet Lane Home for Invalid Children, located at Johns Hopkins Hospital in Baltimore, Maryland.

While at Harriet Lane she began to study Congenital Heart Defects, especially Tetralogy of Fallot (ToF). ToF children suffered from a combination of four heart defects which led to the mixing of oxygenated blood with unoxygenated blood inside their damaged hearts. This caused them to have Cyanosis (have a bluish tinge to their skin due to poor blood oxygenation), have poor stamina, difficulty feeding and usually die before they reached ten years old.  Despite the fact that these children were breathing hard and deep, they were suffocating – and there was nothing that Dr. Taussig could do about it.

Taussig’s frustration would continue until 1943, when Hopkins hired Dr. Alfred Blalock as the new Chief of Surgery. It wasn’t long after his arrival that Taussig and Blalock had a conversation that would change the world.

Hopkins legend states that Dr. Taussig literally broke into a conversation between Dr. Blalock and her boss, Dr. Edwards Park, and convinced him to attempt a surgical repair of the defect. Blalock reminded her that it was impossible to operate on the heart (at that time it was impossible) but Taussig contended that what she had in mind was not an operation on the heart itself, but moving the blood vessels around to send more blood to the lungs. She had the idea, but since she was not a surgeon she could not act on it.

Little did she know that he already had a partial answer. While studying the effects of shock on the human body, Blalock and his assistant Vivien Thomas had sewn a smaller artery onto the Pulmonary Artery in an attempt to increase blood pressure. Blood pressure had not been affected, but blood flow increased. The challenge now was to recreate the effects of ToF in a dog, perform the arterial connection, and evaluate the results. Swamped with his teaching duties and surgical schedule, Blalock turned the assignment almost completely over to Thomas. An African American with a high school education, Thomas had gotten a job in Blalock’s lab after dropping out of college and had become Blalock’s most able assistant.

Re-creating either the heart defect or the planned repair often proved fatal for the dog, but finally Thomas found the perfect combination and a mutt named Anna survived. The next step was to teach Blalock the procedure. The surgeon had observed the operation several times but had never done it himself; Thomas had done the procedure several hundred times – all on dogs.

On November 29, 1944, the trio tried the new surgery. They may have operated sooner than they wanted to, but young Eileen Saxon’s condition was deteriorating. Although she was 15 months of age, Eileen weighed only nine pounds and was badly cyanotic.

As they were preparing for surgery, Blalock turned to his scrub nurse and quietly asked her to summon Mr. Thomas. Although Thomas had taught him the procedure, he wanted his assistant close by in case there was a problem. Thomas entered the surgical suite and stood behind Blalock, guiding him through the operation and giving advice.

Making a five-inch incision on Eileen’s left side, Blalock clamped and cut her Left Subclavian Artery. The Left Subclavian branches off of the Aorta, travels along the shoulder blade (the Clavicle) and down the left arm. For a visual reference, the Left Subclavian Artery is located almost directly behind a police officer’s badge.
Blalock then placed clamps on the left branch of the Pulmonary Artery and made a small hole in the artery. Gently pulling the Subclavian downward, Blalock sewed the vessel onto the Pulmonary Artery, took a deep breath, and disconnected the clamps.

Eileen’s cyanosis almost instantly faded. “She’s a lovely color now!” Taussig exclaimed. Blalock’s surgical notes are a bit more understated, reporting that “the circulation in the nail beds of the left hand appeared to be fairly good at the completion of the operation.”

Originally known as a “subclavian to pulmonary anastomosis,”the operation was soon renamed the Blalock-Taussig Shunt, after the surgeon who performed it and the doctor who conceived it. Thomas received almost no credit for his part of the procedure during his lifetime.

Survivors of the Blalock-Taussig Shunt often have difficulty getting a pulse or a blood pressure reading in the arm on the shunt side (because of the disconnected Subclavian Artery) and should avoid having injections into that arm. In the late 1970’s the Modified Blalock-Taussig Shunt (MBTS) became popular. The MBTS leaves the Subclavian intact and makes the Subclavian-Pulmonary connection by inserting an artificial tube and avoids the arm problems created by the original Blalock-Taussig.
Eileen Saxon did well for a few months but again became Cyanotic as her shunt failed. She underwent another Blalock-Taussig Shunt (on her right side this time) but passed away just before her third birthday.

Blalock’s surgical team performed almost 200 Shunts in the space of a single calendar year and the operation opened the door for Congenital Cardiac Surgery. He continued to operate until just before his retirement in 1964, and died six months later.

Dr. Helen Taussig became known as “the Mother of Pediatric Cardiology” and had a part in averting the Thalidomide crisis in the early 1960’s. She retired in 1963 but often returned to Hopkins, staying current on the latest Cardiac research and contributing  much of it herself. She was killed in an automobile accident in May of 1986.

Vivien Thomas continued to stand at Blalock’s shoulder and eventually became Director of the Johns Hopkins Hospital Surgical Research Laboratories. He trained many of the surgeons who would become famous for their heart surgery accomplishments and invented many of the procedures that they would use. He received an honorary doctorate in 1976 and retired in 1979. Thomas wrote his autobiography, Partners of the Heart: Vivien Thomas and his work with Alfred Blalock and died in 1985, just before the book was published.

Anna the Dog served as the mascot of the Johns Hopkins Surgical Labs until her death in 1957.

Making History

Doctor Blalock!

What are you doing out here? Doctor Taussig is beside herself, wondering where you are! Please get in there and get scrubbed up, or she’ll have my hide!

No I don’t know where Mr. Thomas is. Find him? Send him down to the OR? I don’t know about this… Yes, sir, you’re the doctor and I’m just an orderly. I’ll find Mr. Thomas myself! But right now, you need to be in the Scrub Room!

It is November 29, 1944, and YOU are Dr. Alfred Blalock. Eileen Saxon has just been brought into Room 706 for heart surgery… the first such operation ever attempted. If you think you are up to the challenge, CLICK THIS LINK.

NOVEMBER 29, 1944: THE BLALOCK-TAUSSIG SHUNT

“I had never seen or examined a defective heart, and what I actually saw defies verbal description except in highly technical terms. I was amazed that some of these patients had survived as long as they had.”  — Vivien Thomas, Partners of the Heart: Vivien Thomas and his Work with Alfred Blalock, p. 81

“Like Something the Lord Made”, the original magazine article written by Katie McCabe that appeared in the August 1989 issue of The Washingtonian. (.pdf file)

“I remember… thinking it was impossible.”

The Vivien Thomas Fund

The History of Heart Medicine at Johns Hopkins

Hopkins Reading Room ( LOTS of information about the heart from Johns Hopkins Hospital)

“This operation is new and our knowledge is advancing rapidly; consequently, much of the following discussion may be subject to radical revision.”  — Dr. Helen Taussig, Congenital Malformations of the Heart, volume 1, p. 553.

Teamwork

These two men did pioneer work on blood loss and shock. They developed heart surgery procedures that are still in use. Odds are, you have only heard of one of them.

Vivien Theodore Thomas was born on August 29, 1910 in Lake Providence, Louisiana. After graduating high school in 1929, he planned to attend Tennessee Agricultural and Industrial State Normal School, (Now known as Tennessee State University) with hopes of becoming a doctor.

He had been in school two months when the stock market crashed, causing him to lose his part-time carpentry job. Forced to drop out of college, Thomas still found work as a Lab Assistant at Vanderbilt University Medical School, working for surgeon Dr. Alfred Blalock. Although hired to sweep floors and clean out cages, Vivien Thomas impressed Dr. Blalock with his intelligence. Blalock was so impressed that he trained Thomas to be his Surgical Technician.

Thomas began assisting Blalock in the study of shock during surgery. Shock is caused by a sudden drop in blood flow through the body, and can be fatal. Working together, Blalock and Thomas developed ways to prevent shock from occurring during an operation. By World War II most of their theories were in use, saving the lives of countless injured soldiers.

In 1941, Dr. Blalock was hired by Johns Hopkins Hospital in Baltimore, Maryland, to serve as the hospital’s Chief Surgeon and as a Surgical Professor in the Hopkins Medical School. The doctor asked his trusted assistant to go with him, and Thomas agreed. But while Blalock was responsible for training every surgeon in the school, Thomas had to enter the building through the service entrance. He was also listed on the hospital payroll as a handyman.

The two men respected and trusted each other, but were hardly equal. At one time, Blalock was paid ten times more than Thomas. Often the doctor hired Thomas to serve drinks in his home during a social event. And never was Thomas allowed in the Operating Room.

It was at Johns Hopkins that the two men met Dr. Helen Taussig. Taussig had been hired in 1930 to oversee the Cardiac Clinic of the Harriet Lane Home, (Hopkins’ children’s hospital) and quickly grew interested in “Blue-Baby” diseases.

Usually, blood coming into the heart is routed first to the lungs, where it absorbs oxygen. The oxygen rich blood then goes back to the heart, where it is pumped throughout the body. Blue Babies are born with a badly formed heart or blood vessels that cannot provide enough oxygen to the blood. Their skin has a distinctive blueish tinge, especially in the fingertips. At that time Blue Baby diseases were incurable, and almost all of the patients died very young.

Dr. Taussig approached Dr. Blalock with an idea: if a Blue Baby’s heart couldn’t provide  oxygen to the blood naturally , then why couldn’t a surgeon re-route the major blood vessels? Taussig’s plan was interesting but extremely dangerous. The operation would have to take place near the heart, and heart surgery was so risky it was almost never recommended. Any accidental damage to the heart would have to be repaired within 4 minutes, or the patient died.

Busy with his teaching duties, Blalock asked Vivien Thomas to work out the details of how such an operation could be done. Thomas began by studying medical textbooks, drawings and diagrams of hearts, and even real hearts taken from dead bodies. Then he operated on dogs, intentionally creating Blue Baby hearts in them. Later he would operate again, repairing the heart and making careful notes of everything he did. It was a slow process, learning exactly what had to be done.  Many dogs died, and several of the surgical tools he needed didn’t even exist. Quite often, Thomas would invent them.

X-rays of the patient were another problem. X-ray films provide a good still photograph of the workings of the body. But Taussig preferred to use a fluoroscope. A fluoroscope image is best described as “X-ray TV”– It provided moving images of the interior of the body. If the patient accidentally moved, so did the picture. There was no way to record the fluoroscope image, so the three doctors would have to study their patient’s fluoroscope scans carefully and commit them to memory.

At last they felt they were ready, and Taussig began to search for a proper patient. On November 29, 1944, they operated on a little girl named Eileen. Although fifteen months old, Eileen only weighed nine pounds.

Thomas had planned to be in the observation room, watching the operation. Blalock said no – he felt more comfortable with Thomas close enough to give him advice. In preparation for the operation, Thomas had performed the procedure over 100 times on animals. Blalock had been taught the procedure by Thomas, but had actually done it only once. Breaking all the rules of the time, Thomas entered the operating room and guided  Blalock through the operation.

Eileen’s heart never stopped beating and her blood vessels were only as thick as a  matchstick. After about 90 minutes, Blalock was finished. Everyone held their breath as he removed the last clamp from a blood vessel. After a long pause, Helen Taussig said “Al, the baby’s lips are a glorious pink color.”

Proven to be a success, Blalock’s team performed nearly 300 operations in less than a year. Surgeons came from around the world to study Blalock’s new surgical procedures, only to learn that Thomas was the expert, not Blalock or Taussig. Still, the operation was known as the “Blalock-Taussig Shunt,” named for the surgeon who performed it and the doctor who suggested it.

Blalock retired in 1964 and died four months later. For six years, Thomas continued to teach but took on no major project – almost as if  he were in mourning. But as the 1970’s began, more and more African-Americans were entering the Hopkins Medical School. To them, Vivien Thomas was not just one of their teachers, he became their mentor. And just as he had guided Blalock so many years before, Thomas’ advice and support guided a new generation of doctors through medical school.

Thomas died in 1985, just a few days before his autobiography was published.* Today, Vivien Thomas is almost unknown to the general public. But Dr. Alfred Blalock never forgot him. If someone stood too close to his right shoulder during an operation, Blalock would tell them to back away. “Only Vivien may stand there.”**

* Thomas’ autobiography has been reissued with a new title: Partners of the Heart: Vivien Thomas and his work with Alfred Blalock. A hardback copy of the original title, Pioneering Research in Surgical Shock and Cardiovascular Surgery: Vivien Thomas and his work with Alfred Blalock is usually valued at over $100.

** This photo has been identified by Johns Hopkins archivists as being a photo of the third Blalock-Taussig Shunt taken in early 1945. Dr. Helen Taussig normally would have been in the operating room but is not identifable in this photograph.

Documents

Holding a copy of Helen Taussig’s book Congenital Malformations of the Heart is almost like holding a copy of scripture. This is where it all began: before publication of this book in 1947, there was almost no understanding of Congenital Heart Defects (CHD). No way to diagnose them. No field of Pediatric Cardiology, barely any heart surgery to speak of. Very few survivors. No groups like The Congenital Heart Information Network (TCHIN), Mended Hearts or the Adult Congenital Heart Association (ACHA). Hardly anything. And certainly no Adventures of a Funky Heart.

I have heard stories of doctors from the late 1940’s and early 1950’s examining their patients with a stethoscope in one hand and Taussig’s book in the other. And finally, instead of telling the worried parents that the situation was hopeless, being able to offer at least a small chance: “They’re making amazing progress with surgical solutions at Johns Hopkins, maybe if we contact them…”

She was years ahead of her time. Taussig wrote an entire chapter concerning a defect she described as “Atresia or marked hypoplasia of the aortic orifice prevents the expulsion of blood from the left ventricle in the normal manner. In such abnormalities the development of the left ventricle is also usually defective.” This defect is almost certainly what we know today as Hypoplastic Left Heart Syndrome (HLHS).

Other records exist that actually predate Congenital Malformations. Alfred Blalock’s surgical notes from the first Congenital Heart Surgery (later known as the Blalock-Taussig Shunt) have been saved and are online. You can read them here. (Page 1 Page 2) And here is a photo of the clamp that Vivien Thomas designed for the surgery.

The first operation occurred on November 29, 1944. Blalock and Taussig wrote a paper about the shunt that was published in the Journal of the American Medical Association on May 19, 1945, that brought the news to the world. (Here’s a drawing from that article). Normally works in medical journals are not noted in the public press, but a medical reporter who was actually a doctor (and not a well informed amateur, as many of them are) read the article. He wrote a short blurb about it that was printed in his paper and picked up by the wire services.

And the people came. At first they went to their local doctors, to find out all they could about this new operation. And then they came to Johns Hopkins Hospital…on the train, in cars, and some of them actually walked, bringing their sick children to the one place that might could help them. Blalock and his team actually performed an estimated 300 heart operations in a single year. The American Weekly printed an article about Taussig, Blalock, and the B-T Shunt in its February 17, 1947 issue and still more people came.

And in late 1947 Congenital Malformations of the Heart was published. The life changing surgery was only designed for Tetralogy of Fallot (ToF) patients, but now there  was a way to figure out exactly what was going on in a defective heart, and with knowledge came a chance.

There is a small section titled “The Plan of the Book” in which Taussig notes how her book is organized. In the second paragraph is this chilling sentence, which was true in 1947: “Although occasionally a patient with one of these malformations may live to adult life, in most instances death occurs before eighteen months of age.*” At the bottom of the page, the footnote reads “*The recent advances in vascular surgery may alter the prognosis in this group of malformations.”

I think Dr Taussig would be thrilled with the results of recent advances in vascular surgery.

Anna saved us all

I’m leavin’ in a minivan,

should be back Wednesday night…

Wait a minute, that doesn’t rhyme. I guess my career as a songwriter isn’t going anywhere.

I’m packed for the trip to Atlanta, the laptop is also packed and the batteries are charged, so I should be able to post tomorrow night. Of course, you’ll get a full report once I return home. I’m feeling good and not expecting any problems, though my weight is up a little bit. So the doc may wave his finger in my face. He won’t have to crack the whip too hard; I don’t like for it to be up either. When you have heart failure, your weight creeping up might mean there is a problem brewing. And even if it doesn’t, your heart has to work harder. That’s not good.

First, here are a couple of links that you need to read: Researchers have discovered that a new type of drug can trigger a heart defect in unborn mice. The chemical in question is fairly common, so if you are planning to have children (or more children), clicking these links would be beneficial!

But let’s not get ahead of ourselves; the sky isn’t falling (yet). Taking the results of a research study using unborn mice and saying that we’ve found a way to prevent heart defects is a giant leap, but it is certainly worth continued study.

Is animal research necessary? I have to answer with a resounding “YES!” When he was designing the first congenital heart surgery, Vivien Thomas first had to study the effects of Tetralogy of Fallot (ToF) in a test subject, then figure out a way to correct the defect. Conducting experimental surgery on children with ToF was completely out of the question, so Thomas first had to surgically re-create the defect, then devise a corrective procedure to counter it.

His test subjects were dogs, most of them supplied by the Baltimore City Pound. Thomas is said to have performed heart surgery 200 times or more before Alfred Blalock attempted it on a child, so we must assume that most of those operations were failures. The dogs almost certainly perished.

Finally Thomas figured it out, and not only did the dog (a “mutt” named Anna) survive the procedure that “gave” her a defective heart, she made it through the operation that corrected it. Thomas then taught Blalock the operation (again, on a canine test subject) and on November 29, 1944, with Thomas standing behind him giving him guidence and advice, Blalock performed the first operation designed to relieve a Congenital Heart Defect. (Click this link for a “Who’s Who” in the operating room!) The operation eventually became known as the Blalock-Taussig Shunt. Anna became the mascot of the Johns Hopkins Surgical Lab and lived there until her death in 1957. She even had her portrait hung in the Hospital.

While animal research may be necessary; animal cruelty is not. My personal rule of thumb is “Would I do this to my family pet?” If the answer is no, then that test is not done. (And this standard can be subjective; my dog is not my pet, she is a member of the family. A neighbor who owns hunting dogs does not think of them as his pets, rather they are “tools”. Their main purpose is to do a job: Tracking deer.) So even going by my own rule, Thomas would have never invented cardiac surgery. Because I couldn’t do that to my dog.

So now, all I’ve done is muddied the water! While you are contemplating the fine line between animal research and animal cruelety, carry a couple of doggie biscuts in your pocket and be sure to toss one to a stray. Because if it wasn’t for a mutt named Anna, none of us with a heart defect would be here.