ACKNOWLEDGMENTS JOHN A. ELEFTERIADES, MD CHAPTER 1 "Doctor, I cannot forbid you to perform that procedure," said the clipped, nasal voice in Athan Carras''s ear, "but I emphatically withhold the permission you are seeking from the committee." You vindictive son of a bitch, Carras thought, but into the phone he said, "You don''t have that authority, doctor. You are just the vice-chair of the Human Investigations Committee. Only the chairman has the right to grant or withhold approval." There was a silence on the line, then Carras could hear the thin smile in Dr. James Bonar Auldfield''s voice when he said, "You should have read the committee''s terms of reference more closely, doctor. In the absence of Dr.
Bentham, all of his powers devolve to me." "For God''s sake," Carras said, "that''s Cory Goldenberg on my operating table. Leave aside that he''s a friend and colleague to both of us, he''s one of the top cardiologists in the world. If the technique works, he could live another ten years, save hundreds of lives. But if I don''t do it, he''ll be dead before morning. Guaranteed." Auldfield''s voice was bright with a cold glee. "I''ve told you, doctor, it''s entirely your decision," he said.
"You agreed that there will be no human experimentation until the HIC has seen long-term results from the animal trials. However, if you want to disavow the covenant you have made with the committee, you are free to break your word." "But you won''t cut me an inch of slack, will you, ''Boner''?" Carras heard the sniff that preceded Auldfield''s final remark. "I must do as my conscience dictates. You do as you wish." There was a click and the line was dead. Shouldn''t have called him Boner, Carras thought. Auldfield hated the nickname he''d acquired when they''d been students together.
But Carras realized it wouldn''t have made any difference if he''d abased himself to flatter the other man''s delicate ego. Back in Operating Room 15 of Yale Medical Center, Craig Mason looked up from the dials of the heart-lung machine that was keeping Cory Goldenberg from sliding into death and said, "Are we go?" Carras took up his customary place on the patient''s left and swept his gaze over the monitors before answering. "Bentham''s on some kind of retreat in Montana. Left his cell at home. Can''t be reached before the end of the week." "So who''s on deck for him?" Mason said, then his eyes widened as he answered the question for himself. "Oh, fuck me. Boner, right?" Carras sighed.
"And Boner says we''re on our own." "Well fuck him with the broomstick he rode in on," said Mason. "Like I''m going to let Cory die because that little pissant thinks he''s Pontius Pilate? Let''s do this, Ath. Now." "Let me think." * * * CORY GOLDENBERG SHOULD HAVE KNOWN BETTER. ALTHOUGH HE was a senior cardiologist with Harvard Medical School, he suffered from a condition known as aortic regurgitation: a weakness in his heart''s outflow valve that did not let it be a one-way-only door. After expelling all the blood in the left ventricle, it didn''t slam shut and stay tight; instead, the valve let a little blood leak back into the heart.
The result was a progressive weakening of the organ. Any heart surgeon knew the answer to aortic regurgitation: cut out the faulty natural valve and put in an artificial one. These days it was a routine procedure and postoperative complications were next to nil. Goldenberg could have had his operation anytime over the several years since the onset of his condition. But Goldenberg was a conservative cardiologist. He had taught for years that surgery should not be an instant resort. Patients should wait until there was definite evidence that the heart was enlarging. With hearts, bigger is not better; bigger is certainly not stronger--an enlarged heart is a weak heart.
Goldenberg taught that, until enlargement was evident, surgery should be put off, and he practiced what he preached. In the meantime, he drove himself to a high level of fitness. He played tennis every day, between morning rounds and afternoon office hours, often taking on much younger opponents and beating them in straight sets. He rode a bike and trained with light weights. At sixty, he was lean, strong and looked fit. "I''ve started to enlarge," he had said, sitting in Carras''s long, shoe-box-shaped office in Yale''s venerable Farnum Building, between the modern medical center and the old red-brick morgue. They looked at the echocardiographic images from the lab. The enlargement was small--only one centimeter in diameter--but noticeable.
"No point waiting," Carras said. "We''ll perform the procedure tomorrow morning." He looked again at the echo results and said, "I wish you hadn''t waited." It was an argument as old as modern surgery. Clinicians like Goldenberg preferred to use noninvasive therapies--drugs, exercise, change of diet--to treat the myriad afflictions of which the human body is at risk. Surgeons opted to isolate the part at fault and if they couldn''t repair or replace it, they''d cut it out altogether and let the body''s systems adapt. The body was designed with built-in redundancy. Life could go on without a gall bladder or a spleen, with only one lung or kidney or with substantial portions of the liver missing.
But humans were issued only one heart and it had to last a lifetime, and Carras felt there was no point in unduly stressing the organ when a quick and simple surgical repair could avoid trouble. Goldenberg thought surgery was inherently dangerous, even under gifted hands. A certain number of patients who went under anesthesia never came out of it--the fraction was tiny, but that didn''t make any difference when relatives arrived at the hospital to visit Uncle Waldo after his minor knee surgery and found him chilling in the morgue. "You''re more likely to be hit by lightning," Carras said. "Or bitten by a shark." "If I stay in during lightning storms and stay out of shark-infested waters, the chances of being hit or bit are zero," Goldenberg answered. "As are my chances of dying on an operating table if I stay off one." "You won''t die on mine," Carras said.
"Sometimes I wonder about you, Ath," Goldenberg said. "It''s as if you see yourself in a head-to-head contest with death." "I wouldn''t put it so dramatically," Carras said. "Maybe not out loud," the cardiologist agreed, "but I wonder if there are times when you look across the operating table and see the old reaper reaching for your patient, and then it''s not about the patient anymore. It''s about winning." "All right, sometimes I do feel defeated when I lose a patient. And I hate it. Don''t we all?" "Sure, to some extent," Goldenberg said.
"Just don''t let it get too personal. Even when you''re operating on me. Remember, doctor, pride goeth before a fall." "I''m not the one who''s waited until his heart''s enlarged, doctor," Carras said. "That looks to be a fair-sized stumble on your part." "Touché," said the clinician, "but a little below the belt, don''t you think?" For a moment, Carras was tempted to say, Sorry, that was a low blow. But he and Cory had argued over similar cases so many times, in print and face-to-face at conferences, that the combative habit just naturally came to the fore. And when in combat mode, Athan Carras did not say sorry.
Besides, he told himself, an apology''s not what Cory needs. He needs his heart fixed. Carras fixed it the next morning, in an operation that was entirely routine from Goldenberg''s first shot of sedative to the postop visit by Carras in the intensive care unit. The new Pyrolite carbon valve was clicking away in the cardiologist''s chest and blood flow was normal. But would the moderately enlarged heart recover and return to normal? It took five years for the definitive answer to come in. Cory Goldenberg''s heart had not recovered. Weakened, it had continued to grow larger and less powerful. Partly through medication but mostly by sheer willpower, the clinician had been able to carry on with his teaching and practice, but his condition deteriorated, at first slowly, then later at an accelerated pace.
Now, at sixty-five, he was suffering from end-stage heart failure; the enlargement and contractile weakness of his left ventricle were so extreme that the eleven different medications he took each day could not compensate. He came to Carras for a transplant. The choice of a Yale surgeon by a prominent Harvard physician prompted some ironic comments in Ivy League circles. Carras had held his own in many a contentious academic debate, sometimes supplementing scientific fact with acid wit. He was not universally loved by his peers, of whom there were relatively few, and some of those he had bested detested him. But as Goldenberg said in a widely reposted e-mail, "Sure, Carras can be arrogant, but he has every right to be. In my case, he was right and I was wrong, and if I come out of this alive, it''s because of him." The wait for a suitable donor heart stretched into weeks, then into months.
Goldenberg was maintained on a continuous infusion of the drug dobutamine, which artificially strengthened his heartbeat and maintained an adequate outflow of blood from his failing left ventricle. The cardiotonic medication was delivered to his heart by a catheter connected to a pump. Some days, he used Carras''s office to work on a paper he was writing for the American Journal of Cardiology. Goldenberg was at Carras''s desk when he finally collapsed from pulmonary edema--he began to drown from backing up of blood and pressure into his lungs. Fortunately, Carras''s secretary, Karen.