Even though he was participating only by intermittently helping to maintain the necessary operative field exposure, Mitt was truly taken in by the whole process and for a time forgot how tired he was. He was especially interested in the opening of the left atrium and seeing the damaged mitral valve before it was removed. He then studiously observed exactly how the pig replacement valve was painstakingly positioned and sewed into place.
Mitt also couldn’t help but notice that as all of this was happening, the atmosphere in the operating room was congenial, particularly compared with the day before. An instrument, which Mitt was told was a pair of DeBakey forceps, named after the famous cardiac surgeon Michael DeBakey, somehow managed to leave the instrument tray and hit Dr. Harington’s right elbow as she was about to place another suture on the replacement valve, similar to the incident with Dr. Washington.
“So sorry,” the scrub nurse said apologetically as she quickly took the forceps from Dr. Harington’s hand. “How on earth did that happen?”
“I’m sure it was my fault for blocking your view of the operative field,” Dr. Harington said. “You were probably trying to see over my arm. I know it makes it difficult for you to predict what I’ll be needing if you can’t see.”
Another incident occurred when Dr. Harington and Dr. Rodriguez were exchanging a needle holder, since placement of a specific group of sutures was going to be easier from Dr. Rodriguez’s side. In the process the needle holder dropped. Once again, no ill feelings or attempts to cast blame on the other person.
“Sorry,” Dr. Harington said, immediately taking responsibility. “My fault.”
“Don’t be silly,” Dr. Rodriguez said. “I wasn’t watching like I should have.”
Curiously enough, Mitt had been watching, and he had to blink several times, as it had appeared to him that the needle holder had somehow levitated out of Dr. Harington’s hand. Knowing that was impossible, he attributed the impression to his exhaustion, just as he had attributed last night’s weird hallucinations. As a medical student, Mitt had been tired before, but he’d never been as tired as he currently was. Nor as anxious.
In due course all the sutures attaching the pig replacement mitral valve had been carefully placed, snugged up, and tied. Then there was the closing of the left atrium, which was carried out comparatively quickly. “How long have we been on bypass?” Dr. Harington asked the anesthesiologist as she straightened up when all was done.
“Forty-eight minutes total,” the anesthesiologist said.
“Not bad,” Dr. Harington commented to no one in particular. “Okay! Let’s start the weaning process and get the patient off the heart-lung machine. Are we good to go, team?”
“Good to go,” the anesthesiologist and perfusionist said in unison.
“All vital signs good and stable,” the anesthesiologist added. He switched on the ventilator with 100 percent oxygen, and the lungs began their rhythmical inflating and deflating.
“Excellent,” Dr. Harington said. And then to the perfusionist she said: “Discontinue the cardioplegia solution, while I begin to unclamp the aorta.”
When the clamp was off the aorta, she looked across at Mitt. “What I’m doing now allows normal blood to begin flowing through the heart, rinsing out the cardioplegic solution. That’s going to warm the heart up rapidly and get it to begin beating again on its own.”
Mitt nodded. It was fascinating to get to watch the whole process in real time. As impressive as it all was, he began to wonder if he shouldn’t at least consider a future in cardiovascular surgery as a subspecialty despite the previous day’s disaster.
A few minutes later silence fell as everyone watched the heart, waiting for it to begin beating. Unfortunately, long minutes passed but the heart remained motionless. “Hmmm,” Dr. Harington voiced under her breath, more to herself than anyone else. “I don’t like this. What the hell is going on here?”
Over the next three quarters of an hour, Mitt sensed the atmosphere in the operating room progress from congenial to tense. Ella Thompson’s heart was refusing to cooperate. Instead of immediately returning to its normal beating, it remained stubbornly quiescent. With increasing frustration, Dr. Harington tried a series of shocks using sterile paddles supplied by the circulating nurse. Unfortunately, none of the shocks worked, and the ceiling-mounted heart monitor continued to trace a totally flat line.
Following the unsuccessful shocks, Dr. Harington tried an internal pacemaker at the recommendation of a Cardiology consult conducted over the intercom system. But there was no response whatsoever, even over an extended period. The anesthesiologist sent off an emergency blood electrolyte sample, but the results came back normal.
“Was there anything at all from your end that might have suggested there’d be a problem?” Dr. Harington asked the perfusionist.
“Nothing,” the perfusionist responded. “Not a hiccup. Everything has been rock stable and normal.”
“My word,” Dr. Harington said with obvious despair. “Who would have guessed? Certainly not me. I suppose this ticker was a lot sicker than any of us imagined. But I’m truly amazed. There’d been no hint.”
Mitt sensed where the conversation was going and experienced a rising sense of dismay. The previous evening when he’d done Ella’s history and physical, he’d felt an emotional attachment to the woman, such that the idea that she was now — less than twenty-four hours later — on the brink of death seemed like an impossible transition. It made him feel complicit, as if he were somehow responsible. He’d had several brushes with death as a medical student, but each of those patients had been in extremis when Mitt had been assigned. The deaths had never involved a functioning, seemingly happy, family-oriented, and connected human being, who had lots of grandchildren and even more great-grandchildren.
“What about using ECMO?” Mitt blurted out without much thought. “Couldn’t an extracorporeal membrane oxygenation machine tide her over until her own heart comes back online?” The idea of just giving up seemed totally unreasonable.
Dr. Rodriguez chortled but then admonished himself for doing so. “Sorry,” he said. “I don’t mean to laugh, but using ECMO at this stage would just be putting off the inevitable and ultimately be a disservice to the family and the patient. The heart’s been at body temperature and fully oxygenated for more than an hour. If it was going to restart, it would have done so before now. This is real life. You win some and you lose some.”
Mitt felt a pang of panic. He didn’t want to stop trying. “Isn’t there something else we can do?” There was a sense of desperation in his voice. “What about some kind of ventricular assist device or even a heart transplant?”
“First of all, you can’t assist a ventricle that’s not beating,” Dr. Harington said, sensing and appreciating Mitt’s anguish. “And second, do you have any idea of how many patients are currently waiting for a transplantable heart who are considerably younger than Ms. Thompson? Let me tell you: more than seven thousand. No, she’s not a candidate for a heart transplant. As hard as it might be, we have to accept our limitations as physicians and surgeons. We’ve tried our best, and for some as-of-yet-unknown reason, it wasn’t enough in this case.”
After her minor soliloquy, Dr. Harington abruptly stepped back from the operating table. Reaching behind her neck, she undid her gown, then pulled it off. Next she stripped off her surgical gloves as she turned to face the circulation nurse. “Inform the front desk we’ve had a fatality in here. They’ll know what to do. Meanwhile, everyone just leave everything as is other than turning off the heart-lung machine, stopping the IV, and stopping the ventilator. Don’t disconnect anything! Even leave the drapes in place! Everything!” With that said, she left.