Cardiac Cowboys

Welcome back to Behind the Knife. My name is Jessica Millar, General Surgery Resident, and one of the Behind the Knife Surgery Education Fellows. And I'm Nick Teeman, a cardiac surgeon at the University of Virginia. Now, you're probably used to hearing us talk about the intricacies of cardiac surgery as the cardiac surgery subspecialty team here for Behind the Knife, but today we have a special episode focused on the history and some of the biggest names who helped pioneer the field of cardiac surgery.

To help us do this, we have a very special guest, Dr. Gerald Ember. Dr. Ember is a plastic surgeon based out of New York City, but he's also established himself as a prolific medical writer, having published several books, including Wendell Black, M. D., and Genius on the Edge, The Bizarre Double Life of Dr.

William Stuart Halstead. His latest book, Cardiac Cowboys, The Heroic Invention of Heart Surgery, explores the time setting and challenges faced by five of the biggest names in cardiac surgery. Thank you so much for joining us today, Dr. Ember. Thank you so much for having me. So I'll go ahead and get us started.

And I kind of, I'm really just interested how you got into writing and specifically how you

got into writing about surgical history. Can you tell us a little bit more about that? Getting into writing was accidental. I always kind of liked it, but never considered it a profession. And I trained at the New York hospital Cornell, Cornell Medical Center and two chiefs before I was there in general surgery in plastic surgery, but two chiefs before in general surgery was a man named George Hoyer, who was the prize resident of William Stuart Halsted and Halsted was the father of American surgery.

And so early on in my career, I was a young plastic surgeon. I spent most of my time drinking coffee. And listening to the old guys talk and they all talked about Paul said, and they told these amazing stories about him and I just was mulling over the idea of writing about him. And one day I just put the bit in my mouth and did it.

It was interesting because. Before I wrote the first word, I went to Baltimore and in the library, the medical library in Baltimore is a John Singer Sargent

painting of the four doctors one of whom is Halstead, the four doctors who started Johns Hopkins. And it was so imposing and so wonderful and it meant so much to me.

And all the medical students in the library weren't even looking at the picture and didn't give a damn about it. And I just said, okay, I just have to write about this. I wrote the Halstead book. I'd love doing the research. And I ended up doing God knows how many There must dozens and dozens of talks around the country and the Halstead Society being one of them.

A lot of medical graduations, a lot of medical meetings, even neurosurgery meetings, that sort of thing. And got to the point where I can't even stand the name Halstead anymore. So I went on to the next topic. My agent at the time, book agent was chatting with me and I had talked about the feud between Cooley and DeBakey, which was legendary, and I wrote a piece about it, and she said, this is like a magazine article, you have to do more than that.

So, researching

around it, I called a wonderful guy in Houston named Bud Frazier. He's a heart surgeon, and he's done more heart transplants than anybody in the world, and he's the, father of pretty much the father of the left ventricular assist device. And he's the last remaining active guy from that generation who worked with both DeBakey and Cooley.

And I spent two or three hours on the phone with him and I was laughing the whole time. And after he told me about these guys, I was hooked. And that's where the book came from. You know, I'm, it's such an honor to interview you. I have your book on health on my shelf. It was A guest from my mother-in-Law.

So she'll be very happy to having a chance to speak with to you today. So this is great. Oh, I love it. That's great. I do wanna give our listeners a little bit of background. You know, a, as you mentioned, there's a lot of history in the early days of cardiac surgery. But before 1952, open heart surgery was really considered science fiction.

The heart. Art was kind of off limits to surgeons despite more than half a million Americans dying annually from heart disease.

And the strategy was really to do nothing. But you know, you highlight some of the brave and imaginative surgeons who dared to break the most rigid of medical taboos, which was to not touch the human heart.

The book is full of kind of anecdotes and really great stories, but can you tell us some of your favorite stories that you learned about these men during your course of researching and writing for this book? Well, I think that one of the things I came away with is the heroism of Walt Lillehei. Walt Lillehei, who I knew he was the chief of cardiovascular surgery at New York hospital when I was a resident and I was scared to death to even talk to him.

And I had no idea. of what his contributions were and how he changed the world. Denton Cooley said it properly. He said, if heart surgery was a picnic, Walt Lillehei brought the can opener. And that's, that's basically the story because he, in a year or two, He did everything. He did cross circulation. He was early in the world of

hypothermia.

He invented, with his residents, a 50 dollar bypass, bubble oxygenator bypass machine. He invented with the people around him, the first pacemaker, and the first portable pacemaker, and one of the early heart valves. Whatever had to be done, he did it. He was the first person to use synthetic material for patches on their heart.

He did the first surgical repair of Fallot. He, it's astounding. And he did all this against all odds. The reality is that people don't know is that children with congenital heart defects were doomed to die. And he saved 67 percent of his early patients, his first 40 patients. But He lost 33% of them.

He would've lost everybody. They all would've died. But, so he saved 67%, and yet the nurses on the ward were calling him a murderer. And how do you live with that? And he had difficulty with that. And he would go home to his

wife, who would say, but you, you didn't kill 33%. You saved 67. And so that was the beginning of heart surgery.

You know, before that, this was, as you say, it was unimaginable. You don't touch the heart. So he had the guts to do it, he had the guts to do a lot of things and also a lot of things he shouldn't. And he was a remarkable, remarkable individual. And according to everybody that knew him, a genuinely nice man.

All he wanted to do was move heart surgery forward. You mentioned, you kind of talked about some of the challenges that Lillehei and his colleagues faced and something whenever I'm reading about the history of cardiac surgery is always how did they find patients who are willing to sign up for these types of experimental surgeries.

So can you talk to us a little bit, you know, what it was like for patients during these times of like highly experimental surgeries with unknown outcomes? What was it like for them in finding these patients? Well, it was very difficult in fact the

surgeon in Toronto who had brought hypothermia to the lab for heart surgery was doing it on dogs and he himself couldn't find a patient in Toronto willing to do it.

But Lillehei had and Lewis. In, in Minnesota had an advantage because the heart hospital, the Variety Heart Hospital had just been built by a national organization and children from the whole area with heart disease were brought to this central area and they were there to be cured.

And when they were told there was no cure except surgery. And even that was. Probably not a cure, they were willing to take a chance because otherwise the children were going to die. So when they had a population, a concentrated population, they had a better shot at people giving them a chance.

And nobody asked that question before. It's a very good question. I was really struck by how determined these surgeons were, as you recall, they had death after death

and to persist in that. And, you know, so I'm a practicing cardiac surgeon. I'm just thinking about what that would be like in today's era of, you know, Vizient models and O to E ratios and quality metrics.

And so what was it about that era? and the mentality that al to continue. And will we this again? Like how do h progress the field like t did with the kind of the current environment? Well

The doctor is God and coming to the litigious area in which we live, where the doctor does everything defensively. I mean, your point is well taken. The things that these, these men did would land them in court all the time. It did land them in court a lot, but it would land them in court all the time. But they had, I think that their vision was such that they, in virtually all the cases,

understood that they were doing something that had never been done before, and they might save somebody's life.

In a lot of the cases, they also might make themselves famous. And they did cross a lot of mores that perhaps they wouldn't think of doing now. But you're right. It was a different environment. And they just went and did this stuff. And that's, In our lifetime. In your book, you do refer to them though as deeply flawed geniuses and I'm curious to hear what those flaws are that you discuss in your book.

How do you think it helped them? And kind of similar to what we were talking about, how do you think they would hold up in today's world in medicine? Well, you know, the name of the book is Cardiac Cowboys, and it implies exactly that. They were, some of them were actually cowboys from Texas, but they were cowboys in the figurative sense of the word.

If you want to know some of the flaws, Michael DeBakey,

the most famous and prolific of all these people, Bud Frazier, is quoted as saying, he was just mean as a snake. Simple as that. He was mean as a snake. You didn't want to be in a room with him. He would be in an operating room, and he would say things like, to a senior resident or a fellow, he would say, if I had three hands, I would throw you the hell out of here.

And he threw people out of the residency from the operating room. And people left the operating room in tears. And my exchanges with him were all the exchanges with a silver tongued southern gentleman who couldn't be nicer. And he, there were two personalities. One was his people who work for him, his inferiors, and the other was everybody else in the world we wanted to either butter up or was genuinely nice to.

So that everyone, every patient adored DeBakey, adored him, every doctor hated him. That's, that's DeBakey. Cooley very, the most talented surgeon ever, maybe not just cardiac surgery, but he

was he wasn't a scientific surgeon and it wasn't a lab surgeon. He was a cutting surgeon and he did everything faster, better, and more often than everybody else.

And he was interested in having the biggest practice and making the most money and seeing them being with the most famous people, but he was a great guy. He was a lovely guy. Also, he gave my old book, Genius on the Edge, as a gift to his residents, so I really shouldn't say anything bad about him. But watching him operate was like a gift.

I think I mentioned in Cartier Cowboys that watching other people operate was like watching a square dance and watching Cooley operate was like watching the ballet. Remarkable. Remarkable. Guys like Christian Barnard, who did the first heart transplant, were supremely unqualified to do it. Totally unqualified.

He did a few dogs in the lab. He was not a good surgeon, even by his own admission. He did everything he did in secrecy, he

didn't even have a trained team that knew he was going to do a heart transplant because he didn't want the word to get out and people didn't know he was going to sneak in and do it first, and he did it first and his saving grace was that his postoperative care was wonderful he was devoted to his patients, but he was a lousy surgeon who had Terrible rheumatoid arthritis was slow and was explosive in the operating room, just like DeBakey, and went on to have a life he quit.

I think he did the heart transplant in 60, December of 67, the first heart transplant, and he quit surgery in 85, and he started doing, peddling various life extension beauty products and he just, he just, defamed himself and he was he had some friends in the community, but he was disliked intensely by his brother with whom he worked very, very closely.

Of course, he did not share credit for anything. When he wrote and talked of the first heart transplant, the only word he used was I,

and not easy to like a person like that. Let's talk about Walt Lillehei. Walt Lillehei's flaws were many. He was an interesting guy who never bothered to keep good medical records.

For years didn't pay income tax. And when he was called up on, called out for not paying income tax, he changed some of the records that were, that he kept on in an index cards and a shoe box, that was his filing system. And. Interestingly, he was convicted of income tax fraud as felony and he was liable for 25 years in prison and the judge went and did his homework and said, this guy has saved so many lives, we can't do that.

We're giving community service and a fine. It turned out that they believe that he owed about 100, 000 in back taxes and penalties. His lawyer said that he has given over all of his inventions to the University of Minnesota

and that the government actually owes him hundreds of thousands of dollars but again he didn't bother filling out the forms properly and that one of the inventions was a heart valve in which he did fill out the forms and if they would have waited a little bit, the university, the royalties to the university were more than 15 million dollars.

Thank you very And that more than covered the 100, 000 that he was convicted on, but he was totally sloppy about those things. He was very, he was unable to see his own defects. For example, his, the results of his work on the mitral valve were better than anybody in the country. And the results of his work on the aortic valve were worse than anybody in the country, and he didn't see it.

And he kept on doing it that way. He just wouldn't look at the numbers. You go down the list of these people, the only one whose flaws are perhaps personal, but not visible was Norman

Shumway, who everybody loved, who was just, everybody who worked with him said he made heart surgery fun. Some of the things that Shumway said were just legendary.

At his 70th birthday party, he stood up and he said, this is like being at a wake. Awake and everybody roared. And then after well, little high was convicted of tax evasion and tax fraud at his 80th birthday, the same Shumway got up and said, you know, Walt, you remind me a lot of Al Capone. You killed a lot of people, but they could only get you on tax evasion.

So he, he, everybody just loved him. So these were, you know, there was a complicated individuals, very complicated, and they were all in competition all except Lilahi. He was in competition with himself. The rest of the guys, they were looking over their shoulder all the time, I think Cooley in particular, but, but they were

remarkable individuals.

But again, to quote Bud Frazier, he said, at the end of the day, they were just people like all of us. Yeah, you know, you, so you mentioned this competition and your book obviously goes a lot into that. Tell us more about that, you know, did they perceive this competition? And then what do you, do you think that this was overall beneficial because it advanced progress at a faster pace?

Or did it really just encourage cutting corners and people forcing advancements before they were ready? I think that you hit the nail on the head, the latter. It kind of, and a lot of these things, they should have waited a bit. The heart transplants, classic example, where Shumway did 350 transplants in the lab.

And Barnard did a few, if any, most of them were done by his brother. And then Barnard came went to see you and went to see Shumway and learned everything about their current state of immunosuppression saying he was starting a kidney transplant team and never told him he was about to do this.

And then Shumway. wrote,

finally wrote an article in JAMA in November of 67, saying with the right patient, we're ready to do the first heart transplant. And he said it publicly. And then a couple of weeks later in Cape Town. Christian Barnard went and did it. That, he wasn't prepared for it. It just, it was one of those things he wanted to be first.

And Shumway said two things. He said, Barnard of all people, that's the first thing he said. And the second thing he said is nobody remembers the second man to the North Pole. You know, it's competition. I think that there still is a sense of competition. And I think that everybody wants to get there first and everybody wants to be the important professor because that's what we're made of.

And that's why we've become surgeons. I mean, we're a little crazy to begin with. I would agree with that. You mentioned earlier. Some of the serious consequences that these men faced, you said, you know, a lot of them didn't have the

respect of the nurses at the hospital so can you talk a little bit more about some of the consequences that these men were facing and especially the consequences they would have faced if some of the things they were doing didn't work out the way that they had planned or continue to not work out?

Well, very often the things that they were trying to do, in fact, didn't work out. But the first cross circulation case that Lillehy did in 1954 with Gregory Glidden was just a classic, classic example. The The administration didn't want him to do it. They were afraid of having him do it because some a pediatric surgeon from Chicago was visiting the lab and he said to him, congratulations, you have, you'll be the first surgeon that can have a 200 percent mortality.

And hearing that the administration wanted none of it. And Owen Wangenstein, who was the chief of surgery, just sent him a note and said. By all means, go ahead. And he went ahead and he operated on this child with a VSD and he corrected the

VSD. And 10 days later, the child died after a very stormy course.

And turned out that he died of pneumonia. And in fact Lilahi had cured the VSD because it was completely healed at 10 days on, in postmortem. And that's a very traumatic scene that's played out. But the administration Ben said, okay, no more of this stuff. And he waited until the administrators went on, on, out for a conference.

And as soon as they were at conference, he scheduled two more cases on the cross circulation the minute they left town and did the two cases. And he said that even if the first one doesn't make it, we're doing the second one. So he had the, I don't know if it's courage or guts or insanity to push forward.

And both of them did very, very well. And he became a hero. But that's, you know, if they don't go right, for example, the artificial heart episode, let me give your listeners a little background. In Houston, most of the scientific work and labs

were being done under the auspices of the federal government under grants that were given to Michael DeBakey, who was an.

He was an amazing individual, ran labs, was a great surgeon, defended the mass unit, did all kinds of interesting things, and was on every committee in Washington. And he hired Dominic Liotta, an Argentine surgeon who had done an LVAD to make an artificial heart. And he never allowed him to use it, he just kind of lost interest in it.

And Cooley and Liotta, came to Cooley and Cooley's allegedly gave him some money and they changed a few things, a new console to run it, a few other new things. And then a patient was brought into the hospital in extremis and Cooley said he'll, he needs a heart transplant if we can get one, but in the meantime, we'll try and save him.

And he excised 35 percent of his left ventricle and said, we can't, we don't have a heart. Now, until we get a heart transplant, we have to do something. We're going to put

this artificial heart in as a bridging device. So they put the heart, artificial heart in this man, and it becomes every newspaper, the front page of every newspaper.

It's a gigantic thing. DeBakey finds out about it while he's reading the newspaper in Washington, having his breakfast, and he almost chokes. And he goes, Completely bananas. And he says that, you know, he brings up on charges in the the College of Surgeons and he gets kicked off or forced to quick bailer.

And there's just hell to pay between them. And then the family, ultimately, after thinking that, that Cooley did this great thing and almost saving him and, being on television all the time. The family sued Cooley as well. And it became a, it was two years later, it was a big suit. And their main, their primary witness against Cooley was DeBakey.

The judge brought DeBakey into chambers instead of having him testify publicly. And DeBakey said, I

wasn't witness to this. I don't know if it was appropriate or not. And I won't say anything about it. And he saved Cooley. Very, very interesting. Despite the fact the next 40 years, they didn't speak. That's an incredible story.

So, so to kind of summarize the stories of these men, what do you see as their kind of lasting impact and legacy on the field of cardiac surgery? I think that everything that you do, you cardiac surgeons do, can be traced back to these cardiac cowboys. Their lasting impact is visible everywhere.

It's visible in every heart valve. It's visible in every time you do a cabbage you know, these guys did all that stuff first. It's visible in the bypass apparatus. I mean, they started it. It, you can't avoid it. It didn't just materialize. And a lot of these things haven't changed a hell of a lot from when they began it.

What has changed is people have forgotten their names, largely, and they shouldn't. And that's basically one of the things, the points of

Cardiac Cowboys, is that I think these people should be memorialized. I think they're interesting characters, and they've done something great, and they actually have changed the world, for the better.

No, I think that's an excellent point. I have a personal interest in surgical history, and I think it makes operating even more fun when you know that what you are doing is Literally, quite literally standing on the shoulder of giants doing exactly what DeBakey invented or a procedure that Cooley invented.

And so I think knowing who these men are and kind of incorporating that into my everyday just makes operating that much more fun. Could probably spend hours discussing kind of the rich and interesting history of all of these men, but we'll leave a little bit for our listeners to discover in your book.

Dr. Ember, thank you so much again for joining us and allowing us to kind of explore this very fascinating time in cardiac surgery. We appreciate your time. Thank you. It's a pleasure.