DeBakey's surgery

NYTimes

December 25, 2006
The Doctor’s World
The Man on the Table Devised the Surgery
By LAWRENCE K. ALTMAN

In late afternoon last Dec. 31, Dr. Michael E. DeBakey, then 97, was alone at home in Houston in his study preparing a lecture when a sharp pain ripped through his upper chest and between his shoulder blades, then moved into his neck.

Dr. DeBakey, one of the most influential heart surgeons in history, assumed his heart would stop in a few seconds.

“It never occurred to me to call 911 or my physician,” Dr. DeBakey said, adding: “As foolish as it may appear, you are, in a sense, a prisoner of the pain, which was intolerable. You’re thinking, What could I do to relieve myself of it. If it becomes intense enough, you’re perfectly willing to accept cardiac arrest as a possible way of getting rid of the pain.”

But when his heart kept beating, Dr. DeBakey suspected that he was not having a heart attack. As he sat alone, he decided that a ballooning had probably weakened the aorta, the main artery leading from the heart, and that the inner lining of the artery had torn, known as a dissecting aortic aneurysm.

No one in the world was more qualified to make that diagnosis than Dr. DeBakey because, as a younger man, he devised the operation to repair such torn aortas, a condition virtually always fatal. The operation has been performed at least 10,000 times around the world and is among the most demanding for surgeons and patients.

Over the past 60 years, Dr. DeBakey has changed the way heart surgery is performed. He was one of the first to perform coronary bypass operations. He trained generations of surgeons at the Baylor College of Medicine; operated on more than 60,000 patients; and in 1996 was summoned to Moscow by Boris Yeltsin, then the president of Russia, to aid in his quintuple heart bypass operation.

Now Dr. DeBakey is making history in a different way — as a patient. He was released from Methodist Hospital in Houston in September and is back at work. At 98, he is the oldest survivor of his own operation, proving that a healthy man of his age could endure it.

“He’s probably right out there at the cutting edge of a whole generation of people in their 90s who are going to survive” after such medical ordeals, one of his doctors, Dr. James L. Pool, said.

But beyond the medical advances, Dr. DeBakey’s story is emblematic of the difficulties that often accompany care at the end of life. It is a story of debates over how far to go in treating someone so old, late-night disputes among specialists about what the patient would want, and risky decisions that, while still being argued over, clearly saved Dr. DeBakey’s life.

It is also a story of Dr. DeBakey himself, a strong-willed pioneer who at one point was willing to die, concedes he was at times in denial about how sick he was and is now plowing into life with as much zest and verve as ever.

But Dr. DeBakey’s rescue almost never happened.

He refused to be admitted to a hospital until late January. As his health deteriorated and he became unresponsive in the hospital in early February, his surgical partner of 40 years, Dr. George P. Noon, decided an operation was the only way to save his life. But the hospital’s anesthesiologists refused to put Dr. DeBakey to sleep because such an operation had never been performed on someone his age and in his condition. Also, they said Dr. DeBakey had signed a directive that forbade surgery.

As the hospital’s ethics committee debated in a late-night emergency meeting on the 12th floor of Methodist Hospital, Dr. DeBakey’s wife, Katrin, barged in to demand that the operation begin immediately.

In the end, the ethics committee approved the operation; an anesthesiology colleague of Dr. DeBakey’s, who now works at a different hospital, agreed to put him to sleep; and the seven-hour operation began shortly before midnight on Feb. 9. “It is a miracle,” Dr. DeBakey said as he sat eating dinner in a Houston restaurant recently. “I really should not be here.”

The costs of Dr. DeBakey’s care easily exceeded $1 million. Methodist Hospital and his doctors say they have not charged Dr. DeBakey. His hospitalizations were under pseudonyms to help protect his privacy, which could make collecting insurance difficult. Methodist Hospital declined to say what the costs were or discuss the case further. Dr. DeBakey says he thinks the hospital should not have been secretive about his illness.

Dr. DeBakey’s doctors acknowledge that he got an unusually high level of care. But they said that they always tried to abide by a family’s wishes and that they would perform the procedure on any patient regardless of age, if the patient’s overall health was otherwise good.

Dr. DeBakey agreed to talk, and permitted his doctors to talk, because of a professional relationship of decades with this reporter, who is also a physician, and because he wanted to set the record straight for the public about what happened and explain how a man nearly 100 years old could survive.

A Preliminary Diagnosis

As Dr. DeBakey lay on the couch alone that night, last New Year’s Eve, he reasoned that a heart attack was unlikely because periodic checkups had never indicated he was at risk. An aortic dissection was more likely because of the pain, even though there was no hint of that problem in a routine echocardiogram a few weeks earlier.

Mrs. DeBakey and their daughter, Olga, had left for the beach in Galveston, but turned back because of heavy traffic. They arrived home to find Dr. DeBakey lying on the couch. Not wanting to alarm them, he lied and said he had fallen asleep and awakened with a pulled muscle.

“I did not want Katrin to be aware of my self-diagnosis because, in a sense, I would be telling her that I am going to die soon,” he said.

An anxious Mrs. DeBakey called two of her husband’s colleagues: Dr. Mohammed Attar, his longtime physician, and Dr. Matthias Loebe, who was covering for Dr. Noon. They came to the house quickly and became concerned because Dr. DeBakey had been in excellent health. After listening to him give a more frank account of his pain, they shared his suspicion of an aortic dissection.

Dr. DeBakey and his doctors agreed that for a firm diagnosis he would need a CT scan and other imaging tests, but he delayed them until Jan. 3.

The tests showed that Dr. DeBakey had a type 2 dissecting aortic aneurysm, according to a standard classification system he himself devised years earlier. Rarely did anyone survive that without surgery.

Still, Dr. DeBakey says that he refused admission to Methodist Hospital, in part because he did not want to be confined and he “was hopeful that this was not as bad as I first thought.” He feared the operation that he had developed to treat this condition might, at his age, leave him mentally or physically crippled. “I’d rather die,” he said.

Over the years, he had performed anatomically perfect operations on some patients who nevertheless died or survived with major complications. “I was trying to avoid all that,” he said.

Instead, he gambled on long odds that his damaged aorta would heal on its own. He chose to receive care at home. For more than three weeks, doctors made frequent house calls to make sure his blood pressure was low enough to prevent the aorta from rupturing. Around the clock, nurses monitored his food and drink. Periodically, he went to Methodist Hospital for imaging tests to measure the aneurysm’s size.

On Jan. 6, he insisted on giving the lecture he had been preparing on New Year’s Eve to the Academy of Medicine, Engineering and Science of Texas, of which he is a founding member. The audience in Houston included Nobel Prize winners and Senator Kay Bailey Hutchison.

Mrs. DeBakey stationed people around the podium to catch her husband if he slumped. Dr. DeBakey looked gray and spoke softly, but finished without incident. Then he listened to another lecture — which, by coincidence, was about the lethal dangers of dissecting aneurysms.

Dr. DeBakey, a master politician, said he could not pass up a chance to chat with the senator. He attended the academy luncheon and then went home.

In providing the extraordinary home care, the doctors were respecting the wishes of Dr. DeBakey and their actions reflected their awe of his power.

“People are very scared of him around here,” said Dr. Loebe, the heart surgeon who came to Dr. DeBakey’s home on New Year’s Eve. “He is the authority. It is very difficult to stand up and tell him what to do.”

But as time went on, the doctors could not adequately control Dr. DeBakey’s blood pressure. His nutrition was poor. He became short of breath. His kidneys failed. Fluid collected in the pericardial sac covering his heart, suggesting the aneurysm was leaking.

Dr. DeBakey now says that he was in denial. He did not admit to himself that he was getting worse. But on Jan. 23, he yielded and was admitted to the hospital.

Tests showed that the aneurysm was enlarging dangerously; the diameter increased to 6.6 centimeters on Jan. 28, up from 5.2 centimeters on Jan. 3. Dr. Noon said that when he and other doctors showed Dr. DeBakey the scans and recommended surgery, Dr. DeBakey said he would re-evaluate the situation in a few days.

By Feb. 9, with the aneurysm up to 7.5 centimeters and Dr. DeBakey unresponsive and near death, a decision had to be made.

“If we didn’t operate on him that day that was it, he was gone for sure,” Dr. Noon said.

At that point, Dr. DeBakey was unable to speak for himself. The surgeons gathered and decided they should proceed, despite the dangers. “We were doing what we thought was right,” Dr. Noon said, adding that “nothing made him a hopeless candidate for the operation except for being 97.” All family members agreed to the operation.

Dr. Bobby R. Alford, one of Dr. DeBakey’s physicians and a successor as chancellor of Baylor College of Medicine, said the doctors had qualms. “We could have walked away,” he said.

He and Dr. Noon discussed the decision several times. “We recognized the condemnation that could occur,” Dr. Alford said. “The whole surgical world would come down on us for doing something stupid, which it might have seemed to people who were not there.”

Surgery would be enormously risky and unlikely to offer clear-cut results — either a full recovery or death, Dr. Noon and his colleagues told Mrs. DeBakey, Olga, sons from a first marriage, and Dr. DeBakey’s sisters, Lois and Selma. The doctors said Dr. DeBakey might develop new ailments and need dialysis and a tracheostomy to help his breathing. They said the family’s decision could inflict prolonged suffering for all involved.

Olga and she “prayed a lot,” said Mrs. DeBakey, who is from Germany. “We had a healer in Europe who advised us that he will come through it. That helped us.”

Then things got more complicated.

A Refusal to Treat

At that point the Methodist Hospital anesthesiologists adamantly refused to accept Dr. DeBakey as a patient. They cited a standard form he had signed directing that he not be resuscitated if his heart stopped and a note in the chart saying he did not want surgery for the aortic dissection and aneurysm. They were concerned about his age and precarious physical condition.

Dr. Alford, the 72-year-old chancellor, said he was stunned by the refusal, an action he had never seen or heard about in his career.

Dr. Noon said none of the anesthesiologists had been involved in Dr. DeBakey’s care, yet they made a decision based on grapevine information without reading his medical records. So he insisted that the anesthesiologists state their objections directly to the DeBakey family.

Mrs. DeBakey said the anesthesiologists feared that Dr. DeBakey would die on the operating table and did not want to become known as the doctors who killed him. Dr. Joseph J. Naples, the hospital’s chief anesthesiologist, did not return repeated telephone calls to his office for comment.

Around 7 p.m., Mrs. DeBakey called Dr. Salwa A. Shenaq, an anesthesiologist friend who had worked with Dr. DeBakey for 22 years at Methodist Hospital and who now works at the nearby Michael E. DeBakey Veterans Affairs Medical Center.

Dr. Shenaq rushed from home. When she arrived, she said, Dr. Naples told her that he and his staff would not administer anesthesia to Dr. DeBakey. She said that a medical staff officer, whom she declined to name, warned her that she could be charged with assault if she touched Dr. DeBakey. The officer also told Dr. Shenaq that she could not give Dr. DeBakey anesthesia because she did not have Methodist Hospital privileges. She made it clear that she did, she said.

Administrators, lawyers and doctors discussed the situation, in particular the ambiguities of Dr. DeBakey’s wishes. Yes, Dr. Pool had written on his chart that Dr. DeBakey said he did not want surgery for a dissection. But Dr. Noon and the family thought the note in the chart no longer applied because Dr. DeBakey’s condition had so deteriorated and his only hope was his own procedure.

“They were going back and forth,” Dr. Shenaq said. “One time, they told me go ahead. Then, no, we cannot go ahead.”

To fulfill its legal responsibilities, Methodist Hospital summoned members of its ethics committee, who arrived in an hour. They met with Dr. DeBakey’s doctors in a private dining room a few yards from Dr. DeBakey’s room, according to five of his doctors who were present.

Their patient was a man who had always been in command. Now an unresponsive Dr. DeBakey had no control over his own destiny.

The ethics committee representatives wanted to follow Texas law, which, in part, requires assurance that doctors respect patient and family wishes.

Each of Dr. DeBakey’s doctors had worked with him for more than 20 years. One, Dr. Pool, said they felt they knew Dr. DeBakey well enough to answer another crucial question from the ethics committee: As his physicians, what did they believe he would choose for himself in such a dire circumstance if he had the ability to make that decision?

Dr. Noon said that Dr. DeBakey had told him it was time for nature to take its course, but also told him that the doctors had “to do what we need to do.” Members of Dr. DeBakey’s medical team said they interpreted the statements differently. Some thought he meant that they should do watchful waiting, acting only if conditions warranted; others thought it meant he wanted to die.

The question was whether the operation would counter Dr. DeBakey’s wishes expressed in his signed “do not resuscitate” order. Some said that everything Dr. DeBakey did was for his family. And the family wanted the operation.

After the committee members had met for an hour, Mrs. DeBakey could stand it no longer. She charged into the room.

“My husband’s going to die before we even get a chance to do anything — let’s get to work,” she said she told them.

The discussion ended. The majority ruled in a consensus without a formal vote. No minutes were kept, the doctors said.

“Boy, when that meeting was over, it was single focus — the best operation, the best post-operative care, the best recovery we could give him,” Dr. Pool said.

The Operation

As the ethics committee meeting ended about 11 p.m. on Feb. 9, the doctors rushed to start Dr. DeBakey’s anesthesia.

The operation was to last seven hours.

For part of that time, Dr. DeBakey’s body was cooled to protect his brain and other organs. His heart was stilled while a heart-lung bypass machine pumped oxygen-rich blood through his body. The surgeons replaced the damaged portion of Dr. DeBakey’s aorta with a six- to eight-inch graft made of Dacron, similar to material used in shirts. The graft was the type that Dr. DeBakey devised in the 1950s.

Afterward, Dr. DeBakey was taken to an intensive care unit.

Some doctors were waiting for Dr. DeBakey to die during the operation or soon thereafter, Dr. Noon said. “But he just got better.”

As feared, however, his recovery was stormy.

Surgeons had to cut separate holes into the trachea in his neck and stomach to help him breathe and eat. He needed dialysis because of kidney failure. He was on a mechanical ventilator for about six weeks because he was too weak to breathe on his own. He developed infections. His blood pressure often fell too low when aides lifted him to a sitting position. Muscle weakness left him unable to stand.

For a month, Dr. DeBakey was in the windowless intensive care unit, sometimes delirious, sometimes unresponsive, depending in part on his medications. The doctors were concerned that he had suffered severe, permanent brain damage. To allow him to tell day from night and lift his spirits, the hospital converted a private suite into an intensive care unit.

Some help came from unexpected places. On Sunday, April 2, Dr. William W. Lunn, the team’s lung specialist, took his oldest daughter, Elizabeth, 8, with him when he made rounds at the hospital and told her that a patient was feeling blue. While waiting, Elizabeth drew a cheery picture of a rainbow, butterflies, trees and grass and asked her father to give it to the patient. He did.

“You should have seen Dr. DeBakey’s eyes brighten,” Dr. Lunn said. Dr. DeBakey asked to see Elizabeth, held her hand and thanked her.

“At that point, I knew he was going to be O.K.,” Dr. Lunn said.

Dr. DeBakey was discharged on May 16. But on June 2, he was back in the hospital.

“He actually scared us because his blood pressure and heart rate were too high, he was gasping for breath” and he had fluid in his lungs, Dr. Lunn said.

But once the blood pressure was controlled with medicine, Dr. DeBakey began to recover well.

The Aftermath

At times, Dr. DeBakey says he played possum with the medical team, pretending to be asleep when he was listening to conversations.

On Aug. 21, when Dr. Loebe asked Dr. DeBakey to wake up, and he did not, Dr. Loebe announced that he had found an old roller pump that Dr. DeBakey devised in the 1930s to transfuse blood. Dr. DeBakey immediately opened his eyes. Then he gave the doctors a short lecture about how he had improved it over existing pumps.

As he recovered and Dr. DeBakey learned what had happened, he told his doctors he was happy they had operated on him. The doctors say they were relieved because they had feared he regretted their decision.

“If they hadn’t done it, I’d be dead,” he said.

The doctors and family had rolled the dice and won.

Dr. DeBakey does not remember signing an order saying not to resuscitate him and now thinks the doctors did the right thing. Doctors, he said, should be able to make decisions in such cases, without committees.

Throughout, Dr. DeBakey’s mental recovery was far ahead of his physical response.

When Dr. DeBakey first became aware of his post-operative condition, he said he “felt limp as a rag” and feared he was a quadriplegic. Kenneth Miller and other physical therapists have helped Dr. DeBakey strengthen his withered muscles.

“There were times where he needed a good bit of encouragement to participate,” Mr. Miller said. “But once he saw the progress, he was fully committed to what we were doing.”

Now he walks increasingly long distances without support. But his main means of locomotion is a motorized scooter. He races it around corridors, sometimes trailed by quick-stepping doctors of all ages.

Dr. DeBakey said he hoped to regain the stamina to resume traveling, though not at his former pace.

Dr. William L. Winters Jr., a cardiologist on Dr. DeBakey’s team, said: “I am impressed with what the body and mind can do when they work together. He absolutely has the desire to get back to where he was before. I think he’ll come close.”

Already, Dr. DeBakey is back working nearly a full day.

“I feel very good,” he said Friday. “I’m getting back into the swing of things.”