[HSF] [Fwd: MedEvents - The Man on the Table Was 97, but He Devised the Surgery]

[prasannasimha]

In some ways it is a tribute to the surgery he helped pioneer !!
Prasanna
prasannasimha wrote:
> DeBakey's surgery
>
> -------- Original Message --------
>
> The Man on the Table Was 97, but He Devised the Surgery
> By LAWRENCE K. ALTMAN December 25, 2006
>
> http://www.nytimes.com/2006/12/25/health/25surgeon.html?pagewanted=1&ref=us 
>
>
>
> 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.
> ( Graphic of procedure;
> http://www.nytimes.com/imagepages/2006/12/25/us/20061225_SURGEON_GRAPHIC.htm 
>
> l )
>
> "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."
>
>
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