Pretense-Tense Surgeons, A Heartbeat From Disaster

Walk on Water: Inside an Elite Pediatric Surgical Unit , by Michael Ruhlman. Viking, 340 pages, $24.95.

It would be hard to imagine journalism more precisely and intelligently practiced than that of Michael Ruhlman in this arresting investigation of surgery on congenital heart defects and the men who perform it at the Cleveland Clinic. His gaze throughout the book is steady, unflinching and wide-eyed. He has taken a highly specialized, technologically sophisticated subject, mastered it and made it his own so as to transmit it to the reader in easily understandable terms.

This is not a book for timid souls. From the first page, we’re standing at the operating table upon which a tiny infant is lying, his chest open and heart exposed to reveal that his great vessels-the aorta and the pulmonary artery-are fatally transposed. They must be switched without kinking a coronary artery. To heighten the drama, the author writes in a punched-out, jet-propelled prose, describing the course of the dangerous surgery in the historical present tense, which brings us right up to the event as it’s taking place. The author makes it perfectly clear: Whenever an infant is lying on an operating table with its chest open, disaster is only a breath away. The reader is both observer and emotional participant. One’s own pulse is apt to speed up, go wild.

They are a breed apart, the passionate men who perform these operations. They’re shaped by their work; they become what they do. To the terrified parents of the infant patients, they are a manifestation of divine grace on earth. And in the taut, breath-held silence of the operating room, there is something like a sacramental presence. This, despite the blasphemies and obscenities with which their speech is laced and their tension relieved. To one another, they’re rivals, trusted colleagues, idols and fellow-travelers in uncharted territory. Above all, they share a concern for their tiny patients. Here is one of them trying to explain what it’s all about, and getting tongue-tied: “Everything’s a big deal. Everything’s got to be perfect. You can’t work in this … you can’t do that. You just can’t.” Why not? “Because this is a kid, this is your kid. It’s not a Yugo here, this is somebody’s kid. Nothing is good enough. It’s got to be perfect. There’s no compromise.” It all comes down to the patient.

And so they are demigods-arrogant, egotistical, obsessive-compulsive, “difficult,” unforgiving of mistakes, sentimental and utterly humane. It’s impossible in a brief review to do justice to the entire cast of characters in this surgical enterprise or to convey the excitement and drama of their operations. The “star” of the clinic is Roger Mee, a New Zealander who just happens to have the world’s best success and survival rates in the most difficult of congenital-heart-defect repairs. He’s a legendary figure, both worshipped and feared by his residents. In marked contrast to his aura, his stature is modest: He stands just under 5-foot-6; “his dark tweed jacket is buttoned over a solid gut that adores an egg-bratwurst-and-potato breakfast”. Dr. Mee’s secretary also marvels: ” This short bald guy who scratches his belly! ” she comments affectionately. With the families of the infants, Dr. Mee is unfailingly straightforward. Given a choice between grim and hopeful in tone, he always chooses grim-this despite his complete self-confidence. There are those patients whose hearts are beyond repair and whose only chance for survival is a heart transplantation. For these surgeons, when a donor heart becomes available, they rush to the site, obtain and conserve the heart, then bring it to the operating room where the recipient is waiting. One of these surgeons is dubbed “The Farmer” because he loves harvesting hearts. “It’s so life-affirming,” he says.

Of equal fascination to Dr. Mee is his long-time physician’s assistant, Mike Fackelmann. “Roger’s my guy”, he says, then qualifies: “We’re not buddies.” Inside the O.R., he too is supremely confident, observant and silent unless there is a reason to warn the operating surgeon to “stay away from that.” He has the absolute trust of Dr. Mee, who doesn’t like to schedule particularly difficult cases when Mr. Fackelmann is not on duty. Outside the O.R., he’s maniacally compulsive and far less secure, modest even. “I like to cut my grass and see the lines-perfect line.” He stops at the end of each row, looking back to make sure it’s at 90 degrees, then crosshatches it like a baseball field. “And I do not want anybody walking on it until I can look at it for a while.” When someone compliments his work, he is genuinely surprised. Dr. Mee and Mr. Fackelmann do not waste a lot of time praising one another; it all goes without saying. Once, speaking of Mr. Fackelmann to the author, Dr. Mee said, “It’s ironic. Mike will never be a surgeon, and he will never operate on people. And yet he’s ten times better than the fellows, and they’re going out and operating on people.” Told of this comment by his boss, Mr. Fackelmann was flabbergasted: “You’re kidding me. He said that?” About the residents, and the surgeons other than Dr. Mee, Mr. Fackelmann is candid: “They behave like little kids, they’re just like little kids.” And yet he’s compassionate toward them: “You’ve got a resident who’s standing there not really knowing what to do. Because residents don’t. They’re scared.”

But fear is a good thing in the training of a surgeon-not the fear that is disabling, but the fear of being less than you had hoped. You wake up every morning knowing you’re going to be nervous all day.

One section of the book deals with the discrepancy in the success rates of congenital-heart-defect surgeons at various medical centers around the country. It’s a fact that anyone, however unsuitable, can become a surgeon, given enough determination to do so. Once having arrived, such a person will continue to operate in the face of unacceptable failure rates, which in this specialty means death. Dr. Mee and the handful of others in the surgical pantheon cannot possibly operate on all the afflicted infants, so many are treated by less gifted surgeons. Even standing next to a man like Dr. Mee for a dozen years cannot transform a sow’s ear into a silk purse. Still, that’s the only way to learn how to do it.

Fifty years ago, at the Albany Medical College where I was a student, there was a well-known and hugely successful obstetrician/gynecologist who went to church early every morning to have his hands blessed by the priest-despite which, he had the highest mortality rates in the area. One wonders what Roger Mee or Mike Fackelmann would have said of that.

Richard Selzer is a retired surgeon and author of the forthcoming The Whistlers’ Room (Shoemaker and Hoard) .