What do you do when you have to choose between saving a life or saving yourself?
Renowned cardiac surgeon Dr. Athan Carras’s first concern has always been the welfare of his patients. Then he’s approached by the very wealthy and even more powerful Terry Flynnt—a man who is used to getting what he wants, no matter what.
Flynnt’s son is dying, and his only chance of survival is to receive a donor heart—one that Terry intends to obtain by whatever means necessary. Athan is immediately opposed to performing an illegal and immoral operation, but Flynnt is not about to let that stop him.
Now, caught in the crosshairs of a man with unlimited means and influence, Athan finds his own life—and the lives of those he loves—being torn apart. And he will have to decide how far he’s willing to go, and what he is willing to sacrifice…
|Publisher:||Penguin Publishing Group|
|Product dimensions:||4.20(w) x 7.40(h) x 1.10(d)|
|Age Range:||18 Years|
About the Author
John A. Elefteriades, MD, is the William W. L. Glenn Professor of Cardiothoracic Surgery and director of the Aortic Institute at Yale University and Yale-New Haven Hospital. He is among the most clinically active academic surgeons in the country and serves on multiple scientific advisory and editorial boards. He has written over 300 scientific articles on all aspects of cardiac surgery. He has won multiple awards for his clinical care and his research. He is the author of many medical textbooks, including House Officer Guide to ICU Care (1st, 2nd, and 3rd Editions), Advanced Treatment Options for the Failing Left Ventricle, Controversies in Diseases of the Aorta, and Acute Aortic Disease. Dr. Elefteriades’ books for the general public include Your Heart: An Owner’s Guide, The Woman’s Heart: An Owner’s Guide, and Extraordinary Hearts: A Journey of Cardiac Medicine and the Human Spirit. His work has been featured in documentaries by the BBC, the Science Channel, and RAI Television in Italy. Transplant is his first novel.
Read an Excerpt
JOHN A. ELEFTERIADES, MD
“Doctor, I cannot forbid you to perform that procedure,” said the clipped, nasal voice in Athan Carras’s ear, “but I emphatically withhold the permission you are seeking from the committee.”
You vindictive son of a bitch, Carras thought, but into the phone he said, “You don’t have that authority, doctor. You are just the vice-chair of the Human Investigations Committee. Only the chairman has the right to grant or withhold approval.”
There was a silence on the line, then Carras could hear the thin smile in Dr. James Bonar Auldfield’s voice when he said, “You should have read the committee’s terms of reference more closely, doctor. In the absence of Dr. Bentham, all of his powers devolve to me.”
“For God’s sake,” Carras said, “that’s Cory Goldenberg on my operating table. Leave aside that he’s a friend and colleague to both of us, he’s one of the top cardiologists in the world. If the technique works, he could live another ten years, save hundreds of lives. But if I don’t do it, he’ll be dead before morning. Guaranteed.”
Auldfield’s voice was bright with a cold glee. “I’ve told you, doctor, it’s entirely your decision,” he said. “You agreed that there will be no human experimentation until the HIC has seen long-term results from the animal trials. However, if you want to disavow the covenant you have made with the committee, you are free to break your word.”
“But you won’t cut me an inch of slack, will you, ‘Boner’?”
Carras heard the sniff that preceded Auldfield’s final remark. “I must do as my conscience dictates. You do as you wish.” There was a click and the line was dead.
Shouldn’t have called him Boner, Carras thought. Auldfield hated the nickname he’d acquired when they’d been students together. But Carras realized it wouldn’t have made any difference if he’d abased himself to flatter the other man’s delicate ego.
Back in Operating Room 15 of Yale Medical Center, Craig Mason looked up from the dials of the heart-lung machine that was keeping Cory Goldenberg from sliding into death and said, “Are we go?”
Carras took up his customary place on the patient’s left and swept his gaze over the monitors before answering. “Bentham’s on some kind of retreat in Montana. Left his cell at home. Can’t be reached before the end of the week.”
“So who’s on deck for him?” Mason said, then his eyes widened as he answered the question for himself. “Oh, fuck me. Boner, right?”
Carras sighed. “And Boner says we’re on our own.”
“Well fuck him with the broomstick he rode in on,” said Mason. “Like I’m going to let Cory die because that little pissant thinks he’s Pontius Pilate? Let’s do this, Ath. Now.”
“Let me think.”
* * *
CORY GOLDENBERG SHOULD HAVE KNOWN BETTER. ALTHOUGH HE was a senior cardiologist with Harvard Medical School, he suffered from a condition known as aortic regurgitation: a weakness in his heart’s outflow valve that did not let it be a one-way-only door. After expelling all the blood in the left ventricle, it didn’t slam shut and stay tight; instead, the valve let a little blood leak back into the heart. The result was a progressive weakening of the organ.
Any heart surgeon knew the answer to aortic regurgitation: cut out the faulty natural valve and put in an artificial one. These days it was a routine procedure and postoperative complications were next to nil. Goldenberg could have had his operation anytime over the several years since the onset of his condition.
But Goldenberg was a conservative cardiologist. He had taught for years that surgery should not be an instant resort. Patients should wait until there was definite evidence that the heart was enlarging. With hearts, bigger is not better; bigger is certainly not stronger—an enlarged heart is a weak heart. Goldenberg taught that, until enlargement was evident, surgery should be put off, and he practiced what he preached.
In the meantime, he drove himself to a high level of fitness. He played tennis every day, between morning rounds and afternoon office hours, often taking on much younger opponents and beating them in straight sets. He rode a bike and trained with light weights. At sixty, he was lean, strong and looked fit.
“I’ve started to enlarge,” he had said, sitting in Carras’s long, shoe-box-shaped office in Yale’s venerable Farnum Building, between the modern medical center and the old red-brick morgue. They looked at the echocardiographic images from the lab. The enlargement was small—only one centimeter in diameter—but noticeable.
“No point waiting,” Carras said. “We’ll perform the procedure tomorrow morning.” He looked again at the echo results and said, “I wish you hadn’t waited.”
It was an argument as old as modern surgery. Clinicians like Goldenberg preferred to use noninvasive therapies—drugs, exercise, change of diet—to treat the myriad afflictions of which the human body is at risk. Surgeons opted to isolate the part at fault and if they couldn’t repair or replace it, they’d cut it out altogether and let the body’s systems adapt.
The body was designed with built-in redundancy. Life could go on without a gall bladder or a spleen, with only one lung or kidney or with substantial portions of the liver missing. But humans were issued only one heart and it had to last a lifetime, and Carras felt there was no point in unduly stressing the organ when a quick and simple surgical repair could avoid trouble.
Goldenberg thought surgery was inherently dangerous, even under gifted hands. A certain number of patients who went under anesthesia never came out of it—the fraction was tiny, but that didn’t make any difference when relatives arrived at the hospital to visit Uncle Waldo after his minor knee surgery and found him chilling in the morgue.
“You’re more likely to be hit by lightning,” Carras said. “Or bitten by a shark.”
“If I stay in during lightning storms and stay out of shark-infested waters, the chances of being hit or bit are zero,” Goldenberg answered. “As are my chances of dying on an operating table if I stay off one.”
“You won’t die on mine,” Carras said.
“Sometimes I wonder about you, Ath,” Goldenberg said. “It’s as if you see yourself in a head-to-head contest with death.”
“I wouldn’t put it so dramatically,” Carras said.
“Maybe not out loud,” the cardiologist agreed, “but I wonder if there are times when you look across the operating table and see the old reaper reaching for your patient, and then it’s not about the patient anymore. It’s about winning.”
“All right, sometimes I do feel defeated when I lose a patient. And I hate it. Don’t we all?”
“Sure, to some extent,” Goldenberg said. “Just don’t let it get too personal. Even when you’re operating on me. Remember, doctor, pride goeth before a fall.”
“I’m not the one who’s waited until his heart’s enlarged, doctor,” Carras said. “That looks to be a fair-sized stumble on your part.”
“Touché‚” said the clinician, “but a little below the belt, don’t you think?”
For a moment, Carras was tempted to say, Sorry, that was a low blow. But he and Cory had argued over similar cases so many times, in print and face-to-face at conferences, that the combative habit just naturally came to the fore. And when in combat mode, Athan Carras did not say sorry. Besides, he told himself, an apology’s not what Cory needs. He needs his heart fixed.
Carras fixed it the next morning, in an operation that was entirely routine from Goldenberg’s first shot of sedative to the postop visit by Carras in the intensive care unit. The new Pyrolite carbon valve was clicking away in the cardiologist’s chest and blood flow was normal. But would the moderately enlarged heart recover and return to normal?
It took five years for the definitive answer to come in. Cory Goldenberg’s heart had not recovered. Weakened, it had continued to grow larger and less powerful. Partly through medication but mostly by sheer willpower, the clinician had been able to carry on with his teaching and practice, but his condition deteriorated, at first slowly, then later at an accelerated pace. Now, at sixty-five, he was suffering from end-stage heart failure; the enlargement and contractile weakness of his left ventricle were so extreme that the eleven different medications he took each day could not compensate. He came to Carras for a transplant.
The choice of a Yale surgeon by a prominent Harvard physician prompted some ironic comments in Ivy League circles. Carras had held his own in many a contentious academic debate, sometimes supplementing scientific fact with acid wit. He was not universally loved by his peers, of whom there were relatively few, and some of those he had bested detested him.
But as Goldenberg said in a widely reposted e-mail, “Sure, Carras can be arrogant, but he has every right to be. In my case, he was right and I was wrong, and if I come out of this alive, it’s because of him.”
The wait for a suitable donor heart stretched into weeks, then into months. Goldenberg was maintained on a continuous infusion of the drug dobutamine, which artificially strengthened his heartbeat and maintained an adequate outflow of blood from his failing left ventricle. The cardiotonic medication was delivered to his heart by a catheter connected to a pump. Some days, he used Carras’s office to work on a paper he was writing for the American Journal of Cardiology.
Goldenberg was at Carras’s desk when he finally collapsed from pulmonary edema—he began to drown from backing up of blood and pressure into his lungs. Fortunately, Carras’s secretary, Karen Ferguson, was keeping an eye on him and within minutes she had arranged for the cardiologist to be wheeled up the long glassed-in walkway between the Farnum Building and the recently built medical center’s coronary care unit. He was placed on a ventilator that sent high-flow oxygen into his bloodstream, the enriched mixture making up for poor blood flow from his weakened heart.
Two days later, they found a suitable donor heart. In Boston, a fifteen-year-old boy had discovered where his father had hidden the ignition key of his Yamaha 650 motorcycle and decided to take the bike out for a spin. Helmetless, leaning so far over that one knee almost touched the asphalt, the boy swept around a blind curve and smashed into an oil delivery truck. The surgeons at Boston General kept him technically alive for eleven hours while they assessed the neurological implications of his massive head injury, but the victim was brain-dead.
The boy was big for his age and had been a good athlete. His blood type was a match for Goldenberg’s. When the Yale donor team flew by Learjet to Boston and harvested the heart, the organ looked perfect. They also took a lymph node for tissue typing and the lab result was phoned through to Yale while the jet was carrying the team and the heart back to New Haven.
It was two a.m. when Carras heard they had a good match. He ordered Goldenberg prepped and transferred to OR 15, his favorite of the medical center’s five cardiothoracic operating suites. The heart arrived on time, safe in its ziplock bag of saline solution resting on a bed of ice in a cooler that would not have looked out of place on a picnic blanket—except for the large blue cross and the lettering that said HUMAN ORGAN—DO NOT TOUCH.
The operating team opened the patient’s chest and began to place the catheters that would allow them to connect to the heart-lung machine. The systolic pressure in Cory Goldenberg’s arteries was a limp eighty-five over forty, well below normal readings of one hundred twenty over eighty. That was as expected. The problem came when the catheter in the pulmonary artery reported pressure of seventy over forty in the cardiologist’s lungs, way above the twenty-five over ten pressure that would have been a normal.
“We’ve got pulmonary hypertension,” Carras said.
On the other side of the table, Craig Mason said, “How bad?” and when he saw the numbers on the monitor, “Oh, shit.”
Now a heart transplant could not guarantee the life of Cory Goldenberg. Years of progressive heart disease had thickened and scarred the blood vessels in the cardiologist’s lungs. Even a heart from a young, healthy fifteen-year-old might not have the strength to overcome the vessels’ acquired resistance.
Now that immunosuppressive drugs had controlled the problems of rejection of foreign tissue by a recipient’s immune system, pulmonary hypertension was the leading cause of death after heart transplants. The normal heart was put into a system that had adapted to abnormality. The normal heart often couldn’t handle the load. Fifty percent of such patients died not long after receiving new hearts. Cory Goldenberg’s numbers put him in the highest category of risk.
The right ventricle of the donor’s heart had only had to cope with normal systolic pressure in the maze of blood vessels that permeated the teenager’s lungs. It was, as is natural, a thin-walled chamber, only one fifth the thickness of the powerful left ventricle, which had to pump blood to the rest of the body.
But the right side of Cory Goldenberg’s heart had spent almost the same number of years pushing against blood that had backed up in his lungs because the weakened left side of the organ could not pull it along into the rest of the circulatory system with sufficient strength. To compensate, the right side of Goldenberg’s diseased heart had grown unnaturally thick and strong.
Carras had lectured on the problem often enough. “The right side of the diseased heart is like a body builder who has been curling fifty- and sixty-pound weights, building Schwarzenegger biceps. That’s the kind of muscle it takes to force blood into the congested lungs.
“But the normal heart is Joe Average, used to curling maybe twenty pounds. Now we put that heart into the chest of someone with serious pulmonary hypertension, and it’s like handing an ordinary person a great big dumbbell and saying, ‘Here, curl this. And keep curling it all day, and all day tomorrow and forever.’”
Carras had not only been lecturing on the problem, however; he had the kind of mind that, when faced with no as the answer to a scientific problem, shot back with, Why the hell not?
Cutting out a heart that had an unnaturally strong right ventricle and a desperately weak left one, and putting in an organ that was normal on both sides, simply didn’t work. There had to be another way, yet every logical approach he considered came up dry. But Carras had learned that when his rational mind had gone round and round a problem and found no logical answer, sometimes his unconscious would pull in a solution from way out of any conventional orbit. One of those wild surmises came to Carras one night as he lay dreaming.
He was in the old family kitchen, in the house on Philadelphia’s Market Street where he had grown up. He took a loaf of bread out of the zinc-lined drawer underneath the counter, but when he went to cut a slice from it, he saw that one end was covered in mold. He carried the loaf to the trash container under the sink and was going to throw it away, but then his father was there, young and dark-mustached as he’d been when Athan was a boy, wearing the stained coveralls from the service station that he owned.
He took the bread from Carras’s hand, put it back on the counter and sliced it in half. The moldy end he threw into the trash bin; the other half he held out to Carras, saying in Greek, “To miso eine kalo.” The half is good.
Carras came up out of the dream with the words still echoing in his mind. It was either a dumb idea or it was brilliant. Instead of removing the whole heart, why not take out only the diseased left side and sew the new organ to the Schwarzenegger half that remained? The patient would have a heart and a half, with two right ventricles to cope with the overly high ambient pressure in the lungs.
On the face of it, it was a wacko proposition. The heart was one mass of specialized cardiac muscle. No one had ever tried to separate the two halves. Even in folklore, a broken heart was fatal. How could he cut out half a heart, then stitch a foreign organ to what was left? Carras didn’t know, but once the idea took him, he had to find out.
He put together a small team, himself and Craig Mason plus some students and residents to assist. They started in the morgue, cutting and pasting the hearts of cadavers. Then they sought research funding and began experimenting with live animals.
Their research plan had estimated two or three years to develop the heart-and-a-half procedure or to prove that it was impossible. In the end, it was five years of part-time lab work. There were endless problems: bleeding from the cut edges of cardiac muscle after they were sutured to each other; interruption of the flow of nutrients to the heart’s muscle cells, so that they starved and died; interference with the network of nerves that acted as the heart’s internal pacemaker.
One after another, they faced the problems and solved them, until they could perform every aspect of the new operation routinely, efficiently and consistently. There came a day when Carras and Mason could say to each other with a confidence born of experience, “We could do this with a human being.”
Could, however, was not the same as should. Mason was ready to proceed immediately to a human trial. There were patients whose lives might depend on it. But Carras was not ready.
“Horseshit and hellfire,” Mason said, “it was your damn dream that started this. Listen to your unconscious and let’s schedule the first op.”
They were in the lab watching a pig that now had a heart and a half munch its way through a cabbage. The animal’s chest incision was almost fully healed.
“Look at Porky, here,” Mason said. “He’s happy as a pig in shit. There’s people who need this special thing we can do.”
“Human trials are a big risk,” Carras said. “Animal models aren’t always a reliable indicator.”
“Well, what do you want to do? We don’t have any half man, half animals to work our way up through.”
“Let’s take it to the HIC,” Carras said. “I talked to Charlie Vance and he said they’d be willing to assume responsibility for oversight.”
Carras’s longtime friend Charlie Vance was a dual degree holder, with an MD and a PhD in philosophy, who specialized in medical ethics—he described himself as a “doctor of philosophy and a philosopher of doctoring.” Vance was a member of Yale’s multidisciplinary Human Investigations Committee, whose purpose was to guide and regulate researchers through the complex thickets of moral questions that often sprang up between the orderly gardens of existing knowledge and the deep dark woods that were the unknown.
The committee met in the august Beaumont Room above the rotunda of the massive Sterling Library. Carras and Mason presented a summary of their work to date, much of it already familiar to the committee members from papers the two researchers had published in professional journals. “We are confident that we have validated the technique in the animal models and believe it is time to consider a human trial,” Carras concluded the presentation.
The committee’s chair, the renowned geneticist Taylor Bentham, looked to his left and right, peering over his half-glasses at the other HIC members ranged on either side of him behind the long antique table. “Responses?” he said.
Charlie Vance had always reminded Carras of Jack Nicholson playing Mr. Chips: the face was a close resemblance and the voice was almost identical. Now the ethicist leaned forward from one end of the panel and said, “I have complete confidence in Drs. Carras and Mason. It is good of them to have come before us, even though they did not have to. I say we define a set of conditions governing a first human trial and let them get on with it.”
Bentham nodded and again looked up and down the table, finding a general sense of agreement with the proposal. Then a nasal voice said, “I’m not as sanguine as Dr. Vance.”
“Oh, fuck me sideways,” Mason whispered to Carras. “When did Boner get on this committee?”
Carras’s only reply was a shrug, his attention focused entirely on Auldfield. “I don’t find the animal trials,” the small man continued, placing one delicate finger to his slim jawline, “to be suitably comprehensive.”
Vance said, “They’ve been at it five years.”
“The point of this procedure,” Auldfield said, “is to overcome the problem of pulmonary hypertension resulting from chronic heart disease. Yet all of the animal subjects have had normal lung and circulatory systems.”
“Shit,” said Mason. “He’s out to ream us.”
“No, he’s right,” said Carras. “We should have thought of that.”
“He only thought of it so he could ream us,” Mason said.
But Carras was already rising to his feet. “Dr. Auldfield is right. We will test the procedure on animals that have boggy lungs. We can find a way to induce iatrogenic pulmonary hypertension and challenge our operation against it.”
They took healthy pigs and injected a caustic drug that engendered a kind of congestion in their lungs that closely mimicked pulmonary hypertension in humans, left the animals in that condition for a few weeks, then performed the new procedure. Each time the new heart and a half began to beat, they watched the monitor and saw the enhanced organ steamroller through the high blood pressure in the lungs.
But when they went back to the committee, Auldfield said, “You have an experimental group but no control group. How do we know that an ordinary heart transplant might not have handled the induced lung pressures?”
Mason wanted to argue. “You know that regular transplants don’t handle the problem in humans. That’s why we came up with this procedure.”
But Carras again had to cede Auldfield the ethical high ground. An experiment without a control group proved nothing. So they went back to the lab and did normal heart transplants on pigs with boggy lungs. The normal hearts failed, just as they always had in humans, and the pigs died.
“All very good,” said James Bonar Auldfield when they appeared before the committee again, “but how long do your experimental subjects live?”
“What’s that got to do with anything?” Mason said. It was normal to sacrifice the experimental animals as soon as the results of the experiments were known. It was difficult to care for the creatures after major surgery, especially larger ones like calves and pigs. It was also expensive. “It’s not provided for in our budget,” he concluded.
“Are you comfortable performing this procedure on a human subject,” Auldfield said, “when you have no indication, even from animal models, what the long-term results will be?”
“He’s got us again,” Mason whispered to Carras.
“He’s right again,” Carras replied.
“He just wants to screw us.”
“Actually, he wants to screw me,” Carras said. “You’re just collateral damage.”
“Collateral or not, I’m still getting damaged here, Ath,” Mason said. “I think we’ve taken enough of this crap. If we put up a fight, the committee will split, but I’ll bet Bentham will rule in our favor.”
“But we’ll have won through politics. Auldfield would have the ethical high ground.”
“So what? We can get on with saving some lives,” Mason said. “Listen, Ath, what’s more important, launching a procedure that can save lives or beating that little prick at his own game?”
But Carras wouldn’t budge.
Carras knew that medical ethics had come a long way since the fifties, sixties and seventies, the heyday of creative innovations in cardiac surgery. In those days, the great cardiothoracic pioneers—Cooley, DeBakey and Lillehei—had wasted no time between preliminary testing of a new procedure and the first application to human patients. Many of those patients, even most of them, had died before the surgeons got it right.
Carras had lost patients. Sometimes all his skill and experience couldn’t let him undo the harm that disease or trauma can do to a human heart. He remembered every one of the failures, and every one of them hurt.
It was wrong to risk people’s lives, even the lives of those already on the lip of death, if there was a way to pretest the procedure on animals. He’d said it often enough in the debates that went on among those who were literally on the cutting edge of new medical techniques. Now James Bonar Auldfield was knowingly using Carras’s own standards against him.
“He wants to be able to call me a hypocrite,” he told Mason, their heads together and voices low. “I’m not going to give him the opportunity.”
“Sticks and fucking stones, Ath.”
“No, Craig, I’m going to agree to the extended trials.”
“But who’s going to say when enough time has passed?”
“Bentham’s a sound man. When it’s been a reasonable length of time, he’ll say it’s enough.”
Mason looked at Auldfield’s carefully composed face. “You never should’ve hung that nickname on the little asshole,” he said.
It had been two months and three days since the last series of operations on animals who’d been given boggy lungs. The three pig patients were coming along fine, the enhanced hearts pumping blood into resistant blood vessels that would have stymied normal transplanted organs. The pigs were thriving while human beings with similar problems were being denied heart transplants because of the risk of failure; or worse, they were receiving the transplants and dying.
Carras had decided to give the trials a few more days—that would make it ten weeks—before going back to the committee. Then Cory Goldenberg had collapsed in his office and the Boston teenager’s heart had been a good match.
* * *
CARRAS LOOKED INTO THE GAPING SPACE THAT WAS THE OPENED chest of Dr. Cory Goldenberg, at the grossly swollen mass that was the cardiologist’s diseased heart, its function assumed for now by the humming, gurgling heart-lung machine. Let me think, he had said to Mason. But what was there to think about? He knew he could save this useful man.
“Look, Ath,” Mason said, “so you gave your word to the committee. Do you think if Bentham was here, he’d tell you to plop that kid’s heart into Cory and if he died, tough shit?”
“It will be technically a breach of ethics,” Carras said.
“Then we’re doing it?”
“We’re doing it.”
“Damn straight,” Mason said, and Martini, the anesthesiologist, put in a “Roger that, Ath.”
“But this is on me, guys,” Carras said. “If we blow it, Auldfield will call out the dogs. But it’s me they’ll be chasing, because it’s me he wants.”
“And we all know why,” Mason said, with a wink to one of the nurses.
“Never mind the history,” Carras said. He held out his gloved hand to the circulating nurse and said, “Scalpel.”
Even if the event that made them lifelong enemies had never happened, Athan Carras and James Bonar Auldfield would never have been friends. They were as different as two members of the same profession could be. Auldfield was an internist; he treated the body as a unified system of intricately interlocking parts and processes and believed that the physician’s role, through precise and minimal intervention, was to help the body heal itself.
As a surgeon, Carras was one of the breed that Auldfield disparaged as “cowboys with scalpels instead of six-guns; cut first and ask questions later.”
“Auldfield,” Carras once told a colleague, “has misread the first commandment of the ancient Hippocratic oath. Where it says, Primum non nocere, or ‘First, do no harm,’ he thinks it says, Perpetuum ponderare, or ‘Think about it forever.’ Auldfield will ponder away until it’s too late to do anything at all. That’s when he’ll call me in to do an operation. We’ve had patients leave here in the morgue wagon who would’ve walked out if they hadn’t been on Boner’s list.”
It was a harsh judgment for one doctor to levy upon another, even in a private conversation. The fact that Auldfield had been standing outside Carras’s office and heard every word made the impact worse. The internist was a man who forgave little and forgot nothing.
The root of their enmity went back to their student days, when fate had shown a wicked sense of humor in decreeing that they would be assigned adjoining rooms in Yale’s graduate student housing. They were ill-matched neighbors. Despite four years at one of the world’s best universities, Carras remained a rough diamond from a side street in Philly, propelled into Yale by a top percentile score in his SATs and a brilliant showing at Lansdowne High School. Auldfield had advanced placidly through the best private schools of New England, in the footsteps of ancestors whose portraits hung on the walls of Yale’s oldest halls.
As an undergraduate, Carras had studied French and psychology, his adolescent passions. Auldfield was drawn to computers, which in those days were room-filling machines that calculated by shuffling thousands of cards full of punched holes.
Growing up bilingual had given Carras a facility with languages. His professors were pushing him to continue in French and eventually to teach. Unable to decide, he opted to take all of the graduate school entrance exams—French, law, medicine—and see how he did. The med exam was first, and he scored so well that, assured of a place in Yale’s prestigious medical school, he decided to spare himself the arduous task of taking the other exams.
He could not be said to have had a calling for medicine, but it was interesting enough. It was in his third year that the lightning struck, the first time he assisted at surgery and saw the intricate workings of a human body, the incredible architecture of muscle and bone, the mysterious networks that combine air and liquid and a host of electrochemical triggers in an unfathomable manner that somehow allows what would otherwise be a pile of inert meat to speak and sing, to compose like a Molière or a McCartney, to paint a Picasso or doodle on a cocktail napkin. From then on, he was hooked.
James Bonar Auldfield followed his own path to the doors of the medical school. Carras doubted the clinician harbored any romantic affection for the human body—it was all by the numbers for Auldfield, and that was why the Ivy League scion had ended up as one of the world’s authorities on hemodynamics, the abstruse study of blood-flow patterns and pressures within the heart.
But their differences of background and personality were not enough to make them enemies. They should have been like two parallel species, wildebeest and zebra, sharing the same stretch of veldt, scarcely aware of each other’s existence. But then chance put the thinness of a graduate student residence wall between them, through which—while he tried to concentrate on details of mathematical models—Auldfield could hear the clink of bottles and the raucous laughter of Carras’s fellow surgeons-to-be.
There were other sounds that bothered Auldfield even more. Young Athan Carras had a body, face and manner that young women responded to. It was the seventies and the sexual revolution. Carras never noticed his next door neighbor’s painful shyness around the opposite sex. Nor did he consider the effects on Auldfield of having to listen to the guy next door plow his way through a succession of willing partners, some of whom loudly expressed their appreciation of crucial moments in unmistakable terms.
But even that would have done no more than generate a distinct distaste in the fastidious New Englander for the brash young first-generation Greek-American. The killing point, the event that made James Bonar Auldfield a lifelong enemy of Athan Carras, came in the third year of med school, when Carras met and won Beth Cavendish.
She had the kind of face that instantly pulled a man’s eyes, then pulled them back again for a second look. Not one of her features was perfect, yet somehow they combined to make her more than beautiful in the cover girl sense. She was, it didn’t take long for Carras to realize, just more. And he discovered why: it was because behind those wonderfully combined features was an active intelligence that set Beth Cavendish apart. And the rest of her was everything it should have been.
She was the first woman Carras ever really fell for, the first to make him feel that there was a gap somewhere inside him and that she fitted into that gap exactly. There were at least a dozen men on the Yale campus who must have felt the same way about her, and one of them was the desperately shy James Bonar Auldfield. If there were ever a man designed to worship a woman from afar, it was he; and if there were ever a woman who could only be won by a man with a full flood of blood in his veins, it was Beth.
It was therefore the worst thing that could have happened to Auldfield that he heard noises late one night in the hallway outside his room. He got up out bed, wearing only boxer shorts, and opened the door to tell Carras—of course it would be Carras—to shut up and let decent people sleep. Instead, he found a tipsy Beth Cavendish, still warm and rosy from lovemaking, tiptoeing back to Carras’s bed from the communal bathroom.
She was wearing one of Carras’s shirts, unbuttoned, holding it together with one hand below her throat. When she saw Auldfield in the hallway, she giggled and raised an index finger to her lips. Unfortunately, she used the hand that had been holding the shirt closed, so that it fell open and revealed to the man of numbers an order of reality he had until then only guessed at.
Half-asleep, Auldfield could do nothing but stare. And as he stared, the lower parts of his consciousness reacted as they were designed to do and sent a message to the contents of his boxer shorts, a message that was received and acted upon. She noticed—it was definitely noticeable—before he did, and her reaction turned the original giggle into a full-sized embarrassed laugh.
She scampered quickly to Carras’s door and went through it, leaving a horrified, devastated James Bonar Auldfield to step back into his room and close his own door, only to stand staring at its scarred and painted wood for a long moment—until he heard the sound of muffled laughter through the wall, and then clearly, in her voice, the words “Bonar? His name is Bonar?” followed by something he didn’t catch, and even more laughter.
Auldfield soon noticed that fellow students had taken to addressing him by his middle name and that they seemed to do so with a certain careful intonation or a definite twist to their lips. He never heard the nickname without hearing again the laughter of Carras and the woman for whom Auldfield secretly pined.
He never married, and on the day he heard that Beth Cavendish had finally left Athan Carras, taking their ten-year-old son, Costas, to California, he dined well at Mory’s, the Yale dinner club, and had them bring up the crustiest bottle of port that its distinguished cellar held.
* * *
THE GOLDENBERG OPERATION WAS A RESOUNDING SUCCESS. THE edges of the multiple incisions cohered just as they had in the laboratory animals. Carras and Mason connected the patient’s circulatory system to the new heart’s left ventricle, then weaned the body off the bypass machine. The moment the new organ was given a jolt of electricity, it restarted and began to beat with a strong and steady rhythm. There were no shivers of fibrillation, and the patient did not even require any of the support medications that are routine in heart transplants.
Mason and Carras watched the monitors. Goldenberg’s new, improved pump pushed blood through his resistant lungs like a victorious army routing an enemy from the battlefield. Cardiac output was optimum and the strong flow of oxygenated fluid cleansed the patient’s other organs and tissues of the dangerous acids that had built up since his collapse. Cory Goldenberg would be leaving OR 15 a much healthier man. He was the first person in history to have a heart and a half—Carras’s daring experimental operation.
Carras and Mason sutured and wired the layers of flesh and bone between the patient’s heart and his skin, working swiftly and automatically. As Mason stitched up the outer incision, he said, “You know you’re going to be famous, Ath. Or maybe I should say, even more famous.”
“My old man used to tell me, ‘Fame is just a stepping-stone to destruction,’” Carras said, but he couldn’t keep a smile from forming under his mask.
“Sure, yeah,” Mason said. “‘The paths of glory lead but to the grave,’ and all that. But this path is going to lead to some goddamn gravy for Dr. Athan the Wonder Boy Carras.”
Mason was right. Yale’s publicity department was headed by a brisk young woman named Nancy Polwitz, who had all the skills of a modern public relations professional and an assertiveness of personality that would have fit a Marine drill instructor. Informed that a Yale doctor had developed a revolutionary new procedure that had saved the life of a top Harvard cardiologist, Polwitz reacted like a one-woman air assault division.
“I need you to defer your caseload for the next week,” she told Carras over the phone, the day after the operation. “I’ve booked a suite at the Park Plaza for two days of print interviews—Time, Newsweek, People, the usual dailies—then both Dateline and 20/20 want you in their New York studios. We’re still talking to Oprah.”
“Whoa,” said Carras. “I can’t walk away from my patients.”
The publicity head’s Midwestern twang became more pronounced when she encountered unreasonable people, which she defined as anybody who didn’t agree with her. “Doctor,” she said, “this is not about you. This is about the university. Yale has been very, very good to you. This is your chance to give a little back.”
There were many other calls, including several from illustrious alumni and one from the president of the university. Carras caved in and called Nancy Polwitz and said she should go ahead and make arrangements.
She already had. “We’re booked on the eight fifteen Acela train to Manhattan tomorrow morning,” she said. “I’ll pick you up at seven thirty. Don’t pack any checked shirts or loud jackets. They tend to strobe on TV.”
It was an exhilarating experience. Carras had heard movie stars complain about publicity tours with hour after hour of back-to-back interviews. And, true, it was exhausting to recount time after time how the dream had led to the idea, then how the procedure had been developed and the life-or-death circumstances that had prompted its first application. But being treated like a celebrity, even only temporarily, felt good. He gave full credit to Craig Mason, but the reporters had dubbed the heart-and-a-half operation the Carras Procedure and the label stuck.
The medical reporter for the New York Times was the only one to ask the dark-side question. “What if it hadn’t worked? What if Dr. Goldenberg had died?”
“I would have been devastated. He is my friend.”
“Yet you risked his life with an untried procedure.”
“It had been performed many, many times in the lab.”
“The principles were the same,” Carras said.
“But there were still unknown risks.”
“Yes. Thank God, all went well.”
The reporter flipped a page in his notebook, read something written there, then said, “I understand you did not actually have the permission from the ethics committee to perform the procedure.”
Carras was silent, wondering where the man had heard that. It was not in any background materials Nancy Polwitz had handed out. There could have been only one source.
“Doctor?” the reporter prodded.
Carras said, “The committee chair was unavailable. He was out in Montana without a phone or beeper.”
“But you talked to someone from the committee.” The reporter wasn’t asking; he was looking for confirmation of something he already knew.
“Did you ask for permission to proceed?”
“But you did not receive it.”
Carras chose his words carefully. “I was told it was my decision to make.”
* * *
THE COVERAGE WAS ALMOST UNANIMOUSLY POSITIVE—GREAT NEW breakthrough, many lives to be saved—and the Harvard-Yale rivalry angle was featured prominently in most stories.
The Times write-up took a different tack, lauding the result but asking leading rhetorical questions about the “glaring absence of regulatory oversight for surgical experimentation.” Nothing was said directly, but Carras felt the piece gave a distinct impression that he was some kind of scalpel-wielding maverick. The article ended in a series of open queries: “Will the success of the Carras Procedure encourage other surgeons to play God with their patients? And will the next high-risk experiment end in a life saved—or a life lost?”
Carras read the article in his office. After the second reading, he threw the paper into the wastebasket and swore.
Charlie Vance had picked it up at the newsstand in the med center lobby and brought it over. He sat in the chair usually occupied by patients in for a preoperative consultation. Vance said, “I looked up the reporter’s CV.”
“Yeah?” Carras said, knowing there would be something to come.
“Harvard Med, class of ’82.”
Carras made a confirmatory grunt deep in his throat.
Vance steepled his fingers, cocked his head to one side and raised his eyebrows. The resemblance to Nicholson was almost eerie. “Also, he prepped at Andover.”
It took a moment to sink in. “Boner was at Andover,” Carras said.
“Yep,” his friend said, then leaned back in his chair, his eyes roaming over the wall behind Carras, which was covered with certificates and diplomas, some framed letters from famous people whose hearts he had worked on, and slightly gaudy testimonial plaques from commercial agencies that polled America’s physicians and surgeons to find out who were the Best Doctors in America. “You know,” Vance drawled, “if all that stuff ever pulls that wall down on you, we will have the best metaphor since Dr. Faustus for a man destroyed by his own success.”
“Ha-ha,” said Carras and used his foot to push the Times deeper into the trash.
“I’ll buy you dinner tonight,” Vance said. “I’m not afraid that the fiery glow of your celebritude will consume me.”
* * *
IT WAS A GOOD DINNER AND CARRAS CAME HOME TO HIS EMPTY apartment in a low-rise block on the campus still warmed by his friend’s affection. In the hallway outside his door a man was leaning against the wall with an air of having waited some time. He was thirtyish, in a well-tailored, conservatively cut suit that could not compensate for a round-shouldered physique. His thin face was made to seem unnaturally elongated by a pointed chin and a well-receded hairline, and the corners of his mouth had turned down so frequently that there were little creases there.
“Dr. Carras?” he said. “My name is Leonard Maigrot. I’d like to talk to you.”
The man’s hands were cold and his handshake perfunctory. Carras unlocked his door and said, “I’m not doing any more interviews.”
“I’m not a reporter, doctor.” He handed Carras his card. It showed nothing but his name and a phone number.
Carras needed to get to bed. He had to perform a transplant and repair an aortic aneurysm the next day, plus rounds and some teaching work. His friend Charlie Vance had once wondered if Carras needed sleep because he worked so hard, or if it was the other way round: maybe he worked too hard because fatigue would let him fall asleep the moment his head hit the pillow, and then he wouldn’t have to lie there thinking about the things that hurt too much to think about.
“What do you want?” Carras asked Maigrot.
“It’s a medical matter.”
“Then make an appointment with my secretary. I don’t see patients at my home.” He stepped through the doorway, but Maigrot caught the edge of the door and did not let it close.
“I’m not a patient, and my employer would prefer to remain anonymous for the moment,” he said.
“Let go of the door,” Carras said.
Maigrot flinched a little at Carras’s tone, but held his position. “I’d like to arrange for you to meet my employer. He’d like to make you an offer.”
“What kind of offer?”
The man shrugged. “I don’t know the details.”
Carras had had enough. “Mr. Maigrot, I’m tired and I have to work tomorrow. Your employer can call my secretary or send me a letter or do whatever he likes, but you can tell him that I have a low tolerance for people who like to play games. Whatever he wants, if this is the way he intends to go about it, the answer is going to be no.” He looked the man squarely in the eyes. “Now take your hand off the door.”
Maigrot’s long fingers lifted off the wood like the tendrils of a sea anemone moved by an idle current. “It would be a lot easier on everybody if you’d reconsider,” he said. “I’ll be in touch.”
* * *
IT WAS ALMOST A MONTH AFTER THE GOLDENBERG OPERATION. CARRAS had completed his morning surgery and was in his office attending to a stack of correspondence, much of it generated by the publicity that Nancy Polwitz had orchestrated. The pioneering surgeon was in high demand for conferences and seminars.
Karen buzzed him on the intercom. “That reporter from the New York Times is on the line.”
Carras grabbed for the phone. It was an opportunity to tell the snide insinuator what he thought of him, in detail. But the reporter didn’t give him a chance. As soon as they were connected he said, “Dr. Carras, what is your reaction to the sudden death of Dr. Cory Goldenberg, apparently from complications of your untried surgical technique?”
* * *
DR. CORY GOLDENBERG DIED IN HIS SLEEP. AT TEN A.M., HIS ASSISTANT, concerned that her boss had missed two morning appointments and was not answering his phone or pager, called the police to check the home where the cardiologist had lived alone since the death of his wife. He was already in the first stages of rigor mortis.
The Times man had a beat on all the other major media—Carras was sure that was Auldfield’s doing—and the scribe made a meal of it. He got little from Carras in the telephone ambush, just the surgeon’s expression of shock and regret, but that was all he wanted. The shape of the piece was already in the reporter’s head before he made the call.
Noted cardiologist Dr. Cory Goldenberg always warned against a too ready recourse to surgery for heart disease. Last month he went against his own teachings and put himself under the experimental knife of Dr. Athan Carras. Now he is dead.
What followed was more self-congratulation than reportage. The Times man reminded his readers that he alone had sounded a word of warning, cutting across the rest of the media’s stream of adulation and gee-whiz celebrification of a self-willed doctor who may have gone well beyond the canon of medical ethics, lured by the ignis fatui of fame and professional acclaim.
The article wound its way toward an unsubtle allusion to Dr. Frankenstein, who unnaturally sewed dead parts together to create his own destruction, before concluding with a question: “Will the medical fraternity—especially those who wear a Yale alumni pin—close ranks around a rogue member, so that he may soon resume an apparently reckless course of human experimentation; or will they make of this case an unmistakable example that will save lives and restore public confidence in the profession and in the institution where this outrage was permitted to occur?”
The rest of the media pack followed the scent of blood. Although one or two voices mentioned that no cause of death had yet been established, the general tone of the coverage copied the Frankenstein motif. Some articles spun off into wide-eyed speculation on the possibility of harvesting organs from animals genetically altered to pass for human, at least at the DNA level. Others raised the prospect of mindless clones grown in tanks to provide organs, “like a junked parts-car out in the weeds, ready to supply a replacement set of whatever we need, on demand.”
But whether the coverage stayed on the Goldenberg case or wandered out into the furthest frontiers of medicine, the role of Athan Carras remained central to the stories.
“You’ve become a symbol,” Nancy Polwitz said. “Despite fifty years of doctor shows on TV, from Ben Casey to General Hospital to ER to Grey’s Anatomy, half the country couldn’t differentiate medical science from spells and potions. They have to rely on doctors as if they were an order of priests. When somebody comes along and says one of the priests is really doing black magic, a lot of people get scared.”
She held up a supermarket tabloid with a cover photo of Carras. The flash of the photographer’s strobe had caught him close up as he came out of his apartment block, making him look pale, and someone had retouched the image to enlarge his eyes, so that he looked slightly alien. The headline referred to him as Dr. Death.
“You’re saying I’m a symbol of evil?” Carras said.
“Of fear,” the PR woman said. “Until another one comes along, you’re America’s bogeyman.”
“But we don’t even have the autopsy results. Cory was in his mid-sixties. He might have died from a dozen unrelated causes.”
“You’d better hope he did. In the meantime, no more interviews. This will die down.”
“No fear of that,” Carras said. “I don’t even answer my home phone unless it first rings twice to let me know it’s Karen.”
* * *
THE POSTMORTEM EXAMINATION OF DR. CORY GOLDENBERG SHOWED that he died of cardiac tamponade, bleeding around the heart. He had bled from the pericardium, the sac that surrounds the heart and which is always irritated and inflamed after open-heart surgery.
“It doesn’t make any sense,” Carras told Charlie Vance, looking up from a printout of the autopsy report that had been e-mailed to his office. “We solved that problem in the animal model. There’s no way it should have happened.”
“Let me see.” Vance took the report and scanned the pages. “Did you have him on any blood thinners?” he said.
Carras shook his head. “No. He wanted to use an anticoagulant because he was afraid clots might form at the anastomoses and he’d be at risk of stroke if they went to the brain. But it wasn’t a problem in the animal trials and I talked him out of it. Why?”
“His blood was thinner than it should have been,” Vance said, pointing to the notation on the autopsy report.
Carras reached for the phone. Two minutes later, he was talking to Gulwar Singh, the pharmacist at Harvard Medical Center who had filled Cory Goldenberg’s postoperative prescriptions. The pharmacist ran down a list of medications the cardiologist had been taking—immunosuppressive drugs, diuretics and some blood pressure pills—then he said a word that made Carras sit up.
“Did you say Coumadin?” Carras said.
“Yes, Coumadin,” the pharmacist said. “Five milligrams daily.” It was a strong dose of a powerful blood thinner.
Carras thanked him and hung up. “Well, that’s it,” he told Vance. “He must have still been worried about clotting and decided to prescribe for himself. The blood thinner caused bleeding from the pericardium and that caused Cory’s death. I’m in the clear.”
“Don’t count on it,” Vance said.
“They can’t blame me if he didn’t do what I prescribed.”
“Don’t count on it,” Vance repeated.
“In any court of law . . .” Carras began.
“This ain’t no court of law,” Vance said, dropping into his Nicholson drawl. “It’s the court of public opinion. Case closed.”
* * *
THERE WAS NO CHANGE IN THE TONE OF THE COVERAGE. THE DETAILS of the autopsy results were reported but the story now had its own momentum. Many Americans were scared by their own thoughts about where medical science was taking them, and Athan Carras had become the focus of their fear.
“It will die down,” Nancy Polwitz had said. But it wasn’t dying down. The media maintained that the public was “looking for closure.” The PR woman translated that phrase as the media’s way of saying they wanted a head to roll—and they knew whose head they wanted.
Yale’s board of governors convened a special panel and summoned Athan Carras to appear before it.
“Should I get a lawyer?” Carras asked Vance. He knew the ethicist was closer to the powers that were than he had ever been. Many of them had gone to the same schools.
“Only if you want to make things worse,” his friend told him. He let his eyes wander over Carras’s collection of plaques and testimonials then out toward the morgue. “What I’m hearing is, this isn’t about you anymore. It’s about the university. Some important alumni are phoning. There’s many a quiet word over a drink.”
“I didn’t do anything wrong,” Carras said.
“This country occasionally executes people who can say the same thing,” Vance said. “What counts is not whether you did anything wrong, but whether they can make a case against you.”
“And can they?”
Vance stuck out his lower lip and spread his hands. “Boner has been a busy little beaver. Everybody has heard from him, quietly, and he’s saying he did not give you the HIC’s permission to operate on Cory.”
“He said it was up to me.”
Vance made a face that looked like he’d just tasted acid. “Then they’ve got you.”
“That’s not fair.”
“Fair has got nothing to do with it. You bound yourself to do what the committee said. The committee said wait. You didn’t wait. Ethically, you’re in breach.”
“But Cory would have died,” Carras said.
“Cory did die.”
“But that wasn’t my . . .”
Carras said, “I need a lawyer.”
He reached for the phone on his desk, but Vance put out his hand and stopped him. “No.”
“Tell me, Charlie,” Carras said. “Whose side are you on in this, mine or the university’s?”
“As it happens,” Vance said, “I’m on both sides.”
“Good trick,” said Carras. “Want to tell me how it’s done?”
“You’re a problem for the university. You haven’t done anything wrong, but you have got the press all atwitter. If Yale does nothing about you, the fuss will continue. Some alumni checks will be smaller—maybe they won’t get written at all. So something has got to be done about you.”
What People are Saying About This
“A gripping tale of violence and intrigue set within the world of transplant surgery.” —Mariell Jessup, MD, Professor of Medicine, University of Pennsylvania
“Seduction becomes coercion in this fast-paced thriller.” —Robert Picardo, actor, Star Trek: Voyager
“If you are looking for a rip-roaring thriller, stop. You’ve found it.” —Dave Duncan, author of The Alchemist’s Pursuit
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