Described by one surgeon as "soul-crushing, diamond-making stress," surgery on congenital heart defects is arguably the most difficult of all surgical specialties. Drawing back the hospital curtain for a unique and captivating look at the extraordinary skill and dangerous politics of critical surgery in a pediatric heart center, Michael Ruhlman focuses on the world-renowned Cleveland Clinic, where a team of medical specialists-led by idiosyncratic virtuoso Dr. Roger Mee-work on the edge of disaster on a daily basis. Walk on Water offers a rare and dramatic glimpse into a world where the health of innocent children and the hopes of white-knuckled families rest in the hands of all-too-human doctors.

"Roger, We Got a Problem": An Introduction to the Beautiful,
Horrible World of Pediatric Heart Surgery

"Stay away from that."

Fackelmann says it to Mac the way he says most things in the O.R.- matter-of-factly but definitively. The two men continue to work within the newborn's open chest, Mac dissecting out heart vessels bound in webs of delicate connective tissue.

Makoto Ando, called Mac, is the chief surgical fellow at the Center for Pediatric and Congenital Heart Diseases at the Cleveland Clinic, in Cleveland, Ohio. Raised and educated in Tokyo, Mac is thirty-five years old, married and the father of a two-year-old daughter, and currently half a year into the fellowship here that will conclude his training as a pediatric heart surgeon. This morning Mac has already accomplished what is by now an almost daily routine for him: the opening of a child's chest. He has drawn a scalpel down the baby's midline, then divided the sternum lengthwise with hand shears.

Mike Fackelmann, the P.A., or physician's assistant, across from Mac, has fitted the brackets of the stainless-steel chest retractor along each edge of the sternum and cranked a small handle to ratchet the arms open, exposing the chest cavity. Bob Cherpak, the scrub nurse at Mac's right, organizes an arsenal of sterilized steel tools on the setup table and hands Mac instruments as Mac first removes the thymus gland, then opens the pericardium with a bovie-an electric scalpel that cauterizes as it cuts-thus freeing the baby's heart from the blood-bright tissue, a nearly translucent sac. Mac will cut two rectangular patches of this tissue and store them in solution, for use later in the operation. Two stitches are then placed on each side of the opened pericardium and sewn into the patient's chest to hold the pericardium back and present a clear view of the heart.

Roughly the size and shape of a plum, this neonatal heart is pumping at the rate of about 130 beats per minute, normal for a sedated child of this age and weight-forty hours and just over six pounds. The smooth, deep-red muscle on top, the right ventricle, is filled 130 times each minute by the saclike right atrium above it. With the pericardium tied back, Mac begins the work of distinguishing and separating the vessels from one another so the field will be clear and distinct when the chief surgeon, Roger Mee, arrives. Presently, Mac must pull apart or cut with the bovie the mesh of tissue joining the vessels that rise out of the heart, called the great vessels: the aorta and the pulmonary artery.

Fackelmann says it again: "Stay away from that."

Mac, hunched like a cane over the patient, the personification of Japanese silence and humility, says nothing.

The bovie is about the size and shape of a pen. Mac depresses a small rectangular button with his index finger, and the generator issues a high-pitched tone, signaling that juice is running through the chisel-shaped tip. When Mac touches this tip to tissue, the tissue sizzles and pops, and sometimes a wisp of acrid smoke appears. The blip-blip-blip-blip of the heart monitor, the beeeep of the bovie, and the crackle of moist tissue are the main noises in this bright white O.R.

The baby boy whose heart is open to the room, an apparently normal newborn, is named Connor Kasnik. His eyes, though, are taped closed; his short black hair is matted. His head is cocked to one side, and a ventilation tube has been inserted into his trachea just past the vocal cords; the tube is taped to his mouth. His arms are flat on the table, tiny palms up, a line running into the right radial artery at the wrist. Julie Tome, the anesthesiologist, has also placed a central line in the jugular vein, in Connor's neck, and a peripheral line in a foot vessel. Nothing of this two-day-old baby is visible; everything except his open chest and his beating heart is draped with green cloth, as is the metal cage above his head, where hoses, paddles for shocking, cups, suckers, and assorted tools will rest during the procedure. Julie, stationed behind the cage, has sedated the patient and will determine what goes into his vessels-drugs, saline, albumin, blood-and, until he goes on bypass, what goes into his lungs: oxygen, carbon dioxide, nitrous oxide. She will also draw blood throughout the operation to check the patient's blood gases, which describe how well or how poorly he may be doing.

George Thomas, the perfusionist, is just off the patient's left shoulder, behind the heart-lung machine, which will effectively breathe for Connor and circulate blood through his body. The heart-lung machine allows a surgeon to stop the heart in order to operate inside it (which is why today's procedure is called "open-heart" surgery, abbreviated on the board as MSOH, for "midline sternotomy open heart"), or to reconstruct vessels that would otherwise have copious amounts of blood rushing through them, or to reroute blood entirely via reconstructed synthetic vessels, or to fix valves accustomed to continuous motion. The heart-lung machine is the pediatric heart surgeon's primary tool. George runs through a lengthy checklist, one he completes each time he puts a patient on cardiopulmonary bypass. Lorene Mickunas, known as Lori, tall and slender in sneakers and blue scrubs, is the circulating nurse, assisting all those who are scrubbed, whether to adjust the strength of the bovie, retrieve more 7-0 Prolene sutures for Bob the scrub nurse, or answer the phone-June Graney, a cardiac nurse, will call throughout the procedure so she can update Connor's parents as necessary.

These are the players in this theater this morning. But it's Mike Fackelmann who, though he's not one of the doctors here, seems to command most of the space. Fackelmann stands five feet ten inches tall and has the build and posture of a former athlete who still works out. He wears a shower-cap-style hat that billows slightly over his ears and big, round glasses that enlarge his blue eyes; outside the O.R. he wears small, rectangular frames, but when he's working he needs protection from blood. A pale-green mask, taped over the bridge of his nose to keep his glasses from fogging, covers his nose, mouth, and chin. He wears a standard blue disposable surgical gown, tied in the back, over blue scrubs. Paper booties conceal his immaculate white bucks. He wears size 7½ latex gloves.

Fackelmann, age forty-four, married with two teenage kids, was born and raised in the working-class neighborhood of Parma, southwest of the city, and was a supervisor for a local Ford Motor Company plant, overseeing an eight-cylinder-engine-block assembly line, before a buddy convinced him to become a nurse. At first he pursued anesthesiology, but after spending a year in an ICU and watching surgical nurses in the O.R., he thought, "This is way cooler than putting people to sleep," and changed direction. He's been doing hearts now for nearly fifteen years, and kids' hearts for the last ten. Since 1993, when Dr. Mee arrived at the clinic, Fackelmann has assisted in more than three thousand heart operations. He assists in virtually all of Dr. Mee's cases, and in most of his partner's, when the two aren't operating at the same time. "Roger's my guy," he says.

As Mac continues to dissect out, Fackelmann concentrates on Mac's moves, retracting with a sucker or forceps to help him free the heart and vessels from one another. If this were a normal heart, a thick vessel, the pulmonary artery, would rise out of the top of this right ventricle and divide into two branches carrying depleted blood to each lung. Curving around from behind the pulmonary artery, then arching over it and down behind it again, would be the aorta, the main vessel through which oxygen-rich blood goes to the body. But in Connor's case, these two arteries are side by side, with the slightly larger aorta, a little less than a centimeter wide, rising out of the right ventricle, and the smaller pulmonary artery emerging from the left. In a heart with this defect, called transposition of the great arteries, the main arteries are reversed, so that blue blood circulates continuously through the body and red blood circulates continuously through the lungs. Only a hole that's been opened up in his heart and a fetal vessel called the patent ductus arteriosis have kept Connor from effectively suffocating. The ductus, which connects the two main arteries in utero but then shuts down once a newborn starts breathing room air, has been kept open chemically in this instance. Because lung resistance is high, much of the oxygenated blood courses up the pulmonary artery, shoots through the duct, and enters the aorta, perfusing the body's tissues with oxygen. In Connor's open chest cavity, the ductus is visible as a big, bright bulge between the two arteries.

It's this duct that Mac continues to fuss with. Fackelmann has already said to Lori, "Tell Roger fifteen minutes"-meaning, call Dr. Mee and tell him the team will be ready for him in fifteen minutes. Mac is just trying to make things clear and clean for Dr. Mee, poking around in there with the beeeep and sizzle of the bovie. He's noticed that the tissue on the outside of the big duct bulging with all that oxygen-rich blood is bleeding-just a little-and he wants to cauterize it with the bovie.

"Stay away from that."

Fackelmann has said it three times now, as if annoyed-Cut it out, man, stay away from that-definitively.

Mac hears the admonition and returns to the task of clearing and freeing. But the little leak of blood along the bulging duct persists, and finally he decides to take care of it. He gives the spot just one more little zap-but he pushes too hard, burning a hole through the ductus. Blood immediately fills the field.

As always, Fackelmann speaks matter-of-factly and emphatically, but now he raises his voice to a pitch that signals Julie, the anesthesiologist, and Lori, the circulating nurse, to pay attention. "We're in the duct," he says, getting a sucker in there to pick up the blood that has turned the chest cavity into a bright lake. And then, fixing his eyes on the monitor as the baby's pressures begin a free fall, he says, "Lori, get Roger in here."

Suddenly, several things have to happen in response to the fact that Connor is now losing a lot of blood fast, and the amount of oxygen being delivered to his organs is plummeting. Julie, most critically, has to hang blood, crank the O2, get pressers into the baby, and clamp his vessels down to maintain blood pressure. Lori's got to find Roger, who as it happens is in his office and, great good fortune, already dressed for the O.R. Mac has to remain calm and keep the bleeding down until Roger can get in here, cannulate-that is, insert the tubes for the bypass machine-and get the kid on pump; once he's on pump, he'll be safe. A visitor arriving at this moment might not even realize that anything is wrong: the room is quiet; no one's screaming at anyone, no one's moving quickly; there's no sign of panic-except that Mac says "Fuck." And then "Fuck." It sounds strange coming from him, again and again, because he seldom utters a word in the O.R. "Fuck." Scrub nurse Bob Cherpak, a Gulf War veteran, is silent, but his every cell is stressed. He knows what he's seeing: a kid dying right in front of his eyes.

"Fuck," Mac says again. He tries to cover the hole with his finger, but there are two problems with this strategy: first, they've stopped giving the boy prostaglandin, the stuff that keeps the duct open, so it's already started to disintegrate and now has the consistency of tofu; and second, the amount of pressure required to stop the blood from spurting out will clamp down the duct entirely, cutting off oxygenated blood to the baby's aorta and therefore to his brain and heart.

Fackelmann keeps looking up at the door, wondering what's taking Roger so long. He'd better get in here fast, he's thinking.

Julie's watching pressures, which have fallen into the 30s. The blood's oxygen saturation is dropping, too. This means there's blood in the arteries, but it's not moving very quickly, and what blood there is doesn't have enough oxygen in it to maintain the patient's tissues. Without oxygen, the brain can go undamaged for several minutes; the big worry here is the heart. The heart needs tons of oxygen because it's a perpetually beating muscle and has a voracious appetite. A web of arteries descending from two main coronary arteries feeds it. The main coronary arteries are in turn fed by the aorta. With decreased pressures and a hole in the duct, the heart's not getting enough oxygen. Its response to this is to beat faster, which only intensifies its need for oxygen that isn't there. This will escalate, the heart beating faster and faster, till it runs out of energy and arrests. And that's what's happening now, to this baby. His heart is working, and his oxygen saturations are dropping rapidly, and his blood pressures are low. When his heart stops, he will die-and since they'll still be many minutes away from getting him on pump, and unable to fix the hole in the duct, the main channel for oxygenated blood at this point, there won't be anything anyone can do about it.

Marc Harrison is thirty-six, wears a short, dark beard, has dark eyes, and on Thursday, December 7, the day before Connor Kasnik's surgery, is dressed in khakis and a tie. A white badge clipped to his shirt pocket identifies him as a staff doctor in the Cleveland Clinic's Pediatric Intensive Care Unit. He has just stepped out of room 10, now occupied by the hours-old Kasnik baby. Connor was transported here in an isolette-an incubator-like tank-from Fairview Hospital, a Cleveland Clinic affiliate, where transposition of the great arteries, or TGA, was diagnosed and treatment with prostaglandin, the hormone that keeps the duct open, begun. Connor is critically ill, and the situation is considered urgent. Marc loves this part of his job, when he's like a general marshaling his troops-in his case, a small resuscitation team, residents, nurses, technicians, and respiratory therapists. Everyone has his or her job, and the work is calm, so steady as to seem slow, and all but silent. "When it's done well," Marc says, "the initial stabilization of a critically ill child is a beautiful thing, really elegant."

Even before the traditional ABC evaluation (airway, breathing, circulation), Marc makes a visual assessment of Connor as the nurses hook him up to a monitor, then looks at his heart rate and blood oxygenation and watches for any signs of dangerous distress. He'll want to get him intubated and gain vascular access, insert a line into the infant so he can give him fluids. While the nurses check vital signs, the respiratory therapists set up the ventilator and ready the tools for ventilation. This morning, as a snowstorm whips across the room's window, the procedure is routine.

When it's done and the patient is stable, Marc steps outside the room and sees a man with dark hair and a gray complexion walking the PICU corridor, which has glass enclosures on either side. The man looks right and left and right. Marc suspects this is the father. He looks more than just lost, he looks like he's in an awful dream-confused, in danger, vulnerable, eyes red from sleeplessness or tears-but he is also purposeful: he is searching for his new son. Marc steps toward the lost man and asks, "Are you Connor's father?" The man nods, registering a moment of relief-I'm in the right place-and enters room 10, one of fourteen in the PICU. When he sees his son, he turns to Marc.

"Hi, I'm Dr. Harrison," Marc says. He shakes the man's hand, identifies himself as the attending physician, and explains what is happening: Connor has just been intubated-that is, has had a tube inserted down his bronchus so he can be ventilated-and is now hooked up to a monitor that will display blood pressures, heart rate, oxygen saturations, and temperature. Marc tells Mr. Kasnik that everything is OK.

A moment passes as Bruce Kasnik takes in this information and the sight of his son. He has driven through traffic-clogged, snowy streets, parked in an illegal spot near the ambulance bay in the hope of seeing Connor as he went in (too late), made his way into the massive clinic complex, and found his baby boy; now he's being addressed by a doctor who seems to be in control of the situation. He can draw a breath, pause, not do anything for a moment.

Marc asks, "How are you doing?"

Bruce Kasnik offers a fragile smile and answers, "Not good." Marc knows that conversation can have a calming effect on a rattled parent, and he also wants to glean any information he can about the new arrival. In the PICU, doctors don't treat only the patient, they treat the whole family; families come in an astonishing variety and often bring with them troubles beyond those of a sick child. Nothing appears to be worrisome here: Marc sees an appropriately upset, likely exhausted, but coherent parent in clean, casual clothes.

"Is this your first child?" Marc asks.

"No, second."

"Was it a normal delivery?"

"Yes. It was a normal pregnancy."

This halts Marc for a moment. "So this was a surprise."

Bruce says, "This was a big surprise."

From Walk on Water: Inside an Elite Pediatric Unit by Michael Ruhlman, Copyright © 2003 Michael Ruhlman, published by Viking Press, a member of Penguin Group (USA) Inc., all rights reserved, reprinted with permission from the publisher.

Tags: Pediatrics, Heart Disease

About the Author

Michael Ruhlman, winner of the 1999 James Beard Award for Magazine Writing, has written six books and for The New York Times, Gourmet, Saveur, and Food Arts Magazine.