EP. 108: TALES FROM THE WILD WEST OF CARDIAC SURGERY
WITH GERALD IMBER, MD
A plastic surgeon and medical historian shares stories of daring surgeons who pioneered the field of cardiac surgery, as well as insights on the aesthetic component of his own practice.
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Episode Summary
The history of cardiac surgery is filled with tales of intrepid surgeons with larger-than-life personalities who pushed the limits of the human body and the bounds of what were then considered acceptable medical practices. The result? Heart transplants, pacemakers, artificial heart valves, heart-lung machines, and other once-unthinkable and experimental procedures that have now saved millions of lives.
Our guest in this episode, Gerald Imber, MD, charts these remarkable developments in his 2024 book Cardiac Cowboys: The Heroic Invention of Heart Surgery. While not writing books on the history of medicine, Dr. Imber is a practicing plastic surgeon who specializes in cosmetic surgery. Over the course of our conversation, Dr. Imber talks about the challenging yet rewarding training he underwent as a surgery resident, what it means to have an “eye for aesthetics,” why he decided to write a book on the history of heart surgery, stories of daring surgeons from this history, how he reconciles the drive to push the frontiers of medicine with a regard for patient safety, and more.
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Gerald Imber, MD is an internationally renowned plastic surgeon. He is the author of numerous beauty books, including The Youth Corridor, Wendell Black, MD: A Novel, and the highly regarded biography Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted. Dr. Imber has spoken on the life of Halsted, the father of modern surgery, at numerous medical meetings throughout the country and is the acknowledged expert.
Dr. Imber is an attending surgeon at the New York-Presbyterian Hospital, an assistant clinical professor of surgery at the Weill-Cornell Medical Center, and the director of a private clinic. He has been the subject of numerous articles and has made innumerable media appearances.
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In this episode, you will hear about:
• 2:15 - What drew Dr. Imber to a career in surgery
• 7:55 - Dr. Imber’s grueling experiences as a general surgery resident
• 11:52 - Dr. Imber’s transition into plastic surgery and the aesthetic sensibilities necessary for this speciality
• 22:46 - What Dr. Imber’s current plastic surgery practice looks like
• 24:28 - How Dr. Imber finds fulfillment and meaning in his work
• 25:21 - What motivated Dr. Imber to write Cardiac Cowboys, a book about the history of open heart surgery
• 30:47 - Balancing risks to patient lives with medical and surgical experimentation
• 34:25 - A brief history of open heart surgery
• 40:02 - Key milestones in the development of open heart surgery
• 45:24 - What Dr. Imber hopes readers take away from Cardiac Cowboys
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:01] The history of cardiac surgery is scattered with tales of intrepid surgeons with larger than life personalities who push the limits of the human body and the bounds of what were considered acceptable medical practices of the time. The result? Open heart surgeries, pacemakers, heart transplants, artificial heart valves, heart lung machines, and other once unthinkable and experimental procedures that have now saved millions of lives. Our guests in this episode, Doctor Gerald Imber, charts these remarkable developments in his 2024 book Cardiac Cowboys The Heroic Invention of Heart Surgery. While not writing books on the history of medicine, Doctor Imber is a practicing plastic surgeon who specializes in cosmetic surgeries. Over the course of our conversation, Doctor Imbert talks about the challenging yet rewarding training he underwent as a surgery resident, what it means to have an eye for esthetics, why he decided to write a book on the history of heart surgery. Stories of daring surgeons from this history. How he reconciles the drive to push the frontiers of medicine with a regard for patient safety, and more.
Henry Bair: [00:02:10] Doctor Ember, thank you so much for taking the time to join us and welcome to the show.
Dr. Gerald Imber: [00:02:14] Oh, thank you for having me.
Henry Bair: [00:02:16] Now, we'll of course spend some time talking about this book you've written on cardiac surgery. But interestingly, this specialty is not what you were professionally trained in, right?
Dr. Gerald Imber: [00:02:25] Well, that's quite true. I'm a plastic surgeon and I have been for four decades, and I was trained first as a general surgeon because some old school. And after I finished my general surgery residency, then I did a plastic surgery residency. And I'm interested in all surgery, the history of surgery. And I'm generally written a good deal about medical history. My previous book, genius on the edge, was about William Halsted, who was the father of American surgery, and the current book, Cardiac Cowboys, is about the true invention of open heart surgery.
Henry Bair: [00:03:04] Thanks for giving us a little preview of the book. Let's start with your background, however. What drew you to medicine in the first place?
Dr. Gerald Imber: [00:03:14] That's an interesting question, and everyone has their own story. I had absolutely no interest in medicine. All I know is all my friends who were really smart and did well in school, wanted to be pre-med, and I didn't have any ambition at all. So I became pre-med also. And somehow I ended up in medical school and I remember so well. This is half a century ago when I attended my first few classes in medical school, and I realized that everybody in that classroom with me was smarter than I was. And it's the first time that ever happened to my life. And it terrified me, and it just made me fall in love with the whole thing. Huh.
Henry Bair: [00:03:56] Interesting that that was your response.
Dr. Gerald Imber: [00:03:58] My response was, Holy geez, I got to get going here. These people are smart.
Henry Bair: [00:04:03] Okay, so then that made you want to really push yourself to learn this material, but was there or I'm going to assume that at some point you did fall in love with medicine.
Dr. Gerald Imber: [00:04:13] The first minute because there's nothing boring. Everything can be applied to life and death, and you just have to kind of drill down a little bit. Even biochemistry becomes interesting when you recognize it's really about people. And so the there was nothing that wasn't pertinent to the world. And also there was nothing that I knew before. So it was a constant challenge. And it was a it was such a delight to actually learn. Well, I hope you felt that way because I was just charmed. I just I haven't had an unhappy moment in this profession.
Henry Bair: [00:04:51] That's really lovely to hear. I think certainly in the midst of it, maybe when I'm, you know, 2 a.m., eight hours deep into studying neurobiology, maybe I start to lose a little bit of that pleasure. But, you know, in hindsight, I do I do enjoy all the things I learned in medical school, even though a lot of it granted, I might not be using on a daily basis. It does come up right. And it's very rewarding to know that that thing, that one factoid you learned in that textbook, you know, like my first year of medical school, it does impact someone's life. Like all these. You're talking about biochemistry. Why do we learn about all these amino acid metabolism and all the different cycles and whatnot?
Dr. Gerald Imber: [00:05:33] The bloody Krebs cycle.
Henry Bair: [00:05:34] like the Krebs cycle?
Dr. Gerald Imber: [00:05:37] It torments me still. To this day.
Henry Bair: [00:05:39] I just finished, uh, step three, which is the final stage of the medical, the United States medical licensing exam. I just took it about a month ago. Three questions on the Krebs cycle.
Dr. Gerald Imber: [00:05:50] No
Henry Bair: [00:05:51] Believe it or not. Yeah.
Dr. Gerald Imber: [00:05:52] Wow, I was surprised.
Henry Bair: [00:05:54] I was as shocked as you are just now. No, but to your point about, you know, all these cycles, the urea cycle, you know, when you do come across that rare patient who has their life fundamentally changed because they have a deficiency in one of the enzymes regulating it? For me, it brings a new appreciation for what I went through five, six years ago. Now, you know, obviously much farther, much, much longer ago for you.
Dr. Gerald Imber: [00:06:18] Well, you know, the classic example of people, middle aged people who have gout and the idea that allopurinol just replaces the the missing enzyme is just, you know, that's something you learned in, in medical school and learned it in biochemistry. You know, just really? It's kind of interesting.
Henry Bair: [00:06:37] Yeah. It's actually... It's beautiful. It's elegant. Okay. So then the moment you step foot in medical school, you realize that this is something that you deeply enjoy. And then at what point did you decide to go into surgery of all the specialties?
Dr. Gerald Imber: [00:06:52] I actually had the good fortune of having one of the last of the rotating internships. So I spent three months on each of the major services, and I always thought I wanted to be an internist. And the minute I actually was doing something on a surgical service, I just found it was who I was. And I did my surgery. I did a year of surgical residency, and then I was drafted into the Air Force, and I did two years of surgery there. And then I finished my residency in general surgery, and my chief of general surgery kind of recognized that I liked the ballet of surgery and thought that I would be plastic surgery would be what I should do. And he happened to have a friend who was the chief of plastic surgery program at Cornell, and he said, I got a kid for you. That's how I ended up where I am.
Henry Bair: [00:07:55] What was your I mean, I think when most people certainly people in medical training, but even just from what you see on medical dramas, I think that general surgery training has a reputation for being extremely taxing on the human psyche, on work life balance, on all of those things. When I talk to my colleagues in general surgery, getting up at 3 a.m., sometimes not leaving the hospital until 10 p.m. 12 a.m. sometimes it's so hard for me to imagine how you can take the adequate care for your body required to even function. I'm wondering, can you share with us what your experience was when you were in residency?
Dr. Gerald Imber: [00:08:34] Seven years, every other night.
Henry Bair: [00:08:37] And by every other night? What you mean?
Dr. Gerald Imber: [00:08:39] I mean 36 on, 12 off?
Henry Bair: [00:08:41] Oh my gosh.
Dr. Gerald Imber: [00:08:43] That was hard. It was hard with a family and it was hard to fit moonlighting in as well. And you know, it's what you did. We all did it. And we learned to sleep on a gurney. It wasn't 36 hours of work, but you were there physically in the hospital, and it was serious stuff. And you would it wasn't like you were on call from home. You were there. And so wherever you could sleep, you could sleep. And it became kind of a way you prove yourself. And I hate to say it, but it was fun because we all in the same boat. And it was kind of, you're in a foxhole together and you work together and you're part of an army together. And it's a it's an exhilarating feeling. Also, you're very tired.
Henry Bair: [00:09:26] I can imagine. In the month of January, I was in the cardiac critical care unit, and that was one of the places in the hospital, one of the services in the hospital where you did do overnights, when you did do 24 hours or even longer shifts. Even then, we did it every three days, and I didn't have to do it for more than four weeks at a time. But it was still tough.
Dr. Gerald Imber: [00:09:45] It's tough.
Henry Bair: [00:09:46] So I can't imagine you having done 36 hour shifts, you know, every how many times, every few days, every two days, three days.
Dr. Gerald Imber: [00:09:54] Every... Every day.
Henry Bair: [00:09:55] For seven years.
Dr. Gerald Imber: [00:09:56] But it's different because you know that those 36 hours, you weren't always tending to critically ill people like you were in that unit. I'm half the time we did nothing. We were just there. But still, it's it was difficult on your family life, but it was a rite of passage. I don't know if they discussed it with your generation of physicians, but one of the excuses for it was that they want you to see they, being the powers that be, wanted the young physician to see the patient as they enter the hospital and see the progression of the disease and see the lysis of crisis and see how it turns out. And by being there for 36 hours in a row, you see everything. You're not signing out at 5:00 to someone else and then coming in the next day and say, hey, Mr. Jones, make it. You're at his bedside. And so by that measure, I think it was a better way to learn.
Henry Bair: [00:10:51] Do you still believe, you know, after having gone through all of that training and having trained a few of your trainees along the way? Now, do you believe that that is the best way to train future physicians?
Dr. Gerald Imber: [00:11:03] I do. I think that, um, it's total immersion and you just come away with a better understanding of what you're doing?
Henry Bair: [00:11:13] I think that a lot of people now may think about that and wonder what the implications are of having to stay at the hospital constantly for so much time with the total immersion, with always your mind always being on, does that impact performance? Like have you seen that to be the case? Did you experience that?
Speaker4: [00:11:31] You know, the point you're making, you're kind of setting me up because it has to be it's not a wonderful thing and it does exhaust you. And there are reasons that it's fallen by the wayside, I get it. I just think that it was such invaluable experience for those of us who went through it.
Henry Bair: [00:11:52] I see. Okay, so then after seven years of general surgery training, you mentioned briefly how you were able to get connected with this plastic surgery program. And then how long was that training for?
Dr. Gerald Imber: [00:12:03] Two years.
Henry Bair: [00:12:04] Two years. Okay. And what was your understanding of plastic surgery at that time before you started the program?
Dr. Gerald Imber: [00:12:12] I have virtually none. I understood the reconstructive part of it, but I had no experience with the cosmetic surgery part of it, which turned out, of course, to be what I do every day. My first day in the operating room at New York Hospital, now New York Presbyterian, and they were doing something they thought was a big deal. And it meant nothing to me because I had already done all those years of general surgery. And, you know, I'd been up to my elbows and everything. So the technical part of this was of cosmetic surgery was very easy. A plastic surgery and the esthetic part, the judgmental part was what one had to learn. But all of us coming into plastic surgery residency in my day had all been general surgeons before. So, you know, we've done enough gallbladders and, you know, done enough. Everything's, you know, bowel resections and lung surgery that you had a proper understanding for, for where this was on the, on the totem pole.
Henry Bair: [00:13:13] And I mean, nowadays plastic surgery is its own standalone residency program typically. And it takes about seven years. I want to say I might have to fact check myself on that, but it takes a pretty long time and the diversity of procedures is staggering. And I'm wondering, your program was over the course of two years, was there were there specific techniques that you focused on? Were there specific areas of the body that you focused on.
Dr. Gerald Imber: [00:13:40] Not areas of the body? But we had kind of an introduction to it. Then you had to get a clinic where we did cosmetic, picked up cosmetic surgery cases and learned how to do it. And we had, uh, a rotation through, uh, head and neck surgery, uh, at Memorial Sloan Kettering and then a rotation through head and neck reconstructive surgery at Memorial, and then a rotation through hand surgery at HSS. And then, uh, a year at uh, New York Hospital doing, uh, mostly cosmetic and reconstructive surgery. So it was a good introduction, and we were treated differently than junior residents in a five year or six year plastic surgery program because we were all fully trained general surgeons. So, you know, nobody was saying, hey, Sonny, hold this. We had already earned our stripes. So it was a little bit different, but we all end up in the same place.
Henry Bair: [00:14:34] Yeah. One thing that stuck out to me was when you mentioned that what you did have to learn a lot of was the esthetic part to me. When I hear that it's subjective, is it subjective? Correct me if I'm wrong, but how do you learn something like esthetic?
Dr. Gerald Imber: [00:14:46] Totally subjective, and if you don't have it, you shouldn't be doing it.
Henry Bair: [00:14:50] Okay, well. How did you learn it?
Dr. Gerald Imber: [00:14:51] I didn't did you have it? Do you have it or you don't have it? I mean, it's pretty it's pretty simple. If you know that something looks good, then your taste is aligned with the taste of your community and you'll succeed at what you're doing. There's no right and wrong in this. It's, you know, in each society has their own idea of beauty, and it's modified by each tiny little microcosm of the world. So you have to have an esthetic sensibility that's congruent with the people you're serving.
Henry Bair: [00:15:22] What is the kind of interaction and conversation you have with your patients to better understand that esthetic perspective?
Dr. Gerald Imber: [00:15:30] Well, you know, it's, uh, you see the patient you see immediately have a first impression, and they have a first impression of you and a person going to a plastic surgeon for anything other than reconstructive surgery, walks in and looks at the surroundings, looks at the physician, and says, this person understands me. And the doctor at the same time, looks at the patient and says, I can get along with this patient and help this patient, or this patient is, uh, is wrong for me. And red flags are flying every place, and you have to make up your mind whether or not you're suited for one another. Esthetically, that assumes that we all assume that we're superb technically, but having achieved that, it's a matter of your esthetics are appropriate for your community. It's an interesting psychological aspect to surgery, to the medical practice.
Henry Bair: [00:16:25] Yeah, I think it's pretty interesting. I mean, you talked about how you have a first impression of a patient, and over the course of that initial encounter, you're able to tease out whether or not this person is appropriate for you to treat. What are the things that you look for? What do you mean by red flags?
Dr. Gerald Imber: [00:16:39] Well, you know, when somebody thinks that if they have their, uh, their right ear pinned back, they're going to be able to get a seat on the bus. It doesn't work that way, or something's going to save their marriage. By having breast enlargement, doing this, or getting rid of a wrinkle or nonsense like that. You know, you have to be realistic about everything. Those are red flags or patient that says, oh, I know you're the best and you're going to change my life. That's a red flag. I mean, you hear that? You run like hell. It's unrealistic. And it's very hard for a young physician to make those judgments, because a young physician is desperate to have the work to show how good they are. And, you know, senior surgeons like myself have the luxury of saying, this is not going to work. You combine that with the fact that somebody in the room has to have common sense. If it isn't the patient, that has to be the doctor.
Henry Bair: [00:17:35] You know, when you talk about things like, uh, unrealistic expectations or how the patient sort of expects you to solve all their problems, or this medical intervention to resolve some kind of deep seated issue relationship issue they have in their lives. There's a lot of psychiatry psychology going on in the background here. And is that something that you had to learn how to assess, like was that is this just something you picked up along the way?
Dr. Gerald Imber: [00:18:01] It's just common sense. You pick it up along the way, you stub your toe a couple of times, get whacked across the head a couple of times, you figure it out.
Tyler Johnson: [00:18:09] I've always wondered, oftentimes when surgery is done, the whole point of the surgery is something internal, right? And any external evidence of the surgery is meant to be hidden, right? So if you do an abdominal surgery and they're going to be scars left, part of the point or part of what marks a good surgeon is that the scars become invisible, or they're placed in places where you can't see them or they're, you know, hidden underneath clothing or what have you. But in cosmetic surgery and many forms of plastic surgery, you almost reverse the equation, because the whole point is what you can see. And in particular, if you're doing surgery on the most visible part of a person's body on the face, then, you know, I mean, that's for the most part, how we recognize people, so much so that there's a specific neurologic disorder related to people who can't recognize faces. Right? Which is almost unimaginable to most of us. So how do you think about the I don't know, the burden and stress, I guess, of the fact that the very thing that you're operating on is what sort of presents a person to the world.
Dr. Gerald Imber: [00:19:19] That's something we think about all the time. And the way I like to describe it is the pressure of what we do is taking something normal and trying to make it better. And that's a lot more pressure than taking something abnormal and trying to make it normal. So, for example, uh, early in our careers, all plastic surgeons deal with automobile accidents and trauma, and anything you do is a fabulous step forward because you've taken someone who's devastated. You put them back together, some semblance of normal. That's hard work, and it's great. But there's the kind of pressure you've described, isn't there? But take someone who is normal and wants to improve on that. You're really under a lot of pressure to be able to do that, and you have to do it in a manner that's not noticeable and that people appreciate and isn't a caricature and actually makes people look better and doesn't change who they are. And thus, I mean, sometimes they want to be changed, but for the most part, it's really a fine line that we walk, and that's part of the fun.
Tyler Johnson: [00:20:29] So not to put too fine a point on it, but how do you know what counts as better? Like, I mean, I know it's sort of a funny question, but like, I like I remember one time, this is a very stupid example, but when I was in college, I broke my nose playing ultimate Frisbee. So I was bleeding a bunch. And I went to the emergency department and they stopped the bleeding. And then they gave me an appointment with an ENT. And when I went to the ENT, I showed up and I said, so what do you think? Do I need surgery to fix, you know, to put my nose back in place? And he sat me in front of a mirror and said, well, I don't know, what do you think? Do you need surgery? And I looked at it and said, well, I don't know. I guess I think it looks fine. And he said, well, okay then, I guess you don't need surgery. And that was the end of the visit. Which is just to say that I guess I like, how do you know if a person comes to you and says, I want you to fix this particular thing, quote unquote, fix this particular thing about my face, or I just want you to make my face look better. How do you know how to change it? How do you even know what better means? Or how do you know how to change it so that it looks quote unquote, better after than it did before?
Dr. Gerald Imber: [00:21:37] Well, I think that the, um, the onus on making that decision is upon the patient. And I always ask the patient, what can I do for you? What's the offending part? What would you like to see changed? We start from there. And for example, if someone comes in and says, I want to have, uh, my, uh, wrinkles taken out of my face, I want a mini facelift. And I'm looking at that patient. And the patient has a terribly distorted, enormous nose. And that's what catches my attention. I'm not going to say to the patient, boy, you should do something about that nose, because that person is living harmoniously with that particular feature. It's not my place to add to her distress. I think that that's what would make her look better. But she hasn't brought that up, and I'm not going to bring that up. And I'll talk to her about what she's interested in doing. And if she says, is there anything else you think would make me look better? I would mention you might want to alter your nose or straighten or reduce it or that sort of thing, but it's a matter of common sense, common decency and good taste.
Henry Bair: [00:22:46] What are the kinds of procedures that you perform these days?
Dr. Gerald Imber: [00:22:50] Well, I've done more than 3000 facelifts. That gives you some idea of what my practice is like. I've done, uh, hundreds and hundreds and hundreds of breast procedures. Uh, over a thousand. Uh rhinoplasties. I've done thousands of blepharoplasty eyes. Um, have a good practice for a long time. Uh, and my practice is primarily limited to cosmetic surgery. Um, I do a lot of Mohs reconstruction on the face because I like to do that. It's a way to give back. But, you know, I can't serve emergency rooms because it's impossible for me to see somebody at two in the morning and then operate at 730. It just I can't do that. So my practice is basically elective. It's not primarily a cosmetic surgery practice. It is a cosmetic surgery practice. And the way that happens is one paints oneself into a corner. Uh, for example, you know, after general surgery and plastic surgery residency, I wanted to do everything. And and I did the first hundred. My partner and I did the first hundred breast reconstructions after mastectomy in New York State many, many years ago. He went on to do nothing but breast reconstruction. I was suicidal, I mean, it just got so boring doing the same operation over and over and over, and I want to do the whole range of the things that we do. And then one day I wrote a paper about a kind of less invasive sort of, uh, facelift procedure, which I published a paper on the first thousand that I had done, and I kind of painted myself into a corner anyway. And that's what most of my practice is. But, you know, you find something you like to do and you do it the best you can.
Henry Bair: [00:24:28] It's interesting that you mentioned your experiences doing so many of the same procedures early on in your career, because then what I would want to ask now is what keeps you going? Like after decades of doing these procedures, like what brings fulfillment to meaning to your work?
Dr. Gerald Imber: [00:24:43] Every surgical procedure that you finish, you should look back on and say, you know, I could have done this a little bit better if I did X, or I wonder if it's an easier way to do that and that never ends. You should think about that at every single case, and then you can't wait to get back and do the next case. And every case is a challenge. Every single case is a little bit of squeezing of your coronaries. It's never boring. You know, you're in the operating room, you make the decisions. You're you're the boss. Nobody tells you to take the garbage out. It's really a good life.
Henry Bair: [00:25:21] Yeah. Well, thank you very much for taking us through your practice and the way you think about patients who you help. I'd like to take some time now to turn our focus to this most recent book that you wrote. First of all, you know, we've been talking all about plastic surgery, but your book is about open heart surgery. So tell us a little bit about what motivated you to write this book on this subject matter.
Dr. Gerald Imber: [00:25:44] Well, I've written a good deal of medical history in the past. About ten years ago, I wrote a book called genius on the edge, which is the story of William Stewart Halsted, who was the founding chief of surgery at Hopkins and was a cocaine and morphine addict the whole time. And during those 30 years, he invented the use of rubber gloves, the hernia repair, the radical mastectomy, the residency training system. I mean, he was the father of American surgery. And it was a great story. And I ended up writing that because at New York Hospital where I trained, there were still a number of people on staff that were had been trainees of his favorite resident. And so everyone had Halsted stories, and he had been in New York for a while as well. I just was fascinated with this bizarre story. And so I'd love the act of putting together the information and writing that book. And when I got through with that, I had the bug. And there was at one time, the two most famous cardiac surgeons in the country were in in Houston, Michael DeBakey and Denton Cooley. And they had worked together for a while, and they ended up having a 40 year feud, which was the most dramatic feud in in the annals of medicine. And at the end, it was such a well known feud that both men were on the cover of life magazine. The feud had the picture of these two doctors on the on the cover of life magazine, and when the feud ended at their lay very late in their lives, it actually made the front page of the style section one section of the New York Times.
Dr. Gerald Imber: [00:27:34] It was a big deal. I became interested in that, and I had written a short piece about it and sent it to my agent and said, this might be a good book, and my agent, being more savvy than I said, no, there's not enough here for a book that's to be more about it. And as I was reading, I came upon the fact that at 1950, there was no open heart surgery. Period. None. Zero. In 1950, 1948, I think that the population of the United States was 137 million people. Half a million people a year were dying from heart disease, and nothing was being done about it. It became a kind of opened my eyes, and I began to look into the subject of open heart surgery. And I came across the fact that in 1881, while leading surgeons in in Europe had said that anyone who operates on the heart should lose the respect of his colleagues. And that was the absolutely the law, the rule. You mess with the heart, you kill the patient. It was as simple as that. And the first time anyone actually recorded going into the heart electively was during the Second World War when Dwight Harken, who was a Boston surgeon, was stationed in London, and he came across a soldier who had a piece of shrapnel floating in his heart. And it was a question of the shrapnel killing him or trying to get the shrapnel out, killing him. And he decided that the guy was going to die if he didn't do something. And he just blindly he opened his chest and made an incision in his heart and blindly routed around with a clamp, actually with a Halsted clamp, and grabbed the piece of shrapnel, pulled it out. The soldier lived, and he did it 120 some odd times after that without a fatality.
Dr. Gerald Imber: [00:29:31] So it became clear, yes, you can enter the heart and you can do it without killing the patient. That began the search for a way to do open heart surgery. As you both know, the issue is when you're operating on the heart, you stop the blood flow to the organs of the body, particularly the brain. And after four minutes of anoxia, very bad things happen to the brain. So the Cardiac Cowboys, the book that I've just written, is the story of the five surgeons who made open heart surgery happen. There are a lot of peripheral characters, a lot of wonderful people without whom this wouldn't have taken place. But these five men, and unfortunately, they were all men. I hate to say there were no women involved, but. This is a 1950s and this is America in the 1950s. So it was all men. And these men invented a specialty, and they invented everything from open heart surgery to pacemakers and heart valves. And they save millions of lives a year. And it's just astounding to me that we had an atomic bomb. Before we had open heart surgery.
Tyler Johnson: [00:30:47] So it's interesting because the term cowboy, right, evokes this image of the American West during the 1800s and people sort of pushing out into places that at least those groups of people had not, you know, had not known before and were not familiar with before. And yet, at the same time, it's also true that any time anyone is pushing into new medical territory, they're doing this by operating on actual, real people, right, in this case, on their actual real hearts. And, you know, as a medical oncologist, I'm always struck by this because it's I mean, it is pretty much literally true, especially if you talk about sort of old fashioned chemotherapy drugs. In effect, they are carefully measured poisons. I mean, that's really what you're doing is hoping to poison the cancer cells more than you poison the the real cells. And it is the case that when we do clinical trials, even with with newer drugs that are much more sophisticated in a sense, there are people who die as part of the clinical trials. Right. And yet those clinical trials are the best thing that we have settled on over, depending on how you want to define it, centuries or millennia of medical science to figure out the best way to save lives going into the future. And so there's one way of telling the story of the progress of medical science that is almost heroic, right? That it's people pushing the frontiers, pushing the boundaries of of medical science. But it is also true that any time we're pushing those boundaries.
Dr. Gerald Imber: [00:32:33] We lose people.
Tyler Johnson: [00:32:34] Yeah. And so how as you have studied this, this history, how do you think about that balance?
Dr. Gerald Imber: [00:32:40] Okay, the equation's a little simpler here. First of all, the Terme cowboys I use in this book, in the title of this book, Cardiac Cowboys, because that's what they were. I mean, they were pushing the frontiers. They were just out there. And half the time early on, they were called murderers because they'd lost a lot of patients. But the book makes clear the fact that open heart surgery started essentially in the treatment of cardiac abnormalities, congenital abnormalities in children. And the reason for that is a still didn't know anything about coronary artery disease. So we weren't going to do that. And B, you knew exactly what the anatomical defect was related to most of these murmurs. You knew what the child died from because at autopsy you could tell it was an ASD or a VAC, you know, hole in the atrial septum or the ventricular septum or a tetralogy of Fallot, or what the actual anatomical defect was. The surgeons had the the leg up of being able to, to know that they could fix what this problem is. They also knew that if they didn't fix it, the children would die. So even though you had a mortality rate approaching 50% early on, it was better than a mortality rate of 100%. You saved 50% of these children's lives. They went on to have normal lives. So even though you mourn the 50% that you lost, they would have all been dead.
Dr. Gerald Imber: [00:34:17] So that was the impetus that gave these people the courage to go forward in the beginning. And it was I mean, it was a big leap. I'll just briefly give you a little bit of the history of the of open heart surgery that initially the idea was always to have a bypass machine so that you could provide oxygen to the necessary organs, particularly the brain, and have a clear field and be able to operate on the heart. That didn't turn out to be so easy, and it was the first person who did it was in, uh, in Philadelphia. He had worked on it on a heart lung machine for 30 years and had one success and then three failures and, and just gave up on it. And the center of heart surgery kind of moved to the University of Minnesota. Um, and under Owen Wangensteen Wangensteen had, um, one of his people develop a bypass machine. That bypass machine worked perfectly, but the first two children died and one died for medical error because the anesthesiologist let air bubbles get into the IV and the other person other child died because when they opened up the heart, the diagnosis was incorrect and irreparable. So the next step was a hypothermia. And hypothermia is well known. If you if you cool the body, the oxygen requirements are lessened. The idea was why not do that? And you? Cool the body. The brain will need less oxygen. So instead of 4 or 5 minutes without oxygen, it could live for 8 or 10. And that was initially tried in the lab in Toronto by a man named Wilfred Bigelow. But he couldn't find a patient willing to let him try it. And in Minnesota, John Lewis, uh, used, uh, hypothermia and successfully repaired 60 atrial septal defects. And the world of open heart surgery began.
Dr. Gerald Imber: [00:36:19] The problem with hypothermia was you only got 7 or 8 minutes of operating time and a ventricular septal defect or bigger problems like the tetralogy required more time. So other modalities had to be invented. And actually, each of those next steps also took place in Minnesota. The real birthplace of open heart surgery in the world was in Minnesota, and particularly in Minneapolis, which is shocking. Some of it in good deal of work happened at the Mayo Clinic in Minnesota, 90, 90 miles away. And for the first number of years, that was the epicenter of open heart surgery. And the fellows from, uh, Houston came up to visit and they said, hey, guys, this looks like a good idea. We could do it. And before you knew it, the epicenter had shifted south and became Houston. But the great medical centers of the eastern establishment did nothing early on. I mean, they everybody tried, but the I was going to say the heart of the matter really was in Minneapolis and then Houston.
Tyler Johnson: [00:37:32] I have to say that in all of my medical training, I'm not a surgeon, of course, and so I had relatively minimal exposure to surgery. But I will never forget the first time I saw open heart surgery, because, as you're alluding to, the whole idea of it is just breathtakingly audacious, right? It's just it's it's almost superhuman, right? I mean, is here I am as a little third year medical student, scrubbed in and terrified that I'm going to, you know, break the sterile field and touch something that I'm not supposed to with my hands clasped together and gathered near my chest just to make sure they don't touch the wrong thing. And then they literally split this person's sternum and insert what looked like giant iron claws to hold the mediastinum open. And then, as happens now, they inserted this carefully concocted chemical solution that just they put the person on bypass, and then they just stop the heart. And so you, you know, you're sitting there, you don't even realize that you're watching the, the rhythm of it beating, but it's beating and contracting and contracting and contracting and then. It just stops. And I mean, the whole thing is just it's eerie beyond description because now the person's heart's literally not beating, and yet they're still sort of somehow kind of alive with the bypass machine.
Tyler Johnson: [00:38:53] And then even weirder. So then they go in and, you know, with this unimaginable precision, I mean, we, you know, we forget medical students get so used to talking about coronary artery bypass grafts that we forget the fact that the coronary arteries are millimeters wide, right? That they're they're taking out the diseased one and harvesting a graft from the leg. And, you know, they're using their little microscopic loop glasses to. So in a way that is, you know, on the order of smaller than millimeters. And then they get done with this and insert the whatever sort of opposite, functionally opposite chemical solution. And you watch this thing that now you've gotten used to it just sitting there inert for an hour or whatever. And then you see this sort of nonspecific kind of twitching in different parts of the muscle, and then it starts to sort of quiver, and then all of a sudden whoosh, it starts to beat again, and then they take the person off bypass and their heart works like the whole thing is just as otherworldly. Yeah. You just can't even believe. And then some people, just as you get to the I mean, some people just do this for a living. They now they do it every day. It's so routine that we don't even it hardly even catches our attention anymore.
Dr. Gerald Imber: [00:40:02] Well, these guys, some of the guys in the book were doing 20 procedures, 20 bypasses a day. But in the early parts of the book, cardiac cowboys would talk about the first few cases where they stopped the heart and they repair the defect, and they wait for the heart to start again, and they massage it and they massage it. And ten minutes go by, 20 minutes go by, 25 minutes go by and nothing happens. And finally they would they would, uh, it would start again. And when they started doing ventricular septal defects, which is a more serious and larger whole ventricular septal defects are associated with a higher incidence of heart block because, uh, cardiac pathways, the electrical bundles are located in the ventricular septum. And they, by putting certain sutures in, you actually cause the heartbeat to stop or not start again. And so a number of kids, um, after this wonderful surgery to repair the vsds, had total heart block. So at a meeting when they were discussing this at Eminem, some physiologists stood up and said, you know, we have a low voltage wire that we put in and we stimulate frog hearts that way, and it works fine. And so Walt, Walt Lillehei, who was the surgeon at the time in Minnesota who was a leading heart surgeon in the world, immediately went to the dogleg practice with it. And for his patients, everybody that he did a VSD repair and and then everybody that he did any heart surgery on, he would automatically put these wires led to an outside stimulator which looked like, um, just a couple of dials, like a metronome. That was in popular science. Every patient had that.
Dr. Gerald Imber: [00:41:49] It started their hearts, made sure they had a heartbeat. And then when the heart was beating, well, they just pulled the wires out. Well, um, one of the stories is that these people were then tethered to the electrical outlet, and so they couldn't go anyplace until their heart started. And on one Halloween night, he had operated on a child and the child had heart blocked. And luckily he was plugged into the machine, plugged into the wall, and all the electricity in the hospital went out. There was a thunderstorm in Minneapolis. They had no backup generator and therefore that pacemaker stopped pacing the heart. And unfortunately the child died and Lillehei immediately had the idea of having a battery operated pacemaker and in just one evolved to the next to the next until an implantable battery operated pacemaker. And then they said, why not have a lithium battery in the pacemaker so you don't have to change it every six months? And all these things happened in such rapid succession that it was like it was a miracle. He, this man, Walt Liliha, whose name I'm sure you don't know, um, he invented more things in heart surgery in a 3 or 4 year period than the whole rest of the cardiac world has since. And it's an amazing, amazing human being.
Dr. Gerald Imber: [00:43:12] I had the good fortune to know him very slightly, because the end of his career, he was at New York Hospital when I was a house officer, and he scared the hell out of me, but I knew who he was. I mean, I was just like, dumbstruck, amazing the things this man had done. But he was such a cowboy that he he lasted at Cornell as a professor and chairman of the Department of Surgery. He lasted for, I believe, a year and was promptly. Fired because he wanted to do all sorts of experimental work, and he did multiple organ transplant, and he did a bunch of things good and bad. He was a cowboy in a lot of ways. He was. There wasn't a jealous bone in his body, but he also didn't have a political bone in his body. So if you did something that he thought was unwise, he would stand up in the audience and say, that's not very smart. And so he had enemies everywhere. And he was a wonderful, nice, decent man. But part of his makeup was this drive to save lives and do it quickly. And what are the reasons for that is he was diagnosed with a lymphosarcoma of the parotid gland while he was a resident. He was given about a 20% chance of five year survival. So he really thought that he has to work fast. And it wasn't until many, many years later that it seemed that he was going to survive. And some, some, uh, later looks at the slides showed that perhaps he didn't have a lymphosarcoma of the parotid gland at all, but he had totally deforming surgery performed by Weinstein's team in Minneapolis at age 32, where they did a radical mastectomy, and they split his chest and they did the nodes in his chest. And so his head was always tilted to the side from the loss of the standard sternocleidomastoid muscle and the radiation. But nothing stopped him. He pushed on, and he was just a remarkable individual.
Henry Bair: [00:45:24] Thank you so much for sharing these stories that honestly, I don't know when I would come across them otherwise. So you've now you've written this book filled with stories like this.
Dr. Gerald Imber: [00:45:33] But a lot of stories like this, about five people, each of whom has there's a litany of stories attached to each of the five names.
Henry Bair: [00:45:42] Yeah, yeah. And I absolutely will. We'll have the information to your book in the show notes to this episode, so listeners can go be amazed for themselves at the stories. So to close us off then, I would love to ask. Yes, these stories are interesting and intriguing and terrifying and amusing to listen to, to hear and to read. But at the end of it, what is it that you hope that readers, maybe trainees or clinicians will take away from these stories?
Dr. Gerald Imber: [00:46:11] Well, I think what one should take away from these stories is. The bravery. It's not so much genius, but the dedication and bravery that some of our colleagues have had in understanding the need to change the world, to push things to the limit, to be that cowboy in the new frontier. Not to say this is impossible to say. It is possible to say, we will do this. We can do this. And I am willing to take the chance because I believe in this, because that's what these people did. And without people cowboys like these, there'd be no heart surgery.
Henry Bair: [00:47:00] Well, with that, we want to thank you, Doctor Imber, for taking the time to join us and to share your personal journey in general and plastic surgery, as well as these inspiring stories on the open heart surgery.
Dr. Gerald Imber: [00:47:12] Thank you for your company and your time.
Henry Bair: [00:47:17] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:47:36] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:47:50] I'm Henry Bair.
Tyler Johnson: [00:47:51] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
Dr. Gerald Imber is the author of Cardiac Cowboys: The Heroic Invention of Heart Surgery (2024) and Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (2010).
Dr. Imber can be found on Instagram at @geraldimbermd.
