A Beating Heart
By Vlad Kraven
It was a warm spring night, just past 2 am. The moon was hidden behind a veil of gloomy clouds. At the time I was a resident surgeon at an inner-city hospital in New York. I stepped out for a breath of fresh air, lamenting that I wasn’t a smoker. On a night like that, even a doctor needs a cigarette.
Most evenings would be limited to our set of ‘regulars’ in the emergency room: overdosed junkies, schizophrenic AIDS patients and the occasional stabbing victim. Generally, few of them required my immediate attention, but tonight would be different. Being the first truly warm night of the year, it seemed as if every deviant, degenerate and drunk had been dragged in for emergency care.
It had already been a stressful night when my five minute non-smoke break was cut short by an ambulance pulling up to the ER, with the paramedics calling for me. They were bringing in a young boy, no older than 12, who was shot by his stepfather in a murder-suicide. I would later learn that the mother and stepfather were dead on the scene, but the boy was just barely alive.
When I saw that child pulled out of the ambulance on the stretcher, the grim prognosis was instantly evident. He had been shot in the chest, the bullet grazing his heart. He had no chance of survival, unless a healthy heart miraculously appeared for transplant. That night I learned that the devil’s work can seem deceptively Divine.
I was standing over him, watching every waning heartbeat hopelessly bubble and spit blood through the wound. When I was a small boy, I saw a puppy get run over by a speeding cab. Half of its body was crushed; grafted into the concrete road, while the other half was still trying to run across the street. Seeing the sputtering heart reminded me of the helpless moment.
It was impossible to save him, all we could do was alleviate the pain as he slowly died.
Suddenly a nurse called for my immediate attention. Another child, was rushed in; a beautiful girl in her late teens. Her hair was jet black, as dark as the sky on that overcast night, with a streak of crimson dye. But the red in her hair wasn’t coloring, it was blood coming from her ears. Bleeding ears are a telltale sign of a serious head injury, likely a fractured skull. I would soon see that it was much worse.
Her boyfriend had just bought himself a motorcycle and, without learning how to ride, decided to show off in front of his friends. Unfortunately his recklessness would quickly turn to criminal negligence when he offered them rides. She was first, clinging tightly to his back as he accelerated in first gear. Having barely an hour of riding experience, he didn’t even know how to correctly shift gears. His bike was powerful; a few hundred CC’s too powerful for a novice. The bike roared, the adrenaline pumped and as he hit the clutch to shift into second, it began to shake from side to side. The wobbling quickly became catastrophic and the motorcycle practically disintegrated under them. They were catapulted: lovebirds airborne in a short but sad flight.
He was up seconds later with just a few scratches and bruises. The poor girl didn’t get up. She crashed into the pavement headfirst, denting her helmet and severely fracturing her skull. When the group saw her limp body in the middle of the street, they felt a collective hollow in the pits of their stomachs.
Helpless and motionless she now laid before me, the deep sorrow now in my gut. Two hours ago she putting on mascara and lip gloss, sending silly texts to her friends and full of life. Now she teetered at the edge of death.
I was tasked with the grim responsibility of deciding whether she was dead or alive. Most people don’t realize, but in medicine, there is no single moment of death, since organs can shut down at different rates. The physician must play God, pronouncing death based on best practices and experience. There is a literal checklist of tests to judge if a person is alive or not. In this case, I was looking for brain-death, a common medical standard for mortality, where the brain is irreparably damaged yet the other organs still function.
I subjected her body to a series of basic stimuli, waiting with dissolving hope for her to show some signs of brain function. There were none. She was dead at 19.
Medically speaking, she was a Beating Heart Cadaver; fancy talk for a corpse with organs to harvest. The nurse quickly informed me that she was indeed an organ donor, a fact known by simple signature on her driver’s license. With that, the horrible pieces came together. I had a dying boy with a broken heart, and a dead girl with a healthy one. At this point I was certain that the heart was compatible — that all the tests would make the transplant possible — that in its own twisted way, some justice would be served that night.
An excitement was building in me. This hopeless, bleeding, beautiful young child would have a second chance at life, a chance nearly stolen by the contemptible evil of a man that was supposed to love and protect him. If you think that evil is just a relative concept, then you have never seen a child murdered by the hateful hands of a parent.
Dear reader, please understand that what happened next was done swiftly, with little time for thought.
I ordered that the boy’s treatment change from alleviating the pain before death to keeping him alive under any circumstances. Simultaneously, blood work was to be done in the hospital lab so that we could proceed with the surgeries. Finally, I began assembling the teams of physicians, technicians and nurses for the long and complex journey awaiting us all. The heart would have to be excised immediately, even as we waited for the transplant surgeons to fly in. Cardiac failure tends to follow closely behind brain death, and under no circumstances would I be calling the time on two children that night.
The first round of blood tests came back as the girl’s body was being prepared: the heart would be a match for the boy. But I could have told you that without lab work.
Five of us stood in the operating room as the transporter wheeled in the Beating Heart Cadaver. On paper, the procedure is relatively straightforward: the rib cage is split at the sternum and the heart is carefully cut out to preserve for the next owner. I would be handling the core of the operation, with the assistance of another resident, an anesthesiologist and two nurses. (Anesthesiologists preside over organ extractions to make sure that they maintain proper function without failure, not to anesthetize the body.)
Right away the operation went wrong.
I started by making a midline incision from the sternal notch to the symphysis. Her skin was pale after the long winter. When the scalpel pierced the flesh for the first cut, there was an immediate Pilomotor Reflex. Goosebumps. I looked up at the anesthesiologist and saw concern in his eyes. Deep, contemplative worry. Just a coarse reflex I said, reminding myself of an article from a medical journal that decreed the meaninglessness of such reactions.
Next I was handed the Sternal Splitting Saw, a tool that looks like it came from a hardware store instead of a hospital, and proceeded to carefully separate the chest bones. Whether you’re cutting through wood, metal or bone, it’s the same basic process, just saw up and down in a straight line. When I put the blade to the bone to make the first cut, my eyes played a strange trick on me: as the fine teeth of the saw began to grind away at the bone, I thought that I noticed a twitch in her right leg. A sudden, slight kick of the leg, movement that I barely caught in my periphery and nobody else seemed to notice. I discounted it as a trick of the mind in those stressful moments. Methodically, I sawed the sternum in half.
I then took a Sternal Retractor, a tool that looks and functions like a Medieval torture device. The F-shaped tool is inserted into the newly-cut chest cavity, with two cupped stainless steel ends grabbing the separate bones, pushing apart the two sides of the chest to an accompanying symphony of loud cracks. As I forced the metal tool in place and began to turn the powerful lever, her right leg jerked with each loud snap of the bones.
This time a nervous nurse pointed it out; I knew that I wasn’t hallucinating. JUST A REFLEX , I told the crew testily. Just a reflex.
With one final turn of the lever and snap of her ribs, the heart was exposed. Her legs stopped shaking. My hands were just starting. A dying boy with a failing heart comes in , and a dead girl with a healthy one shows up minutes later. She was legally dead! Her brainstem, the medical core of her humanity, was gone, I tested for it myself. Short of being on medical-grade Barbituates or Benzodiazepines, she was certainly and unquestionably dead.
A pink, healthy, beating heart inside of a dead person. A grotesque and queer concept, foreign to any other civilization or time. To any other people that have ever inhabited the earth, the heart is a precious vial that contains the soul; a carrier of the very essence of the person. But to our modern, Western sensibilities, it’s just an organ in an animal, one that can be removed, dissected and replaced.
Back at the operating table, I stood with an undeniable sense of fear and nervousness, two emotions that a surgeon should never be possessed by. I cross-clamped the aorta, and took a deep breath to steady my nerves before the most delicate moment. And then horror. It shouldn’t have happened, it wasn’t supposed to happen, it was impossible. Ethically, legally, medically, she was dead.
As the scalpel inched towards the heart, the corpse made a deep, ugly, guttural groan. We were all startled. In the shock of the moment, I carelessly yanked my hands back. The groan got louder, then, like an old car on its last breath, the sound sputtered and stopped. When I looked down at her chest, I felt a deep, hollow pain in my stomach. There was a thin slice straight through the center of the heart. In that lost moment of fear, I absentmindedly damaged the organ. It was dead.
Then a click in the door behind me, a voice screaming frantically, “Stop the operation, she’s alive!”
When I proceeded with the surgery, I only had one set of lab tests on hand; the results showing the organ compatibility. With the clouded vision of a clear purpose, I didn’t even think to wait for the chemical tests to come back. If I did, I would have seen the inordinate Benzodiazepine level in her system.
She was high on Xanax.
We would later learn that he hot-shot boyfriend was a low-level drug dealer, pushing pot and pills for quick cash. The young lady took a liking to both him and his Xanax. When he showed up with his motorcycle, she was terrified by the idea of riding along, so she took the pills to calm her nerves. Without thinking, she overdosed heavily. The head trauma knocked her out, but the Alprozolam (Xanax) almost completely shut down her nervous system. It was a freak coincidence on a night of freak coincidences, all of the factors together making it seem with unparalleled certainty that she had suffered brain stem failure with no hope of recovery.
My zealousness took over from there. Everything was done to medical standards, except waiting for the chemical test results — which we did not have time to do! As the surgery began, the drugs must have started to wear down. Most sadly of all, while her nervous function was still impaired, she was likely conscious through the whole procedure; she was awake, but couldn’t move. And she would have survived with the right treatment.
The boy died two hours later.