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Small Miracles

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Draping the patient provides the surgeon with a psychological cushion, too. Better to operate on a heart than on a 3-year-old with big eyes and a fretful mom. It’s the paradox at the center of pediatric surgery: Help people but don’t get too close. To function at his best, Quaegebeur enforces a kind of emotional no-fly zone. “Trust me, I’m going to fix your baby’s heart” is all he told Kimberly during a brief stopover before surgery.

“To make good decisions day after day, you have to, for your own stability, keep a certain distance,” he says. After all, not every sound medical decision is a pleasant one. Recently, a young patient was rejecting her transplanted heart; her new heart had stopped three times in one day. A sibling, who’d also received a heart transplant, had already died at the end of a similar process. Still, the desperate family implored the surgeon to put the child on a life-support device. A dispassionate surgeon had to step in. “We can’t save everybody,” the surgeon said. “It’s time to cut our losses.”

Pediatric heart surgeons like to say that their work is graceful and precise—not like clunky orthopedic surgeons who smash around in the knee—but the beginning of surgery is hardly delicate. To operate, Quaegebeur stands on a stool to Dorothy’s side. He uses an air-powered oscillating saw to cut bone, careful not to cut into the heart, and an electric cautery to stop bleeding. The room smells of singed meat, like a barbecue.

Some surgeons curse merrily through surgery as if in a locker room, some play music, some throw fits. Quaegebeur can get annoyed—on occasion, he’s been known to growl, “I am surrounded by assassins”—a phrase he uses for effect—but usually he doesn’t speak much. Rozelle Corda, a nurse-practitioner who often works with him, says, “I can go through an entire case with Dr. Q without exchanging a word.” Assistants learn to interpret his few words. “If he says ‘Okay,’ that means he’s very happy,” says one. Sometimes Quaegebeur turns the silence on aggressively. “If he doesn’t really respect you, he’ll make believe you’re not there,” says Mosca.

Quaegebeur’s quiet suits his personality, but it’s also a conscious technique. “I watched surgeons where there was a tremendous amount of activity, a lot of talking and music and two or three different instruments passing hand to hand,” he says. “If you watch carefully, absolutely nothing happens. I decided very early I was going to develop a simple style of operating, with minimum movements, but always doing something.” In this, he is meticulous—“no wasted moves,” admirers of his OR technique repeat—which is his idea of beauty. “You can make an operation look beautiful,” says Quaegebeur. To do this, he can be demanding about the smallest detail. Once, when the supply of operating-room scrubs ran out, he made a point about slipping standards in a dramatic way: He showed up in the OR in his boxers.

Within a half-hour, a couple inches inside the hollow of her chest, Dorothy’s heart appears. It’s the color of uncooked chicken. Dorothy’s heart is enlarged and globular. It will never look like a normal heart, but hopefully it will work like one. Quaegebeur plans to convert it from a two-pump heart, the normal setup, to one pump. Some force may be lost, but if the reconstruction is successful, Dorothy will get more oxygenated blood. Conceptually, as one surgeon says, “it’s a crazy idea,” but usually, it works.

“You can be as confident as you want,” Kimberly explained. “t’s still heartbreaking to leave your daughter’s life in another person’s hands.”

Surgeons sometimes operate on a beating heart, stitching as it moves—“working on a beating heart is like landing a plane on a moving aircraft carrier,” says Chen. During part of most surgeries, though, the heart is stopped, and the bypass machine takes over cardiac function. Dorothy goes on bypass a little before 2 p.m. Her temporary heart sits a few feet from her body, in one of the sterilized clear-plastic pumps connected to her real heart by polyvinylchloride tubes. In a few minutes, the pump team applies cardioplegic solution (“the plege,” they call it), arresting her heart, which sags into her chest. At 2:08 p.m., an anesthesiologist points to the screen monitoring Dorothy’s heartbeat. The rhythmic line goes flat.

Before recirculating Dorothy’s blood back into her body, the pump team cools it, plunging Dorothy’s body temperature to near 64 degrees fahrenheit. At that temperature, metabolic demands are greatly reduced, which helps protect against the insult of surgery. Quaegebeur pours a pitcher of refrigerated water into the hole in her chest, cooling her heart further.

During some operations, a patient’s entire blood supply is dumped into the bypass machine. “We do what people call suspended animation. All their metabolic processes essentially stop,” explains Mosca. Basically, you kill a kid for 30 or 45 minutes. Under such rigorous time constraints—dawdle and a kid might never remember her phone number—surgery can seem like a kind of athletic contest with knives.

To be a great pediatric heart surgeon, you must be a technical virtuoso. That alone eliminates all but a small percentage. One surgeon described the first time he saw Quaegebeur operate: “It was like seeing my favorite symphony performed perfectly.”

“Cardiac ORs are full of crisis,” says Chen. “Things happen that are very dire.” Improvisation is often called for, and often, in the nick of time. Every heart surgeon needs to know that he can, as one puts it, “remain calm and fix the problem when all hell is breaking loose.” And, of course, you must do that, as Mosca says, knowing “that one stitch is the kid’s entire life.”

Quaegebeur believes he’s calmer in the OR than out of it. “I have to be,” he says.

No matter how gifted you are or how calm or how hard you train, some of the time you must tell a family they’ll be going home without their child. How a surgeon deals with failure may, as much as anything, determine his effectiveness.

One evening at Jean Georges, Quaegebeur recalled a period when failure shook him. He was wearing a knit tie and khaki-colored pants—he looked like a prep-school English teacher. He chatted amiably with the sommelier and the maître d’, but the topic of failure set him on edge.

Half a dozen years ago, Quaegebeur said, he lost control of a specific operation for kids born with half a heart, a condition not dissimilar to Dorothy’s. “I’d had a very good run for a while. I’d had excellent results,” he said. “Then suddenly, bang, bang, bang, we had several kids die in a row.” Other types of cases would go fine. But in this one complex procedure, “I could technically have a very good operation and still run into trouble. I wasn’t sure that even with a good operation the outcome was going to be good.”

NE?d?ke of those deaths, his confidence seemed to erode. “That’s the worst thing that can happen,” he says. “If in your heart you’re uncertain, you make more mistakes.” The humbling outcomes seemed to arrive out of nowhere, like a curse. He’d done just what he’d done before. “That was one of the most upsetting parts.”

Quaegebeur isn’t the type to cry with disappointed families. He prefers to be upset on his own. He would go home, sit in front of the TV, and zone out—there was always surgery the next day, so you could hardly let loose. He’d reoperate the cases in his mind. Could I have done something else? Something different?

He hunkered down with his team and picked through details, desperate for a clue. But Quaegebeur couldn’t find any clear-cut error. In the end, it seemed that a few little details and very fragile kids had collided. “You can start with a small error,” he said. “Then you might, yes or no, do the right thing. If you don’t, you get into a little more trouble.” Quaegebeur changed one aspect of the procedure, adjusting blood flow. And anesthesia, bypass, ICU bored down on every aspect of care. Little by little, they seemed to get the procedure under control.

When kids stopped dying, Quaegebeur’s confidence bounced back. His mood lifted, which it did again at dinner, as if he had passed, again, out of that difficult phase. Suddenly, he liked the wine from Alsace. And his duck was very good, and he’d never seen turnips so delicate and small. “Now I’m pretty confident that the outcomes are going to be very good,” he said. Though he can’t keep from adding, “Unless some mistake is made.”

Three hours into dorothy’s surgery, Quaegebeur’s blue gown is sprayed with her blood—at one point, it jumped out of her chest. He wears loupes, glasses from which black magnifying scopes protrude. His eyes shift around the scopes. He looks at Dorothy’s deflated heart. Then he glances at a piece of bovine pericardium, the lining of a cow’s heart, which is spread over her abdomen. He sizes it up, glances back at her heart, then snips a patch that will enlarge the pulmonary artery, in effect creating a new passageway for blood.


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