Product Description

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.

Product Details

• Amazon Sales Rank: #407164 in Books
• Published on: 2004-03-30
• Released on: 2004-03-30
• Original language: English
• Number of items: 1
• Binding: Paperback
• 352 pages

From Publishers Weekly
What kind of person operates on babies' hearts for a living? This is the question Ruhlman set out to answer when he entered the pediatric heart center at the Cleveland Clinic, in Ohio, to observe Dr. Roger Mee, one of the best pediatric heart surgeons in the world, and his team at work. Ruhlman, who has written two other books about people striving for excellence (The Soul of a Chef and Wooden Boats), describes with awe the precision, speed and ingenuity required to repair or transplant an infant's tiny heart. His gripping OR scenes capture the life-and-death nature of each surgery and illustrate why only perfection is good enough in this new and rapidly developing specialty. As the clinic's physician's assistant tells Ruhlman with a bluntness characteristic of the people he depicts, This is a kid, not a Yugo here. The anguish the families endure only adds to the pressure on the surgeons. And while congenital heart defects are the most common kind of birth defect, the book reveals that most parents are unaware of the vast difference between having surgery performed by a virtuoso like Dr. Mee and an average surgeon whom a local cardiologist might feel compelled to refer patients to because of HMO protocols. Ruhlman also provides some historical context, weaving in the stories of the maverick surgeons who pioneered the specialty. Although the medical terminology can slow the reader down at times, most will tear through this engaging and often wrenching account.
Copyright 2003 Reed Business Information, Inc.

About the Author
Michael Ruhlman has written extensively for the New York Times and numerous magazines, and was the winner of the 1999 James Beard Award for Magazine Writing.

Excerpt. © Reprinted by permission. All rights reserved.

1. "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 71Ž2 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...

Customer Reviews

amazing and eye-opening
My daughter was born with a heart defect in 2007. She had had one open-heart surgery by the time I was introduced by word-of-mouth to this book. I can't say how important it was to me as a parent to read this book. It gives an insider's view of the world of congenital heart surgery and if you are a parent who wants to know what doctors really think and do, you have to read this - if you are a parent who wants to put all of your faith in the perfection of doctors, then don't read it. My family is very grateful that things have turned out well for my daughter, who is now 15 months, and can't thank her healthcare team enough... but if she needs another surgery, we are going to go to one of the surgeons mentioned in the book. We'll fly her to another state - whatever it takes to get the very best care for her. I hope if you are looking at this book because someone you love has a heart defect, that things turn out well for you, too. What a living nightmare. Read the book.

No divine powers, just attention to detail
Roger Mee, the surgeon profiled in this very well-researched and well-written book, would be the first to tell you that he possesses no divine powers. As he stresses, and author Ruhlman emphasizes, the craft of surgery is in attention to detail. An interesting contrast is drawn between Mee, who strikes the reader as very down-to-earth, and a brilliant but difficult intern, who (after this book was published) took his own life.

The book also contains excellent portraits of Mee's surgical nurse, the difficulties facing anesthesiologists when working with 5-pound neonates, and is very sensitive to the awful, gut-wrenching torment suffered by the new parents, who would rather be anywhere than inside a pediatric ICU.

Ruhlman is at his best when writing about how difficult it is to do things right, as in his other great book "Wooden Boats."

What it means to be the best
Imagine opening a newborn baby's chest and holding his plum-sized heart in your hands, confident that you can repair it and give the child a healthy life.

Meet Dr. Roger Mee, one of the world's top pediatric heart surgeons. Dr. Mee and his team at the Cleveland Clinic in Ohio do just that, two or three times a day, five or six days a week. Author Michael Ruhlman spent a year as an embedded observer in this center of excellence, exploring an elite surgical specialty and the professionals who devote themselves to perfecting it.

"Walk on Water: Inside an Elite Pediatric Surgical Unit" is the wonderful product of that year, and you won't find a more fascinating or inspiring story. Ruhlman gives us a satisfying mix of history, anatomy, biography, and personal interest.

The unit specializes in the repair of congenital heart defects. Each chapter starts with a case or an individual, suffering from or exemplifying some condition. Then the author catalogues the development of treatment options for that condition. Finally, he returns to the clinical setting to finish the story.

Ruhlman discusses medical politics and the story behind outcome statistics. What is the impact on a unit's statistics when that unit is a referral center for the sickest babies? How can a patient -- or a parent -- know the importance of the BEST care versus GOOD care? Thorny questions are raised.

But this is first and foremost the story of New Zealand-born Dr. Mee and his team, and the huge demands they make on themselves every day for the sake of these babies who got an unlucky draw -- at least, unlucky until they come under Dr. Mee's care.

"Walk on Water" is action-packed and sensitively written. If you are interested in medical non-fiction, you WILL be stunned by this book. It's a completely absorbing read and I highly recommend it.

Linda Bulger, 2008