The turning point

His heart failing, a writer finds cutting-edge medicine in
a place where basic care once was hard to come by.
By Edward Martin

It’s dark. I try to move, but I’m wrapped like a mummy in warming blankets. A second ago, it seems, it was daylight and a nurse was asking me my name. Tubes protrude from my right side. They feel like garden hoses. Smaller ones sprout from my arms. One is in the big vein in my neck, the one that bulges when I laugh, except I don’t laugh as much as I used to, before my heart began failing. I free my left hand and wave feebly. “You want to know what time it is?” a nurse softly asks. I blink. “Eleven o’clock.” It’s night? Seven or eight hours must have passed.

For many of them, I learn later, a surgeon with thin gray hair and sharp blue-gray eyes bent over me. They had deflated my lungs, and through a four-inch incision under my right breast he tunneled through my chest. Bypass surgery six years ago had left dense scar tissue. Beyond it lay my motionless heart. “We can fix it,” he had told me a few weeks before, “if we can get to it.” He would use a tiny camera and lights, long endoscopic scalpels like stainless-steel chopsticks and perhaps the robot they call da Vinci.

They had chilled my body core to about 80 degrees, nearly halting my metabolism. In nature, I would be dying of hypothermia, but here a machine oxygenated and circulated my blood. The surgeon’s progress slowed. Though he had pioneered robotic and minimally invasive heart surgery, he had warned me this might happen.

For weeks now, I had bolted awake, dreading that in mid-operation he’d have to switch to a sternotomy. That’s how they had opened my chest for the bypass. I had been unconscious, oblivious to the details, but a few years afterward had suited up in a surgical gown and mask to watch a bypass for a story I was writing. I remembered the patient’s torso drenched in copper-colored antiseptic. I remembered the soft buzz of the small reciprocating saw as they split his breastbone and, with a muffled pop, pried it apart and inserted a retractor to hold it open. Doctors in Charlotte said my previous surgery had made it so dangerous they were afraid to crack open my chest again. They didn’t consider this less-invasive procedure an option. The clock moved. Before the surgeon had started work, his assistant had told him it looked hopeless.

Eleven o’clock. Darkness. Under the blankets, I move the fingers of my left hand like spider legs, inching up my stomach. I feel my navel, my rib cage and, now, the middle of my chest. There’s stubble where they shaved it, just in case. My fingers search. No bandages! A tube runs down my throat. I’d laugh if I could.

This is partly about medical technology such as endoscopy, robotics and cryosurgery and partly about W. Randolph Chitwood Jr., the cardiothoracic surgeon many believe is the best in the world at them. In January, in a hospital in the one-time tobacco town of Greenville, he cut open my heart and sewed a nickel-alloy ring about 1¼ inches in diameter around the base of my badly leaking mitral valve so that it again seals between beats. Then, with a probe chilled by argon gas to 130 degrees below zero, he scarred my heart — good scars this time — to block errant electrical impulses that cause atrial fibrillation. That’s what, through a stethoscope, had made my heartbeat sound like a stutterer with hiccups. Either eventually would have killed me. Together they were wasting no time. Three days after I woke up, I walked out of the hospital. I went back to work in two weeks.

But this is equally about Greenville, the spot it has come to occupy in the state and national medical landscape and how, 40 years ago, at the mercy of politics, regional rivalry and academic competition, it almost didn’t get to appear on that map at all. One turn of events underscores its present status. When I set out to find a surgeon who might be able to fix my heart without the sternotomy, Charlotte doctors referred me to one at Duke University School of Medicine in Durham and another at Cleveland Clinic in Ohio, by reputation the world’s best heart hospital. When I contacted them, I found that Chitwood had trained both in Greenville.

When it comes to medicine, Greenville is an unlikely locale for those North Carolinians accustomed to seeking care in larger cities. “It’s probably more recognized outside the state than at home,” says Al Delia, a former East Carolina University researcher who’s now an economic developer in Kinston. Case in point: He recently received an inquiry from John Paul II Hospital in Krakow, Poland, which was interested in affiliating with the medical school and Pitt County Memorial, its teaching hospital.

More of Chitwood’s patients — he has performed 600-plus endoscopic valve operations like mine and 400 more using the da Vinci robot he helped design — come from outside North Carolina than from in it. The patient next to me in the cardiac unit was from California. Four years ago, Chitwood — formally vice chancellor for health sciences at East Carolina University’s Brody School of Medicine and director of the East Carolina Heart Institute — turned down an offer to join Harvard’s faculty. A Boston newspaper described him as “a household word in the world of cardiac surgery.”

But Chitwood’s reputation shouldn’t overshadow Greenville’s own rise as a medical center. “Unlike many parts of Eastern North Carolina, which are economically stagnating or growing just a little, Greenville is a boom town,” says John Tucker, a native who left for Davidson College in the 1970s and returned to become ECU historian. “It’s turned the city into a medical utopia, compared to what we had when I was growing up here.”

After I recovered, I talked to Dave McRae, CEO of University Health Systems of Eastern Carolina. He outlined how the network had grown. He estimates that Pitt Memorial, its flagship, was worth about $12 million in the 1970s. It’s now a sprawling, $800 million complex with $600 million of construction planned. Projects at ECU’s medical school, plus private clinics and offices, could push the total to more than $1 billion of medical construction started or finished here in the next five years. “We’ll double the size of the campus, just here in Greenville. That’s not the university — it’s just health care.”

Those are the hard numbers. Then there’s the human impact. When Virginia Hardy, associate dean of academic affairs at the medical school, was growing up in the 1970s, there were only a handful of doctors in Pitt County. “There were eight of us in the family, and with one exception, we were all delivered by midwives,” she says. The county now has 647 doctors — one for every 220 residents, the third-highest ratio in the state.

Medicine is rapidly becoming dominant in this city of about 75,000. It’s the home of the health system, which has a footprint that covers 29 counties, nearly a third of the state. About 5,500 of its 8,500 employees work here. Darting back and forth around the clock, angling low over west Greenville with its scores of medical practices and clinics, the EastCare fleet of three medical helicopters — the state’s largest — transported 2,634 patients last year, ferrying them from accident sites and the five other hospitals that the system owns or manages and five more that it’s affiliated with. Those patients and more than 37,000 others came to Pitt Memorial and the medical school last year. Like me, they came for heart care. Or strokes, diabetes, grave pediatric illnesses and various other life-threatening ailments. That’s tertiary care, Steve Lawler, the hospital’s president, explains. Others were victims of car wrecks, farm accidents and fishing-boat mishaps, often flown here because it’s the only Level One trauma center east of Raleigh.

If Pitt Memorial is the pulse of Greenville’s medical industry, the medical school, which graduated its first class of doctors in 1981, is its heart. The school is staffed by doctors such as Chitwood — he has trained more than 350 others to use the da Vinci robot for cardiac operations — and Walter Pories, the surgeon who developed gastric bypass for weight control. The procedure now known as Roux-En-Y originally was called Greenville Gastric Bypass, and Pories has shown more recently it might be used to cure some types of adult diabetes.

I knew the numbers, the credentials. At least, I did in my head. But as the days of January dwindled and my surgery approached, the credentials I was most interested in preserving were my own: husband, journalist and former medical writer — I coincidentally had interviewed Chitwood in May 2000 when he performed the first robotic heart-valve surgery in North America — and now the owner of a badly deteriorating heart. Did I mention quaking self-doubter?

Have you lost your mind? I drive our little gray Honda north on Interstate 85, leaving behind the big hospitals of Charlotte, both just five minutes from my doorstep. I dice with big trucks as we skirt exits to Winston-Salem, home of Wake Forest University Baptist Medical Center, then Durham and Duke and down I-40 to Raleigh and its big WakeMed system, all among the nation’s best. Mostly I drive in silence, my wife beside me.

East of Raleigh, U.S. 264 bypasses sleepy crossroads like Sims and Bailey, places I had never been despite 40 years as a reporter in North Carolina. Old tobacco barns, grain bins and irrigation ponds line the highway. It’s four lanes, like an interstate, but at times on this midwinter Monday morning ours is the only car in sight. The lump in my throat grows. This had been my idea. When my Charlotte doctor had suggested that I go to Cleveland, I had insisted on coming here. I talked to Chitwood on the phone. He signed off with, “We’ll take good care of you.” Now, as I drive east, tall pines seem to close in on both sides of the highway. Oh man, what have I done?

Leo Jenkins was a New Jersey Yankee, a Marine who fought on Guam in World War II and an educator who died in 1989, 11 years after retiring as chancellor of East Carolina University. In January, he — or at least what he wrought — helped me make my decision.

After more than a decade of bitter debate, the General Assembly voted in 1974 to establish the state’s fourth four-year medical school — Duke, Wake Forest and UNC Chapel Hill had theirs — in Greenville. McRae recalls the divisiveness. “Some wanted the medical school in Charlotte, and others thought the UNC school in Chapel Hill should be expanded. I lived in Raleigh then, and it was in the headlines every day. They were going to put the medical school down east in a rural part of the state at a school that didn’t even have a Ph.D. program.”

Jenkins, who had joined the faculty of what was then East Carolina Teachers College in 1947 and had become its president in 1960, campaigned for the medical school like he was storming a beach. “To say the least,” Tucker says, “he was gung-ho.” The UNC Chapel Hill student newspaper described him as “the sly, wall-eyed Leo Jenkins,” cartoonists lampooned him, and Piedmont politicians vilified him. It’s a legacy that has lasted, says Nicholas Benson, vice dean of the medical school. “We sometimes wonder when our legislative initiatives in the General Assembly go forward if some members still have the attitude, ‘Hey, I remember what Leo Jenkins did in the late ’60s with the big push for the medical school, so why should I support ECU now?’ Memories die hard.”

But aided by a powerful bloc of eastern politicians, he made the legislature listen. The medical school was much more than a prize for a university campus. It was vital to a region where the options for thousands of residents boiled down to dying young, living poor or moving away. “There were many counties without a single physician,” says Delia, president of North Carolina’s Eastern Region Development Commission in Kinston. “Now, graduates are doing what the legislature intended — staying in the region to improve the health care of residents of Eastern North Carolina.” It also has contributed to the economic health of the region. A study by the Association of American Medical Schools, based on 2005 numbers, shows it has a $14 billion annual impact, ranking 10th among the nation’s medical schools. Its $150 million annual payroll provides for nearly 2,000 jobs. “There’s nothing I can think of that would have had this kind of impact on Eastern North Carolina,” Delia says.

Bill Bedsole, CEO of Beaufort County Hospital in Washington, outlines how University Health Systems and Greenville touch most of Eastern North Carolina. His 158-bed hospital opened in 1958 and can hardly afford — or justify to hospital regulators — multimillion-dollar machines such as magnetic-resonance imagers. Patients had to be examined in a mobile unit sent by Pitt Memorial once a week. But after forming a joint venture with the Greenville hospital — in effect, borrowing on paper some of its vast patient numbers — Beaufort County Hospital was able to land one of its own. “The benefit to our patients of having an MRI available 24/7 is tremendous,” Bedsole says.

As he speaks, an EastCare copter flutters down on a landing pad. “We can take care of emergency needs here, but Pitt County has trauma surgeons on standby 24/7. And we don’t have invasive cardiology, so all our patients are stabilized and transferred to Pitt. Before, they had to go to Chapel Hill or Raleigh.” That’s where I come in — invasive cardiology. Mine is as invasive as it gets. That’s how I come face to face with Mamie, Mr. Buzzy, Wendy and a lot of contradictions.

She’s in her 60s, grew up on a farm as I did, and she discusses hog killings and country life with authority. On the morning of my surgery, aide Mamie Roland helps me with my antiseptic shower. She returns with an electric razor. “Here comes Mr. Buzzy,” she says, waving it menacingly. She lays it on the foot of my bed as she prepares to shave my arms, groin, stomach and the middle of my chest. Just in case. When she turns away, I hide it under the sheet. As she hunts for it, grumbling, my grin gives me away. We share a big laugh.

Wendy Radcliff, a cardiovascular nurse practitioner, helps ease my anxieties, patiently explaining heart surgery and the next minute — we’re both car buffs — bantering about rebuilding souped-up engines. Like most I meet here, she grew up in Eastern North Carolina and is down-home friendly. As days go by, I’m impressed by their competence and efficiency. Partly, I learn, that’s due to Pitt Memorial’s sophisticated information-technology system, but there’s more to it. “You have to be a little better,” Lawler, the hospital president, would explain several months later, “when everybody is skeptical of you.”

He reminded me that Leo Jenkins had promised legislators that a medical school would bring better health care to Eastern North Carolina. Patients like me might come here from everywhere for specialized care, but the medical school is as basic as cornbread and collard greens. Its students — 73 graduates this year — are all from North Carolina, an entry requirement, and of the 1,800 doctors it has graduated, 59% still practice in the state. Two-thirds enter primary care, such as family medicine. “They’re on the front lines,” Benson, the vice dean, says.

Nurses, too. ECU’s College of Nursing has about 1,000 students, with 193 graduates in 2008, the most of any school in the state. They attend classes in a $60 million, 300,000-square-foot nursing school that opened in 2006 near the hospital. Nearly 90% practice in the state — more than 60% in Eastern North Carolina.

The stocky guy in a blue business suit standing at the foot of my bed a couple of days before my surgery might be the biggest contradiction of all. Chitwood, 62, is a member of the elite Royal College of Surgeons in England, among other things. He’s explaining that, after my surgery, he has to fly to Fort Lauderdale, Fla., to be installed as president of the 5,400-member Society of Thoracic Surgeons, but he’ll be back to follow up on me. He later tells how he gave up his first job, back in the ’70s, to do this. Industry lost a chemist; medicine gained a surgeon.

Chitwood’s father and grandfather were doctors in the mountains of southwest Virginia, where he grew up, but he started out in Wilmington, Del., as a textile chemist for DuPont. He learned to look for patterns in numbers. He still does. He and his department — today, 11 surgeons — have done 1,000 or more operations a year for about 20 years, feeding results into a database and mining it to see what works best. “We called it process engineering. Find where the defect is in the process and correct it. It’s the same whether you’re trying to get dye to stick to a rug or getting the patient out of the operating room safely.” My surgery and recovery unfold like clockwork — at this point, at this time, you should be feeling this or doing that.

That’s logic. So is the reason Chitwood came here in 1984 after completing his residency at Duke. ECU dangled a big carrot — chief of the division of cardiac surgery. “They decided they needed a heart program, so I came and did what everybody told me to — build a heart program. I don’t think they ever thought it’d get this big.” Lured to the University of Kentucky Medical Center in 1988, he returned a year later to become vice chairman of the medical school’s surgery department and director of Pitt Memorial’s heart center.

“My vision,” he says, “was that we could do it differently.” The question was how to lessen the trauma to patients already desperately ill. The answer was minimally invasive surgery, penetrating the chest through small incicisions between ribs and inserting tiny cameras and fiber-optic light to guide the surgeons. In 1996, he performed the world’s first endoscopic heart-valve replacement on a 47-year-old Charlotte man. But it was an uphill struggle. “I got a lukewarm reception at national meetings,” he recalls. “It was, ‘This might be possible, but it’s not traditional.’” He pushed ahead, designing many of the long, specialized instruments now widely used in endoscopic surgery.

In the late ’90s, Sunnyvale, Calif.-based Intuitive Surgical Inc. asked him to help adapt endoscopic technology to the robots it develops. The result is the da Vinci Surgical System, widely used in heart, prostate and other surgery. When he peformed the first American valve operation with the machine eight years ago, it attracted international attention. Since then, ECU’s medical school, renowned for turning out primary-care physicians, has won acclaim for a high-tech speciality, its teaching center for robotics training hundreds of surgeons. “Randy could have taken his attributes to Charlotte, Cleveland, Milan, Italy — anywhere — and been successful,” Benson says.

Why hasn’t he? Consider the Harvard courtship. “I had to say, ‘OK, wouldn’t it be great to be a Harvard professor?’” Chitwood admits. “That was my ego. But here my robotics program was going great, we had our research lab going well, we had a large clinical practice with excellent surgeons. When I sat down with my wife to talk about it, she said, ‘You’ve become nationally and internationally known from right here in Greenville, N.C. You don’t have to go anywhere.” Nevertheless, he put Harvard’s advances to use. When ECU and University Health Systems officials learned he was being recruited, they wanted to know what it would take to make him stay. “I said, well, I’ve had the vision of building a heart institute, and I’m not sure it’s ever going to come to fruition here.”

Today, a six-story, 375,000-square-foot, brick-and-glass building rises beside Pitt Memorial. This is the $160 million East Carolina Heart Institute, due to open early next year. It will add 120 beds — the figure could rise to 168, all heart beds if Chitwood has his way — to Pitt Memorial’s existing 745. Based on the latest North Carolina Hospital Association figures, that would push it past Carolinas Medical Center in Charlotte, with 861, and make it second only to Duke University Medical Center’s 989. Nearby, the medical school is building a $60 million cardiac research and education center.

Chitwood will run the heart hospital and research center. The hospital, of course, will be for patients like me. The research center, true to Leo Jenkins’ vision, will take a broader approach to health care and the economy of Eastern North Carolina. “You’re getting, first, an economic bellwether for Eastern North Carolina, with the jobs, construction, the new nurses we’ll need — everything in that building,” Chitwood says. “But we also want to make the work force better, healthier. Not just from the disease-treatment side but from the prevention side.”

Since January, yellow construction tape seems to have spread over western Greenville. A $90 million dental school is expected to open in 2011. The state has the nation’s third-lowest number of dentists per capita, and four eastern counties have no dentist. A $47 million family-medicine and geriatrics center is expected to open in 2010. Both would not only treat patients but focus on keeping them well. That sounds good to me. And I’m not the only one.

Chitwood had bypass surgery several years back, and when I talked to him a few weeks ago, I jokingly asked where. “Right here. Had Mark Williams, one of my surgeons, do it,” he replied. “I’d worry about a surgeon who’d go to another center for his own surgery. That happens, you know.” I ask if he’s taking care of himself nowadays. He mutters under his breath: “Need to lose some weight.” The vein in my neck bulges when I laugh.