In his study at home Dr. Ralph Berg holds a clay model of the human heart. He pioneered open heart and heart transplant medicine in Spokane 50 years ago. He was the first heart surgeon and developed many of the present day practices performed in local hospitals. He also has an avid interest in hunting as witnessed by some of the mounted trophy above him. Christopher Anderson/the Spokesman-Review (SR)
The year is 1969. A patient begins having heart palpitations and chest pains. When they get to the hospital, and it’s determined to be a heart attack, the patient is not rushed into the emergency room or operating room. They are put under observation, essentially bed rest, and hoped to survive. Many did not.
This is how many heart attack patients were treated until a team of Spokane surgeons, cardiologists and nurses at Sacred Heart Medical Center 50 years ago changed the trajectory of heart medicine for decades to come.
In March 1971, doctors at Sacred Heart performed the first emergency acute bypass surgery on a person having a heart attack, according to Providence hospital records and cardiologists and surgeons who published their findings later that decade.
The procedure had never been done before in the United States in an emergency. Open-heart surgeries had been performed for more than a decade at that point, but a person having a heart attack was considered too risky for surgery.
Not only was the procedure considered too dangerous, the cardiology community actively rejected the idea that operating on a patient having a heart attack would do anything more than add more insult to an already damaged heart, said Dr. Sam Selinger, a now-retired heart surgeon who came to Spokane in the 1970s.
But that first bypass surgery, performed on a 64-year-old man, was a quiet success. The patient recovered and had improved heart function seven weeks later.
The Sacred Heart team was on to something, and it would take a decade to prove it to the wider world. In the mean time, operating on heart attacks quickly was producing fantastic outcomes.
Dr. Robert Hustrulid came to Spokane in 1971 to practice internal medicine. Some of the patients he treated had heart disease or had suffered heart attacks. Many of them did not do well.
“I was constantly (treating) people who had heart attacks who did poorly and then all of a sudden, they started doing great, and it was all because of the surgery,” he said. “This changed the world.”
While the Spokane team would change the world of cardiology, it didn’t happen immediately.
Surgeons at Sacred Heart had done open heart surgeries for more than a decade by 1971, but these procedures were always scheduled in advance.
In the 1970s, the medical community did not know what, exactly, caused a heart attack. But the Sacred Heart cardiologists and surgeons at the time had a hunch that precipitated quick action.
When a patient having a heart attack came to Sacred Heart after March 1971, they were likely first taken to the catheterization lab, where a tube, passed through the groin into the heart through the coronary vessels that feed into it, is used to inject liquid dye and get an X-ray of the blood flow into the heart. This X-ray served as the roadmap for surgeons to see exactly where the arteries were blocked.
It was these arteries that would need to be bypassed, while the heart and lung machines were used to keep the patient alive. After the X-ray images were taken, patients were rushed to the operating room, where nursing and support staff had sterilized and prepared all the instruments and machines necessary. Then surgeons went to work.
The Sacred Heart teams found that their success rate in patients was highest when they operated on a heart attack victim within six hours. Estimates vary, but Selinger, who came to Sacred Heart in 1978, says the emergent bypass cut mortality rates significantly.
“The improvement was so spectacular for the heart, and the muscle that would have died lived,” he said. “And the injury and mortality were reduced; they had much more muscle that survived, and these people did well.”
In 1972, just a year after the first successful emergency coronary bypass, Sacred Heart established its 24/7 heart attack team, with a surgeon, cardiologist and nursing staff always on call to get to a heart attack patient as quickly as possible. This standard remains today.
Selinger said part of what made the Spokane team’s contributions and efforts so remarkable was the lack of an academic institution’s support.
“The story is a little known story because this was not some famous academic institution and so forth, it was a community of well-trained, dedicated people at all levels who really had the community interest at heart and wanted to deliver the best care,” Selinger said. “And it was proven to be correct, (but) it really wasn’t until the mid-1980s that this started to be accepted around.”
Not that the Spokane team didn’t try to get the word out. Surgeons Dr. Ralph Berg and Dr. Robert Kendall, who have since died, as well as Dr. George Duvoisin, Dr. John Ganji, Dr. Lloyd W. Rudy and Dr. Francis Everhart published their findings in the Journal of Thoracic and Cardiovascular Surgery in September 1975.
In the 1970s, the doctors also began presenting their data to others in the cardiology community but received a very cold reception.
The team tracked the first 96 patients’ outcomes for a year after they were operated on while they had heart attacks. The overall mortality rate compared to patients who were not operated on was staggering: the Spokane team’s patients had a 6.3% mortality rate, while the mortality rate of standard treatment at the time was about 30%.
“Most patients with acute myocardial infarction are best treated by emergency coronary artery bypass surgery,” the 1975 Journal paper concludes.
In 1980, Berg told the Spokesman-Review that the emergency bypass “isn’t mildly better, it’s fantastically better.”
He presented his findings to the American Association for Thoracic Surgery in 1975 and received no questions or feedback.
“Nobody said a word; I couldn’t believe it,” Berg said in a recorded interview with Providence before he died. “So finally I just stepped down, but the reporters were real interested.”
It took a few more years for the cardiology community to come around to the idea that treating a fresh heart attack could result in better outcomes.
In Spokane, however, patients recovered after their surgeries, and doctors continued to perform bypasses on patients having heart attacks.
In the mid-1970s, cardiologists and surgeons at both Sacred Heart and Deaconess hospitals were doing what no one else in the country was doing.
Heart care became a standard at Sacred Heart Medical Center, and despite not having a large academic institution’s support, cardiologists and researchers there continued to explore new and innovative ways to treat heart conditions and learn about causes of those conditions.
This led researchers to an all-important discovery.
The prevailing theory for what caused a heart attack in the 1970s was based on autopsies done on people who had died from a heart attack. But often, a person may not die until two to five days after an attack. Researchers thought heart attacks were caused by a part of the heart dying, and the clot that formed was in the vessel feeding it because it had nowhere to go, Selinger said.
Spokane researchers would prove the opposite to be true: the clots were often present in the early hours of a heart attack, which suggested that they caused the heart attack in the first place.
“What they found here in Spokane was that these people tended to have total blocks of the artery and that part of the heart would die, which was the attack,” Selinger said.
Knowing what causes heart attacks would, again, change the field of cardiology forever. After a decade of collecting data, Deaconess and Sacred Heart doctors published research in 1980 that for the first time explained what happens during a heart attack.
Dr. Marcus DeWood and a group of doctors in Spokane found that in 87% of heart attack patients they studied, the arteries do become completely blocked. It was a groundbreaking and vital finding that helped push medicine further forward to where we are today.
“Every treatment that has come since then is based on that knowledge,” Selinger said.
Their findings were published in the New England Journal of Medicine, putting the Spokane team on the national and international map a decade after teams began operating on heart attack patients. The accomplishment, without the support of an academic institution at the time, was done using a “bare bones budget,” The Spokesman-Review reported in 1980.
“Prior to the group’s work, medical experts did not know if the coronary arteries closed during a heart attack,” a 1980 Spokesman-Review article says.
Soon, opening up a person’s chest cavity would not be necessary to treat a heart attack. With the knowledge that heart attacks are caused by blocked arteries, medicines and therapeutics to dissolve blockages and keep arteries clear are now standard. New ways of operating on patients in less invasive ways took hold. Stents and balloons can be placed in arteries to keep them open or prevent collapse, a now common practice in treating heart conditions.
Today, very few patients undergo open heart surgery during a heart attack.
Dr. Phil Huber, a cardiologist at Sacred Heart today, said of the 277 acute heart attack patients treated by Sacred Heart teams during an emergency last year, fewer than 1% had to have their chest opened.
Now, surgeries can be done going through a person’s arteries in their wrist or groin, making procedures much less invasive than in prior decades.
In 1959, Berg, Dr. Henry Lang and Dr. Richard Kleaveland completed the first open heart surgery in Spokane at Sacred Heart, becoming the first facility without a major academic institution to do such a procedure in the country, according to the hospital. Berg was fixing a hole in the heart back then, a procedure that Huber said takes about 20 minutes today.
Even a patient with several holes in their heart can be sent home the next day.
“How the field has evolved is unbelievable,” he said. “There’s always an emphasis on what we can do better, how can we make this easier, less invasive and perform better care, and in all of that, Spokane has retained the ability to recruit physicians and keep cutting edge technologies here.”
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