Part XV- Norman E. Shumway- Standing on Tall Shoulders-The History of Cardiac Surgery By Thomas N Muziani PA-C, CP With An Ending Note By Mary Ann Overton CCP

Introduction by Gary Grist RN CCP Emeritus: This is the fifteenth in a series of articles by Thomas Muziani. This article is about the history of cardiac surgery from the perspectives of how he both learned and lived the history. I (Gary Grist) once had a long conversation with Dr. Shumway by phone.  I was looking to change employers so I sent him my resume directly.  Out of the blue he personally called me.  I was flabbergasted even then (about 1970).  He did not have a job for me at the time but he spent almost an hour (on an expensive long distance call) telling me about his concept for the future of "extracorporeal technology" and encouraged me to stick with it.  It definitely was a high point in my early career! This was a time in American medical culture when doctors were treated like gods (the 1960s). And the most godly of them all were the heart surgeons. Nurses were expected to stand and give up their chair whenever a surgeon came on the floor or entered the operating room.  (I am not kidding about this! Note the picture showing a 1960s heart surgeon in consultation with a colleague.) And if a nurse or any other paramedic were to offer advice to any doctor, they were considered uppity and disrespectful.  It could even cost them their jobs if the doctor complained to the hospital administration. I remember one surgeon saying that any “monkey” could run a heart pump. This was an intentional insult from him, not a joke. Dr. Shumway and his group started to change  that attitude in a good way. Thomas Muziani is president and CEO of Hemo-Stat Blood Management Consulting. He served as a combat medic with the U.S. Army’s 7th Special Forces and later was trained as a physician’s assistant at Brooke Army Medical Center in San Antonio, Texas. He also was director of emergency room/triage clinic at Madigan Army Medical Center in Tacoma, Washington.

“A kind gesture can reach a wound that only compassion can heal”- Steve Maraboli

Author’s note:Through a series of totally unrelated events over the last several weeks I have witnessed several very close friends, in the words of the Nez Perce Tribe: “Start their journey to the spirit world”. All were amazing people. Their common thread in the fabric of their life story was…all of them gave so much of themselves, with no desire for reciprocation, accolades or attention.

They will all leave something behind. Norman E Shumway MD, PhD, who passed in 2006 most assuredly left something behind.

Norman E. Shumway and Stanford: The Origin Story

It is through this prism that I would like to tell the story of Norman E. Shumway and the individuals at Stanford University. In the year that I began working in cardiac surgery, 1968, Dr. Shumway and his associates performed the first successful human heart transplantation in the United States. It would not be hyperbole to claim that, during this time, mainly due to poor outcomes and the logistical complexity of the operation, all other surgeons had abandoned the procedure. Stanford made it a routine surgery.

In 1959, Stanford University made the decision to relocate its medical school, Stanford-Lane San Francisco to the site of its main campus in Palo Alto, California. Stanford-Lane held a stellar reputation as a clinically oriented medical school. With the move to Palo Alto, Stanford now had the advantage of closer ties with its growing research facility. The dean of the new medical school, Robert Alway M.D. had a vision of a pristine medical research facility working in conjunction with the medical school.

Of importance at the time, a pioneer in cardiac surgery, Dr. Frank Gerbode, elected to remain in San Francisco.

The offices for the School of Medicine located in the Department of Surgery were configured in such a way that a six foot hallway was the only divide from the school and the research laboratories. Shumway’s lab measured 30 by 30 feet in size. The majority of the room was occupied by the latest of innovations; a Kay-Cross rotating disc oxygenator. Due to the fact that surgical residents were required to spend time doing research and the physical facilities were relics of a past era…even for 1950’s…the surgical laboratories resembled a bus station. The wash basins were made of cement with totally exposed plumbing. On rainy days even animated conversation could not drown out the syncopated sound of rainwater dripping into buckets. Incandescent lighting fixtures cast a glow and shadows that reminded an observer of a Lon Chaney movie.

Norman E. Shumway was born in Kalamazoo, Michigan in 1923. His early career as an attorney was placed on hold upon being drafted after just one year of prelaw studies to enter army service during World War II. Since infantry did not hold any attraction for him, when he was presented with the opportunity to take up medical training, he grabbed it. The service allowed him to leave for premed training at Vanderbilt, from which he graduated in 1949. His residency at the University of Minnesota in surgery was cut short due to his mandatory return to service during the Korean conflict. After several years, Shumway returned to University of Minnesota to complete his training.

The chairman of surgery was the famed Owen Wagensteen M.D. Wagensteen was a general surgeon but through his tutelage, Minnesota evolved into a central hub for the then embryonic field of open-heart surgery. C. Walton Lillehei became the principal investigator into the clinical development of cross-circulation and mechanical cardiopulmonary support. F. John Lewis M.D. maintained a very strong bias in the practicality of total-body hypothermia providing rudimentary myocardial protection while working on the heart.

Dr. Lewis became Shumway’s mentor. As a result, Shumway decided to do his doctoral thesis on the effects of hypothermia and the heart. Shumway was fascinated with the heart’s threshold for ventricular fibrillation, graphically showing that as temperature fell, less current was required to fibrillate the heart.

After five years of training, Shumway opted not to accept the rotation through Dr. Wangensteen’s service which insured that he would not be elevated to chief resident status. So, in 1957, Shumway set up private practice in Santa Barbara, California with an older surgeon as partner. From all accounts, it was not a good fit and Shumway moved again to Northern California. The options at Stanford-Lane were minimal so he chose to operate the kidney dialysis machine and build up a private practice. It became readily apparent that Dr, Frank Gerbode, a very established cardiac surgeon, would not offer Shumway any opening into Stanford’s cardiac program.

As is so often the scenario; serendipity speaks.

Dr. Ann Purdy was a pediatric cardiologist at Stanford. In the late 50’s, pediatric cardiology was a fledgling specialty and seemed to attract very bright women into the service. Female physicians in the 50’s and 60’s experienced widespread misogyny and distrust in the clinical arena “by their male counterparts”. ; ) Dr. Purdy was the wife of Dr. Emile Holman, the long-time chief of surgery at Stanford. Ann Purdy was not satisfied with her professional relationship with Gerbode and Dr. Saul Robinson, another pediatric cardiologist. She decided to move her practice to Children’s Hospital San Francisco, a formidable decision.

Dr. Roy Cohn, an established Stanford surgeon, who performed the first kidney transplant on the West Coast suggested to Ann Purdy that he and Norman Shumway would be a good fit for Children’s. Cohn provided funds for equipment purchases and obtained referrals from Purdy. Unfortunately, Cohn’s clinical work began to blossom and he was forced to excuse himself from the laboratory preparation. Therefore, Shumway, who had been relegated to operating the heart-lung machine started running the operative team.

Norman Shumway made the wise choice to immediately choose Raymond Stofer, a doctor of veterinary medicine to assist in the operation of the heart-lung machine, perfusion configuration and attending equipment. It must be remembered that during this time, all necessary tubing arrived in bulk in very large rolls, non-sterile. The necessary connectors and perfusion equipment were usually metal non-sterile and assembly/disassembly was no minor feat…for every case. If you utilized ETO sterilization for your equipment, you would be without that equipment for at least 24 hrs. Using the autoclave had to be limited due to certain items would melt, others would be too hot and you ran the risk of breakage. Cleaning broken glass up in an autoclave was no fun, I think I have a Boy Scout badge to prove it.

Raymond Stofer was ex-marine. He presented as a Master Sargent type in both disposition and appearance. Stanford recruited him to be in charge of the surgical laboratory. Under his bluff exterior, he was a master metal worker and when it came to anything perfusion, he would readily set his projects aside to fine tune his perfusion circuit.

Working in concert with Shumway, Ray Stofer designed a very utilitarian Spartan heart-lung machine. Gauges and monitors were kept to an absolute minimum, thereby allowing observation cleaning and repair to remain quick and efficient. The machine that Shumway and Stofer designed was the polar opposite to the complex and laborious oxygenating system that Gerbode’s perfusionists and anesthesiologists constructed and utilized. This simplicity would become a hallmark of Shumway’s conceptual approach and surgical applications.

In preparation for writing this article, I asked for the assistance of my longtime friend and associate, Mary Ann Overton CCP. She has remained at Stanford forever and was a close colleague of Raymond Stofer. This is what she had to say;

“Ray Stofer and Dr. Shumway did most of their research in San Francisco with the disc oxygenator on dogs. When they moved Stanford hospital down to the University Campus, they were still doing cases with the disc oxygenator. Dr. Shumway thought it was the most gentle to the red cells. Even after we switched to some disposables he continued to use the disc on pediatric cases. Most of the original perfusionists at Stanford had to spend time in the dog lab using the disc oxygenator. The cleaning procedure on the discs took three hours. Soap then sodium hydroxide then 100% alcohol. That alcohol was confiscated for the Stanford Christmas parties.”