when you have time- great article about Parrish's heart surgeon

To Save a Child’s Heart

Chuck Fraser and the Unbelievable Life of a Pediatric Heart Surgeon
by Tim Taliaferro

They keep it meat-locker cold in the O.R. It smells of sterilizing chemicals. The bypass machine, a maze of tubes and tanks, whirs quietly next to another machine that keeps the temperature of the patient’s blood below freezing, inducing hypothermia. It hums like a refrigerator. Several monitors show a continuously updated bank of color-coded numbers with coordinating line graphs. The surgeon’s saw, high pitched at first, drops several octaves when its teeth meet breastbone.
Today’s operation, a complete atrioventricular canal defect surgery, is a complex one, even for Charles Fraser, BA ’80, chief of congenital heart surgery and cardiac surgeon in charge at Texas Children’s Hospital in Houston. He’s one of only a few surgeons in the world who can repair hypoplastic left heart syndrome, a fatal condition where the left side of the heart, the one that pumps oxygenated blood to the body, doesn’t fully develop and must be rebuilt over three separate operations. In the course of a year Fraser’s team will do between 20 and 30 heart and lung transplants. This operation, he says, should last four or five hours.
You would never know if you met him socially that Fraser, Life Member, Outstanding Young Texas Ex, and a member of the Texas Exes Board of Directors, is one of the world’s elite children’s heart surgeons. Chances are he’d want to talk about you. Were you to follow him around for a day, though, you’d likely hear him discuss fly-fishing, his four kids, or anything having to do with his beloved alma mater. What he would never tell you is how good of a surgeon he is or how wholly dedicated he is to his patients and to his hospital. In fact, if you met him at a party, he’d probably just say he was a doctor and leave heart surgeon unspoken.
Were you to press him into talking about his work, you’d notice that while he reflexively dodges praise directed at him he’s perfectly willing to brag about his team. He’s happy to point out that U.S. News & World Report has ranked Texas Children’s as high as sixth on its list of the best kids’ hospitals in the country. He’ll gladly tell you that the heart surgery division, third on the Report’s list, has one of the lowest mortality rates anywhere. He’ll boast of the specialists and nurses who work in the division but leave out that one of the main reasons many of them came to Texas Children’s was to work with him.
Doc Fraser arrived at the hospital this morning minutes after 6 a.m., taking his customary circuitous route from his home in River Oaks to the medical center, avoiding traffic lights at all cost. In the past Fraser would ride his bicycle to work in the mornings but under enormous pressure from the hospital administration, worried that their superstar doctor might get hit, he stopped. Now he drives his white suburban with a big orange Longhorn silhouette on the door and parks on the ground floor. He greets the traffic cop by name as he steps into the crosswalk on his way to the hospital entrance.
The lights are off in the Congenital Heart Surgery office when he arrives. Outside, the sun remains a good half-hour from the horizon. After changing into his white doctor’s coat he heads upstairs to the cardio vascular ICU, where he meets with his fellow surgeons around a monitor. They check out the latest images, discuss progress, then head off in a pack to each patient’s room, where a nurse is waiting chart-in-hand to deliver updates. It is a deluge of information — a tsunami — one number after another, and the doctors stand, listening carefully, allowing it all to wash through their internal filters. Fraser asks the occasional question or calls on his colleagues for their assessments. They move along.
While Fraser is a force in the operating room, you have to see him with patients to understand what makes him such an extraordinary surgeon. Fraser doesn’t fit Hollywood’s surgeon stereotype, the cocky, glam, insensitive braggadocio. “Patients are not just cases for him,” explains his pastor and fellow Phi Gamma Delta Larry Hall, BBA ’65. “Chuck has a big heart. He feels deeply. He cannot avoid being emotionally engaged with the person.”
While he is by nature a compulsive fixer — problems have a way of consuming him — Fraser often reminds his colleagues not to treat a malady as though it exists independent of the afflicted. “I’ve seen him come home and cry countless times,” says his older son, Charlie, a sophomore at UT. “He gets really frustrated if people he works with don’t engage themselves emotionally with the patients. That really upsets him.”
Fraser’s medical philosophy draws heavily on the writings of Sir William Osler, a 19th-century Canadian-born physician often credited with having established the medical residency program. Osler was a medical humanist, extremely well read, who in instructing his students to treat the whole person could quote everyone from Plato to Matthew Arnold to King Solomon to Robert Louis Stevenson. One of Osler’s most widely read works, Aequanimitas, is a collection of lectures and speeches he delivered to medical students. “My dad lives by that book,” says Fraser’s older daughter, Laura, who in May graduated Phi Beta Kappa from Plan II.

At precisely 7 a.m. the pack of surgeons files into a conference room. Every Monday morning the pediatric cardiologists and the pediatric cardiothoracic surgeons meet in this room to review previous cases, get updates on current ones, and discuss candidates for surgery. It was one of the first changes Fraser made when he came to Texas Children’s in 1995. “They brought me here to change the culture and expectation of this hospital,” says Fraser. Oftentimes cardiologists and heart surgeons practice entirely independently, even in separate buildings on separate sides of town. Here he gets them together in one room.
The bulk of the discussion assumes the shape of a debate. When cardiologists have patients who they believe need surgery, the patients’ files are read aloud to the group and the case for surgery is made. The surgeons, who sit in the front row, ask a variety of questions about the patients, whose cardiologists then answer. A technician at the back of the room can pull up any medical record the group may want to see and project it onto the main screen.
It is a remarkably civil exchange, given the company and the propensity that people accustomed to being the smartest guy or gal in the room have for turning impatient when questioned. For the most part, the interlocutors start in with phrases like, “Are we sure that…?” or “Isn’t the issue really…?” or “While I see your point, doctor, from looking at the saturation data, I’m not convinced….”
Chuck Fraser, listening quietly up at the front, appears to possess ideal traits to lead this group discussion, what may well be the brainiest meeting of the minds happening anywhere in the world on Mondays at 7 a.m. If he has an ego, he keeps it checked. He’s calmly impatient — open-minded but allergic to redundancy. His credentials gleam: UTMB, Hopkins, a stint with famed children’s heart surgeon Roger Mee in Australia. Before Texas Children’s wooed him to Houston he was working at the legendary Cleveland Clinic.
Fraser sits directly in front of the main screen and immediately next to his father-in-law, Denton Cooley, BA ’41, Life Member, and Distinguished Alumnus.They are the gravitational center of the room. Cooley, 87, attends these meetings even though he no longer operates on patients and is not an employee of Texas Children’s. He’s Fraser’s guest, and even if he weren’t, no one would tell one of the first and greatest heart surgeons in history to get out. For the most part, his participation consists of occasionally leaning over and whispering a comment to Fraser, who nods or whispers an answer back.
Chuck first met Cooley’s daughter, Helen, at LakeTravis, on a blind date arranged by mutual friends. They spent three days together playing tennis and waterskiing. Helen, BA ’83, Life Member, grew up playing tennis, and so did Chuck, who after learning from legendary coach David Kent at MidlandHigh School played varsity at UT with Kevin Curren, Brad Nabers, Steve Denton, and Gary Block. “He was probably thinking, ‘This girl could use some work on her backhand, but man can she lay a blade down,’” says Helen.
He was in medical school in Galveston at the time, and the two dated long-distance. Helen would drive to Galveston, where her parents had bought a beach house, and she and Chuck would take turns early in the morning pulling each other behind the boat. “We used to ski for 30 minutes each,” says Helen. “Now we’re lucky if we stay up for five.”
Time by the water remains special for the couple. Like many parents whose work keeps them away, for Fraser, vacation is a time for family. “Whenever I can get away, I spend the time with my family. We go on a lot of trips,” says Fraser. The family goes on fly-fishing trips to Idaho or to their lakehouse near Austin as often as they can.
Fraser has always been a passionate and emotional father. “He’s very sentimental,” says Helen. “He cries at everything.” He has a tradition of writing his four children letters, sometimes to commemorate major milestones or holidays and sometimes just out of the blue. “He wrote me one while we were traveling together in Japan recently,” says Laura, whose eyes mist up at the thought. On Charlie’s bulletin board hangs his most recent one, a long letter spilling his pride in and expectations for his oldest son.
* * *
Despite his prominence, Fraser might be the most unassuming surgeon at the Monday morning meetings. From the way he asks questions of his colleagues and from the tone with which he addresses them, you can tell he respects them all. Throughout the meeting, he never once seizes an opportunity for self-aggrandizement. He’s content to let his juniors duke it out. Only when the conversation starts going in circles or has overlooked something entirely does he pipe up.
In one instance, after a particularly long discussion that appears headed toward resolution, Fraser suddenly speaks up. The case in question boils down to a choice between two options, one safer and less intrusive, another much riskier but with the potential to dramatically improve the heart’s performance. The group seems headed toward consensus on the first option until Fraser says, “The other piece of information that’s pertinent is that this patient’s dream is to play baseball.” While the less risky operation might lead to some clinical improvement, it wouldn’t result in any change in the patient’s quality of life. “I think perhaps we should give the parents and the boy the option to decide,” he says. There’s a moment of thoughtful silence before someone agrees, and then someone else, and just like that the consensus swings to offering the family the options. “What’s next?” asks Fraser, and a new discussion begins.

When Fraser arrives at 10 a.m. in the hallway just outside the O.R., he’s wearing his traditional burnt-orange Crocs. The five-month old has already been prepped and anesthetized. Once Fraser scrubs in and attaches his head camera, he reminds all 10 people in the room who the patient is and what surgery will be performed. Fraser likes his operating room silent. He doesn’t tolerate chit chat. You can feel the force of his concentration, a total, all-consuming focus. He’s a meticulous surgeon, preferring to make his way deliberately rather than quickly through the layers of flesh surrounding the heart. When he gives directions to his assistants it’s in that nearly inaudible voice one stop above a whisper. Everyone’s on their toes. He gets everyone’s acknowledgement before stepping up to the table, crossing his left foot over his right, and holding out his hand. “Scalpel,” he says.

Fraser counts himself a deeply religious man. “Faith is a big part of my life,” he says. Every morning he and Helen get up and read from the Bible together. He keeps a verse written on the whiteboard in his office. Whenever he’s not in surgery and can make it to church on Sunday, Fraser takes notes while Pastor Larry Hall speaks, jotting down questions that come to him so he remembers to ask his friend for clarification later. “He asks some hard questions,” says Hall. Once, before an emergency surgery, Fraser called Hall at 6 a.m. and asked him to come to the hospital. “We all held hands in the operating room and prayed before the surgery,” says Hall. Afterward Fraser called to tell him the surgery went well and that the patient survived.
He wasn’t always pious. Eight years ago, Helen had a spiritual awakening, and since that time Fraser has grown steadily more devout. “He started talking about things at work in a lot more religious terms,” remembers Charlie. The family began going to Hall’s St. John the Divine Episcopal church every week. Now they’re a staple in the church community. Says Hall, “They’ve been such a valued family. So gracious, so involved, so caring. They’re regular, constant people.”
* * *
Every heart surgery has four basic steps. The first involves opening the chest by cutting through the breastbone. Step two is getting the patient on bypass. For a surgeon to open up a heart, he or she must stop it, requiring a machine to then circulate and oxygenate the body’s blood. They call it bypass because the surgeon will insert tubes into the aorta and the inferior and superior vena cavas that will divert or bypass the blood away from the heart. Step three is stopping the heart and repairing it. Step four is getting off bypass and sewing everything back up.
Each step takes considerable time, and each has its particularly tricky moments. Choosing the size of the bypass tubes is one such moment: a tube that’s too big could damage the artery or vein, while one that’s too small might hinder bloodflow. And moments before you begin the bypass, the patient must be given blood thinners, which means from that point on any cut or puncture will be much harder to stop from bleeding uncontrollably.
Once the patient gets on bypass, the room goes totally quiet. The monitors that had been softly beeping go mute, and after an injection of potassium into the surrounding coronary arteries the heart very suddenly ceases beating. Now, with one quick movement, Fraser slits it open.
Even though he’s seen the insides of hundreds of hearts and has seen many scans of this one, Fraser can’t know exactly what he’ll find until he looks inside. No two hearts are exactly alike, and when dealing with congenitally defective hearts, anything is possible.
It’s easy to take for granted nowadays that doctors can open up a heart and fix it. The novelty of open-heart surgery has faded in the decades since it was first done. What was once a rare and brave new medical enterprise is now an everyday one. It’s not that it’s no longer impressive — it’s just not surprising anymore.
Yet something happens the first time you peer into an infant’s open heart, formerly beating, currently stopped, while a surgeon manipulates its innards, correcting with scalpel and stitch what went wrong when some tiny strands of genetic coding crossed. The sight defies belief. This isn’t a real 5-month-old on this operating table, with its chest sawed open and its strawberry-sized heart sliced down the center — it can’t be.
But it is. And not only that, but after hours of surgery, this child’s heart, stitched up and restarted, might well beat once again, sending blood and life and a future to a body that earlier this day was dying. What happens when you see this is something both unreal and hyper-real. It’s something awesome and emotional. Something spiritual.
You feel small.
Standing there, looking down into the atria and ventricles, the enormous scale of the operation hits — and the stakes. Hearts aren’t meant to be seen. When they are, it usually means someone has died or might soon. As far as treatments go, heart surgery represents the nuclear option, a bold final effort to save a life by bringing it to the brink of death. The risks are high.
What most people probably don’t realize is that, aside from the surgeons, there’s an entire hospital staff who in one way or another contributes to what happens on the 18th floor. Weeks ago a cardiologist diagnosed the baby’s condition and recommended surgery. Before any incision could be made, nurses prepared IVs, catheters, and monitoring devices. Before that there were people who admitted the child and comforted its worried parents. Someone cleaned and stocked the waiting area where they now sit, nervous and scared, not knowing how long the wait will last or whether those desperate hugs and kisses they gave their baby in the holding area will turn out to be the last.
Ten people in this operating room have devoted their lives to these sorts of surgeries, the very tip of medical cutting-edge. They went to school for years, endured grueling residencies, and outperformed their peers to do it. Some run the bypass machine, some control the anesthesia, some watch the echocardiogram. All respond to the direction of the surgeon on this April morning.
All these things hit you as you watch the painstakingly delicate handiwork a heart surgeon must perform to correct a problem without causing a new one. Infant hearts are tiny, the arteries and veins smaller still. There’s little room to maneuver the sharp surgical tools. The heart is bloody and slippery, and manipulating its shape or orientation to get at the chamber that needs attention calls for an elaborate system of strings, which must be passed through sections of heart muscle like a marionette then pulled gently to roll the organ left or right, up or down. Meanwhile, the baby’s life hangs in the balance.
On his way toward the heart, Fraser had cut a small piece of the pericardial sac, which surrounds the heart and lungs. From that he’ll create a patch to separate the two atria, another the two ventricles, and repair two valves that let blood into the heart. Measurement after measurement, stitch after tiny stitch, Fraser goes to work. His hands move rapidly and with purpose. He changes instruments often. An assistant squirts his hands down to keep the latex gloves from sticking. There are a few false starts, a couple of darnits uttered, but in time the patches are in and he stitches the heart back up. Three steps down, one big one still to go.
* * *
One of Sir William Osler’s sayings that Fraser quotes is: “It is astonishing with how little reading a doctor can practise medicine, but it is not astonishing how badly he may do it.” Fraser reads voraciously. The sitting room at his home is covered with books, everything from poetry to literature to philosophy. He recently finished Gabriel Garcia Marquez’ Love in the Time of Cholera. “You know he and Castro are buddies,” Fraser says.
Among his favorite articles is a 2006 piece in the New England Journal of Medicine called “Thoughts from the Transition Zone” by J. Terrance Davis describing an experience many surgeons have of flying across the country to harvest live organs for transplant. “It’s the most poignant description of what we do that I’ve read,” says Fraser.
When a person falls into a vegetative state, if she is a donor, her blood and body type are compared against the donor waiting list, and by some marvel of international medical administration, hospitals across the country with patients on that list are notified immediately. “When that happens,” explains Fraser, “we put a surgeon on a plane right away and one of us stays and prepares to do the transplant. It’s almost always in the middle of the night.” Then the hospital pages the patient on the donor list, who could be anywhere and have been hoping and praying for that pager to go off for years, and tells them a donor has been found. They then have a matter of hours to get to the hospital.
The midnight flights to and from the hospital where the donor lay unconscious are what Davis describes as the transition zone, and for Fraser they adopt an otherworldly feel. The jumping on a jet, walking through the foreign hospital wearing foreign scrubs, past the grieving family who knows exactly why he has come, harvesting the heart alongside other surgeons from other hospitals, who are harvesting the liver or the kidneys, then getting back on the plane and flying back to Houston, the organ stashed in a cooler between his legs, and arriving at his own hospital to find a completely different environment, one of great hope instead of great sorrow — all of it takes on a transcendental gravity for Fraser.
* * *
Three steps completed, one still to go. Getting the patient back off of bypass is no easy matter, and in a way it’s a moment of truth. The heart opened, the fix made, and the heart closed back up, this is the first chance to see whether it will work.
The heart is restarted. It’s beating fine. Fraser instructs the perfusionist, the person who runs the heart-lung bypass machine, to reduce bypass to 90 percent. “Yes, sir. 90 percent.” All’s OK. Then 80 percent. Something beeps in the background. Now 70 percent. More beeping. Fraser looks thoughtfully at the heart. The beeping gets louder, more urgent. Something’s not right. Fraser looks down again, then back up at the monitor. The patient’s vitals are falling. “Go back on bypass,” he says.
A great many people have arrived in the operating room. Some had been here earlier and left. Others are new. The atmosphere has turned tense, and everyone’s alert at their stations.
The patient is safely on bypass, but Fraser’s perplexed. “I’m not understanding this,” he says, between looking up at the monitor readings and checking around the heart. He’s wracking his brain. The minutes crawl by.
Every time they try to back off the bypass, the patient responds poorly. The problem doesn’t appear to have to do with the heart, which is beating fine. Apparently the lungs are to blame.
Fraser seems mostly frustrated at not being able to do something. There doesn’t appear to be a surgical fix for the problem, so he must stand there, his hands restless, watching the monitor, hoping in the seconds between each update that the numbers will improve.
As the minutes turn to half-hours, the experience drives home what an audacious idea the notion of heart surgery is. There’s no such thing as a minor surgery. It is risky, intrusive, Promethean work trying to fix what nature got wrong. And even the very finest surgeons in the world sometimes get stumped.
Fraser tries again to back off the bypass, this time in smaller, slower increments. Ninety percent. Stop, wait. A few beeps and a slight downward slope on the graph. Then steady. Now 85 percent. A few more beeps but no crisis. Slowly, and with caution, they back off the bypass completely, and in time Fraser is satisfied that the patient is stable. He begins the long, slow effort to stitch up the child’s chest and wire shut its sternum. At 6:15 p.m., he finally steps away from the operating table for the first time.
When surgery goes well, and Fraser manages to fix and restart the heart, ease the child off of bypass, and sew up its chest; and when, after eight nonstop hours of intense concentration, he finally steps back from the operating table; and when, hours later, the infant opens its eyes and sees its parents’ faces, the whole episode seems, in a word, miraculous.
For Chuck Fraser, this is why he became a surgeon. It wasn’t just because he had the brains, the hands, and the constitution for surgery. It wasn’t for fame, prestige, or money. He became a surgeon for those moments afterward when it becomes clear that a child’s life has been profoundly changed. “I became a surgeon because the results are immediate,” he says. “I became a children’s heart surgeon because the results last a lifetime.” It’s what gets him up every morning, what sustains him through emergency weekend-long transplant operations, and what makes the time away from his family worth it. His wife, Helen, says, “It’s the difference between a job and a calling.”
* * *
At a little after 7 p.m., he’s just passed the 13-hour mark and Fraser is sitting in his office on the 19th floor. He’s still in his surgical scrubs and hat, leaning back in his chair, elbow on desk, head on fist. He stares vacantly ahead: he’s just now coming down from the adrenaline high. Far from a hero’s welcome, several dozen e-mails await him, and he expects an hour of paperwork still ahead.
Shortly after 8 p.m. Chuck Fraser turns out the lights in his office. His secretary has long since left. He bids the crossing guard good night as he walks back to his suburban and drives his tortuous route home.
What amazes someone when this miracle is his daily grind?
Fraser’s not in the mood to talk about the surgery. Instead his mind is on fly-fishing. He tells the story of a time he fished Silver Creek in Idaho, a fly-fisherman’s mecca known for having water so clear that though you can see the fish, the fish can see you too. “The fish are very picky,” he says. “Sometimes they will bite only one kind of fly, and you have to present it to them perfectly. Once they see your line, it’s over, so you’ve only got one shot at it.”
When he first arrived at the banks, Fraser spotted a huge brown trout in the stream and decided it would be his target. Keeping to the brush and trees along the banks, Fraser stalked upriver, careful to say out of sight. Once safely upstream, he waded into the water and began the intricate weaving motion fly fishers make with their rods. Then, with one last swing, he cast the fly just in front of the trout, and it burst up out of the water and took it whole.
“It was amazing,” says Fraser. “Totally amazing.”