6.12.1913  -  12.12.2002

Books of N.M.Amosov

Diary. November, 1

October is over. Three months of experiments with ether narcosis and early extubation. Three months of my "shock efforts," and here are the results: six deaths for 60 operations with the replacement of one valve. Ten percent as compared to twenty-five over the last three years. We did not select our patients. On the contrary — there were many seriously ill patients, every fourth, a Third-Degree Risk case. All this gives a ray of hope. But it is still too early to bestow laurels. The newspapers usually put it in the following way: "We have to firm up the results achieved." A hundred operations is the minimum for a stringent assessment. Much better would be a year of operations "with no losses" (cliches are on the tip of my tongue). There were also lucky periods in the past, and then it got worse once again.

Moreover, these successes have been scored only with the prosthesis of one valve. If two valves were replaced, the results were just as bad as before. And in general, there were no improvements with congenital defects. Problem number one is still operations on small children. The two kids that died in September give me no peace.

The profession of a surgeon, particularly of a heart surgeon, looks very romantic. How could it be otherwise: to save people from certain death. What could it be compared with, even if the success rate is not a hundred percent? A fatal heart defect will always steal the show.

Look at our work from outside and without any prejudice. The cycle of my relations with a patient consists of approximately 20—30 days. I will examine him and will appoint screening. I am torn to pieces: much is indefinite; he may die. When I am operating — tension, stress. If everything is O.K. (he wakes up) — happiness. If he dies, my life is poisoned for a week or two, until by new efforts and torments I "pay off" the loss in the face of destiny, the Lord, my people. The collective works, but a mistake made by anyone affects the patient and myself. But then, if everything goes well, in a month, the patient will come to my office to say goodbye and bring flowers. (One- or even two-thirds leave quietly. This is not important. I know that they have been discharged, and I am equally glad for them and for those who come with flowers.) Each new patient signs off a new race. And that's how it goes my whole life long.

How does it differ from any other routine work? A cobbler spends, say three days making a pair of shoes. Then he makes new ones. A worker on an assembly line tightens a screw in two minutes, then comes a new vehicle — and a new screw. The cycle lasts two minutes. They make up a day, a week, a lifetime. Different professions have different periods of work cycles, a different stress load, their own difficulties — intellectual and physical tasks alike. I have been operating with the AIK machine for 19 years and cannot say that the content of the work cycles has changed drastically. It is almost like the work cycle of a cobbler. Its main content remains untouched. The same with me: I know that thousands of my patients are alive, scores of thousands of those who recovered come to the clinic, and some of them are mine. Some are healthy and have forgotten all about the dissease; others suffer and recall us. But all this is somewhere in the distance, in the big wide world which does not let out too many signals. My life is the cycles of the present day; my present patients. (For instance, tomorrow — two patients for valve prostheses. One patient has a problem: a big extension of the aorta; we have to narrow it. Subconsciously I am worried about her.)

As soon as the professional activity of such a "cycle" worker is stopped, his life is paralysed. He has to find a new interest. When you are young, it is possible. But what about when you are getting old? The best way out for a surgeon is to do consultations, to which you are invited out of pity, if you are no longer operating yourself.

But there is work without cycles. Or at least with long cycles. Each cycle is unlike another.

This is creative work.

Surgeons will say: our profession is an act of creation. That depends. No doubt a doctor always has to solve riddles in diagnosis, in treatment, and a surgeon must figure out how to cut off and sew in. But this is not an act of creation — this is merely the art of puzzle-solving.

At the same time though, heart surgery keeps a man in permanent tension. It is capable of fully employing his brain and feelings, leaving no time or strength for other things. That's what happens to me when I operate every day. The source of feelings, inciting tension in me is external, not internal.

But as soon as the operations end, there will be an end to everything. The gods from Olympus will pronounce: Stop. And that will be the end of it.

Throughout my conscious life, I have looked for prolonged cycles, distant goals, activity where stimuli are internal rather than coming from the environment. This was manifest in my hobbies: the study of the theory of medicine and later, my interest in cybernetics. This was partly achieved through writing on different subjects. But I could not give up surgery. The problem lies in the balance of stimuli. In their future changes.

A man lives and is guided only by his own stimuli, even when he sacrifices his life for others. He cannot do otherwise. He will be unhappy, if he does otherwise, unhappy that he is alive. He would prefer to die in such a case.

My own stimuli made me go into surgery until now, that is. This is my passion. Then there is intellect, deriving models with great generalizations in time. There is memory which stores information about feelings.

The intellect reminds me: you are sixty-seven. How more years do you have in surgery? Three? Five? It is difficult to imagine that I will work any longer. And then what?

My memory says: I derived satisfaction from creative work even if its product was rejected — due to errors or unacceptability.

But you are sixty-seven. If you let those three to five years pass by unnoticed, what will remain? Won't it be too late? That is why I have not been able to choose between surgery and more distant goals for the past fifteen years.

The march of time is inexorable, and what remains of my life is constantly diminishing. The logic reduces the possible dates of plans for the future. When you are young, it seems that you will achieve everything. You don't even notice when the time comes, and other thoughts torment you: "Time does not allow you to do this or that. Choose your priorities." The time will come when you will tell yourself: "I have no more energy." However, now it seems to me that this would not be so dreadful.

Let's sum up: decision has been taken. Once again compromises, as before.

Meanwhile, I will write three days a week. Interpretation on paper of the fruits of former reflections. Although "a mouthed thought is a lie," at the same time it is an external model. Statement is the jist of thought. It's a new cognition.

Since no new discoveries are expected, I am interested only in the eternal questions:

"What is the truth? Intellect? Human nature — physical and phychic. Relations between man, society, and nature. Life and death... Old age as a transition process..."

I want to build a bridge between my observations and recollections and these very "eternal questions." I do not know whether I'll succeed. Another objective is the cognition of myself. This is also an eternal problem.

Let's return the present for a moment.

I have just had a call from Misha Atamanyuk: a patient was in trouble. Last Wednesday we operated on a terrible case, Ostap by name. His fourth heart operation. Three commissurotomies in 1962, 1967 and 1973. The last two in our clinic. And now he is bed-ridden with stenosis, but the last note in the operating journal reads that the valve cusps are extremely dense (calcified). I made up my mind to replace the valve not only because the patient asked me to do it, but it seemed to me that it was possible to operate according to Panichkin's findings ("Elema").

Late at night, as I was leaving, Oleg put him on independent respiration and the tube was removed before their night's report to me. But he was in a bad way on Thursday morning. Most important — he had dyspnea and asthenia. He was not able to cough. In the daytime, I had to perform tracheostomy so that the sputum could be easily sucked off. And into the bargain, he had smoked for thirty years and that meant chronic bronchitis. On Friday he felt better, began to comprehend where he was, and his blood pressure was satisfactory. On Saturday and Sunday I did not go to the clinic; I was satisfied with twice-daily reports from the doctors-on-duty: they were reassuring. But today, like a bolt from the blue — tachycardia — pulse up to 160! That's too bad with an artificial valve with its inertia of the hemisphere... To cut it short, several times a day I discussed the dosage of drugs with Misha, although there was no point in it. I feared the outcome. There you are with your ten percent mortality rate —• up to "world standards." And we had two more patients with valves implanted after complicated operations. One mine, the other Sitar's.

That is why it is not easy to switch over to the "eternal questions."

Therefore, let's talk more of our surgical life. Let's go back a month. On October the first, I operated with three Americans present as observers, and on the second, I had to take a plane to Vilnius. A conference of Baltic surgeons to which guests were invited. There were two symposia in the programme on the surgery of acquired heart defects. "Prosthesis of Valves After Preceding Operations." The first was chaired by Georgiy Tsukerman, and the second, by myself. Algimantas Marcinkevicius called me several times, pleading with me to come. I gave my word, which meant I had to go. Besides, I was interested in the conference. The plane left at 14.30. I hoped it would be late so I would have time to perform another operation. A patient with aortic deficiency. Not very serious, so no surprises were expected. We began on time. Everything went smoothly. I had planned to wait until he woke up. But... you can't have planning in our profession. Because of my overcautiousness with the removal of air, it got into the coronary arteries, resulting in cardiac weakness. The heart was contract­ing while the AIK machine was on. We stopped the AIK machine — in several minutes, heart contractions slowed down; the pressure went down as well, and we had to switch on the AIK machine again... We administered drugs. It did not help. By the time another half hour had passed, I was really scared. I couldn't do it. I'd ruined his life. He would be imbecile. And here Anya was telling me that the plane would take off on schedule. To hell with Vilnius. I wished I could cope with it.

For almost an hour, we made abortive efforts to restore the capacity of the heart. Almost no hope was left... We knew that it would contract worse and worse, with shorter periods of independent contractions after the AIK machine was switched off, until the heart stopped forever. And I, Dr. Amosoff, would take my briefcase and leave for home.

And then came the miracle. But since there are no miracles, some intracellular mechanism went into action, restoring the energy oxidizing processes. The heart contractions regained their force right before our eyes. We could hardly believe it, so we waited for another half hour, doing nothing, fearing we'd scare the heart and it would shut off. But everything was O.K. Total perfusion — 2 hours 30 minutes. And it was twelve to two; I had time to catch the plane. I had to go — they were waiting for me at the conference. But I was afraid to leave him. Cardiac weakness might recur. He might start bleeding. And — what I dreaded most — he might not wake up. Without me, he would be kept on an artificial respiration. Later everything would be the way it was before...

But I went to the airport, still perspiring after what had happened. In the car, I was bargaining with myself: "You have time to turn back. But they are waiting for you there. And Algimantas Marcinkevicius asked you to come. So what if something happens? There can be no excuses. What can I do if something happens? I have given all the necessary instructions." A mean thought crept in: "If he dies, it will be better if you are not there. What would you tell his mother? That you made a mistake and failed to estimate the sucking force properly? She would never understand, and there can be no excuses for you." I told her it was not very dangerous... Dangerous, but not very — her son was still rather strong. I took the plane with the thought: "Fate will punish me by all means. And justly so."

Rather strange is this concept of justice. It seems to me that there is an innate feeling of justice — biological one. It appeared in higher animals when they began forming families. This feeling is necessary in any relations between species. Relations represent an exchange: of bites, caresses or threats, and perhaps food. In man — of things, information and the verbal equivalents of whatever is exchanged.

We live in a world of exchanges. The objects are the work, money, things, love, actions and words, which cause different feelings. In one type of exchange the equivalents are known and are made the law by the community (payment). In other types of exchanges, they are specifically individual: What amount of stress, effort, or work must you pay for a caress? For respect? For recognition?

Justice is a unit of exchange. It assumes the assessment of what is given away and received instead — the comparison of both. It is just when the exchange is "adequate." How can this be determined? The unit of measurement is feelings. Feelings resulting from what is given should be compensated for by the feelings resulting from what is received. The compliance of these feelings is expressed by a special criterion —"the feeling of justice." A dog responds to evil with evil, to good with good. Each has its own feelings and its own equivalents. But even a good-natured dog will snarl if another one chases it.

The ability to compare feelings in the process of relations, during taking and giving, is biological justice. Evil for evil, good for good.

These are the roots of the fear of retribution. In biology.

Surgeons are superstitious. I know when some of them see a black cat, they cross over to the opposite side of the street. Almost all of them have "lucky or unlucky" clothes or objects, routes. I noticed that I subconsciously follow the necessary "conditions" for lucky days. I have told myself over and over again: "Nonsense" and have actively tried to suppress this feeling. But I also have my own rather strange observations concerning "retribution." If I make a mistake after a lucky period and a patient dies, then this is followed by a period of misfortunes resulting from various causes. I have "scared off the luck." Rationally, I know that this is sheer nonsense. If I were a psychologist, I would find an explanation: the psyche has been thrown off balance. I have tried to control myself. No, I cannot always keep myself in hand, and after deaths occur, I am doubly attentive. I scold my assistants during operations to break the tension, when it is too thick (a bad habit), but I am never lost.

Surgeons do not believe in God. They are extreme realists. Another thing is the "guilt complex," resulting from the same biological justice °f exchange. Some people are subject to it.

However, let us not exaggerate the moral qualities of my colleagues. During my long years in surgery, I have seen reliable men weep after the death of their patients. I know some surgeons do not sleep nights during their unlucky periods. But the majority get used to deaths, and in my opinion, are too calm about it all. I am enraged by the chatter and chuckles in the hall at morning conferences, when the causes of these deaths are being analysed. Each case is a tragedy, yet some find reason to chuckle. The worst is when the surgeon who operated is the one chuckling at any joke whatsoever.

I do not know of a single case when a surgeon has changed his profession because of failures during operations. And there are surgeons who have had too many failures. Our long-suffering state medicine tolerates it all.

It is good when there is a "conscience" in the clinic — some doctor (not infrequently a woman) whose nerves are exposed to injustice and hard-heartedness, and who is unable to adapt.

The heart of the matter lies in adaptation. But this is quite a different matter. Once again I have gotten carried away.


About conferences, congresses in general, and the one in Vilnius in particular.

No one met me at the airport. I dropped into the first aide station. The nurse on duty not only called the proper place, but served me coffee. Sometimes popularity is useful.

In about a quarter of an hour Marcinkevicius arrived in a car to pick me up. I am afraid to give references to prominent living surgeons, since, in such cases, one never tells the truth. Others will get offended that you have not praised them. But Marcinkevicius is a real surgeon. His appearance does not meet my standards of an ideal — he is too heavy. Apparently it is his build that produce an impression of an even temper, benevolence and strength. This strength is vividly manifest. He created a first-class heart surgery clinic in a total vacuum, at the Medical College of Vilnius University. He began much later than Moscow, Leningrad, Novosibirsk, Gorky and us, and now ranks first in prosthetics of valves, coronary disease and even in some congenital defects.

Marcinkevicius was embarrassed that he had confused the time of my arrival and drove me to the hotel.

A banquet was appointed for the same evening. We had some time before it began, and I tried to call the intensive care ward in Kiev, but without any success. I told myself: "Drop it, you would not be able to help anyway."

What is a conference held for? This is clear to one and all: to discuss disputed questions. To share experience. To maintain personal contacts. To report new information faster than it appears in the press or professional journals. What else? To go sightseeing. To distract oneself, better at public expense than one's own. A conference is a kind of a fully-paid leave.

But it is bothersome for the organizers. Hotels, buses, train tickets, printing of abstracts and programmes. Sightseeing tours. Theatres. Even cloakrooms and buffets. Visits to clinics. A banquet. Meeting and seeing off... One particular responsibility is to meet prominent scientists and big chiefs. They all want special treatment: a good room or a car at their disposal. They like to be entertained and invited home. Let's not envy them, the hosts. In a quarter of a century, only three times our clinic has ventured to host such a conference.

All the "academic types" strive to squeeze into the agenda of the conference as many of their reports as possible. The main inducement is their publication in the form of abstracts. An abstract is considered to be a publication. This is prestigious and absolutely essential for those seeking advanced degrees. Every report, even one lasting only three minutes, has five or more authors, each of whom will put this report in the list of their publications. One and the same report can be presented at conferences in different towns, providing the title is altered. This can be done easily if the authors represent prestigious establishments, particularly if the first name in the list of authors is that of their chief. (He may not go himself, present a report, or even see his abstracts.) A report from a second rate clinic may not be accepted — there may be no time, and there is usually no room in the collection of abstracts. So all the abstracts included, the presentation time is limited to 5, 7 or 10 minutes. This is more than enough time — there is little to report. Sometimes the conference is opened by a prestigious name; in that case he is given from 20 to 30 minutes. Subject reports, devoted to important problems, are set up at big congresses. A sage is asked to present the subject report.

The scientific value of some surgical conferences is not very great. The relevant information has been devulged several times previously; a few new figures are added, and that is all.

No doubt one may dig up bits of information. "How many valves has Tsukerman already implanted? What are the latest mortality indices at the clinic?" Figures pronounced from the rostrum are not always credible unless they are printed in the abstracts.

Eight years ago, our clinic changed radically this system of reports and replaced it with symposia. (This was not our invention, and we do not make any claims on it.) We selected the subjects, prepared key questions that got right to the point, mailed them out and warned everyone that discussions will replace reporting. We asked everyone invited to send us brief replies to all the questions and printed them. In this manner we held two symposia in 1972 and 1978, and all the participants liked the new system.

Only "run in" problems should be discussed at symposia when the participants have their own opinion and are ready for a dispute. "Poster reports" are suitable for informing others of a new fact or methodology. A brief report in big letters with illustrations? You may come up, read and ask questions. The authors stand beside their posters and give explanations. Each participant chooses the subject that interests him and may receive the necessary information in an informal discussion. If we have symposia and poster reports and add a couple of big reports presented by prominent specialists, we always find it both interesting and instrumental. All the other attributes — meetings, banquets, sightseeing tours, visits to clinics or laboratories — remain, of course.

The Vilnius conference was not ideal, but at a good level. Particularly the unofficial part. Marcinkevicius paid such lavish attention to me that I was permanently confused.

A banquet was given in the evening. Heart surgeons were in the minority; the majority of participants were general surgeons from all the Baltic Republics. There was a fair number of guests — from Moscow, Leningrad, and other cities.

Alcohol lowered the standards set for the quality of conversation, but still it was rather dull. I noticed that surgeons do not like to talk shop at such gatherings. We do not have the art of bragging like fishermen. Apparently we do not want to discuss something we cherish in a careless way. Something inside us prevents from divulging "the dramas that occur in the operating room." I have also noticed that military men avoid telling about critical turns of events in a battle; they take to describing comical situations and trivialities. They also fear the touch of doubting fingers. I was so worried over the morning's operation that I could not restrain myself and almost began to tell my colleagues at the table about it. But they gave me no support, my narration lapsed into confusion.

Soon the band began to play loudly. Oh, the bands in our restau­rants — a scourge from on high. I had to leave. I failed to get a call through to the clinic — they weren't answering, damn them.

I had a lucky strike at six the next morning — I got my call through to Kiev in almost no time, and they answered it. And my patient was quite O.K. The doctor-on-duty did not even understand my anxiety.

"The one with the aorta? And what of it? The tube was removed yesterday, long before our shift. He is in good shape. What about the others? They are O.K, too."

Overjoyed, I ran to the park, despite the rain. An excellent park it was, and very close. Old pines — majestic and somewhat sad and solitary. There were no bushes between them.

The morning's peace and freedom were over, and the day rolled over the rails of organization.

We went to the first part of the conference. A fine old mansion with stucco moulding. They say it was the HQs of Napoleon on the way to Moscow and of Kutuzov on the way back.

The symposium was rather good. There were three main clinics taking valve prosthetics: Tsukerman's (the Bakulev Institute), Marcinkevicius' and mine. As to the number of operations, we were the first, as to the results — George is ahead of us, while Vilnius and ours are neck and neck.

Before lunch we discussed valve prosthetics after commissurotomies. I won't describe the jist of the discussions. There was almost nothing new for us: the techniques are widespread, the only differences being minor details. Rather important was one problem only — hemispherical valves — which resulted in more embolies and deaths from subsequent causes. There's your contribution. However when the ventricular cavity is small under mitral stenosis, there is no alternative — spherical protheses are too big.

We had lunch with Marcinkevicius at his place. A small modern apartment, but was so well furnished that one could die of envy. And the lunch was up to the mark, as were his wife's attire and appearance — up to European standards.

His father was also a doctor; the old man is still alive. And the third generation has also taken up surgery.

At the second symposium, we talked of "resewing" prostheses in the case of abruption, thrombosis or sepsis. These are rather rare operations — we had performed about twenty of them, and the others even fewer. Half of the patients die. Therefore, the discussion was rather brief. We managed to finish by four. At the end of the discussion, I could not restrain myself and told the participants about our new experiment of returning to the old technique and what the results of it had been this far. I made a reservation: "This is for your information."

With this we parted.

We were invited to a sauna in the evening. It fell within the framework of the social programme. Finnish saunas have become rather fashionable: all who can afford it go. I am out of the game for good when it comes to saunas.

I took off early in the morning — on time. I was touched by the reception and confused. I felt indebted.

The result of it was distraction. Bits of information. It was pleasant to see my fellow surgeons.