Mary Jane Frye, mother of three, sat in room 3105 of Children's Hospital National Medical Center, glancing toward an empty stainless steel crib near the door, a crib that had been occupied by her 7-month old daughter.
"This morning, when they came to give her the shot she was just laughing like nothing was going to happen today," Frye thought. "I've got to keep a cool head. I can't go hysterical or anything.
"She had nothing to be hysterical about. At that same moment, three stories below in operating room 1, the operation to close a hole and repair a defective valve in Kizzy Frye's heart was going smoothly.
Eleven years ago, 61 percent of the 18 infants who underwent cardiovascular surgery at Children's died. Last year 86 percent of the 88 cardiovascular patients younger than one year survived.
Surgeon Frank M. Midgley calls the awful mortality rate in 1967 a "sign of the basic newness of our specialty . . . and a manifestation of a lot of things; a lack of proper equipment, expertise and experience.
'But as the number of cases increased the basic number of mortalities has stayed the same, but we've had a dramatic increase in the number of patients and the percentage of mortalities has dramatically lessened.
"This baseline (of mortalities) probably can't get below 10 percent," said Midgley, chief of cardiovascular surgery at Children's, "no matter who, what or where they are unless there's a second coming of Christ. There's just a certain baseline of things you just can't deal with."
But what can be dealt with today, and in babies no more than five days old, staggers the nonmedical imagination.
Surgeons operating on hearts the size of golf balls can repair valves, stitch or patch holes between chambers, save babies with transposition of the great vessels, a condition in which the chambers of the heart are, in effect, in exactly the opposite position from the one they should be, and thus close the patent ductus, a natural connection between the aorta and pulmonary artery that is supposed to close itself off at birth.
"Just yesterday I did one (a patent ductus) on a little 1,000 gram baby, which is under two pounds, no bigger than that," said Midgley, barely separating his hands to indicate the size of the baby . . . "And we've done 60 of those without an operatin room mortality."
Kizzy Frye needed what is commonly known as open heart surgery, like 44 other infants who underwent the surgery at Childrens from July 1974 through December of last year.
She was born with both an atrial septal defect, a hole between the right and left atria, and a blockage in the pulmonary artery caused by a valve that was not opening wide enough.
The septal defect permitted unoxygenated blood returning from the body to mix with oxygenated blood returning from the lungs, and the failure of the value to function properly causes the heart to work harder than usual, building up muscle, further narrowing and eventually closing off the opening to the pulmonary artery.
"The kid isn't desperately ill and desperately symptomatic," Midgley said of Kizzy a few minutes prior to surgery last Wednesday morning, "but we know from dealing with these . . . children in the last several years that if you don't operate on the child early enough they can have progressive problems" and eventually die.
The valve normally has three leaflets, or cusps, which open to allow blood to flow out of the heart, and then close to prevent it from seeping back. In Kizzy's case the edges of the three cusps were partially stuck together, not unlike pages of a book that never were separated at the bindery. Midgley's job was to finish separating the cusps.
"Even two or three years ago we didn't have the facility, the dexterity, the good pumping apparatus and post-operative care to be able to offer an operation like this to a child this age," said Midgley. We used to put it off a year or two. But then they got all these progressive, and sometimes irreversible, changes in that chamber" of the heart.
Kizzy was in the operating room by 7:45, and anesthetized by 8 a.m. By 9:24, when Midgley entered the room, she lay on the operating table, her tiny body completely uncovered, adhesive tape covering her eyes and mouth.
On an observation window across the room from the child-size table was taped a large, hand lettered poster with the name FRYE, KIZZY, her age, weight, height, body surface area, percentage of solid material - red and white cells - in her blood, the estimated flow of the pump, the so-called heart-lung machine, her estimated blood volume, the amount of Heprin that would be used to keep her blood from clotting on the machine and th e amount of Protamine that would be used to cunteract the Heprin at the end of the operation.
The body surface area measurement is needed "to estimate the amount of flow that the patient will use on cardiopulmonary bypass," explained perfusionist John O'Conner, the man who runs the machine. "We peruse (oxygenate) 2400 cubic centimeters (of blood) per minute for every meter of body surface area squared. So in her case we took the body surface area, 32, multiplied it times 2400, and that comes out to the estimated flow of 775 ccs."
When the patient is in infant the size of Kizzy, rather than an adult, O'Connel uses the pump "differently. The Pump is the same but we employ it defferently. The tubing (which caries the blood from the patient to the pump, where it is oxygenated, and back into the body) is smaller because we're using less blood volume - it's quarter-inch rather than three-eighths or half-inch.
"We're probably more careful about monitoring (blood) temperatures in kids than we are in adults," he explained. "The oxygenator," which carries out the functio of the lungs, "is smaller, it's a baby version."
Another difference between working with children and working with adults, said O'Conner, is that "our blood (testing) is all done by microtechnique. Everything we do is designed not to use up any of the child's blood . . . I'd use 2 ccs to do the tests that would take 5ccs in an adult."
At 9:24, in a scene from a thousand movies, Frank Midgley strides into the operating room, the bright blue gown covering his surgical green scrub suit, flapping open behind him.
He extends his hands, freshly scrubbed and dripping to scrub nurse Lydia Messerschmidt, who drapes a clean towel over them, helps with drying and thern holds the surgical gloves in which Midgley seals his hands.
The gown properly tied, he steps up to the operating table and is handed a pair of forceps containing a cotton swab drenched in Betadine, a brownish anesthetic solution. He rubs the solution all over the child's torso.
The body is draped with surgical toweling, and at 9:30 Midgley asks "shall we begin? What time is it?" And then draws a gleaming scalpel 4.75 inches along the midline of Kizzy's chest and abdomen. A pencil-line thick of blood springs up in its wake.
Though the skin, fat, muscle, breast-bone - "it's mostly cartilage" - and into the chest cavity.The entire opening is so small it looks more like and oral surgical procedure on an adult than cardiovascular surgery.
By 9:44 Midgley calls for disecting scisors to open the pericardial sac, the membrane taht surrounds the heart, and the heart is completely visible. It is, as he said it would be, no bigger than a tennis ball.
For 23 minutes the surgeon and his staff work preparing to hook up the heart-lung machine, the pump. "Purse strings" are sewn into the heart. They will be used to attach the lines from the pump.
At 10:07 Midgley calls to O'Connel, "Go on bypass and cool to 30 degrees (centigrade - 85 farenheit) slowly.
"Okay," replies O'Connel, "I'm ready to go on bypass."
The flow rates are adjusted, the purse strings checked, and the machine has temporarilly taken over the work of Kizzy's heart. Midgley begins his repair work.
The hole is easy to close. Two stitches and it's done. "The valve is very thick. Number 11 blade please," he says, reaching for a surgical knife.
The entire valve structure is not much larger than the eraser at the end of a pencil. The surgeon makes three 8 millimeter incisions between the cusps and the work on the valve is done. It is 10:26. The repair work itself has taken about 15 minutes. Midgley gives the order to "fully rewarm" the blood prior to turning the pump off.
The lines are disconnected one by one and the flow from the pump is reduced. AT 10:37 Midgley tells O'Connel to turn off the pump and Kizzy's heart again is in its own.
It is all pro forma from here; checking the heart for any leakage, cleaning the area, removing some of the remaining lines, closing the chest cavity, muscle, fat and skin. It will all be over by 11:50.
Meanwhile, on the third floor, primary care nurse Marilyn Clare walks into a playroom where Mary Jane Frye is talking to a reporter.
"Hi!" she begins with a smile. "I just wanted to let you know she's doing fine. They're starting to close and there were no problems . Dr. Midgley will probably be up to see you within an hour and then we'll go with the rest of our procedure from there. He said to tell you it went fine. He kidn't have to put a patch in" to cover the hole. "Like to take a deep breath?"
"Yeah," responds Frye, who breaks into a wide grin.
Things could not have gone better, Midgley said Friday afternoon. Kizzy was already back in the room she was sharing with her mother - in keeping with Children's policy of encouraging parents to room-in with their children.
Despite the increasing success of such operatons, there is still one major unanswered question: What will happen to these children over the lon run? While they can lead normal lives as children and adults, there is not yet a large enough group of such children who have survived long enough to know if they may need further surgery in their middle or old age.
Asked about the bills, Frye said "Medicaid will have to pay for those. Ain't no way in the world I can pay for it. Not here anyway. It's expensive."
The entire procedure, including surgeon's fees, the room, intensive care and medication will probably cost about $8,000. But Mary Jane Frye, who lives in Herndon is covered by Virginia medicaid.
"She'll spring right back," she said of her daughter, and indeed she did.