Heart of the Matter
Not since Edgar Allan Poe has there been a telltale heart that produced more drama and mystery than the heart of Reggie Lewis, captain of the Boston Celtics. Over the last two weeks, since his frightening collapse on the parquet floor of the Boston Garden on April 29 during a playoff game with the Charlotte Hornets, Lewis's heart has come to haunt a diverse group of people.
That group includes Lewis, who has endured an agonizing medical netherworld in which he has been told that he may or may not have a life-threatening condition, and who may or may not play in the NBA again. It includes the Celtic organization, which may or may not have to overhaul its roster, depending on whether Lewis, the team's leading scorer, can play. It includes the Celtics' team doctor, who should or should not have sent Lewis back into action after his collapse, but who certainly talked too much and too publicly about the case. It includes the staffs of two of Boston's premier medical institutions—New England Baptist Hospital, and Brigham and Women's Hospital—who were left bickering over the protocol and ethics involved in a bizarre late-night incident in which Lewis and his wife fled Baptist for Brigham accompanied by a top administrator from Brigham, a security guard and a police dog. Finally, and perhaps most surprising, it includes a number of Boston's best cardiologists, who have been dragged into a public debate over two radically different diagnoses: 1) that Lewis's heart is damaged in a manner that could threaten his life or 2) that it is essentially normal.
The night he collapsed Lewis was playing like a man possessed. He scored 10 points in the first three minutes. Two and a half minutes later he crumpled to the floor, where he lay unable to orient himself for several seconds before rising unsteadily and walking to the bench. Arnold Scheller, 45, the Celtics' team physician, later said that he assumed Lewis had "had his bell rung," and he allowed Lewis to return to the game following three minutes on the sidelines. But Lewis was still wobbly, so after playing another minute, he and Scheller retired to the locker room.
After watching tapes of the game during halftime, Scheller realized Lewis had not been struck before collapsing. That meant he had fainted—a fact that raised serious medical questions. Lewis insisted that he felt fine and that he wanted to return to the game. Celtic CEO Dave Gavitt grilled Scheller about whether he was "100 percent comfortable" with the idea of Lewis's starting the second half. According to The Boston Globe, Scheller replied, "There's nothing there that I can determine other than maybe it's low blood sugar or just he's so excited." Lewis started the second half, lasted six minutes before appearing to be unsteady again and was removed from the game for good.
Scheller's decision to let Lewis reenter the game raises the classic conflict-of-interest question facing team doctors: Which comes first—the interests of his team or the interests of his patient? The situation is often further complicated by the athlete's desire to return to action sooner than he should. Arthur Caplan, director of the University of Minnesota Center for Biomedical Ethics, defines the issue this way: "The team doctor too often treats the player only in the context of the team. He must consider the patient and his family. There is more at stake than fitness to play. The needs of the public are secondary. The ethical duty must be to the patient first. But there's always a danger that a team doctor will shade his diagnosis more toward the positive than he should."
Marc Rodwin, an associate professor at the Indiana University School of Public and Environmental Affairs who has published widely on medical ethics, told the Boston Herald, "Any employed corporate physician has his loyalty compromised. He may act with the best of intentions, but he knows who he's working for." In fact, a former NFL team physician told SI that an association with a professional team can be such a boon to a medical practice that some team doctors actually pay teams to serve in that capacity.
In defense of his decision to put Lewis on the floor in the second half, Scheller said, "When someone gets light-headed in athletic competition, there can be any number of reasons. The most common are dehydration or low blood glucose." He points out that Lewis's blood pressure was stable and that he showed no sign of arrhythmia, meaning an abnormal rhythm of the heart.
However, Caplan asks bluntly, "Why doesn't fainting result in automatic benching for the day?" And Dr. Robert Cantu, president of the American College of Sports Medicine, told The Boston Globe that, in his opinion, when a player faints during vigorous exercise, "you need to rule out a cardiac problem before you allow him to go back to strenuous physical activity."
Indeed, Scheller had responded with alacrity to hints of a cardiac problem only four days earlier—albeit under totally different circumstances. An Army reserve officer who is also trained as a Ranger, the Army's elite guerrilla fighters. Scheller had been climbing Mount Kilimanjaro in Tanzania as part of a promotional trek for a new all-terrain hiking boot made by a shoe company with which he has a contract. Also on the climb was a 45-year-old commercial photographer, who complained on the way up of symptoms that could have been indicative of a heart problem. No second half for this fellow: Scheller sent him down the mountain, pronto.
Some experts say that Scheller's failure to see potential peril in Lewis's playing after he had fainted was understandable. Robert E. Leach, a former Celtic team doctor and currently the editor of the American Journal of Sports Medicine, the leading magazine in the field, puts it this way: "When you are a team doctor taking care of top athletes in their 20's, you do not expect a heart problem. This is not a 58-year-old man with chest pain. This is a young man performing at the highest level of athletics. It takes you by surprise."
Maybe Scheller should not have been so surprised. Had he taken a comprehensive medical history from Lewis, he presumably would have been told about a similar instance of dizziness and disorientation during a game in Miami on March 24. Indeed, after the April 29 collapse in Boston, Lewis told another doctor that he had had dizzy spells no fewer than five or six times over the previous two months. Following the Charlotte game Lewis told the Globe's Jackie MacMullan. "I was scared. I started having flashbacks to that Hank Gathers thing."
He was referring to the death of the 23-year-old Loyola Marymount star during a game on March 4, 1990, in Los Angeles. Gathers had collapsed during a game for the first time in December 1989 and was later diagnosed as having cardiomyopathy, a treacherous condition that can cause violent arrhythmia and, ultimately, heart failure. Despite this diagnosis Gathers was able to continue playing basketball—and to keep his NBA hopes alive—with a medication called Inderal. Trouble was, a fully prescribed dose made him lethargic. The night he died. Gathers had taken a drastically reduced dosage in an effort to keep his energy up.
Questions arose then about the wisdom of sending Gathers back onto the basketball court with such a dire medical condition. Lewis and his doctors might yet face a similar life-or-death decision. Two days after collapsing he checked into New England Baptist, the hospital with which Scheller is affiliated, and began some procedures to test his heart. But this was not to be a routine, run-of-the-treadmill workup. After all, the patient was none other than the Celtics' brightest star, a hero felled during the NBA playoffs, when press coverage is at the peak of its intensity.
Partly because of this hyped-up atmosphere—and partly, perhaps, to defend themselves against any future court claims by Lewis of inadequate treatment—Scheller and the Celtics assembled 12 of the finest, most-renowned cardiologists from the local medical community, which is overrun with fine, renowned cardiologists. Scheller called the consultants on Lewis's case "the Dream Team of cardiology."
What happened next was no dream, however. After a couple of days of tests at Baptist, Lewis and his wife, Donna Harris-Lewis, left New England Baptist late on the night of May 2 and moved to Brigham and Women's to seek a second opinion. Late last week the couple explained in a radio talk-show interview over station WEEI, the Celtics' local broadcast outlet, that they had changed hospitals not because they had been given a devastating diagnosis by the Dream Team but because the superstar consultants had refused to confer with them in person about that diagnosis, leaving only Scheller to explain the bad news to them.
"We did request to speak with [the 12 cardiologists], and the request was denied," said Donna. "Dr. Scheller was wonderful in bringing those doctors together, but we couldn't meet with those doctors. As far as I'm concerned, they're invisible."
What wasn't invisible was Lewis's abrupt—and highly unorthodox—transfer from Baptist to Brigham. The move was facilitated by George Kaye, vice-president of human resources at Brigham. Donna had once worked for Kaye, and she called him earlier that night to relay the frustration and annoyance she and her husband felt at both the diagnosis and the attitude of the Dream Team doctors. Kaye responded by arriving at Baptist at 10:30 p.m. with a Brigham security van, replete with a uniformed guard and a police dog, to pick up Boston's most-publicized hospital patient.
What bothered the Baptist people about Lewis's leaving was not so much Kaye's aggressive attitude or his failure to give any advance notice of his intentions or his failure to show any identification; what bothered them was the fact that Kaye did not move Lewis to Brigham in an ambulance. Baptist spokesman James Rattray, who was at the hospital at the time of the walkout, told the Boston Herald, "What we would have liked to have seen was for [Lewis] to go down to Brigham by ambulance, hooked up [to heart monitors]. We gladly would have arranged that. There absolutely should have been a medical attendant with Reggie at all times. He was absolutely put in potential danger. It was unprofessional, unethical and unsafe. The way he was transferred did not take into account his medical condition."
Even with all the commotion, things might have calmed down if Scheller hadn't launched a media barrage. The next day he went on television and, without permission from Lewis, revealed that the 12 wise men had concurred in a diagnosis of cardiomyopathy, the same ailment that had killed Gathers. He said that Lewis suffered from ventricular tachycardia, "the most life-threatening arrhythmia," and that Lewis had "dodged a bullet" when he fainted in the Charlotte game. He held out little hope for Lewis's basketball future, declaring that there was a "strong probability" he could never play again.
Scheller then suggested that the Lewises had probably been in a "phase of denial" over the seriousness of Reggie's condition when they stalked out of Baptist. He also took the opportunity to congratulate himself and the Celtics for assembling the Dream Team. "It was like putting together 12 cardiologists with egos as big as the Atlantic Ocean and not always agreeing," Scheller said. "They came in on a Sunday afternoon (May 2) and put their egos aside, and they were going to solve this one problem. I don't think Reggie appreciated that. I hope he does in time come to realize the level of medical care he had at his access before he walked out on it."
Lewis, who had not been examined by even a single member of the Dream Team, was appalled. "I just thought that no one should have been saying anything at that point—not about my life," he said in his radio interview last weekend. "If I wanted people to know something, I feel like I have the right to give out that information."
Added Donna, "We did take that initial diagnosis very seriously. I felt at the time that information should not have been released."
Many in the medical community were aghast that Scheller had gone public with the dire diagnosis—with or without Lewis's permission. Leach, the editor and former Celtic doctor, said, "The thing to do is hold back, let the team make the announcements. Thinking out loud in front of TV cameras is not going to help anyone. And the 12 cardiologists were a bit of overkill."
The diagnostic news was all the more crushing for Lewis because he had only recently come into his own as Boston's centerpiece player. Like every Celtic veteran of recent years, he had performed in the shadow of Larry Bird, but in his sixth season, with Bird retired and Kevin McHale about to be, the team had begun to rebuild around Lewis. His life was a dream in itself—particularly for a kid from a drugs-and-gunfire neighborhood in Baltimore. He and Donna own a house in Dedham, Mass.; have a 10-month-old son, Reggie Jr.; and can pretty much live as they please on the $3.3 million a year, guaranteed, that Boston pays him. Having come so far, how could he not insist on a second opinion?
The man who had approved his transfer from Baptist was Dr. Gilbert Mudge, director of clinical cardiology at Brigham and Women's Hospital, which specializes in cardiac medicine (Baptist is best known for orthopedics). Mudge began a slow, thorough workup of Lewis. "I questioned him very carefully," Mudge told SI. "It took hours. We went over it again and again."
Mudge learned of the other dizzy spells. Lewis told Mudge that he felt all right when running full speed, but that he felt strange when he stopped. "Reggie said if there was a timeout and he sat down, he felt bad," said Mudge. "If he stood up, he was immediately O.K."
Mudge studied the test results from Baptist. He repeated the echocardiogram, which bounces sound waves off the heart to search for physical damage and congenital abnormalities. "It was normal," said Mudge. "He had the normal heart of an athlete."
Mudge also redid the stress thallium test, in which thallium is injected into the bloodstream so that blood vessels are visible on an X-ray. At first the results were abnormal. Then Mudge realized that the angle of the X-ray machine needed to be adjusted for a man of Lewis's height (6'7"). When that was done, the test was normal. Another test, in which a catheter was inserted in a vein in the groin that feeds up to the heart, found the cardiac arteries to be normal but also found a minor abnormality in the pumping action of the heart, which Mudge attributed to a drug, ergonovine, that Lewis had taken during tests at Baptist.
Next, Mudge did a tilt test, in which the patient is strapped to a table and put through a sudden shift from horizontal to vertical positions. Lewis told Mudge that the procedure made him feel the same as he had during his various dizzy spells. Lewis was given medication, and the test was repeated. This time the result was normal.
At that point Mudge was ready to announce his diagnosis: Lewis was suffering from neurocardiogenic syncope, a relatively benign neurological condition in which the vagus nerve, which transmits information that regulates the tempo of the heart, sends confused signals to the heart about how hard it should be pumping blood. The condition results in fainting episodes caused by an inadequate supply of blood sent to the brain. Mudge said the condition is "poorly understood."
Harold Klawans, a Chicago neurologist, says, "It is a crazy reflex abnormality. We really have no idea what makes it happen. But the incorrect signals from the vagus nerve can be easily blocked by medication."
On May 10, Mudge told a press conference, "I am optimistic that under medical supervision, Mr. Reggie Lewis will be able to return to professional basketball without limitation." That's clearly what Lewis hopes to do. "I'm just glad," he said, "it's finally come to an end."
But it hasn't. Mudge's rosy diagnosis stood for less than a day before it came under attack by a member of the Dream Team. Mark Josephson, director of the Harvard/Thorndike Electrophysiology Institute at Beth Israel Hospital, told the Globe, "I still think ventricular arrhythmia is more likely the cause of his collapse than neurocardiogenic syncope."
Josephson disputed Mudge's findings in the echocardiogram ("cardiomyopathy can be missed with an echocardiogram"), the catheterization ("ergonovine cannot explain the abnormal results") and the tilt test ("it can be falsely positive 15 to 25 percent of the time, and a positive tilt test may have nothing to do with the problem"). He said that Lewis's electrocardiogram at Baptist had been "very abnormal; it was not subtle" and that the Dream Team doctors "did not make up" their findings.
"I would love for him to have [neurocardiogenic syncope]," said Josephson, "but our thallium and catheterization tests were consistent with each other and with an MRI [magnetic resonance imaging test]. All showed damage to part of the heart."
So what does it all mean? About the only thing one can say for sure is that the questions remain almost as puzzling as they were the night Lewis collapsed against Charlotte. Can Lewis ever play again? Should he? Should the Celtics let him? What are the legal ramifications? The medical? The financial? The telltale heart pounds on and on.
PHOTO
BILL BRETT/BOSTON GLOBE
When Lewis went down on April 29, Scheller initially did not see any cause for concern.
PHOTO
STEVE LIPOFSKY
[See caption above.]
PHOTO
EVAN RICHMAN/BOSTON GLOBE
With some late-night help from Kaye (right), Lewis (center) bolted Baptist for Brigham.
DIAGRAM
ENID V. HATTON
Right Ventricle
Left Ventricle
Affected Area
DIAGRAM
Vagus Nerve
PHOTO
FRANK O'BRIEN/BOSTON GLOBE
After a week of tests Mudge announced new medical conclusions that left Lewis elated.
TWO PHOTOS
BRUCE HAZELTON/THE DAILY BREEZE
Gathers, who suffered from the ailment that may plague Lewis, collapsed and died in '90.
PHOTO
FRANK O'BRIEN/BOSTON GLOBE
Reggie and Donna were far happier after they had turned their backs on the Dream Team.
DIAGNOSIS # 1
Cardiomyopathy
Damage to or thickening of an area of the heart wall—in Lewis's case, the left ventricle. This condition makes a patient sunsceptible to ventricular tachycardia, a potentially lethal quickening of the pumping action in that portion of the heart that delivers blood directly to the body.
DIAGNOSIS # 2
Neurocardiogenic Syncope
Heart rate and blood pressure fall during periods of heavy exertion because of inappropriate neurological signal sent via the vagus nerve to the heart. The condition can be treated with medication that blocks those inappropriate signals to the heart.