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| Walter J. Nicholson, M.D. |
The teacher was preparing his six eager pupils in the “extremely advanced” science and math sessions at Georgetown Prep “to think,” said interventional cardiologist Dr. Walter Joseph Nicholson, one of those lucky students.
Jay, as he is known in the York community, made the decision to go into medicine when he was attending that rigorous all-male Jesuit Catholic school. He told me that he wanted to help people. No, that he had to help people. And that he didn’t want to get bored. And that he wanted to be (and that he is) a diagnostician.
The family left Jersey City for Middletown, Pennsylvania when he was in grade school and they later moved to Pittsburgh, and then Dover, Delaware. After high school, Jay went to Georgetown University for a year and then transferred to (then all-male) Franklin and Marshall College in Lancaster for tough pre-med studies. He met his wife Carol (a native of York) while at F&M. She was studying at nearby Millersville, long recognized as a fine training ground for teachers.
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| Georgetown Prep in Bethesda, Maryland (from Archdiocsis of Washington) |
When Jay went to Dr. Jensen one day and informed him that he had changed his mind, that he wanted to switch to cardiology and to go to Emory, the insightful Dr. Jensen “was not surprised.” The professor had good contacts, and he graciously facilitated the future cardiologist’s transition to Dr. J. Willis Hurst’s program.
But before he went to Atlanta Jay served two years (1969-1971) in the United States Public Health Service in Tampa where he practiced general medicine as he took care of those in the Coast Guard and Merchant Marines as well as retired military. He left the Service with the rank (his wife, who was listening quietly as she was sitting across the room during our late February afternoon interview, had to remind him) of Lieutenant Commander. He and Carol still enjoy visiting the Tampa-Clearwater Beach area for a few days when it’s frigid up north.
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| J. Willis Hurst, M.D. |
Jay did a formative year-long fellowship with master diagnostician Dr. R. Bruce Logue (1911-2007). Jay found him to be “the most intense man on the planet” and “a terror.” He was “totally intolerant of indecision.” (Those who work with our protagonist in the cath lab may, perhaps, spot faint glimmers of those endearing traits during an especially busy day, or when there is a tricky case.)
Dr. Logue, with his steely gaze, could “seize on the one important piece of information” that would instantly clarify a clinical situation and clinch the diagnosis. Jay worked hard, side-by-side, and hour after hour, with him to acquire that valued skill.
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| R. Bruce Logue, M.D. |
Anyway, Jay’s second fellowship year was spent with innovator Dr. Spencer B. King III in the cardiac catheterization lab. It was there that Jay experienced the beginnings of what would become his passion in medicine. At the time (the early- to mid-1970s), a diagnostic cath was the only “procedure” available to the non-surgical heart specialist.
Reflecting on these experiences, Jay noted that, as a doctor-in-training, the most important lesson he learned was to make himself available to the mentor. To be there. He said that he cannot stress that enough to young people. He realizes, however, that advanced training in medicine has changed, and that a close and extended mentor-mentee relationship is not common anymore.
After Atlanta, and with a single catheter in hand (“99% use three,” he said), Dr. Nicholson joined the congenial and welcoming York Hospital staff in 1976. He teamed up with cardiologists Dr. Jack Gracey and Dr. Ed Martin. The “three musketeers” relied on the patient’s history, the physical exam, the EKG, the chest X-ray, and the simplest of echocardiograms to make a diagnosis; “everything was clinical” then, Jay told me (with obvious nostalgia for those disappearing skills).
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| Laennec's Baton ~1816 (he later coined the term "stethoscope") (1960s poster by Robert Thom) |
Anyway, when starting out in York, Jay’s goals (apart from expert patient care, of course) were to teach and to develop a strong and enduring cardiac program. He felt an “obligation” to share his knowledge. And he wanted to build something. So he went to work.
At that time, the late 1970s, the cardiologist’s treatment for heart attacks in the coronary care unit (the CCU) was limited to controlling dangerous rhythm disturbances, especially chaotic ventricular fibrillation (that often resulted in sudden death), and alleviating acute congestive heart failure (due to the weakened heart muscle).
Specific medical therapy to restore blood flow to the area of the heart that was deprived of oxygen and dying was simply not available; the heart surgeon was needed for that. After a heart attack, if you survived, you carefully rested for weeks while waiting for the damaged muscle to slowly heal.
But the next year, 1977, things changed.
The charismatic and darkly handsome Dr. Andreas Gruentzig, from Dresden through Zurich, had been inspired by the work of radiologist Charles Dotter (1920-1985). Dr. Dotter showed that clogged arteries in the leg could be gradually opened using a series of rigid catheters.
But there were complications of the procedure as the plaque was scraped off of the wall of the artery and plugged up smaller vessels downstream. Andreas had a better idea. He thought he could open an artery, even a narrowed coronary artery, more safely if with a less traumatic technique.
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| Dashing Andreas Gruentzig, M.D. with his balloon catheter |
He came up with a working prototype and then spent the next two years looking for someone to manufacture the unlikely contraption that everyone knew would never work.
Dr. Gruentzig finally succeeded, and on 9/16/77 he cautiously (with the surgeon standing by, waiting for something to happen) used his device to open up a short segment of Adolph Bachman’s critically narrowed left anterior descending artery. This instantly relieved the awake patient’s chest pain, and the surgeon could quietly put his scalpel away. Cardiology (and medicine) was changed forever.
(As noted in an article on Gruentzig in Wikipedia: “By utilizing the arterial circulation as a 'therapeutic highway' many types of devices and drugs can now be delivered directly to the heart, kidneys, carotid arteries, brain, legs, and aorta without the need for major surgery and general anesthesia.”)
Dr. Andreas Gruentzig was given a standing ovation when he presented his revolutionary data at the big American Heart Association meeting later that year.
Dr. King (against Dr. Hurst’s advice, at first) managed to convince the sought-after Dr. Gruentzig to join his staff in Atlanta in 1980. While there, Andreas enthusiastically shared his knowledge with the world. Dr. Nicholson, ever hungry for learning, “took all of his courses.”
“These mentors, and a bit of hard work, have made me who I am,” said Jay. (You see, his mentors had something he wanted.)
(He felt that Dr. Gruentzig, the most famous cardiologist of our time, would have received the Nobel Prize for his work had he not died in 1985 at 46 when his single-engine Beechcraft Baron crashed in a violent storm as he was piloting it back to Atlanta to take care of scheduled patients.)
It may seem to you that cardiology, the cath lab (that was named after him four years ago, to his slight embarrassment), and commitment to the York Hospital (who last year honored his 50 years of steady dedication and support) might be Jay’s whole life, but there’s much more.
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| Dr. Nicholson (you can spot him in the white shirt and tie) and his loyal cath lab team |
“But then all these kids showed up,” marveled the proud, and (mockingly) surprised father. Tommy, now 50, arrived first; Billy and Cindy soon followed. All three played basketball in school. Jay coached both boys and rearranged his schedule so he could go to “a thousand” of their games.
Tommy was a talented “sixth man” scorer at F&M while Billy (also a student at his father’s alma mater) settled on the more gentlemanly sport of golf. Both boys went into medicine (a bit more on this later). Cindy (owner of, get this, eight varsity letters) was terrifyingly intense on the basketball court. She decided to take that energy to the court of law where she defends physicians against claims of malpractice.
When the kids were involved in their high school sports Carol was the busy “taxicab driver.” A pizza for dinner from Domino's was the routine. And Jay remarked that if they missed ordering a pie two days in a row someone from the shop would call to see if there was anything wrong. (Hey, could it be that they just wanted to try Papa John’s?)
“I tried to be the best dad in the world, and it was a thrill to have the kids,” said the sometimes-modest Dr. Nicholson. He told me, in fact, that he had the “best time” of his life with them.
Jay’s own father, one of eight children, grew up in Brooklyn during the Great Depression and didn’t finish high school. He worked for the government, and Jay said that he was “the smartest guy” he ever met. He “always wore a white shirt and tie.” He was a “gentleman and a gentle person.” Jay’s mother graduated from college at 41 or 42. Sadly, she died in her later 40s as a result of trauma.
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| Men in a bread line in Brooklyn during the Depression (from Hulton Archive) |
In 1980 it was definitively shown, contrary to the conventional (and wrong) thinking at the time, that heart attacks occurred as a result of an acute clot, or thrombosis, in a coronary artery, not progressive gradual narrowing to a critical point (with the clot occurring later).
In 1986 an important study showed that adding a medicine (streptokinase) to break up the fresh thrombus resulted in a slightly lower death rate at three weeks (10.7%) compared to usual treatment alone (13%). But there were bleeding complications, sometimes severe.
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| Process of acute coronary thrombosis (from bioninja) |
The balloons and stents have relieved countless patients of debilitating anginal chest pain and preserved the heart muscle of millions of individuals who were in the throes of an acute MI. The sooner angioplasty is done during a heart attack, the more vital tissue is preserved, so speed matters (and Jay, as I’ve heard, is fast, really fast). This technology has allowed patients to avoid the physical trauma, the slow post-op recovery, and the inherent risks of general anesthesia and coronary bypass surgery.
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| Most with an acute MI now have angioplasty within 90 minutes (from PLOS ONE) |
Listening to him, I asked Dr. Nicholson (who said he’s done more than 60,000 procedures) if there were any of his former patients that he still thinks about. Yes, he said, as he looked towards his wife. He cleared his throat (he had used a lozenge-what a funny word, “lozenge”) and recalled that there were “about five patients” who stayed with him.
Were these miraculous and dramatic “saves” in the cath lab, like on TV? Were these people brought back from the brink of death? No. They were not.
These unforgettable patients were individuals who demonstrated remarkable bravery as, over the years, they underwent repeated major heart surgeries while their complex disease, disease that could not be fixed with a catheter tip or the latest medication, worsened. Jay felt their suffering, and he admired their courage and their faith.
Speaking of faith, as a practicing Catholic, Dr. Nicholson said that he attends church regularly. He gives thanks for what he’s been given, and what he has been able to give to others.
Let's get back to the heart. Unfortunately, many patients with advanced disease, it turns out, have no (or only vague non-specific) symptoms before they suffer an acute heart attack or sudden death. Stress tests and CT scans looking for calcium build-up in the coronary vessels (a good study, if negative) are useful, but they are imprecise. “If you want the 100% test you need a heart catheterization,” said Jay emphatically. And he feels that “patients want to know,” that they want the study that will give them a clear answer.
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| Calcium CT scan showing calcified vessels (from Radiology Associates of Clearwater) |
The effective treatment of elevated cholesterol, or hyperlipidemia, with so-called statins, discovered in 1976 by dogged Japanese chemist Akira Endo, and weakly approved by the FDA in 1987, revolutionized the medical treatment of coronary atherosclerosis. (Statins also stabilize plaques and reduce inflammation of the vessel wall.)
Thus, Jay’s typically no-nonsense straightforward advice to his patients: “Stop smoking and take a statin!”
And about half of the decline in the death rate over the years has been due to better management in the CCU and efforts in the cath lab. In the 1960s nearly 50% of those admitted to the hospital with heart attacks died in a few days; the fatality rate now is only 4-6%. However, the decline has been leveling off over the past decade, and heart disease is still the leading cause of death in the United States.
So Dr. Nicholson, wearing a crisp white shirt and a tie, and with our dog, Toby, quietly nestled by his side, told me that to accomplish his goal of providing an enduring source for the best cardiac care possible for the people of York he managed to recruit many talented physicians who could have easily chosen to go elsewhere. He feels that the heart program here is strong. He first envisioned a free-standing cardiac center about ten years ago. It took a while, but construction for this began recently.
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| Artist's rendering of the new WellSpan Heart and Vascular Center (from Wohlsen Construction) |
And what about his doctor-sons I mentioned before? The elder, Tommy, is a colorectal surgeon in a busy practice across town with two partners. His younger son, Billy, followed his father’s example more closely and went to Atlanta and became an interventional cardiologist himself.
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| Father and son team |
Dr. Nicholson has often told his wife that if he “dropped dead” today, they could say of him that “that guy found what he wanted to do, and he had the best time in the world doing it.” That “he got everything he anticipated, and a lot more.”
“It has been perfect.” Jay was pleased to tell me.
But things change. Billy is set to move on. He wanted to be more active in teaching at all levels, and he’s been asked to head up the renowned interventional program at Emory. Jay said he hates to lose him, but he understands why his son needs to take advantage of this wonderful opportunity.
So, from Dr. Paul Dudley White to Dr. J. Willis Hurst and Dr. R. Bruce Logue, to Dr. Spencer B. King III, to Dr. Andreas Gruentzig, to Dr. Walter J. Nicholson, to Dr. William (Billy) Nicholson, to...
When a generous teacher meets an engaged student good things happen.
(Note: Despite the fantastic advances in heart care over the past 50 years there is much more to be done. Roughly 640,000 Americans still die of heart disease each year. And heart disease has been the number one cause of death in the U.S. every year since 1910--Except for the years 1918-1920, when the most common cause of death, by far, was influenza and pneumonia during the devastating Spanish flu pandemic.)
Recommended readings:
1. Forrester, James S., M.D. The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives. New York: St. Martin's Press; 2015. (Enjoyable, and very well written.)
2. Jauhar, Sandeep. Heart: A History. New York: Farrar, Straus and Giroux; 2018.
3. Hurst, J. Willis, Logue, R. Bruce, Schlant, Robert C., and Wenger, Nanette Kass, eds. Third edition. The Heart; Arteries and Veins. New York: McGraw-Hill, 1974. (Later editions are okay, too.)
4. Warraich, Haider. State of the Heart: Exploring the History, Science, and Future of Cardiac Disease. New York: Martin's Press; 2019.
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| Orchid opening (photo by SC) |
