Heart: An American Medical Odyssey

by Cheney, Dick

  • • •

  I waited for Sung to finish, and together we walked over to tell Mrs. Cheney that all was well. The vice president’s family was waiting in a secure area that during the week served as a small postprocedure recovery room, but had been dressed up for the occasion to function as a family lounge with a couch, food, TV, and Internet access. Sung and I were in good spirits when we entered the room, but right away it was apparent that Mrs. Cheney was not.

  In 2001, ICD therapy was unknown to most of the public, and even within the cardiology community, it was still very much a cutting-edge technology that had yet to be fully embraced. It’s easy to convince a patient who survives sudden cardiac death of the merit of a small implantable device that can prevent another episode, but it’s a much harder task when the patient seemingly is well. Gary, Sung, Lew, and I had discussed the rationale for our recommendations in depth with the vice president when we met with him earlier in the week, but we had not met with Mrs. Cheney, and I think she clearly still had some questions about the need for the procedure. Now that the device was implanted, Mrs. Cheney was concerned about the safety of the ICD in the unusual environment in which the vice president lived, worked, and traveled.

  Mrs. Cheney had done her homework and knew that ICDs could be affected by electromagnetic interference (EMI). Weak electromagnetic fields are emitted from all electrically powered equipment, but some types of gear emit significantly more EMI, which can mimic ventricular fibrillation and induce the ICD into inappropriately delivering a shock. Medtronic, the manufacturer of the vice president’s new implant, lists antenna and large radio transmission equipment as significant sources of EMI. Mrs. Cheney reminded us that the vice president’s limousine, residence, helicopter, airplane, and the White House itself were filled with high-power radio transmission gear, and she wanted to know how we knew it was going to be safe for her husband.

  The truth is I didn’t know. I had been focusing on the treatment algorithm (low ejection fraction + ventricular tachycardia = ICD) but had neglected to fully consider the unique considerations that might accompany this patient’s job. It was a humbling moment, one that I was determined never to repeat.

  Sung and I located John Naylor, the representative from Medtronic, who had been present during the implant, and explained Mrs. Cheney’s concerns. John got on the phone, and over the next several days, company engineers swept the vice president’s residence, offices, and vehicles for EMI. To our great relief, they found no areas that would be a safety concern.

  CHAPTER 11

  Treating the Vice President

  DR. REINER

  The summers in Washington are long, but on this early September morning, the cooler air and crystalline light offered a whispered promise of the fall to come. I had an appointment at the White House with Vice President Cheney later in the day, so I dressed in a dark suit, a bit more formal than usual, and headed off into the dense DC morning traffic.

  It had been about three months since Sung Lee implanted the defibrillator. Lew Hofmann had arranged for one of the WHMU nurses to draw blood from the vice president early in the morning and messenger it up to the lab at Bethesda Naval Hospital that day, so the results would be available when we met with him. We planned to arrive about fifteen minutes before our 5:00 p.m. appointment and review the labs with Lew before we saw Cheney.

  At 9:00 a.m. a small crowd gathered around a television mounted on a wall in the hospital’s first-floor radiology waiting room.

  “What’s going on?” I asked.

  Someone said that a small plane had crashed into the World Trade Center in Lower Manhattan. I stood with a growing group of patients and staff and watched as smoke poured from the North Tower.

  There is always something happening in New York.

  I remembered the story of the B-25 bomber that struck the Empire State Building at the end of World War II. On that day, there had been dense fog in New York, but on this morning, there wasn’t a cloud in the sky. A few minutes later, United 175 hit the South Tower, setting that building ablaze. The crowd of hospital staff and visitors stood in silence as the buildings burned; there were screams when they fell.

  “Nothing will ever be the same,” I said to no one in particular.

  • • •

  It wasn’t long before we heard that the Pentagon had also been hit. From the upper floors of our office building, we could see smoke billow from across the river, and rumors began to circulate that another plane was headed for DC. The White House and the Capitol were evacuated, and the streets filled with thousands of people, some running, all trying to get out of town. I called Charisse and told her to go pick up the kids from school. Charisse asked me to come home, but I told her that the hospital had mobilized for casualties, and I was going to stay. Even if I wanted to leave, there was gridlock everywhere and no way to get out of town.

  I heard from Lew in midafternoon. He was with the vice president; they were okay and soon to be on the move. He told me he would be in touch when he could.

  Lew called again later. Despite the chaos of the day, the vice president’s blood had somehow made it to the lab in Bethesda and the results were back. The blood had been drawn early in the morning, and after everything that had happened during the day, I had forgotten all about it. Lew told me that the vice president’s potassium level was a potentially lethal 6.9.

  “Say that again, Lew.”

  He did, and I told him that it must be an error. He said that’s what he thought, but the lab had verified the result.

  A high blood concentration of potassium is called hyperkalemia, and a level that high is a medical emergency because it can lead to cardiac arrest. Lew asked if the vice president’s defibrillator would protect him, and I told him if the vice president really was hyperkalemic, it would not.

  I asked Lew if there was any way to repeat the potassium test that night, and he told me that it was possible, but it would take a couple of hours to get the blood to a lab. I did not ask Lew where they were going; it wasn’t something I needed or wanted to know. Many years later, I learned that to ensure the continuity of government, the vice president was taken to Camp David, the presidential retreat in the Catoctin Mountains of Maryland. On the helicopter ride from the White House, Lew passed a note to the vice president informing him that we needed another sample of blood.

  “Not tonight, Lew. You can have it in the morning,” the vice president responded.

  • • •

  The back cover of Vice President Cheney’s memoir, In My Time, features a solemn photograph taken aboard Marine Two, the vice-presidential helicopter, as it left the South Lawn of the White House on September 11. The image, taken by White House photographer David Bohrer, depicts the vice president and Mrs. Cheney in an intensely personal moment. Just visible in the vice president’s hand is the note from Lew Hofmann alerting Mr. Cheney to our concern about his blood.

  VICE PRESIDENT CHENEY

  On the morning of September 11, 2001, I was at work in my West Wing office with John McConnell, my speechwriter, when my assistant, Debbie Heiden, called in to report that an airplane had struck the World Trade Center in New York. I turned on the TV and a few minutes later saw the second hijacked aircraft strike. I placed a phone call to the president, who was in Florida, and we agreed this was clearly a terrorist attack and discussed what he was preparing to say to the press.

  As colleagues on the White House staff gathered in my office, the door suddenly burst open, and Jimmy Scott, one of my Secret Service agents, came rushing in and told me we had to leave immediately. He placed one hand on my left shoulder, and with the other hand he grabbed the back of my belt and propelled me out the door. When we reached a tunnel underneath the White House, we stopped as more agents joined us and additional weapons were taken out of a locker. At that point, Scott told me they had evacuated me from my office because of a report from the control tower at Washington Dulles International Airport that an aircraft, believed to have been hijacked,
was headed for the prohibited air space over Crown (the code word for the White House). This plane was American flight 77, which had struck the Pentagon. There was a small black-and-white TV set in the tunnel as well as a secure phone, which I used to call the president. I told him that Washington was under attack as well as New York and recommended that he not return to the White House until we could ascertain the extent of the attack. The Secret Service made the same recommendation.

  After the call we proceeded down the tunnel to the Presidential Emergency Operations Center (PEOC), where I would spend most of the rest of the day. Norm Mineta, secretary of transportation, joined me there and was instrumental in working with the Federal Aviation Administration in getting all of the aircraft down out of the sky that day. Initially we had reports of six hijacked aircraft and many inaccurate reports of car bombs, explosions, and other incidents.

  One of my major concerns was to “preserve the continuity of government.” In the event that an attack should take out both the president and vice president, it’s crucial to make certain that potential successors are safe and secure. On 9/11, I worked to arrange for the movement of Speaker Hastert to a secure location, since he was next to me in the line of succession.

  At one point shortly after I arrived in the PEOC, an Air Force officer came into the room and said that a plane believed to have been hijacked was headed for Washington and was just eighty miles out. He wanted to know if they were authorized to shoot it down. Based on a conversation I’d had previously with the president, I gave the order to take it out. A short time later, we received a report that a plane had gone down in Pennsylvania. Initially we believed one of our aircraft had shot it down. It was sometime later that we learned that the courageous passengers on United flight 93 had taken it down. If it hadn’t been for their bravery, flight 93 would most likely have been flown into the Capitol or the White House.

  Later that day after the president returned to the White House, he convened a meeting of the National Security Council and addressed the nation. That evening, Lynne and I flew by helicopter to Camp David, where we spent the night. I sat up until the early morning hours watching television coverage of the events of 9/11 and thinking about the policies we would need to pursue to make certain we didn’t get hit again.

  The events of 9/11 marked a sea change in terms of our priorities and policies and fundamentally changed the focus of our administration. Before 9/11, terrorist attacks such as the assault on the World Trade Center in 1993 and the attack on our embassies in East Africa in 1998 were treated as law enforcement problems. The FBI would investigate, capture the suspects, bring them to trial, and if convicted they would serve their terms in US prisons. But 9/11 changed the paradigm. The destruction of the World Trade Center, the attack on the Pentagon, and the murder of nearly three thousand Americans was an act of war, worse than the Japanese attack on Pearl Harbor.

  Our main priority for the remaining seven and a half years we were in office was to make certain the terrorists were never able to launch another mass-casualty attack against the United States. We were especially concerned about an attack using weapons far deadlier than airline tickets and box cutters, such as biological or chemical weapons or even a nuclear device. Using the president’s constitutional authority as commander in chief and the congressional authorization to use military force to capture al Qaeda, we implemented a number of programs designed to provide the intelligence we needed to prevent further attacks.

  The two most important programs were the Terrorist Surveillance Program (TSP) and enhanced interrogation techniques. TSP permitted us to intercept contacts between al Qaeda terrorists overseas and their associates inside the United States. According to General Keith Alexander, director of the National Security Agency, this program has allowed us to intercept some fifty attacks targeting the United States and friends overseas. The enhanced interrogation program was instrumental in our ability to develop vital intelligence about al Qaeda. In 2004 the CIA produced a report concluding that Khalid Sheikh Mohammed, the mastermind of 9/11, had been the “pre-eminent source on Al Qaeda.” KSM was subjected to these techniques more than any other high-value detainee. Both programs have generated considerable controversy, but they both produced valuable intelligence we needed to keep the country safe. The record speaks for itself.

  • • •

  For the twelve years prior to my election as vice president, I had no significant incidents involving my health. I experienced the one heart attack during the Florida recount, but it was a minor event, barely qualifying to be called a heart attack. For the eight years I was vice president, however, there were events that indicated my coronary artery disease was progressing. I never believed that the disease inhibited my capacity to do my job. I basically dealt with each problem as it came up, relying on my doctors to keep track of how I was doing physically and to let me know when I needed to make changes in my regimen or my medications. I did not sit in my office wringing my hands, worried about when the next heart attack would occur.

  After my first heart attack in 1978, I felt a strong sense of fragility in the period immediately after I was released from the hospital. I worried that if I moved too suddenly, I might trigger another event. As I reengaged in that first political campaign, I frequently recalled Dr. Rick Davis’s advice that “hard work never killed anybody.” As I grew stronger and was able to take on more and more responsibility in the campaign, I no longer worried about that next attack. I assumed my lifestyle changes had solved my problem.

  By the time I began my service as vice president I could look back on twenty-two years of living with heart disease. I had accomplished a lot in spite of my condition and was confident going forward that I could continue to do the same. The key was to deal with my health separately from my job and never to let one interfere with the other. I didn’t want worries about my heart disease to keep me from focusing on the requirements of my job. And I didn’t want the job to be an excuse for not doing something that needed to be done to deal with a health problem.

  As we approached the 2004 reelection campaign, I raised with President Bush the possibility of my stepping aside so he could appoint someone else to serve as vice president in his second term. This wasn’t related to my health, but rather because I felt strongly that the president should have the opportunity to make a change if he thought it would strengthen the ticket. I believed, as the incumbent vice president, that it was my responsibility to make it easy for President Bush to select someone else if he wanted to do so. The first two times I brought the subject up, I felt President Bush had not really focused on it. So I went back a third time and he agreed to think about it. A few days later, he came back to me and said that he wanted me to continue on the ticket, which I was honored to do.

  DR. REINER

  When Lew Hofmann redrew the vice president’s blood early in the morning on Wednesday, September 12, he had more on his mind than just potassium. The repeat labs were normal, and ultimately we deduced that the high potassium was simply the result of the prolonged delay in processing the sample, which ensued following the evacuation of the White House. This is the note that he sent to the vice president:

  September 12, 2001

  Mr. Vice President

  I am very pleased to report that your repeat potassium was NORMAL! Both Dr. Reiner and Dr. Malakoff share my joy. . . .

  Find enclosed your dose of Cozaar and K-Dur for today. Additionally, there is a packet of doxycycline antibiotic for protection from anthrax infection as we discussed this morning. Dr. Malakoff is fairly certain that he has given you this medication in the past without adverse effect. You should take one tablet twice per day for three days. Should the threat persist beyond then, I will provide another packet of medication. . . .

  Lewis A. Hofmann, MD

  White House Physician

  In the days and weeks following September 11, people in Washington, New York, and other cities around the country wondered whether, and when and how, the next a
ttack would come. National Guard Humvees were posted around DC, including on the sidewalk in front of our clinic, antiaircraft batteries were positioned on the National Mall, and police stationed at strategic locations brandished automatic weapons. Within this new reality, the White House Medical Unit took steps to protect the president and vice president from potentially weaponized biological agents.

  In a note to the vice president on September 15, Lew wrote:

  We began the prophylaxis in an uncertain threat environment in order to provide protection, flexibility, and reassurance to you. . . .

  Monitoring has been in place for several days, and no evidence of chemical or biological attack has been identified. . . . The risk of taking the medication is very small compared to the severity of illness that would be caused by exposure to anthrax. Therefore until the threat landscape becomes more clear, I recommend continuing the doxycycline.

  A few days later, letters containing anthrax spores were mailed to two US senators and several media outlets, resulting in the deaths of five people, prompting Lew to change his advice for the vice president:

  Dr. Tubb has recommended anthrax vaccination for the President, and I recommend the same for you. . . . I am writing to you as your White House Physician rather than as a biological warfare expert. . . . My recommendations are specific to your situation only, and cannot be generalized to large groups, forces or populations. They should also be placed in the context of intelligence reports you may have received to which I am not privy.

  In his book The White House Physician, Dr. Ludwig M. Deppisch calls the WHMU “an apolitical, professionally focused, tightly structured, military-staffed health maintenance organization,” but in post-9/11 America, the fuller scope of the medical unit’s mission became apparent.