Heart: An American Medical Odyssey

by Cheney, Dick

  After more than eight years serving the president and vice president of the United States and their families, Lew’s time in the White House was coming to an end. At the conclusion of President Obama’s inauguration, Lew was going to take one last flight out to Wyoming with Vice President Cheney and then return to Washington to take some well-deserved, and long-overdue, time off before tackling the last assignment of his twenty-six years in the military, flight surgeon for Air Force One.

  Our meeting with Vice President Cheney would be our last consultation during his time in office, and as I waited for him, I reflected on how my world, and his, had changed during that time. My beautiful little girls were becoming teenagers, my father and my sister Melanie were now gone, and my career had bloomed and become irrevocably interlaced with the care of this man.

  Cheney was a singularly complex patient. First, the sheer duration of his illness was extraordinary. The year 2008 marked the thirtieth anniversary of his first heart attack, the opening act of a drama that no doubt had been in the works for years before the thirty-seven-year-old congressional candidate was admitted to Cheyenne Regional Medical Center. Cheney’s remarkable survival was a testament to his dogged determination to live despite his disease and also to key therapeutics like aspirin, beta blockers, coronary care units, bypass surgery, statins, stents, and defibrillators—breakthroughs that were being added to cardiology’s armamentarium seemingly just when he needed them.

  A single heart attack can kill you, and this patient had outlasted four, but not without paying a steep price. The most recent echocardiogram revealed that the vice president’s heart was enormous, the biggest I had ever seen, about twice normal size, the end result of his malignant coronary disease.

  Now, three decades into his disease, the intervals between medical crises for Dick Cheney were becoming shorter and shorter and his rebounds not quite back to baseline. The trend, which had been level for so many years, was now clearly on the decline. As the vice president made the transition from public to private life, his illness was also entering a new stage.

  We told Vice President Cheney that although Lew Hofmann would be moving on to other duties, the rest of our medical team would ensure that his continued care would be seamless. The vice president seemed very much at ease, but I worried what I would do without Lew. I saw the vice president dozens of times during his two terms in office, but Dr. Hofmann and his colleagues were with Mr. Cheney every day. Whether in the West Wing, the Naval Observatory, Air Force Two, or Jackson Hole, and in war zones, undisclosed locations, and for many thousands of miles around the world, a member of the WHMU was always close by. It’s impossible to overstate the impact of their omnipresent, professional vigilance on his longevity. Lew never missed an opportunity to thank me for my help, but it was I who owed him the real debt of gratitude.

  I knew that when I next saw Mr. Cheney, he would no longer be the vice president of the United States, and I searched for the right way to acknowledge the moment. The usual platitudes seemed hollow, and instead I simply thanked him for his efforts over the prior eight years, and his long career, to keep my family, and this nation, safe.

  Cheney smiled warmly, shook my hand, and said, “Thanks Jon, you made my day.”

  Our meeting had a bittersweet air. As I watched Mr. Cheney leave the clinic, accompanied by his Secret Service escort for the last time as vice president, I knew this wasn’t the end of his story. In some ways, I feared, it was just the beginning.

  • • •

  Well over one million people attended the inauguration of President Obama on Tuesday, January 20, 2009. Because of the enormous assembled crowd and George Washington University Hospital’s proximity to the National Mall, the hospital activated an emergency preparedness plan, placing multiple hospital units on standby. I had been a guest at the previous two inaugurations, but I was on call for this event, and as I watched the televised ceremony from the operating room lounge, I was saddened when the cameras showed Vice President Cheney sitting in a wheelchair.

  Over the weekend as the Cheneys packed in preparation for their departure from the Naval Observatory, the vice president wrenched his back while reaching for a small box. His left-sided back pain was incapacitating, and on television he looked decidedly uncomfortable as Sarah Creason, a WHMU nurse, pushed his wheelchair onto the podium. It was ironic that for every one of his 2,922 days in office, I had worried about heart attacks, arrhythmias, aneurysms, and heart failure, but what ended up disabling him was something as prosaic as a bad back.

  • • •

  Over the next several months, Mr. Cheney’s cardiac status remained relatively stable. He was bothered most by the recurring pain in his lower back and left leg caused by the herniated disc incurred during his last days in office. When physical therapy and epidural injections failed to provide adequate pain control, we considered minimally invasive spine surgery. Although I was loath to expose Mr. Cheney to the stress of an operation, his pain was disabling, and I felt that with careful perioperative care, we could minimize his risks. On the morning of his back surgery, when it was time to go to the operating room, Dr. Paul Dangerfield, the anesthesiologist, asked Mr. Cheney if he wanted to ride down the corridor in a wheelchair.

  “No,” he said, standing up gingerly. “I want to walk. It will remind me of why I’m having this surgery.”

  The operation, performed by Dr. Anthony Caputy, GW’s chief of neurosurgery, was thankfully uneventful, and it quickly and remarkably resolved Cheney’s pain.

  A few months later, on December 1, 2009, Mrs. Cheney called and asked if I could see her husband because he was short of breath. After the vice president had left office, Medtronic enhanced our monitoring capabilities by installing devices in the vice president’s homes enabling him to upload telemetry and other data from his ICD to a secure website to which we had access. This technology allowed us to keep an eye on Cheney’s volume status and heart rhythm even when he was not in Washington, and for the most part, he had been stable. Now something had changed. Later that day the Secret Service, which would continue to provide protection for another month, brought Mr. and Mrs. Cheney to our offices in Foggy Bottom.

  A year earlier, a visit to GW would have involved elaborate logistics, including a motorcade with an armored limousine, several Secret Service Suburbans, a Metropolitan Police escort, at least a dozen agents, sometimes a bomb-sniffing dog, and, on one occasion, a black-clad counterassault team, replete with automatic weapons, camped in a stairwell. Now, ten months out of office, the former vice president’s protective detail was decidedly lower profile, composed of just a few agents.

  Mr. Cheney told us that his leg and back discomfort had completely resolved, but his stamina had worsened to the point that he used a wheelchair to get around airports, he was fairly winded climbing a flight of stairs, and his weight was up about ten pounds.

  When I examined the vice president, I found edema in his legs and crackles in his lungs, signs of heart failure. Telemetry data from the ICD revealed that he had been volume overloaded for many weeks, likely since the time of his back surgery.

  I told Mr. Cheney that a higher dose of furosemide should help his breathing, and although it might never be necessary, if his symptoms became harder to manage, we might need to consider more aggressive therapeutics, including eventually even heart transplantation. I emphasized that it was way too early to go down those roads, but I thought it was time to tell him that if he got worse we still had options.

  Mr. Cheney simply said, “Okay.”

  • • •

  One week later Mrs. Cheney called my cell phone.

  “Hi, Jon, this is Lynne Cheney,” the familiar voice said. “The oddest thing just happened. Dick passed out.”

  Mrs. Cheney told me that they were in Wyoming, and the vice president had gotten into his car to run an errand. Coming to the end of his Secret Service protection, he often drove his own car, accompanied by agents in another vehicle. As Mr. Cheney put his Jeep in
to reverse, he suddenly lost consciousness and struck a tree at the end of the driveway. The agents ran to the vehicle and saw that he was unconscious, but they were unable to open the locked doors. As they began to bang on the windows, the vice president regained consciousness. Mrs. Cheney said that her husband appeared to be no worse for wear with the exception of a knot on his forehead.

  In phonology, the word syncope refers to the loss of sounds from within a word (e.g., fo’c’sle instead of forecastle), but in the medical lexicon, syncope is the term for the loss of consciousness. Syncope has many possible causes, including dehydration, emotional stress, fast heart rates (tachycardias), slow heart rates (bradycardias), medication reactions, seizures, and rapid changes in body position. In 2002, for example, President Bush had briefly passed out after choking on a pretzel. For a patient with severe heart disease like Vice President Cheney, however, the most likely and deadly etiology for syncope is sudden cardiac arrest (SCA), and I told Mrs. Cheney to take him to the nearest hospital.

  • • •

  The human body is composed of trillions of individual cells, each one containing a microscopic metabolic engine fueled by oxygen and glucose supplied continuously via the blood. Some organs can tolerate a temporary interruption in blood flow, but the brain will not. Despite representing only 2 percent of the body’s mass, the brain consumes 20 percent of a human’s total energy requirement, and a pause in blood flow of as little as five seconds results in a loss of consciousness; after just a few minutes, irreversible brain injury, and subsequently death, can occur. For the nearly one thousand people every day in the United States who suffer a sudden cardiac arrest, the events that occur in the first few minutes of collapse will determine whether they live or die.

  Most cases of sudden cardiac arrest are caused by V Fib, the chaotic electrical storm that causes the ventricles to quiver, output of blood from the heart to cease, and blood pressure to drop to zero. Sudden cardiac arrest is a supremely lethal event, afflicting 360,000 Americans each year with a survival rate that varies regionally in the United States but averages only about 11.4 percent. According to the Sudden Cardiac Arrest Foundation, every year SCA kills as many people in the United States as breast cancer, motor vehicle accidents, cervical cancer, Alzheimer’s disease, colorectal cancer, HIV, prostate cancer, diabetes, assaults with a firearm, suicides, and house fires combined.

  The medical community has long understood the benefits of cardiopulmonary resuscitation (CPR) and prompt electrical defibrillation for patients with SCA, but the time window during which these resuscitative techniques will translate into survival is very narrow, on the order of about five minutes. Unfortunately, there is also often a substantial delay in the arrival of emergency medical services (EMS) personnel, and every minute in delay to defibrillation results in about a 10 percent decline in chance of survival. Nationwide, the average time from a 911 call to EMS arrival is greater than seven minutes, too late for most patients to achieve a meaningful neurological recovery.

  Although CPR can attenuate the severe survival penalty that results from a delay in defibrillation, most patients with SCA do not receive bystander CPR prior to EMS arrival, and even when trained responders do provide CPR, its quality is often poor. Ultimately, to improve the survival rate from SCA, the victim must be defibrillated quickly, and to make that more feasible, automated external defibrillators (AEDs) were developed.

  Automated external defibrillation (AED), introduced in 1979 and first deployed on offshore drilling platforms, exponentially amplifies the number of potential SCA rescuers by enabling the medically untrained to use a defibrillator. The development of AEDs was made possible by two innovations. The first was the adhesive electrode, invented by R. Lee Heath in the 1980s, which allowed a rescuer to defibrillate a patient without having to hold the potentially perilous paddles, and the second was the development of computer algorithms capable of automatically determining whether a shock is advisable. A modern AED is an intuitive device designed for use by laypersons with no prior medical training. Step-by-step audio prompts walk users through placement of two patches on the victim’s chest.

  In 1994, the American Heart Association noted that making AEDs more widely available should significantly improve SCA survival and recommended clinical trials to further evaluate AED use by first responders and the lay public. In 1997, American Airlines began to place AEDs on board selected aircraft, later expanding this program to include their entire fleet. Four years later, the Federal Aviation Administration mandated that all commercial aircraft flying with at least one flight attendant carry an AED.

  The gaming industry was also an early adopter of this technology, and with its intensely monitored spaces, it turned out to be a unique environment in which to evaluate the impact of AED deployment. Nevada casinos installed AEDs in the late 1990s and found that SCA victims received a shock on average about four and a half minutes after collapsing, 50 percent faster than the almost ten minutes it took local paramedics to reach the scene. As expected, based on these rapid defibrillation times, survival rates were extraordinarily high, almost 60 percent, and for patients who received their first defibrillation within three minutes of collapse (a virtually unobtainable time without pre-positioned AEDs), the survival rate was a remarkable 74 percent.

  Despite the overwhelming data proving the effectiveness and safety of AEDs, many legislative and administrative hurdles have impeded the widespread dissemination of the technology. The Food and Drug Administration (FDA) still classifies AEDs as Class III devices (they require approval from the FDA before they can be marketed), and some models require a physician’s prescription. Some states require physician oversight of an AED program or specific training, and some states require registration. Although every state has enacted a Good Samaritan AED law, the details differ from jurisdiction to jurisdiction as to who qualifies for immunity. This national patchwork quilt of AED laws creates an air of liability uncertainty in the minds of potential AED owners and rescuers and is a major reason that many hotels, national retail chains, and big-box stores do not deploy them. A bill before the 113th Congress that I helped to author seeks to solve this problem, but even a topic as apolitical as sudden cardiac arrest is subject to the partisan paralysis endemic in Washington.

  • • •

  You must be lucky to survive a malady that kills nine of the ten people it afflicts. I get to care for the fortunate few who reach the hospital alive, and their stories are always amazing. A fifty-year-old man has a cardiac arrest while jogging on a treadmill at a health club and is resuscitated by the AED that, just months before, he’d urged the club to acquire. A sixty-two-year-old runner drops dead three miles into the Marine Corps Marathon, resuscitated by Dr. Fred Lough, GW’s chief of heart surgery, who is running just behind him in the race and does CPR until the AED arrives. An engineer collapses in front of a firehouse in Chinatown and is saved by the firefighters who retrieve their AED. A White House butler develops chest pain, then arrests just as he is being evaluated in the White House Medical Unit. The common thread these survivors share is luck: they all were lucky to have their cardiac arrest in close proximity to both an AED and someone willing to use it.

  Over the past two decades, researchers have been able to identify specific patient characteristics that increase the risk of developing sudden cardiac arrest. These include patients with a significant impairment in heart function, survivors of a prior cardiac arrest, and certain inherited predispositions to arrhythmias. For many of these patients, implantable cardioverter defibrillators (ICDs) will dramatically reduce their risk of dying from sudden cardiac arrest.

  • • •

  On December 9, 2009, the European Center for Nuclear Research announced that its new large hadron collider had accelerated protons to a record 1.2 trillion electron volts, Bank of America reported that it had fully repaid its $45 billion TARP loan, and President Obama traveled to Oslo, Norway, to accept the Nobel Peace Prize. December 9, 2009, would also have been the
date of Dick Cheney’s death had his ICD not terminated the ventricular fibrillation embroiling his heart.

  The data downloaded from the vice president’s ICD at St. John’s Medical Center in Jackson, Wyoming, revealed that at 3:11 p.m., the device detected an abrupt jump in his heart rate to 222 beats per minute, which the implanted computer correctly interpreted as V Fib. The ICD had been programmed to try to disrupt the arrhythmia by rapidly pacing the heart (pace termination), which it attempted five seconds later but without success. The device then charged its capacitor, which took seven seconds to accomplish, rechecked the rhythm, and then discharged 34.5 joules of electricity directly into Dick Cheney’s heart, successfully terminating the arrhythmia. The entire event, from recognition to resuscitation, had taken sixteen seconds.

  When I spoke with Mr. Cheney, he was upbeat, sounding more surprised than upset, and other than a bump on his head, he felt well. In an attempt to reduce the likelihood of a recurrence, I increased the dose of his beta-blocker medication, advised him not to drive until further notice, and told him to rest for a couple of days.

  CHAPTER 13

  Downhill

  VICE PRESIDENT CHENEY

  For many years, I had been on various anticoagulants to minimize the possibility of developing blood clots leading to an embolism or a stroke. In January 2010, not long after returning from the holidays in Wyoming, I began to experience serious nosebleeds. The most worrisome was an arterial nosebleed I developed one afternoon when Lynne and I were at our home in McLean. Every time my heart beat, blood shot in a stream from my nose. When I tried to stop the bleeding with pressure, blood ran down the back of my throat. I called Dr. Reiner and told him I was heading for the emergency room at George Washington University Hospital.

  Our Secret Service protection had just ended, so Lynne rushed me down the George Washington Parkway to the hospital. Since she hadn’t driven herself in almost a decade, the drive there wasn’t without its own risks. Once we arrived at GW, the doctors packed my nose and stopped the bleeding. I was released and Lynne and I went home.