Heart: An American Medical Odyssey (27 page)

As if the concerns about a possible attack with
anthrax, smallpox, botulism, tularemia, and plague weren’t enough, in September
2001, a dead crow that tested positive for West Nile virus was found on the grounds of
the vice president’s residence in Washington.

•  •  •

Several weeks later, I met Lew and two of his White House colleagues for
an early lunch a few blocks from my office at Mr. K’s, an elegant Chinese
restaurant that for years was a favorite haunt of lobbyists and K Street lawyers. When
we arrived, the restaurant was eerily quiet.

“Do you have a reservation?” the maître d”
asked.

We didn’t. He didn’t seem to notice that his restaurant was
completely empty. After some head scratching and flipping back and forth in his
reservation book, he sat us alone in a large formal dining room, the tables set with
golden flatware and porcelain chopsticks rests.

It had been about a year since I first met Lew Hofmann, and he was quickly
becoming a close friend. Lew’s specialty is family medicine, which, the American
Academy of Family Physicians states, “encompasses all ages, both sexes, each organ
system and every disease entity,” an excellent background for a doctor who may be
called on to treat trauma, tonsillitis, or ventricular tachycardia. Despite rising to
one of the most prestigious postings in military medicine, Lew managed to maintain a
sincere humility, an admirable and uncommon trait in Washington.

Over lunch, the conversation veered toward some of the biological threats
that had been in the news. I was curious whether the smallpox vaccine administered to
everyone born before 1971 would still offer protection. Lew said that the best estimate
was that the old vaccination would probably not keep you from getting the disease but
might prevent you from dying of it.

Other tables were starting to fill with customers, and as we continued our
not-so-light lunchtime conversation, a man I recognized approached our group. It was the
prominent Washington lawyer Bob Bennett, who had represented President Bill Clinton.
Bennett had been sitting
at a nearby table with his brother,
William Bennett, the former secretary of education, and he looked a little annoyed.

“Listen, guys,” he said without a smile. “I can hear
your conversation, and I really don’t want to.”

Such was the mood in Washington in the wake of the attacks, and for the
vice president, bioterrorism countermeasures became an unexpected adjunct to his
cardioprotective regimen that included aspirin, Plavix, and Lipitor.

•  •  •

When my home phone rang on a Saturday morning in late December 2001, the
caller ID was blank. Expecting to hear a telemarketing pitch, I reluctantly answered the
call, and when I did, a familiar voice on the other end said, “Hi, Jon, it’s
Dick Cheney.”

The vice president was in Jackson, Wyoming, and was calling to report that
he had been short of breath the previous night. He described the sensation as feeling
that he wasn’t able to take a full breath, but he denied experiencing any chest
pain or difficulty with exertion and hadn’t noticed any change in his weight.
Unable to sleep, the vice president had gotten up and read for a while, but when he went
back to bed, he still felt short of breath and didn’t sleep for the rest of the
night. When we spoke in the morning, he said he felt okay and thought his symptoms were
similar to an episode a few years before that at the time we thought was altitude
sickness.

Altitude sickness is a common constellation of mostly annoying symptoms
such as headache, nausea, and insomnia that may occur at elevations higher than eight
thousand feet. High-altitude pulmonary edema (HAPE), by contrast, is a potentially
life-threatening condition involving fluid retention in the lungs, encountered
unpredictably by otherwise healthy climbers and skiers, also usually occurring at
altitudes above eight thousand feet. Untreated, extreme forms of HAPE can lead to
death.

I thought it was probable that Cheney’s symptoms were altitude
related, but it was also possible that he was developing early signs of congestive heart
failure (CHF);
it was really impossible to tell for sure over the
phone. Fortunately, the vice president traveled with medical support, and I was able to
speak with Captain Thomas Waters, a White House physician’s assistant, who
examined Mr. Cheney. Together we surmised that the altitude was probably to blame, but
in view of the vice president’s known cardiac dysfunction, we prescribed a low
dose of Lasix, a diuretic, which would help if the symptoms were due to CHF.

I told the vice president that I would call later to check on him, but
after I hung up, I realized that I had neglected to ask for the phone number in
Jackson.

“Why don’t you press star six nine?” my wife, Charisse,
suggested.

“Don’t be ridiculous. I’m sure that’s
disabled.”

Surprisingly it wasn’t, and when I called later that evening, I was
glad to hear that all was well. Although I still thought the thin mountain air was
probably the cause of the breathlessness, Jackson is only about a thousand feet higher
than Denver, and I was left with a lingering concern that Mr. Cheney’s symptoms
might have represented some early heart failure.

•  •  •

For much of Mr. Cheney’s first term in office, he felt well, and
our visits during those years were largely uneventful. The usual protocol for a patient
with an ICD includes a quarterly evaluation during which the device is
“interrogated” using an external programmer roughly the size of a large
laptop computer, and during those visits, we always performed a quick history and
physical examination. Often Lew Hofmann arranged for us to see Cheney in the vice
president’s West Wing office, usually at the end of the day, and he would
pre-position a programmer in an inconspicuous corner of the suite. We tried to keep
these visits brief, assuming that the vice president had more important things to do
than spend time with a handful of doctors. Typically Gary Malakoff, Sung Lee, and I
would make the ten-minute walk to the White House together, and after Sung left for
private practice in Maryland in 2004, Dr. Cindy Tracy, GW’s new head of
electrophysiology, a nationally renowned
electrophysiologist, took
Sung’s place in what Lew called “the three amigos.”

We made a conscious effort to be discreet, never wearing white coats or
openly carrying medical equipment. On her first trip to the White House, Cindy met us on
the street still dressed in operating room scrubs.

“Cindy, you can’t wear scrubs,” I said.

“Why not?” she asked, looking surprisingly surprised.

“Because, we’re going to the
White
Hous
e
! Also, if the press spots scrub-wearing
doctors entering the West Wing, they’ll think Cheney’s having another heart
attack.”

“Okay,” Cindy said, and ran back to the hospital to
change.

•  •  •

Most of the vice president’s staff was situated in the Eisenhower
Executive Office Building next door to the White House, but the vice president worked
out of the West Wing in a small suite of offices staffed by a few aides led by Debbie
Heiden, his longtime assistant. Debbie was the only member of the vice president’s
staff entrusted with any detailed knowledge of his personal medical history. She was
also clearly the gatekeeper.

I looked forward to the White House visits, in part because of the
singular venue, but more and more because I enjoyed seeing the vice president. I
didn’t really know him that well and had seen him only a few times before he
decided to run in 2000, but over his two terms in office, I would spend dozens of hours
with him at the White House, his residence, our offices, and the hospital.

My father used to say that it’s one thing to have a disease, but
quite another to let the disease have you, and clearly heart disease didn’t have
Dick Cheney. Each time Cheney faced a serious health crisis, he seemed to respond not by
slowing down but by doing just the opposite and taking on increasingly demanding jobs.
After the heart attack in 1978, he was elected to Congress, eventually rising to a
leadership position in the House. Ten years later, after another heart attack and bypass
surgery, Cheney served as secretary of defense, managing the
military during the Gulf War and the collapse of the Soviet Union. Another decade later,
after another MI, he became the vice president of the United States. The man managed to
live an extraordinarily full life despite having had to live with an extraordinarily
aggressive disease for a very long time.

In June 2001, when Vice President Cheney met with the White House press
and announced that he was going to undergo testing the next day that might lead to the
placement of an ICD, a reporter asked him if he was worried that his coronary disease
might be getting worse. The vice president’s candid answer that day is a glimpse
into how he has lived his life.

Well, no, I’ve—it’s obviously a
question I asked my doctors, in terms of what this might signify going forward. But as
everybody knows, my history of coronary artery disease goes back to 1978. My entire
career in politics, in elective office, in Congress, in the Defense Department, eight
years in the private sector, now as vice president, it’s all taken place after the
onset of coronary artery disease. It’s something you live with. And it’s my
great good fortune that the technology’s gotten so good, that it’s kept pace
with my disease, if you will, so we’ve been able to manage it through the years.
And as I say, if there were any inhibition on my ability to function, if it were the
doctors” judgment that any of these developments constituted the kind of
information that indicated I would not be able to perform, I’d be the first to
step down. I don’t have any interest in continuing in the post unless I’m
able to perform adequately, and the doctors have assured me that is the case.

About once a year, the vice president underwent a series of comprehensive
examinations that took days to plan. Our goal was to create an efficient, tightly
choreographed schedule that condensed the maximum number of clinical evaluations into
the smallest amount of time. Lew and I called it “kabuki theater” because
there was quite a bit of stagecraft
involved in coordinating the
various consultants, and we generated timetables that would make NASA flight controllers
look like slackers.

For a visit in July 2005, we assembled the following schedule:

Naval Observatory

Timeline for the Vice President’s Evaluation

July 16, 2005

The ability to coalesce, into a single morning,
multiple tests that would usually be separated by several days is a perk not typically
available to the general public, but very helpful for a patient who must travel with a
large protective detail. The vice president had been due for a screening colonoscopy and
upper endoscopy, and the relative quiet of a Saturday morning was the ideal time to do
it. Patients with unusual security requirements can create significant disruptions in
the normal work flow of a hospital, and using off-hours is often easier for both the
hospital and the patient.

That day, the vice president was also scheduled to undergo a CT scan to
evaluate his aorta and the arteries of his legs. An earlier ultrasound had identified
the presence of aneurysms (abnormal dilatations) in the popliteal arteries, behind
Cheney’s knees, and we wanted to learn more about these. A localized weakening in
a vessel wall can result in an aneurysm, and if it develops in the aorta or the brain,
the principal risk is rupture, which can be devastating. An aneurysm in a popliteal
artery doesn’t usually rupture, but the clot that forms in the dilated sac can
embolize and threaten the leg downstream.

The CT scan revealed that the aneurysm behind the vice president’s
right knee was large, measuring more than 4 centimeters, about the size of a golf ball,
and it contained a lot of clot. The aneurysm in the left leg was a little smaller but
still fairly big. Popliteal aneurysms are typically seen in patients with
atherosclerosis, almost always in men, and left untreated, they can begin to shed small
clumps of clot, causing gangrene of the lower leg and foot, a disaster. In the
mid-1990s, a report from the Mayo Clinic showed that many of the popliteal aneurysm
patients who suddenly developed symptoms (e.g., cold and painful foot or toes) would
ultimately require an amputation. It was clear that both legs needed to be repaired
before something bad happened. The only question was how.