Heart: An American Medical Odyssey (29 page)

When you have recovered adequately from the sedation,
you will be transported to your overnight room on the VIP ward. Although exact times
are difficult to predict, we anticipate that you will be fully alert by
1430.

Here is a summary of your operative and medical
team:

Dr. Jonathan Reiner

Dr. Ryan Bosch

Dr. Paul Dangerfield, Cardiac
Anesthesiologist

Dr. Cynthia Tracy, ICD Cardiologist

Dr. Anthony Venbrux, Interventional
Radiologist

Dr. Barry Katzen, Interventional
Radiologist

Dr. Peter Gloviczki, Vascular Surgeon

Dr. Joseph Giordano, Vascular Surgeon

I know you are in the best of
hands. . . .

Very Respectfully

Lewis A. Hofmann, MD, FAAFP

White House Physician

•  •  •

When the motorcade bearing Vice President Cheney
arrived at George Washington University Hospital early Saturday morning on September 24,
2005, the news media had already assumed their familiar vigil. The aneurysm repair had
taken two months to plan and involved dozens of physicians, nurses, technologists,
administrators, and security personnel. The VIP wing of the telemetry floor was
configured for the vice president’s planned overnight stay with freshly painted
walls, polished floors, hotel-like furniture, rugs, and new linens. Operating room
personnel were placed on standby, just in case, and Secret Service agents were posted
throughout the hospital. Dr. Gloviczki and Dr. Katzen were granted temporary DC medical
licenses and GW clinical privileges, and they returned to Washington to lend a hand.

The procedure to treat Vice President Cheney’s right leg was complex
but uncomplicated. After numbing the upper leg with lidocaine, Tony Venbrux placed a
large sheath (about the diameter of a soda straw) into the superficial femoral artery. A
thin wire was then advanced through the upper leg, into and beyond the aneurysm behind
the knee and down to the level of the calf, using X-ray guidance. Two stent grafts were
then slid, one at a time, over the wire, positioned within the aneurysm, and deployed by
pulling a “rip cord” that released a constraining stitch, allowing the stent
with “memory metal” to expand on its own.

Although typically we would opt to treat one leg at a time and separate
the procedures by at least a week or two, we had discussed the
possibility of repairing both legs during the same session because the logistics for
treating the vice president were so intricate. Since Cheney was clinically doing fine,
we made the decision to treat the left leg as well, which took another couple of hours
to accomplish and again required two stent grafts.

When we were done, I called my wife, Charisse, who asked how it went.
Before I could answer, I heard Tony Venbrux, who was speaking nearby into his own phone,
respond to the same question.

“It was a triumph,” he said.

•  •  •

In early January 2006, only three months after the repair of the
popliteal aneurysms, the vice president developed a painful flare of gout in his left
foot, a condition he had experienced before. Gout is an inflammatory arthritis, often
involving the big toe, caused by the deposition of uric acid crystals in the joint.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually effective in reducing both the
pain and the inflammation of the acute episode, and the vice president had an old supply
of indomethacin, which he began.

NSAIDs, a class of drugs that also includes ibuprofen and naproxen, are
widely used but not without some risks. The familiar medications can cause gastric
irritation or, less commonly, ulcers; they also may increase the risk of a cardiac
event, mediated in part by adverse effects on kidney function. In patients with existing
heart disease, these agents can result in substantial fluid retention.

Late at night, a few days after beginning the indomethacin, the vice
president called the physician’s assistant on duty for the WHMU and reported that
he was having trouble breathing. He stated that he had gained seven to ten pounds over
the prior few days, his legs were swollen, and around midnight he developed shortness of
breath. Now, three hours later, his breathing was getting worse.

Five minutes later, Lieutenant Jerald Jarvi, a Coast Guard
physician’s assistant on call for the WHMU and sleeping in another building
on the Observatory grounds, was standing at the vice
president’s bedside. Jarvi’s examination of Mr. Cheney was significant for
coarse breath sounds called rales, caused by accumulation of fluid in the lungs, as well
as significant edema in both lower legs. Jarvi called me and we agreed that the vice
president had congestive heart failure. I said I would meet them at the GW emergency
room.

In the ER, Cheney was stable but clearly fluid overloaded. Blood tests
showed no evidence of a heart attack, and there were no EKG changes. After a dose of the
IV diuretic furosemide (Lasix), the vice president’s breathing eased considerably.
Although the CHF likely was precipitated by the indomethacin, the episode did vividly
illustrate the fragility of Mr. Cheney’s clinical balance. It also validated our
approach to the aneurysms a few months before. If a few tablets of indomethacin could
tip Cheney into heart failure, what might have happened if he had undergone vascular
bypass surgery?

During my time as vice president, the one instance where the job clearly
had a direct impact on my health occurred in February 2007. I was scheduled to make a
trip to the western Pacific with stops in Japan, Guam, and Australia. At each stop, I
visited with senior government officials and US military personnel. While I was in
Australia with Prime Minister John Howard, one of our best allies and friends, President
Bush asked me to continue on around the world and add stops in Pakistan and Afghanistan.
I was scheduled to see President Musharraf in Islamabad and President Karzai in Kabul.
When I arrived in Afghanistan, I first made a stop at our major base at Bagram, north of
Kabul, for briefings and meetings with our senior military leaders in the country.
Unfortunately, I got snowed in at Bagram and had to spend the night. I planned to
continue to Kabul the next day.

As I was preparing to leave the next morning, I heard a loud explosion:
a suicide bomber had detonated his bomb at the front gate of the
base, killing twenty-three people, including two Americans. When the bomb went off, my
security detail took me to a bunker near the room where I had spent the night. A short
time later, we resumed my schedule as planned. After the attack, a Taliban spokesman
claimed the attack had been aimed at me. That was not credible since I was about a mile
away from the site of the explosion, and I was on the base only because of a last-minute
schedule change the night before. But it was a demonstration of the kind of violence the
Taliban and their allies were visiting on the people of Afghanistan. And it was evidence
of the danger our military personnel faced every day.

When I returned to Washington, I had been gone nine days, traveled some
twenty-five thousand miles, and spent sixty-five hours in the air. After I had been home
a day or two, I noticed a pain in the lower part of my left leg. I reported it to my
doctors and arranged for an exam, which included an ultrasound of my left leg. It showed
I had developed a blood clot in a vein—a deep vein thrombosis (DVT). It was
apparently the result of all those hours on a plane during my recent trip. It was
potentially dangerous if it migrated to my lungs or heart and caused a pulmonary
embolism. We treated it with regular injections of enoxaparin and oral doses of
warfarin, powerful anticoagulants, and over time it dissolved. But managing my
medications became more difficult as we had to strike a balance between using the blood
thinners to avoid clotting, while at the same time not using so much that we created
problems with bleeding.

In 2007 Vice President Cheney embarked on a nine-day,
twenty-five-thousand-mile trip that included stops in Afghanistan, Pakistan, Oman,
Australia, and Japan. A few days after returning, following a speech at the national
legislative council of the Veterans of Foreign
Wars, he called to
tell me he was experiencing some discomfort in his left calf. There are many potential
reasons for discomfort in the leg, but calf pain after extensive air travel is a DVT
until proven otherwise, and I recommended that the vice president come to our offices
right away for further evaluation.

Medical Faculty Associates

The George Washington University

March 5, 2007

Dr. Lew Hofmann called late this morning to report that
Vice President Richard Cheney had informed him that he had developed discomfort in
his left calf. The vice president then presented to the MFA [Medical Faculty
Associates] for evaluation at 1:30PM. The vice president was seen with Drs. Lew
Hofmann, Ryan Bosch, Joe Giordano, and Michael Hill.

Overall, the vice president has felt well. He recently
completed a long overseas trip which covered approximately twenty-five thousand
miles and sixty-five hours of flight time. Two days ago after arriving back in
Washington, DC Mr. Cheney began to note some mild discomfort in his left calf,
extending up to the back of the knee. The vice president did not note any swelling
in the ankle. There was no chest pain or shortness of breath.

On examination the left calf is subtly larger in
diameter and mildly more tense than the right calf. The left leg has a mildly
positive Homans” sign [pain in the calf when the foot is flexed]. The DP and
PT pulses are 2+ bilaterally.

Arterial and venous ultrasound of the right leg
revealed no evidence of DVT and the popliteal stent graft is widely patent. Venous
ultrasound of the left leg shows a prominent thrombus in the left popliteal vein
extending into the TP and tibial and peroneal veins. Arterial imaging of the left
leg was not performed.

In summary, Vice President Richard Cheney has
developed a left lower extremity DVT [deep vein thrombosis] most likely caused by
his recent extensive plane travel. We have begun enoxaparin 100mg SC q12 hours
(first injection given at the time of this examination) and warfarin 5mg qd [blood
thinners]. . . .
I told Vice President Cheney not to perform his usual exercise
regimen. We will plan to repeat the venous imaging study in 1 month’s
time.

Jonathan S. Reiner, MD

Blood returns to the heart from the long and
capacious veins of the legs aided by periodic propulsive compression of surrounding
muscles that essentially “milk” the veins of their blood. Clots can form
anywhere blood pools, and it has long been recognized that prolonged immobilization,
such as that which occurs in a bedridden patient or a long-haul traveler, can lead to
the development of thrombi in the legs. In 2003, David Bloom, a thirty-nine-year-old NBC
reporter covering the invasion of Iraq, who had spent several days riding in a cramped
position inside a tank recovery vehicle, died from a pulmonary embolus that originated
in a DVT in his leg.

It has been estimated that 1 in 4,600 people who fly
will develop a DVT within two months of travel, a condition erroneously referred to as
“economy class syndrome.” While there is no evidence that sitting in economy
class increases the risk of developing a DVT, the likelihood of developing a clot does
increase with flights of more than eight hours and also with assignment to a window
seat. Vice President Cheney traveled on Air Force Two, a spacious Boeing C-32 (a
modified 757), but even with plenty of room to move around, long flights equal long
sedentary stretches. Risk factors for the development of a DVT other than prolonged
immobility include a genetic or acquired predisposition to clotting, smoking, cancer,
oral contraceptive use, age greater than sixty, and congestive heart failure.

In isolation, the vice president’s DVT was a fairly common and very
treatable condition, but its occurrence did leave me with some concern about the general
trend in his health.

Medical Faculty Associates

The George Washington University

June 6, 2007

Dr. Lew Hofmann called this afternoon and relayed a
message that the vice president needed to talk with me. I called Mr. Cheney and he
stated that he has felt more fatigued recently. We saw the vice president 1 week ago
for a device check and to discuss plans for routine follow-up. At that time Mr.
Cheney stated that he had no chest pain, shortness of breath, palpitations, edema or
change in his exercise tolerance. Today Mr. Cheney noted that for the last week to
week and a half he has felt more fatigued. He stated that he has been having
difficulty keeping the RPM of his exercise bicycle above 60. He notes that he may be
a little more short of breath climbing stairs. He has not had any chest pain
and . . .
has not been short of breath at night. He has not had edema. His
weight is down somewhat and is currently around 210.

I told Vice President Cheney that we should proceed
with our planned echo and nuclear stress test earlier than July and we agreed to
have the vice president return on June 8, 2007 for testing. I discussed this plan in
detail with Drs. Hofmann and Bosch.

Jonathan S. Reiner, MD

Two days later, the vice president returned to our offices for a
comprehensive cardiovascular examination that included an EKG, an exercise stress test
with myocardial perfusion imaging (nuclear stress test), and an echocardiogram. Although
both the EKG and stress test were unchanged and showed the effects of the earlier heart
attacks, the echocardiogram revealed that the vice president’s heart function had
declined. Prior echos had estimated Cheney’s ejection fraction about 30 percent
(normal ejection fraction is greater than 50 percent), but now it was closer to 20
percent, a significant drop. In my note summarizing the vice president’s
evaluation, I wrote: