Heart: An American Medical Odyssey (31 page)

The enlisted aides take care of all the needs of the vice president and his family, including cooking and cleaning. They take over the daily chores of life so the vice president can focus on the responsibilities of that office. In private life, I used to do most of the grocery shopping and cooking. As Lynne will readily tell you, cooking isn’t her greatest strength, although it took both of us a little time to admit it. The first year we were married, we pretended she could cook, and I pretended I liked her cooking, but after that I took over.

Once when I was secretary of defense during Desert Storm, I had my driver stop at the local grocery store on my way home from the Pentagon so I could pick up some needed items. In the checkout line, I was confronted by a woman who made it clear she thought it was totally inappropriate for the secretary of defense to be grocery shopping while there was a war on. When I was vice president, the naval-enlisted aides went to the supermarket.

I am often asked if I miss anything about being vice president. Travel on Air Force Two comes to mind. Counting my time as secretary of defense, the Air Force had taken care of my flight requirements for twelve years. Going back to commercial air travel was a big adjustment. The Secret Service continued to provide protection for me the first year I was out of office. They don’t carry luggage, nor should they, since their job is to guard against threats. But there is nothing like having Secret Service agents with you to facilitate passage through airport security.

Another big adjustment was driving myself. Beginning the morning of the day George W. Bush announced I would be his running mate in July 2000, the Secret Service had taken over all responsibility for driving Lynne and me. The only time in eight years that I had gotten my hands on a steering wheel was on one of my trips to Saudi Arabia. Lynne and I were guests of King Abdullah at his farm outside Riyadh. His son took us for a drive in a Cadillac Escalade. Part of the
way through the tour, he asked if I would like to drive. I jumped at the chance and got behind the wheel before the Secret Service could stop me. During the year after we left office, I gradually did more and more driving on my own, with the Secret Service following in a separate vehicle.

That is how I came to be backing myself out of my garage in Jackson, Wyoming, on December 9, 2009, when I blacked out. When I regained consciousness a short time later, my car was on top of a large boulder in an aspen grove in front of our house. My Secret Service agents were pounding on the windows with their fists because the doors had locked automatically when I had shifted into gear. I had a large knot on my forehead where I had hit the steering wheel. Aside from that, I felt fine, but in fact I had just been through a very serious incident, a near-death experience.

When I came to, my agents took me to St. John’s Medical Center in Jackson. There we were able to download the information from my implanted ICD and transmit it to George Washington University Hospital, where Dr. Reiner confirmed I had indeed experienced ventricular fibrillation. V Fib occurs when the left ventricle, the main pumping chamber of the heart, begins to flutter and is no longer moving blood into the aorta. It is nearly always fatal. The only reason I survived was that eight years earlier, Dr. Reiner had had the judgment and foresight to recommend I get an implantable ICD. That decision saved my life.

“Good morning, Jon, it’s Lew.”

Somehow Lew Hofmann always managed to sound cheerful, even at “o-dark-thirty” when he already had been up for hours.

Lew was no doubt calling about the vice president. Cheney had been under the weather for several days with a lingering cough that initially seemed to improve after antibiotics, only to worsen again. What worried Lew now was that the vice president was short of breath, particularly
while climbing stairs, and had noted a several-pound weight gain, which Mr. Cheney attributed to the warm hospitality of hunting lodges he’d visited recently and the Thanksgiving dinner he enjoyed with his family a few days later.

When we replaced Mr. Cheney’s defibrillator over the summer, we specifically chose a device with the ability to detect the fluid buildup that accompanies congestive heart failure. I thought the feature would be useful for exactly this type of circumstance: helping to discern whether new symptoms were related to heart failure or something less dire, like a cold. Lew agreed to check the ICD and said he would arrange for us to evaluate the vice president as soon as possible. Later that day I wrote:

I was called this morning at 5:50 by Dr. Lew Hofmann. Dr. Hofmann stated that he had been called by the vice president who had complained of slightly more shortness of breath than usual. The patient had had a viral syndrome and cough starting about 10 days ago and had used a Z-Pack for 3 days. His symptoms (productive cough, myalgias) improved but recurred a few days ago. . . . I went to see the vice president at the White House. He has not had chest pain. Has not exercised much in past 2 weeks although he has been on several hunting trips. Admits to some dietary indiscretions (including spicy/salty Cajun food). Has gained about 4 pounds over last couple of weeks. Has not noted any edema. Has not noted any palpitations. Does feel a little more SOB [short of breath] going up stairs and feels like he is not getting a full breath. . . .

Overall Mr. Cheney looked okay but he had atrial fibrillation (A Fib), a common arrhythmia affecting more than two million people in the United States, characterized by incessant and chaotic electrical activity that causes the atrial chambers to “fibrillate” (quiver) ineffectively.

For most people, the heart squeezes sub rosa, its cadence unnoticed
until it makes itself known through the quick punch of a premature contraction, the gallop of a rapid rate, or the fluttering of a disorderly rhythm. Some patients with atrial fibrillation immediately identify the irregular heartbeat, while others experience a more subtle shortness of breath or a decline in stamina, and some patients have no symptoms at all. Atrial fibrillation can occur in someone with a normal heart or in patients with disorders involving the heart valves, thyroid disease, or congestive heart failure. The major risk of A Fib is a stroke caused by embolization of a clot that can form in the static recesses of the now-immobile left atrium.

In May 1991 President George H. W. Bush experienced unusual fatigue while jogging at Camp David and was found to have atrial fibrillation, later determined to be the result of a hyperactive thyroid gland. Dr. Allan Ross, GW’s chief of cardiology and Dick Cheney’s doctor at the time, was called in to consult. The president was taken by air to Bethesda Naval Hospital, where he was treated with digoxin to slow his heart rate and procainamide, an antiarrhythmic.

President Bush later made a public service announcement warning about the risks of untreated atrial fibrillation:

Hi, I’m one of two million Americans who have a type of irregular heartbeat called Atrial Fibrillation, or AF. Left untreated, AF can lead to a stroke, the third leading cause of death in this country. In fact, this year 80,000 Americans will have a stroke because of AF. Luckily, it can be detected and treated. And the first step to seeing if you might have AF could be an easy self-exam. You can learn a simple way to check your pulse to see if you have an irregular heartbeat, and what to do about it. If you’re over fifty, it means taking sixty seconds to check your pulse twice a year. Strokes can be prevented. Learn the warning signs and how to reduce your risk. Talk to your doctor.

Blood thinners can greatly reduce the chance of stroke, particularly for patients who have risk factors like congestive heart failure,
hypertension, diabetes, or a prior stroke, and we immediately injected the vice president with a quick-acting anticoagulant. Decades of heart disease had left Cheney with a weakened and tenuously compensated heart without much reserve, and when the atrial fibrillation reduced his cardiac function just a little, it was enough to tip him into heart failure. Cindy and I thought that Mr. Cheney would feel better if we could restore his usual rhythm, and we made plans to bring him to GW to electrically reset (defibrillate) his heart. The White House released the following statement:

The vice president visited with his doctors this morning for evaluation of a lingering cough from a cold. During examination he was incidentally found to have an irregular heartbeat, which on further testing was determined to be atrial fibrillation, an abnormal rhythm involving the upper chambers of the heart. Later this afternoon, the vice president will visit George Washington University Hospital for further evaluation and, if indicated, cardioversion, delivery of an electric impulse to the heart, which is a standard treatment for atrial fibrillation. This will be an outpatient procedure, and the vice president is expected to return home Monday night.

Data retrieved from the memory of the ICD showed that Mr. Cheney had been in atrial fibrillation for ten days, which was exactly as long as he had felt unwell and more than long enough for a clot to form in his heart. Before attempting to convert Mr. Cheney’s rhythm back to normal, it was imperative we know whether a potentially devastating thrombus, which can be jarred loose by electrical cardioversion, lurked inside his left atrium, and the best way to do that is with echocardiography.

•  •  •

Cardiac imaging with sound waves (echocardiography) is a technological offshoot of sonar, the naval echo-ranging system developed almost a
century ago for tracking submarines.
First used in 1953 to examine cardiac structures and refined greatly since then, echocardiography provides detailed cross-sectional cardiac images reconstructed from sound waves that are bounced off the heart. Although often capable of producing vivid pictures, transthoracic echocardiography, obtained with a handheld transducer positioned against the wall of the chest, is not ideal for large patients who have a substantial amount of subcutaneous tissue, or for cardiac structures such as the atria that are located deep and toward the back of the heart. For these applications, and for examining cardiac valves, transesophageal echocardiography (TEE) is a better option.

The esophagus, the muscular conduit for food and drink that connects the pharynx to the stomach, transits the chest directly behind the heart and provides a nearby vantage point from which to examine cardiac structure and function. The transesophageal ultrasound transducer is sealed inside the tip of a long and deflectable endoscope-like probe and is advanced down the throat of a sedated patient to a position adjacent to the heart. The resulting two-dimensional and three-dimensional moving images depict the elegant intracardiac anatomy with a detail previously obtainable only at surgery or necropsy.

•  •  •

We waited several hours for Vice President Cheney to digest his early morning breakfast, and in the late afternoon he came to George Washington University Hospital for a quickly arranged TEE cardioversion. Sara Hennig, an experienced cath lab nurse, placed an IV catheter in Mr. Cheney’s right wrist and shaved his chest to provide better electrical conductivity and more humane removal for the saucer-sized adhesive electrode patches that have largely replaced the familiar defibrillator paddles used for decades to deliver the energy. Dr. Paul Dangerfield, a cardiac anesthesiologist familiar with the vice president from prior GW hospitalizations, then administered intravenous sedation. After the vice president was soundly asleep, Dr. Jannet Lewis, GW’s director of echocardiography, passed a TEE probe through a hollow plastic bite-block positioned in Cheney’s
mouth, advancing the long transducer down his esophagus to the level of the heart.

With the lights in the procedure room dimmed, Jannet slowly surveyed the vice president’s heart for clots, paying particular attention to the left atrial appendage, a long, tubular outcropping of the left atrium, previously thought to be a relatively unimportant cardiac structure but now known to be the critical location where clots often hide. Satisfied that there was no thrombus in the heart and with the vice president still asleep, we proceeded with the electrical cardioversion.

The use of a defibrillator to restore a normal rhythm has become an iconic medical procedure immortalized in too-numerous-to-count movies and television dramas, two notable examples being the
MacGyver
episode in which the eponymous character resuscitates a friend using two candlesticks and microphone wire and the 2006 remake of
Casino Royale
in which, after being poisoned by a digoxin-laced martini, James Bond attempts to defibrillate himself. In reality, defibrillation (cardioversion) as a treatment for atrial fibrillation is safe and quick and is performed in a highly controlled environment.

Just like in the movies, Cindy called “Clear!” which was Sara’s cue to arm the external defibrillator, the device issuing a dramatic high-pitched whine for several seconds as it charged its large capacitor. After double-checking that everyone had heeded Cindy’s admonition to move back, Sara depressed the flashing button on the defibrillator control panel.

Secret Service agents watched from the control room as 120 joules of electricity arced through Cheney’s chest with a soft, audible “pop,” causing a quick spasm of his torso and arms, the patient’s response more closely resembling a sudden startle than the violent levitation depicted on television. Our attention then turned from the patient to the EKG monitor, which displayed the newly normalized rhythm.

The successful cardioversion had solved the acute problem, but there remained reason for concern. In general, atrial fibrillation is a very common and treatable disorder, but occurring in the setting of the vice president’s long history of ischemic heart disease, impaired ventricular
function, deep vein thrombosis, and heart failure, it portended the transition of Mr. Cheney’s illness from its long era of stability to the steep slippery slope of end-stage heart disease.

•  •  •

In October 2008 Lew Hofmann was once again called to see the vice president because of a sudden increase in weight.