Heart: An American Medical Odyssey (32 page)

The Naval Observatory

October 15, 2008

06:30

The vice president asked me to visit with him this morning at the Naval Observatory when he noticed that his weight had increased by six pounds over the past 5 days. He feels that he has “lost some stamina” over that period, but denies any change in his baseline exertional shortness of breath. No chest pain, palpitations, ankle swelling or orthopnea. He did wake up in the middle of the night two evenings ago with a “coughing fit’. He states that he has been carefully compliant with diet restrictions, especially salt, over the past month. No other new symptoms or problems.

Lew examined the vice president and found that his pulse was irregular, a finding suggestive of atrial fibrillation. Cheney’s weight had increased, there were crackles in the lungs, and slight swelling of the ankles, all consistent with congestive heart failure.

Lew arranged for us to come to the White House to see the vice president, and we did confirm that Cheney was back in atrial fibrillation. Data downloaded from the ICD disclosed that the arrhythmia had recurred precisely two days, sixteen hours earlier, and there was a large spike in intrathoracic fluid over the same period of time consistent with congestive heart failure (CHF). It was impossible to know for sure whether the CHF was caused by the atrial fibrillation or the atrial fibrillation was caused by the CHF, but likely it was the former, and although Mr. Cheney didn’t
look particularly sick, his poor heart function clearly did not tolerate the loss of atrial function that occurs in A Fib. We discussed this at length with the vice president, and he agreed to return to George Washington University Hospital in the afternoon, where we once again successfully cardioverted him.

About a week later, we ran some blood tests and discovered that there had been a decline in the vice president’s kidney function, a not entirely unexpected consequence of Mr. Cheney’s more pronounced heart failure and the escalating medications we employed to keep the fluid from reaccumulating in his lungs. In a note to Vice President Cheney, Lew Hofmann summarized our assessment:

We think that your decreased kidney function is due to the combination of your baseline decreased heart strength, your recent brief episode of “atrial fibrillation” (which decreased your heart’s efficiency below baseline), and the extra fluid which accumulated. In essence, that “perfect storm” decreased the delivery of blood to your kidney cells, and their ability to function has been slightly compromised.

The first thirty years of Cheney’s disease had evolved languorously with widely spaced, important but momentary events that were dealt with and discarded. Now the dominos were dropping quickly, the recovery from each mini-crisis incomplete. I was confident that he would finish out the remainder of his term, but without a doubt Cheney was getting sicker. It was painful to watch. A popular notion maintains that to be an effective physician, you must maintain a protective distance from your patients, an emotional firewall. If that is true, I’ve never been good at it.

One late summer evening several years ago, Martha, the daughter of a patient, called to share the sad news that her father had died earlier in the day. Her dad’s name was Milton, my father’s name as well, and I first met the patient when, as a brand-new cardiologist, I repaired a worn-out bypass graft that had been causing him chest pain. He was
already eighty years old when I became his doctor, and during his many visits to my office over his last five years, I made some changes to his medications and ordered the occasional test, but mostly we just talked about his long and rich life and politics and the people and things he loved. My care had comprised only a small part of his life, but it had occupied almost the entire span of my young career. Martha graciously thanked me for looking after her father. I told her that I was going to miss him, and when the call ended, I wept for both her loss and mine.

•  •  •

On January 15, 2009, five days before the conclusion of Mr. Cheney’s time in office, Lew Hofmann, Ryan Bosch, and I met with the patient in the Eisenhower Executive Office Building to discuss the medical transition plan. Although by law departing vice presidents get an additional six months of Secret Service protection (which President Obama later extended another six months), the coverage of the White House Medical Unit would end at noon on January 20, 2009.

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 into 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.