Heart: An American Medical Odyssey (33 page)

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.

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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.

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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.

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.

Just a few hours later, the bleeding started again, and this time it was even worse. We made the drive again to the emergency room, this time with me holding a trash can in my lap to catch the blood. At the hospital, I was rushed into the operating room, sedated, and the artery cauterized. For a long time afterward, I carried a small packet of materials designed to stop a nosebleed should one occur. It turned out this episode may have been more life threatening than all the coronary episodes that had taken me to emergency rooms over the years.

A month later, in February 2010, Lynne and I were at our house St. Michaels on the Eastern Shore of the Chesapeake Bay, where we had bought a home after the 2004 election. We had a number of friends in the area, enjoyed the beauty of the region, and I loved to hunt duck and geese there in the fall. My health was also a factor in our decision. I knew that as I grew older and my heart disease progressed, I would find it increasingly difficult to spend time in the Tetons in Wyoming because of the high altitude.

After dinner one evening, I developed some chest discomfort that I thought might be related to my heart. I did not have other symptoms, but I was sufficiently concerned that I wanted to check it out. Lynne drove me the twelve miles to the nearest hospital, in Easton, Maryland. On arrival, I was examined, and the preliminary judgment was that it might be another heart attack. After contacting Dr. Reiner at GW, we decided to return and check my condition there. We used a life-flight helicopter service to fly me from Easton back to Washington, DC. I had flown on helicopters thousands of times all over the world, but this was the first time I was flat on my back, strapped to a gurney with an IV and blood pressure cuff on my arm. The crew was experienced and very competent. Since George Washington University Hospital did not have a helicopter landing pad at that time, we had to land in the parking lot at the Washington Nationals baseball stadium and complete the journey to GW by ambulance. At the hospital, doctors determined I had suffered my fifth heart attack. Although it was relatively minor, it was further evidence of my deterioration.

Later that spring, I visited King Abdullah of Saudi Arabia to discuss developments in the Middle East. I also took the opportunity to stop in Abu Dhabi to see my friend the crown prince Mohammed bin Zayed. The meetings in both capitals were good ones, both interesting given the challenging events unfolding across the region. But I recall that between the meetings, all I wanted to do was sleep. I was experiencing a definite decline in energy level that I chalked up to jet lag and time zone changes.

Lynne and I flew to Jackson Hole for Memorial Day as we had
done most years. If any more evidence was needed of my deteriorating situation, it came during that visit to Wyoming. For several years, Memorial Day had marked the beginning of my fishing season. My good friend Dick Scarlett always organizes two days of fly-fishing on the South Fork of the Snake River along the Wyoming-Idaho border. The spring runoff from the mountains is always a problem, but a dam on the border catches the runoff in Palisades Reservoir. The water below the dam is high in May, but it is clear and fishable. The tailwater fishery below the Palisades Dam on the South Fork is one of my favorite stretches of water. I was looking forward to getting back on the river with my fly rod.

The first night home in Jackson, I experienced considerable difficulty breathing. I had trouble climbing stairs. I couldn’t sleep. I was going to have trouble spending a week at sixty-two hundred feet. We went to the local hospital and transmitted the data from my ICD to Washington so Dr. Reiner could review it.

The report indicated that I was having an episode of atrial fibrillation. While A Fib is less serious than V Fib, it can lead to the development of blood clots. I needed to go back to Washington, DC. A friend loaned us his plane, and a doctor and nurse from St. John’s Medical Center flew with Lynne and me back to Washington. I wasn’t sure I would ever see Wyoming again.

By the beginning of June 2010, I was approaching end-stage heart failure. As I went through the month, I found it increasingly difficult to carry out any tasks around the house. Walking to our front gate to get the morning paper was no longer possible. I could no longer climb the stairs to get to the second floor. My world was getting smaller and smaller. The one evening I felt slightly more energized was when we attended the annual reunion of the White House staff and cabinet from the Ford administration. The rest of the time, I just felt exhausted. Every morning when I woke up, all I wanted to do was get to the overstuffed easy chair in my office, put my feet up, and go back to sleep.

I felt no pain or physical discomfort associated with this stage of my disease. But I was conscious I didn’t have much more time to live.
Over the years that I had suffered from coronary artery disease, I had believed that sooner or later, I would run out my time and that the end would come as a result of heart failure. What was happening was hardly a surprise.

I was losing my appetite. There wasn’t much I wanted to eat, but the things I craved were foods from my childhood—my mother’s chocolate chip cookies, for example. Mary baked batches for me using my mom’s recipe. My family was trying to keep my strength up, so they also spent a good deal of time making me milk shakes with protein powder sprinkled in. They were deeply worried about me.

I wasn’t fearful or anxious about my situation. I had lived a wonderful life, and now it was ending. Contemplating my death was much harder for my family than it was for me. I felt a need to express my wishes with respect to final arrangements, but it was a difficult subject to bring up with my family. They didn’t want to face what we all knew was happening.