My partner once told me, "If you want to get busy, plan a vacation." It always seemed like work reached a crescendo prior to taking time off. The last two weeks had been an exhausting grind, and the kids were complaining that they weren't seeing enough of me. They were off school midweek for Veterans Day, and I planned to take the day off. The agenda was to wake up late, go out for lunch and catch a movie. I had finished my last case and was headed out, when I bumped into my cardio thoracic colleague. "I am out," I told him before he could say anything.
Five minutes later, I was sullenly looking at the cardiac films of an 89-year-old who was transferred from another hospital for open heart bypass. We had worked long enough together, that I knew exactly what he was suggesting without him saying a word. I hated to admit it, but the lady would be better off with a stent to the main artery supplying her heart. This was an area of some controversy, surgery was the gold standard, but our lady was not a good surgical candidate. I thought about the logistics, if we did her as the first case, I could still get back home and continue with the previous agenda.
Patty Smith was 89, but had a lot of spunk. She lived by herself, was active and mentally sharp. She had a brisk handshake, and went with the stent option, after we explained the rationale. She thanked me for coming in on my day off. Since there was a significant amount of calcium, which is essentially rock in the artery, I would have to use a drill to clear it out, before placing the stent. Since we would be temporarily interrupting the blood flow to the heart while drilling, we decided to use a pump, which could be described as a temporary artificial heart.
The Impella device is the world’s smallest heart pump. It is the size of a pencil and the motor is the size of an eraser. It is placed into the pumping chamber of the heart, through an artery in the leg, and can generate an output of 3.5l per minute. To put this in perspective, the normal heart generates 5l per minute. The introduction of this device allowed us to push the envelope on treating patients who would normally have decompensated during the procedure, as the device would sustain output even if the heart failed, a safety net. The price tag is a mind-numbing $25,000.
We got underway early next morning. The pump went in without a hitch, we drilled out the calcium, and a stent completed the procedure. We took the pump out, verified that the hole in the artery was closed, and headed out to the waiting area to talk to the family.
“Piece of cake,” I thought to myself as I headed home. We headed out to an early lunch. During lunch, I made a call to the ICU to check on Smith, the nurse told me she was doing well, but her pressure was trending down. One of the decisions I had to make earlier was whether to start her blood-thinning medications before or after the procedure. I decided on after, because of the small possibility of emergent open surgery, if things really went south. I had put her on the intravenous thinner till the oral dose kicked in. I told the nurse to stop the intravenous thinner.
I called back 10 minutes later and things were getting worse, her blood pressure continued to fall. The kids knew the drill, when I told them to move. They finished and were in the car in five minutes. I dropped them home and went back to the ICU into a situation of utter chaos. Smith was struggling, to put it mildly. Her blood pressure was in a free fall and she was not responding to any of our interventions, which included fluids, blood and medication to support her. The problem was that the intravenous blood thinner was too much for her body and she was oozing from every pore. It was temporary, but the low blood pressure was affecting her major organs.
I knew from experience that she was not going to make it. It is the feeling you have when you step into the court against a far superior player. You can try your best, play your heart out, but at the end you are going to get beaten, beaten badly. I made the long walk to talk to the family. It is a very lonely walk, which doctors have to do all the time. The words that best describe the feeling are “abject failure”.
I went back to Smith’s room afterwards. The frenetic activity was over, it was just the nurse and I and the dwindling blood pressure. It was raining outside to complete the gloomy picture. I had nowhere to go, and settled into a chair in the corner, waiting for the inevitable. All of a sudden, Smith started mumbling. I was surprised that she was still conscious. The nurse and I went closer to hear what she was saying. The old lady looked right into my eyes and said, "What the f**king kind of dog and pony show are you running?” We looked at each other and smiled. Smith turned around after that. Blood pressure improved, and two days later she walked out of the hospital.
I saw her in the office a week later. When I told her about what she had said, she profusely apologised and said she had no idea. We laughed about it. I was never going to see her again, as she would be following up with her local cardiologist. At the door I turned around and nodded my final goodbye. She smiled and I can swear she winked at me.