Miracle Cure (13 page)

“Why thank you, Nellie,” Jessup said, sweeping into the room, scrubbed, capped, and masked. “Good morning, everyone. I assume you all remember Dr. Holbrook. Brian, why don’t you scrub. We’ll be ready to go as soon as you do.”

There was a small prep area between the locker room and the lab. Brian donned a mask and hair-cover and did a four-minute scrub over the stainless-steel sink. Despite the fact that he had performed a thousand or more cardiac caths, and even though he was only going to assist today, his heart was doing the flamenco in his chest. He shook
the water from his hands, backed into the cath lab, and allowed the scrub nurse to help him gown and glove.

“Okay, gang,” Carolyn said, “let’s get started. Nellie, are you ready?”

“My back’s already starting to ache. So let’s get this over.”

“Grumble, grumble.”

Jessup gave Nellie Hennessey’s history as she worked.

“Mrs. H. is a sixty-nine-year-old retired schoolteacher—”

“Sixty-eight-and-a-half,” Nellie interjected.

“Sixty-eight-and-a-half, who was referred to me almost two years ago for chest pain—”

“Actually, it was up here in my shoulder and sometimes my neck,” Nellie said, her speech beginning to thicken. “Never really in my chest.”

Jessup put two fingers over Nellie’s femoral artery pulse and smoothly slipped the large-bore needle through the anesthetized skin beneath her fingers and into the vessel. Then she advanced the arterial catheter through the needle and up toward the left-side chambers of Nellie’s heart.

“Having Nellie as a patient,” she said, “is like being back in school. You get marked off for everything.”

“You still get an A, dear,” Nellie said, her tongue and mouth now parchment-dry.

“That Ward-Dunlop catheter really is slick,” Brian noted.

“I expect you to use it exclusively when you start doing cases on your own.”

“No problem there.”

“Well, to continue, Nellie’s treadmill stress test was positive, and a subsequent cath showed fairly severe coronary artery disease. She was a perfect candidate for randomization into the Vasclear study. Right, Nellie?”

Nellie, eyes closed, was breathing deeply and regularly.

“Jennifer,” Jessup went on, “maybe we should be giving her a tad less pre-op medication. If I have to stay awake for this, everyone does.” She glanced over at the nurse, her eyes smiling. “Seriously, nice job. She’s perfect.… Anyhow, Brian, Nellie’s symptoms disappeared almost immediately and haven’t returned. This is her third and last follow-up cath. Then she becomes an alumna.”

“What Vasclear group is she in?” Brian asked, already knowing the answer.

“Beta. Okay, Doc, you’re on. Let’s switch sides. You do the right heart and afterward I’ll switch back and do the coronary-artery shots. Nellie’s asleep so you’re not being graded on this. Just relax and have fun.”

“Thank you.”

Surprised and pleased at being asked to do anything other than observe, Brian moved behind Carolyn to take her place at the table.

“Everything on the Ward-Dunlop works pretty much like the one you’re used to,” she said, “except the controls are much more responsive, and the connections on the ports just click and lock.”

“Impressive,” Brian said, proceeding with the pressure studies and dye injections.

The nurse, Jennifer, was working beside him now, keeping a careful watch on Nellie, checking her blood pressure and IV.

“Everything okay?” Brian asked her.

“All systems are go,” she replied.

Brian took some pressure measurements through the catheter, then injected some dye to check the tricuspid and pulmonic valves. The moment he had thought might never come was here. He was back in the cath lab, regaining control, piece by piece, of his own destiny.

“You seem pretty comfortable there, pardner,” Jessup said, returning to her position to do the left heart and coronary-artery exam.

“Just like riding a bike. She’s got a pretty healthy-looking heart.”

“Wait till you see her coronary arteries. These pictures we’re about to shoot are going to be the eighteen-month-afters. The befores are in the cine-library through the door just past the women’s changing room. Did security give you a code for the keypad?”

“They did.”

“Great. Sometime soon, go and take a look at Nellie’s pre-Vasclear films. We’ve got two Vangard viewers in there. One for backup.”

“I’m impressed,” Brian said. The viewers, from what he remembered, cost around twenty thousand dollars apiece.

“You’ll be even more impressed when you review her films,” Carolyn said. “Now, let’s take a look at her left heart and coronarles.”

The experimental Ward-Dunlop catheter was exceptionally easy to manipulate, and certainly showed up well on X ray.

“Left anterior oblique cranial … right anterior oblique caudal …”

Jessup called out each angle, waited for Andrew to position the X-ray camera, then injected some dye and activated the camera with her foot pedal. Overhead, one screen showed the bright white of the X-ray-opaque dye as it briefly filled Nellie’s coronary arteries before being washed away, and another traced her heartbeat, oxygenation, and other vital signs. In the glassed-in control room to their right, the other nurse, Lauren, monitored duplicate screens, and kept watch over the machine that was recording the injections on videotape. Later, the tape
would be reviewed by Jessup, and a report dictated. The width of every significant artery and every blockage would be carefully measured by computer and recorded.

“…  Right anterior oblique cranial,” Carolyn said, completing the last of the five left coronary-artery views. “Okay, everyone, if there is anyone with reasons why this woman and this catheter should remain in holy matrimony, let him speak now or forever hold his peace.… There being no objections to removal of this line, I hereby do so.”

Carolyn withdrew the catheter with the same smoothness, the same confidence, as she had displayed throughout the procedure. But quite suddenly, a brief flurry of extra heartbeats appeared on the screen. Then another burst.

A few moments later, Nellie Hennessey moaned.

Then she opened her eyes.

Then she began screaming.

“O
H, MY
G
OD! … MY CHEST, MY CHEST! … OH
, God, I can’t breathe!”

Nellie Hennessey, wailing piteously, clutched at her chest and thrashed back and forth, slamming her arms and shoulders against the X-ray tube still positioned just above her. Overhead, the monitor continued to record salvos of extra heartbeats, often the prelude to a full-blown cardiac arrest.

There was no doubt in Brian’s mind what was happening. The woman was having a coronary occlusion—a heart attack. But why? They had just examined her coronary arteries and they were virtually clear of arteriosclerosis. There were only two explanations that made sense.

“Give her morphine,” Jessup ordered urgently. “Three IV. No, make it four. How’s her pressure?”

“One-eighty over one-ten,” Jennifer replied.

“Brian, what do you think?”

“She’s either in coronary-artery spasm,” Brian said, “or the tip of that catheter broke off while you were pulling it out. Has that ever happened before?”

“No,” Carolyn said, too quickly. “I mean, not here. Not in a while.… Nellie … Nellie! You’ve got to try and lie still. Jennifer, where’s that morphine?”

“Four milligrams in.”

“Hang a nitroglycerin drip up, please.”

“Right away.”

“Oh, my God!” Nellie shrieked. “Help me! … Please help me!”

Brian knew he was just there to assist, and Carolyn Jessup was a seasoned specialist, a professor. Still, Nellie Hennessey’s life was at stake. He had spent seven years as a partner in a very active private practice, the last three of them as chief of a busy cath lab. If it became clear that he saw something Jessup didn’t, he wouldn’t hesitate to call her attention to it. But for the moment, she was handling things flawlessly. And regardless of who was in charge, Nellie Hennessey was in big, big trouble.

“Let’s give her seventy-five of Xylocaine to do something about those extra beats,” Carolyn said. “Nellie, please, try to hold still! Andrew, give me an LAO caudal angle. I’ve got to see if the catheter tip has broken off and wedged itself in an artery.”

Andrew moved the camera electronically to the left anterior oblique position. Nellie, perhaps responding to the IV morphine, settled back a bit, but continued moaning in pain. Jessup clicked the fluoroscopic camera on with the toe plate.

“There,” Brian said.

It took a few moments for the others to see the fragment, but there it was—a small, bright white line on the black-and-white screen. It was three-quarters of an inch
long, resting on top of the upper portion of the heart muscle, moving with each beat.

“What do you think?” Jessup asked. “Left main?”

“Hard to say, but yes. That’s my guess.”

Almost certainly, the catheter tip had broken off and become lodged in the left main coronary artery—the Widowmaker.

“Lauren, call the OR, please,” Jessup said to the control-room nurse. “Have them assemble the pump team and whichever surgeon’s available. We’re going after this, but I want them on standby as quickly as possible.”

“Oh, sweet Jesus, I can’t breathe!” Nellie was crying. “Do something … My chest is being crushed! … Please, please, oh God, do something!”

The tension in the room, already bowstring tight, was ratcheted even tighter by the woman’s unremitting cries. Brian was impressed and relieved to see that everyone on the team seemed able to handle the strain. For a moment, Andrew’s eyes met his. Although outwardly composed, there was no masking the technician’s concern.

“Jennifer,” Jessup said, “if her pressure’s okay, give her another two of morphine.”

“Given.”

“Brian, what about intubating her? Are you sharp?”

“I moonlighted in an ER for my first few years in practice. If anesthesia can’t get down here, I think I can do it.”

“Lauren, page anesthesia. Andrew, get things ready for Dr. Holbrook to intubate. Be sure to check the balloon on the tube. Nellie, hang in there. Can you hear me?”—Nellie nodded weakly—“Good. Now listen, please. A piece of the catheter we used has broken off in one of your arteries and is blocking the flow of blood. We’re going to get it out. Understand?… Good. As soon as it’s out you’ll feel much better. Now, who came with you today?”

“My … daughter.”

“We’ll speak with her shortly. Meantime, just tell Dr. Holbrook if your pain’s not getting better, and he’ll give you some more medicine. Andrew, I need a Microvena snare. Quickly, please.”

The snare was a wire loop, threaded up through a catheter, and operated by a finger trigger. It was tricky to use under the best of circumstances. But with Nellie unable to lie still for more than fifteen or twenty seconds at a time, and the fragment of catheter tubing moving with each heartbeat, the retrieval was going to be a bear.

Brian was impressed to see that Jessup was meeting the challenge head-on. But as first one, then another pass with the snare failed to catch the tubing, he could hear the strain creeping into her voice. Her eyes were narrowed. She shook her hand to loosen the muscles.

Nellie’s heart attack was evolving rapidly. A large portion of the muscle in the front of her heart was getting little or no blood, and that muscle was reacting to the diminished oxygen supply with viselike pain and electrical instability—continued bursts of dangerous extra beats. There was no permanent damage yet. But soon, almost certainly before she could be brought to the OR, there would be. And if two of the premature beats should fire off at the same time, her heart might well be thrown into electrical standstill—a cardiac arrest.… Brian did his best to shelve that thought.

Jessup tried a third time … then a fourth. Her fists were clenched with frustration.

“Lauren, are they ready in the OR?”

“Not yet.”

“Pressure’s dropping some,” Jennifer said quietly.

Jessup readied the snare for another try. Then she glanced over at Brian. Her eyes looked flat, defeated. There was nothing to do, her expression was saying—
nothing to do but hope the cardiac surgical team sent for Nellie before her heart gave out altogether. But even then, once Nellie was in the OR and on heart-lung bypass, another battle would be fought—the battle to salvage as much cardiac muscle as possible. With each passing second, the likelihood of her making it without massive damage was diminishing, as was the chance that she was going to make it at all.

“Oh, please.… Oh, please.… Oh, please.…”

Nellie was moaning continuously now.

Brian checked her pupils and saw maximum narcotic constriction. Giving her more morphine would be risky. A narcotic-induced crash in her blood pressure or a respiratory arrest would make a grave situation even worse.

“Any ideas?” Carolyn asked softly.

“Just one,” Brian replied. “Try using a biopsy forceps instead of the snare.”

“What?”

“Andrew, do we have a BIPAL biopsy forceps?”

“I think so.”

“I’ve used them a couple of times for endocardial biopsies. It has two little prongs to snip off pieces of tissue. I’d like to take a crack at clamping down on the catheter tip with those prongs.”

“I have one right here,” Andrew called out.

“Do it, please,” Jessup ordered, stepping aside to make room for Brian.

“The OR just called,” Lauren said through the control-room intercom. “They’re ready.”

Jessup hesitated. A miss now would consume more time than Nellie had left, but a dash to the OR was chancy at best. For five seconds, ten, there was only silence.

“Brian, I know it’s been a while,” she said finally. “Are you okay with this?”

Brian looked down at Nellie Hennessey, who lay there, eyes closed, whimpering softly. Tears of pain had tracked down over her cheeks. He knew, as did Carolyn, that this was rapidly becoming the worst of disasters. If the obstruction wasn’t removed immediately, the best Nellie could hope for was life as a cardiac cripple.

“I can try,” he said.

“Go ahead.”

Brian took a single calming breath and guided the two-pronged forceps up the aorta toward the fragment. Over the years, he had spent countless hours studying textbooks and models of the heart, assisting in the OR, and working in cath labs. Now, all that experience was at work, helping him to visualize Nellie’s heart in three dimensions—to see through the flat image on the monitor screen and to angle the forceps just so.