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Deadman, Chapter 18

Chapter 18

If we of the unit were the young Turks of the hospital, Art Lee was our Ataturk. He was also one of the very few doctors I addressed using his first name.
Art was an interventional cardiologist back when that was a threat more than a title. A Stanford medical school graduate, and only a few years older than most of us, he was something different.
There was a strict caste system that separated doctors and nurses back then. Doctors were officers and nurses were enlisted women. Most of the talking that happened between the two was either non-verbal, as in written orders, or businesslike, attempts by a doctor to find a new wife to replace the last nurse they had married. There was not much give and take of ideas or thought processes. There was a marketplace of ideas, but we each used a separate entrance to get into it, and they owned all the shops.
Since male nurses were a small percentage of the action, we confused everyone. Doctors thought that we were either medical school flunkouts or lower class unfortunates that needed to work our way into medical school slowly, for financial reasons. Nurses thought we were their brothers, husbands, or one night stands that had left them alone without a kiss goodbye while it was still dark outside. They had mixed feeling about us, but usually left us out of the pulling each other into a pit they did to each other.
And everyone was shocked when they found out we were not gay.
Art was of a new breed of doctors who thought the unit was a fun place to hang out after work, and that we were fun people to amuse himself with.
Back then, interventional cardiology happened in a small annex of the x-ray department, and was considered to be a special sub category of them – like angiography or cancer treatments. We sent patients to them from the unit for movies of their hearts as they beat. They would thread a long catheter up the femoral artery until it was right where the coronary arteries started, and then inject dye into the arteries while taking a continuous x-ray of the action in real time (fluoroscopy.)
But they had bigger dreams than that, and Art was on the cutting edge of them.
This was not the cath lab you see today, stocked with thousands of different varieties of tubing’s and sophisticated pieces of specific and expensive machines, all managed with tight procedures of control -- this was a cowboy town of interventions done on the edge of unpaved roads inside flimsy walls of best guesses. Empirical evidence was what they got after they were done for the day, not the thing or place they started from.
Art would spend his day poking and prodding his patients with the few items available to him in the lab, trying to get arteries to open up by reaming them out, and then devising ways to keep them open after he did. After his day in the lab ended, he’d come up to the unit and do his money maker thing – inserting complicated central lines in critical patients and then monitoring the numbers he got from them for other doctors.
He was fun and talked about everything he was doing, or trying to do in the lab, with us. He did more than talk about work, he’d come up with other creative inventions and games for us to consider or play.
He modified fireball – using cotton balls and alcohol, we would turn up the oxygen in a empty patient room, set the balls on fire, and play catch with them using lead gloves he’s stolen from the x-ray department. Turning the oxygen on made them burn brighter and created less smoke – a twofer.
He came up with kite fishing: tying a kite to fishing line still connected to a fishing pole, and then casting the kite into the wind and using the line to let it play out. I never did figure out why this didn’t catch on with the public, but I always thought it genius.
Art took a lot of chances with his patients back then, sometimes it worked, but other times they crashed and burned on him. He was passionate about what he did, even when it went south on him. When a patient crashed, he took it personally, and worked hard to fix whatever happened, even if it wasn’t his fault, though a lot of time it was.
The image of him I remember best: Straddling a patient on a gurney giving CPR, as I pushed it as fast as I could down a long hall on our way to surgery after he had punched a hole in a heart trying to get a pressure measurement with a catheter. I was going so fast that I remember the sound and sight of the wheels shaking on the bottom of the gurney, like a bad shopping cart from a marginal outlet store, as I bounced it down the tiled hallway, sort of both in and out of control.
If I had not thought he did more good than bad, I would have thought him dangerous. If I were old and comfortable, I would have considered him a lot of work.
Working with Art was not like being part of an American movie, where all the blood is catsup and no one tortures kittens. It also wasn’t like a French movie, where nothing happens, slowly. Working with Art most resembled a tragic reinterpretation of the TV series M.A.S.H., with more blood, less sarcasm, and staring Jackie Chan. There was a lot of action when he was around. One might say it was his gift.
When he bounced into Posey’s room that afternoon to insert a Swanz-Ganz catheter in him, I was happy to see him. After introducing him to Mrs. Posey, we left the room – me to get the equipment, and him to review the chart. Mrs. Posey left for another trip to the waiting room.
A Swanz-Ganz catheter (Also known as a pulmonary artery catheter) was to be inserted into Posey to measure the pressures inside both sides of the heart, in order to better evaluate how to treat him -- with either drugs or fluid, or both. It consisted of a bunch of separate tubes (lumens) contained and surrounded by one tube. Bright yellow, it was placed in a large vein and pushed up through the right side of the heart – through the atrium and ventricle, and then into the right pulmonary artery where the tip of it was left.
Each separate tube had an opening that corresponded to an estimated part of where it would end up in the heart. By turning stopcocks, you could measure the pressure at each opening. You could see the preload and the contractility by measuring how much went in -- and how much was left over after it went in. This was a little better than the older way of taking measurements – a central venous pressure line – it added a better measurement of the actual contractility of the right heart in addition to giving you the preload, or CVP.
But the magic was in how it measured the pressures of left side of the heart.
Measuring the left side of the heart always brought up big time problems. If air was introduced or pieces of the lining of the arteries were knocked off – the patient stroked – anything loose or foreign in the arteries pumped straight up to the brain, where it lodged and occluded anything on the other side of them – or, simply, it stroked them out.
The left side of the heart was also a high-pressure system and difficult to place a catheter into, or keep it there once you placed it for any length of time. Cardiac catheterizations were done by placing a line in the arterial side (left heart) but were only placed for the amount of time it took to do the procedure, and even with just that length of time, a major complication was heavy bleeding from the site that the catheter was inserted – trying to measure consistent pressures over time would have caused a patient to bleed to death.
What the Swanz-Ganz catheter does is measure the left side pressures in an indirect way -- indirect, but very accurate.
At the tip of the catheter in the pulmonary artery was a small balloon that could be inflated with saline. When inflated the balloon would drift up the artery, until it got into a space too small to go any further, and would then stop --occluding it. From the point of the occlusion, a measurement could be taken that reflected the pressure in the left atrium, (since there wasn’t anything between the occluded area and the left side of the heat – no valves or other obstructions, only a little lung that didn’t make much difference in the measuring.)
The Swanz-Ganz also had thermometers strategically placed at a couple of spots along its length, and by a complicated mathematical magic, (thermal dilution) you could measure, by injecting a large syringe of saline into a port of it, an indirect measurement of what the left side of the heart was ejecting with each contraction (cardiac output.)
Now knowing how much fluid was going into the heart and how fast it was leaving it, the catheter would also give another number through another calculation involving mathematics – the systemic vascular response (SVR.)
The SVR was a measurement of how tight the tubing was that the heart had to pump into. The higher the number, the tighter the tube, and the harder the heart had to work – the more resistance it met with each contraction.
But wait, there’s more – the Swanz-Ganz also gave you central access to a big vein through its ports. Medicine and fluids now had a much better way of getting to the places they needed to get to.
With all these numbers you had an accurate measurement of what was going on in the heart, and how to assist it.
If the right side pressures were high it meant that the amount going into the heart was too much and was backing up. By increasing the Nitroglycerine you could relax the rest of the venous system and allow the fluid to back up there, or you could increase the Lasix and force the body to get rid of the fluid through urination. If the numbers were too low, you could give additional IV fluid.
If the heart wasn’t contracting enough, you could increase the Dopamine or other forms of inatropes, or you could decrease the amount of work it had to do with beta-blockers or other medicines from this class.
If the numbers indicated that the tubing the heart was pumping into was too constricted, you could add Nipride, a smooth muscle relaxer that worked especially well on the arteries, to get them a little bigger and easier to pump into.
The catheter was a big advance in medicine for its time, and for marginal heart attack patient, one who had suffered a survivable event and just needed additional support to get them over the hump, it could be a lifesaver. For an event not survivable, it was just a better way of keeping score.
It was not without complications however, and wasn’t used willy-nilly on just anyone. It required a patient that didn’t move much, and then the close attention of the nurse to take care of it.
At this point, it was perfect for Mr. Posey.


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