A Miracle in the Desert

I'm so pleased to host Dr. David Carnahan who will be blogging every month or so here at Redwood's. To introduce him, he's doing a three-part series on the Widow Maker--- and I'm not talking black spiders...

Part I about why this medical condition is so deadly can be found here.

Welcome back, David!

“I need to make you aware of a situation.” The Intensive Care Unit Director, Dr. Thomas Winfield, said as he entered my office. “We have an American contractor in the ICU who is having a large anterior wall MI.”

I heard the words “widow maker” in the back of my mind because those were the words used when I learned an anterior wall myocardial infarction was the worst kind to have. “What’s his name?”

“Richard Hall. He showed up at the clinic and collapsed. The ambulance got him to the ER and they started coding him there. We don’t know how long he was down, but we’ve coded him four times since he’s been in the ICU.”

It was here that the ICU director and I were thinking the same thoughts. Will he be a vegetable when he wakes up? If, he wakes up. We could save the heart, but lose the mind.

“Have you called about a special mission?”

He anticipated my question and before I finished it, he said. “They can’t make it until after midnight.”

I shook my head. In the Iraqi desert, all we could do was give him medicine to bust the clot up and wait for transportation to fly him to Germany, but in the states we would send this man to the Cardiac Cath Lab where he would get a state-of-the-art stent.

“I don’t think he’ll make it twelve hours and if he does ….”

I nodded. “It’s too early to call it.”

“We’ll keep coding him.”

Dr. Winfield and I returned to the ICU and saw Dr. Baur running through the advanced cardiac life support (ACLS) algorithms. The team was tense, but composed. When the patient recovered, Dr. Bauer put her card in her pocket. “Great job everybody.” She gave us a weary look as we approached her.

“What was he in?” Winfield asked.

“V tach.” Ventricular Tachycardia is when the bottom two chambers of the heart start going faster than usual and if prolonged is incompatible with life.

“How many times have you coded him?” I asked.

“I’m losing count. He seems to be coding about every twenty minutes.”

“Have you talked with his friends? Does he have family?”

Dr. Bauer looked to Dr. Winfield, who said, “I’ve told his coworkers he’s probably not going to make it. They told me he has a brother who they’re trying to reach.”

“Dr. Bauer,” a strained voice from the patient’s bed called out. “He’s coding again.”

The ACLS dance began again. I turned to the group waiting outside the ICU. I needed to have a discussion with them myself. As I approached, the expressions on their faces said everything. He was more than a co-worker; he was a brother. Thousands of miles from home, tons of sand and the threats of a combat zone will do that.

“I’m Dr. Carnahan. Who’s Mr. Hall’s supervisor?”

“I am,” said a stocky man with a mustache and goatee. He extended his right hand. “Tim Williams.”

“Mr. Williams,” I said as I lowered my voice to a respectful hush, “it doesn’t look good.” He nodded as did the others crowding around him. “We’ve coded him about five or six times in the short time we’ve had him.”

“Doc, we appreciate everything you’re doing.”

I met his eyes. “I just want you to know that the next plane to Germany probably won’t be able to get here for another twelve hours.” They looked at me, trying to find the meaning in this kernel of information. “I don’t think he'll make it that long.”

Then, their expressions dropped.

Stay tuned... the remainder will post Friday.


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Dr. David Carnahan is a Board Certified Internist, who fell in love with writing while getting his Masters Degree in Epidemiology at the University of Pennsylvania. He has served in the Air Force for the past 14 years as an academic clinician/educator and now works in the area of Healthcare Informatics. He has a wonderful wife and two beautiful daughters, and invites you to read about his life (www.dhcarnahan.blogspot.com), and weekly installments of his current work in progress, The Perfect Flaw (www.theperfectflaw.com).

Sudden Death: The Widow Maker

I'm so excited to have Dr. David Carnahan joining Redwood's as a guest blogger because for a while now I've been wanting to do a series on those things that cause sudden death. When David sent his first hand experience with such a case, the infamous widow maker, I knew he'd be the perfect expert to blog on this topic.

Welcome, David!

It sounds like a name you’d give an advanced military weapon or a designer drug, but in the medical community, it refers to a scenario far too many Americans experience. In 2007, the United States had a little less than a million people present with a new heart attack; while over 400,000 died from Coronary Heart Disease.

The scariest statistic is that over 150,000 Americans died of cardiovascular disease who were less than 65 years of age.² No matter how you slice it, Coronary Heart Disease has been the uncontested leading cause of death for many years, and the widow maker is a significant reason why.

Why is the widow maker especially dangerous?

It comes down to the anatomy. The blood vessels to the heart branch very early into the right and left coronary arteries. The primary purpose of these arteries is to feed nutrients and oxygen to the heart itself.

The right coronary artery is not as critical because it provides blood flow to the right side of the heart, which is the proverbial weakling who gets sand kicked in his face. Sure, it will hurt and cause damage, but nothing like the other side of the heart.

The left coronary artery starts as an artery we call the left main artery, but quickly divides into two other arteries: the left circumflex (not important to know), and the left anterior descending artery (also referred to as the ‘LAD’). If the left main or LAD arteries are blocked with cholesterol plaques and then a blood clot shows up, the patient could die in minutes.

You might be wondering why? How could these blockages cause the whole body to die?

It really comes down to a simple principle: without oxygen, every organ in the body will die. These arteries provide oxygenated blood to the left side of the heart, which pumps oxygen to the rest of the body. This makes this part of the heart crucial to your body’s survival. So, if the blockage kills the left side of the heart (a.k.a. the left ventricle) then the rest of your body will follow suit.

The scary thing about the widow maker is that there can be little warning that there is a problem. The press is full of examples of young, healthy people who suddenly die due to a blockage in these critical areas.

One striking example was Daryl Kile, a professional baseball pitcher for the St. Louis Cardinals, who died at age 33 while resting before a game. The manager had to break down the hotel door when he wouldn’t answer his messages.³ Autopsy showed he had two arteries that were completely blocked – I’m betting one of them was the left main or the LAD.

Another recent example was Tim Russert of Meet the Press notoriety. He died at the age of 58 while working in preparation for another Sunday morning show. Despite having a colleague witness the collapse and immediately start CPR (cardiopulmonary resuscitation) and having EMS arrive at the scene within 5 minutes of the 911 call, he was pronounced dead within an hour of his collapse.⁴

So, when you hear someone refer to a widow maker or when you plan to use it in your writing, the important thing to realize is that it is primarily a designation of the location of the blocked artery: usually the left main artery or a proximal LAD lesion. Though, it would be a cool name for a super secret military weapon.

References:

1. Words that Harm, Words that Heal. [Interesting article about how doctors use language and why they may use the terms they use] http://archinte.jamanetwork.com/article.aspx?articleid=217147

2. American Heart Association Statistical Update on Acute Myocardial Infarction. http://circ.ahajournals.org/content/123/4/e18

3. Daryl Kile: http://www.nytimes.com/2002/06/25/sports/baseball-heart-disease-can-hit-even-the-young-like-kile.html?ref=darrylkile

4. Tim Russert: http://en.wikipedia.org/wiki/Tim_Russert\

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Dr. David Carnahan is a Board Certified Internist, who fell in love with writing while getting his Masters Degree in Epidemiology at the University of Pennsylvania. He has served in the Air Force for the past 14 years as an academic clinician/educator and now works in the area of Healthcare Informatics. He has a wonderful wife and two beautiful daughters, and invites you to read about his life (www.dhcarnahan.blogspot.com), and weekly installments of his current work in progress, The Perfect Flaw (www.theperfectflaw.com).

Up and Coming

I'm so excited to be presenting a new guest blogger to Redwood's Medical Edge.

Dr. David Carnahan will be blogging all this coming week. He's an internist who's served his country in the military as well. He answers a strange prayer of mine-- starting a series of posts on medical calamities that cause sudden death.

These are amazing posts and I know they are good for authors everywhere!

This week.... the dreaded widow maker... and I'm not talking black widow spiders.

Jordyn

Why McDreamy is the Worst Neurosurgeon Ever

First and foremost, let me say that I am a Grey's Anatomy fan-- not for the medical accuracy for sure-- but it is a guilty pleasure of mine. So, considering the known medical inaccuracies I've seen, I don't have to be a neurosurgeon to guess that they are likely a little loose with the surgical details.

But this one I could not ignore.

Neurosurgeons place VP (ventriculostomy-peritoneal) shunts. What is that?

A VP shunt is a tube that is placed in a person's brain, specifically the ventricle, to drain off excess cerebrospinal fluid (CSF). Placing a VP shunt is primary treatment for a condition called hydrocephalus where there is excess accumulation of CSF in the brain. Too much CSF will lead to increased intracranail pressure-- which can be deadly.

A VP shunt helps keep the brain at an even pressure by draining extra fluid into the perotoneal cavity (or your gut.)

Here is a primer on traumatic brain injury. This post covers some important principles of managing traumatic brain injury. For quick review, the skull contains three components: your brain, blood, and CSF.

Back to Grey's.

Derek (aka McDreamy) and his surgeon wife adopt a baby named Zoila. One of the principle reasons for the adoption was that the child (approx 2 y/o) had a VP shunt and Dr. McDreamy would be an expert at managing her condition.

Really?

So, when the child begins to have vomiting and fever-- he makes the statement, "Well, she just has the flu."

The first thought in a neurosurgeon's mind, until ruled otherwise, is that something is wrong with the shunt in her head!

This concept is drilled into emergency medical personnel-- particularly pediatrics, that if a person with a VP shunt presents with headache, vomiting, and fever-- it is an emergency. First assumption is something is wrong with the shunt and if not treated, the person could have elevated intracranial pressure (which is bad) and die (which is super bad!)

Classic symptoms for increased pressure in the brain is headache and vomiting. These could mean that the shunt is obstructed and no longer draining CSF. Fever could indicate the shunt is infected-- which essentially means the patient has a brain infection (meningitis)-- another really bad thing.

So for super surgeon, McDreamy, to blow this off as a viral illness is a big no-no. Off to the ER little Zoila should have gone.