| General Fiction posted June 29, 2008 | Chapters: |
...28 29 -30- 31... 
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Dr. Barnett works to save Michael Conti's life.
A chapter in the book Caduceus
Michael in the Cath Lab---Part One
by cardiodoug
Barnett entered the cardiac catheterization lab wearing blue scrubs and a lead apron. He handed his cell phone and pager to Nikki, who placed them on a counter. The cath crew, Marsha, Jennifer and Nikki, had come in from home for the emergency procedure. Michael Conti was on the cath table, covered chin to toe with a sterile drape. It had an opening over his right groin where the nurses had shaved and prepped Michael's skin in preparation for needle puncture access to his femoral artery.
"Marsha, what's his BP?"
"Ninety to ninety-five systolic, Dr. Barnett. He's on dopamine at twenty micrograms."
Twenty mics of dopamine is a massive dose, thought Barnett. The cardiac monitor showed a sinus tachycardia at one-hundred-twenty beats per minute. His heart rate was climbing. Michael Conti was in a dire situation.
David put on a mask and head cover, quickly scrubbed in and had his scrub nurse, Marsha, help him don a sterile gown and gloves. It was eight-fifteen p.m.
* * *
In the ER conference room, Carlo Conti was pacing the floor. Laura remained seated at the table, starring down with tear filled eyes--head held in her hands.
"Laura, I can't stand this. I'm goin' out to my car to call my brother."
Laura nodded. She thought of calling her parents.
* * *
David walked to the head of the cath table to speak with his patient.
"Michael, are you okay?"
"I'm still here, doctor. My chest pain's gone."
"Good. We're going to start the procedure now. You'll feel a needle stick in your groin. I have to inject some anesthetic. It's gonna sting."
"I'm ready."
Barnett used his fingers to locate Michael's femoral pulse, injected Lidocaine in the overlying skin, and gently rubbed the area to dispense the anesthetic. He waited a minute to let the numbing effect set in, and inserted a sixteen-gauge needle through the skin toward the femoral pulsation. Michael was thin; hitting the target was easy. A stream of bright red blood shot from the head of the needle. Marsha, standing next to Barnett, called out, "We have arterial." Nikki noted the time of femoral puncture on Michael Conti's chart.
* * *
Carlo Conti was in the parking lot, sitting in his car, using his car phone.
"Hello."
"Tony, It's Carlo."
"Hey, Carlo. What's up?"
"It's Michael. He's in the hospital in Toledo. He's having a heart attack."
"Oh shit! You gotta be kiddin' me. Is he okay?"
"Apparently not. It sounds like he's in trouble. Tony, I'm really scared."
"What the hell happened? Did he collapse? I thought Mikey was in great shape."
"Laura says he's been having chest pain for awhile. He saw some doctor last week. I never knew about it. This afternoon his pain got real bad, so she took him to the emergency room."
"In Toledo?"
"Yeah. I wish I'd never sent him down here to this shit hole. He was better off in Detroit."
"Carlo, I'm sure that has nothing to do with it."
"Probably not."
"My God, Carlo, what else could happen to you? I'll be prayin' for you and Mikey."
"Thanks, Tony. I gotta get back in there to see Laura. She's really shook up."
"Carlo, be sure an' keep in touch. Gimme a call later and let me know how things are goin'."
"I'll call you, Tony."
* * *
Barnett checked the IV lines and injection syringe for evidence of air bubbles. The lines were clear. Marsha presented the tip of a long guide wire to the doctor, who inserted it through the needle into the femoral. The needle was removed and a Teflon sheath was passed over the wire, into Michael's arterial circulation. David removed the wire and inserted a left coronary catheter through the sheath. As he watched under fluoroscopic imaging, Barnett passed the catheter upward through the aorta and around the aortic arch, positioning the tip just above the heart.
* * *
The human heart has four chambers, two atria on top and two ventricles on bottom. The left ventricle (LV) is a strong, muscular chamber responsible for pumping oxygenated blood through the body. The LV receives ninety percent of the coronary arterial blood flow and is the site of nearly all myocardial infarctions. Occasionally, heart attacks occur in the right ventricle--virtually none in the atria.
Myocardial blood supply is derived from three coronary vessels: the left anterior descending (LAD), the circumflex (Circ), and the right coronary (RCA). The LAD and Circ branch off from the short, left main coronary, originating from the left aortic base, immediately above the heart. The origin of the RCA is above the heart at the right aortic base. In most cases, the LAD and RCA deliver a major portion of the blood supplying the left ventricle.
* * *
David cautiously aspirated blood from the catheter, flushed it with saline and made a final check for errant bubbles. The catheter was filled with x-ray contrast and a small test injection was made at the base of the aorta. He carefully positioned the catheter tip in the opening of the left main. His pager sounded.
"I'll get it, said Nikki. She called the number listed on the pager. "Dr. Barnett, you have a consult at Toledo CCU."
"Ask if it's urgent."
"The nurse says it can wait till later if you're tied up."
"Okay, write down the name and room number. Tell 'em I'll be there tonight."
* * *
Laura Conti decided to call her parents. She left the conference room to use a telephone at the receptionist's desk.
"Hello, Mom."
"Hi, honey. How are you?"
"Not so good. It's Michael. He's having a heart attack."
"What! How can that be? He's so healthy."
"I know, Mom. I can't believe it. I'm really worried. Mom, I'm scared!"
"Oh, Laura. I hope he's gonna be okay."
"Mom, what will I do? I can't make it without him."
"You have to be positive, honey. Medical care is miraculous these days. He's gonna be alright."
Laura wept quietly into the phone.
"Your father and I will be praying for you and Michael. Please call back as soon as you know more."
"I will. I gotta go."
"Goodbye, Laura."
* * *
Michael Conti's heart rate had risen to one-hundred-thirty. An intra-arterial blood pressure recording, obtained through the femoral sheath's sidearm, was visible on the hemodynamic monitor. His blood pressure still hovered at ninety millimeters of mercury.
"Mr. Conti, can you hear me?"
"Yeah, doc. I hear you."
"I'm ready to take a picture. You'll need to take a deep breath and hold it when I give the word. You can breathe when you here the camera stop."
"Okay. Tell me when."
* * *
Carlo Conti returned to the conference room to find Laura seated at the table.
"Laura, have you heard anything?"
"No!"
"What the hell's taking so long? Where's that goddamn doctor?"
"Carlo, he's working on Michael. I'm sure he's busy. We just have to wait and pray."
"Wait and pray. Wait and pray. I've been praying my whole life. What good has it done?"
Laura turned to her father-in-law with a look of disgust. Carlo started pacing the floor, muttering to himself. "Pray, pray, pray. Fuck it."
"Carlo! Please stop! Please, I'm terrified enough as it is."
* * *
Barnett stepped on the fluoroscope peddle. "Go ahead, Mr. Conti. Take a deep breath." The x-ray image improved as Michael's diaphragm dropped on inhalation. David quickly moved his foot to the cine peddle to take a permanent, moving picture as he injected contrast. He pushed the plunger on the contrast syringe. Dye flowed into Michael's left coronary system.
Marsha, watching the injection on a video monitor, exclaimed, "Oh, my God!" Her voice hung in the air.
The doctor was stunned by what he saw. He whispered to himself. "Holy shit." The contrast slowly trickled through numerous, tight constrictions in the LAD and Circumflex. Michael's left coronary system was replete with severe atherosclerotic plague. There were high grade narrowings everywhere. His coronaries looked like those of a ninety-year-old man, not a thirty-nine-year-old athlete.
Michael, hearing Marsha's remark, asked,"Is something wrong. Am I Okay?"
"You're fine, Mr. Conti," answered David. "The test is going well."
Wanting no more outbursts frightening his patient, he turned to Marsha, placed his gloved index finger close to his mask, and gave a soft "shh".
Marsha whispered, "I'm sorry."
X-ray contrast is mildly toxic to the heart. Barnett decided to limit his injections to two, instead of the usual five or six. In addition, taking a picture of Michael's left ventricular chamber was out of the question. In his case, the large volume of dye required would likely be fatal. He quietly spoke to his other nurse. "Jenny, we'll only take one more picture. Let's go sixty degrees LAO."
Jennifer moved the x-ray tower to a lateral position.
"Mr. Conti, one more deep breath."
Barnett hit the cine peddle and made a second injection. The left coronary vessels, viewed from a new angle, looked as bad or worse than before. David closely reviewed both pictures on a digital screen. A tight, ninety percent lesion in the proximal (early) portion of the LAD, had a tiny remnant of fresh clot. He pointed to that spot and softly spoke to Marsha. "Here's the culprit. He had a total thrombosis right here. The thrombolytics worked, partially dissolving the clot, but the damage was done. His atherosclerosis is just too severe."
Marsha acknowledged with a nod. David had to do whatever he could to keep the LAD lesion open. A balloon angioplasty would be much too hazardous. The time involved would not be worth the minimal benefit. The safest way to keep Michael's coronaries open would be with increased anticoagulation.
"Jenny, bolus him with another thousand units of heparin and increase his drip to twelve hundred an hour. Marsha, wait about ten minutes for the increased heparin to kick in, then draw some blood for a stat PTT."
David reviewed the coronary pictures again. To make matters worse, there were small collateral blood vessels connecting the distal (end portions) of the LAD to the right coronary artery. Collaterals develop slowly over time, usually years, only when there is demand for blood from an adjacent vessel.
This meant the right coronary had gradually closed off sometime in the past. The collaterals, supplying blood retrograde, backwards from left to right, had protected Michael from an infarction when total blockage of the right coronary occured. He probably had minimal, or no symptoms, at the time. However, when Michael's LAD occluded hours ago, blood supply to his collaterals was cut off. Consequently, he had two simultaneous infarctions--one in the distribution of the LAD, and a second in the distribution of the right coronary. Barnett thought, He's wiped out his anterior wall (front of the heart) and his inferior wall (bottom of the heart) Know wonder he's in shock.
* * *
Shock, in medical terms, occurs when blood pressure is too low to sustain life--usually below eighty systolic. At such pressures, the supply of oxygen to vital organs is inadequate. The kidneys shut down first, liver damage ensues and skeletal muscle starts to necrose. Continued muscle metabolism in the face of poor oxygenation leads to anaerobic breakdown of tissue. Lactic acid, produced by muscle necrosis, is released into the blood stream. Acidosis leads to dangerous electrolyte imbalance. Death follows soon after.
* * *
Barnett, to make sure his suspicions were correct, switched the left coronary catheter for one designed for right coronary cannulation. He injected a small bolus of contrast into the RCA. As anticipated, the artery was totally occluded near its origin.
A cell phone rang. Nikki answered. "Hey, doc, it's your daughter, Maddie. She wants to know if you liked the show?"
David chuckled. What a time for her to call. "Tell her I loved it. She was wonderful."
Nikki relayed the message. "Nikki, tell her I can't come to the phone right now. And remind her that it's past her bedtime."
Nikki laughed. "She said she stays up later now."
"I'm not surprised. Okay. Tell Maddie I'll call tomorrow afternoon."
He turned his attention back to his patient, noting that Michael's breathing was more labored. He checked the pulse-ox reading on the monitor. Michael's oxygenation was suffering the consequences of his extensive infarction. And, despite huge doses of dopamine, his pressure was falling--systolic BP hovering around eighty. His pulse-ox, on maximal nasal oxygen was critically low. David thought, we need an echocardiodgram to asses his left ventricular function and severity of mitral regurgitation. He needs more oyygen.
"Nikki, call for a stat echocardiogram. We'll do it right here in the lab. Jenny, please call respiratory. Start a non-rebreather mask at one-hundred percent oxygen. Barnett said to himself, he's developing pulmonary edema.
* * *
Pulmonary edema is the medical term for wet lungs--congestion in lung tissue. A damaged, failing heart causes increased back pressure, resulting in the accumulation of fluid in lung tissue. Mitral regurgitation adds to the problem. The congestion causes reduced up-take of oxygen in the pulmonary vessels. In Michael's case, it was an ominous sign.
* * *
"Mr. Conti, we've taken two pictures of your heart. How do you feel?"
Michael was fading. His speech was garbled. "I. . .I'm short of breath. I feel. . . dizzy."
"Okay, Michael. We're gonna fix that for you. Jenny, get me a blood gas syringe."
David aspirated arterial blood from the femoral sheath. It was dark red, not as bright in color as it had been. "Nikki, send this for a blood gas. Tell 'em to run it stat. Jenny, he's gotta be getting acidotic. Push one amp of bicarb, give him twenty of Lasix IV push and turn the saline drip down to keep open. He can't handle anymore fluids. And Jenny, please tell respiratory to get here now!"
Jennifer ran to the supply counter for an oxygen mask, Lasix and bicarb. Nikki, after sending the blood gas, returned to the lab. "Nikki, call anesthesia. I want him intubated. Then call cardiac surgery--ask for a pump tech. I need an intra-aortic balloon pump up here pronto.Jenny, please get that oxygen mask in place. We'll use that until he's intubated."
"I'm on it, doc."
"Nikki, I also need someone to talk with the family. We can't afford to have any of you leave. Call Karen in the ER. Ask her to bring the family up to the cath conference room. "
"Okay, right after I call for anesthesia and the pump tech."
Glancing up to the wall clock, David noted the time. It was ten after nine. They had been in the lab for nearly an hour.
Michael's pressure dropped to seventy-five systolic. Jennifer and Nikki were busy, scrambling around the room, giving meds and making phone calls. Barnett, exhausted from the weight of his lead, ripped off his blood smeared gloves, gown, and lead apron--dropping all of it to the floor. His scrubs were soaked with perspiration. "Mr. Conti, we have to put a breathing tube in your airway. It goes in your mouth, down in your trachea. It'll help you breathe."
Michael murmured something through the mask. David couldn't here what he said. He was getting frustrated. His patient was crashing. "Nikki, what's takin' anesthesia? Where are they?"
"Hey, doc, it's only been a minute since I called. They said someone would be right up. I'll call them aga. . ."
"Forget it. Pull the crash cart over here. I'll do it myself."
The doctor pulled Michael's mask off and used an Ambu bag to deliver three good inhalations of oxygen. "This is gonna be uncomfortable, Mr. Conti. I have to put some pressure on your jaw."
Michael Conti opened his mouth wide. David inserted a retractor blade and pulled up, peering down Michael's throat to locate his vocal cords. The tissue in his airway was swollen, edematous from fluid retention. Vocal cords came into view. "Jennie, hand me that number twenty-one ET tube with a wire trochar."
With his free hand, Barnett carefully slid the wire stiffened tube between Michael's vocal cords, removed the retractor and trochar, and immediately attached the Ambu bag to the tube emanating from Michael's mouth. More inhalations were given. "Jennie, secure the tube with tape. You'll have to bag him until anesthesia gets here. Nikki, call respiratory again for assistance with his airway. Marsha, what's his BP?"
"It's down a little more, bouncin' between seventy and seventy-five. His rates up to one-forty, sinus tach."
Barnett's pager went off. " Nikki, please answer that."
"Dr. B, its the CCU upstairs. You have another consult."
"Ask them what's going on with the patient."
"It's a fifty-five year old woman, doctor. She was admitted through the ER by Dr. Goetch. Her attending want's you to assess her chest pain."
"Okay, Nikki.Tell them I'll run up and check her out as soon as I leave the lab."
"Will do, doc."
David turned back to his patient. He walked to the opposite side of the table and increased the dopamine drip to thirty micrograms, an incredibly high dose. He yelled, "Nikki, where are you?"
"I'm right behind you."
"Oh, sorry. Check his Foley bag for me. See how much urine he's made."
Nikki reached under the long drape hanging from the table. "Not a drop of urine in here, doc."
"None?"
"I emptied the bag when we started. None since."
"Marsha, he's in renal shutdown. Draw blood for stat electrolytes, BUN and creatinine. Jenny, I'll take over bagging while you make up an Isuprel drip. Start it at ten mics. Nikki, give him another bolus of Lasix, eighty milligrams IV push."
A moment later the respiratory tech arrived. "Hi, Dr. Barnett. I'll take over for you."
David knew him. "Thanks, Doug. He's hypoxic as hell. Bag him at a good rate--twenty a minute."
"Okay, I got it."
A small Asian woman in scrubs entered the lab. Barnett had never seen her before. "I Dr. Kim, anesthesia. Sorry I late. I tied up in operating room. You need help?"
"No, we've got it under control."
"Okay, I go?
"Sure, thanks." David thought. Thanks for nothing. Get the hell outta here.
David turned to the digital screen to review the arteriograms once more. There's nothing I can do here. His thrombosis is dissolved and there's no need for an angioplasty. A balloon dilatation would be risky. Besides, I wouldn't know where to start. He has too much disease.
The doctor knew Michael's only chance was to support him mechanically, thereby buying time for his infarction to heal. Even then, the extent of his ventricular damage and the diffuse nature of his coronary atherosclerosis would preclude coronary bypass surgery. If, against all odds, he lived through the night, he would have a rough road of healing ahead. His only chance for a long, meaningful life, would be a heart transplant. The hard truth was that Michael's chance of survival, even for a few hours, was nil.
Barnett entered the cardiac catheterization lab wearing blue scrubs and a lead apron. He handed his cell phone and pager to Nikki, who placed them on a counter. The cath crew, Marsha, Jennifer and Nikki, had come in from home for the emergency procedure. Michael Conti was on the cath table, covered chin to toe with a sterile drape. It had an opening over his right groin where the nurses had shaved and prepped Michael's skin in preparation for needle puncture access to his femoral artery.
"Marsha, what's his BP?"
"Ninety to ninety-five systolic, Dr. Barnett. He's on dopamine at twenty micrograms."
Twenty mics of dopamine is a massive dose, thought Barnett. The cardiac monitor showed a sinus tachycardia at one-hundred-twenty beats per minute. His heart rate was climbing. Michael Conti was in a dire situation.
David put on a mask and head cover, quickly scrubbed in and had his scrub nurse, Marsha, help him don a sterile gown and gloves. It was eight-fifteen p.m.
* * *
In the ER conference room, Carlo Conti was pacing the floor. Laura remained seated at the table, starring down with tear filled eyes--head held in her hands.
"Laura, I can't stand this. I'm goin' out to my car to call my brother."
Laura nodded. She thought of calling her parents.
* * *
David walked to the head of the cath table to speak with his patient.
"Michael, are you okay?"
"I'm still here, doctor. My chest pain's gone."
"Good. We're going to start the procedure now. You'll feel a needle stick in your groin. I have to inject some anesthetic. It's gonna sting."
"I'm ready."
Barnett used his fingers to locate Michael's femoral pulse, injected Lidocaine in the overlying skin, and gently rubbed the area to dispense the anesthetic. He waited a minute to let the numbing effect set in, and inserted a sixteen-gauge needle through the skin toward the femoral pulsation. Michael was thin; hitting the target was easy. A stream of bright red blood shot from the head of the needle. Marsha, standing next to Barnett, called out, "We have arterial." Nikki noted the time of femoral puncture on Michael Conti's chart.
* * *
Carlo Conti was in the parking lot, sitting in his car, using his car phone.
"Hello."
"Tony, It's Carlo."
"Hey, Carlo. What's up?"
"It's Michael. He's in the hospital in Toledo. He's having a heart attack."
"Oh shit! You gotta be kiddin' me. Is he okay?"
"Apparently not. It sounds like he's in trouble. Tony, I'm really scared."
"What the hell happened? Did he collapse? I thought Mikey was in great shape."
"Laura says he's been having chest pain for awhile. He saw some doctor last week. I never knew about it. This afternoon his pain got real bad, so she took him to the emergency room."
"In Toledo?"
"Yeah. I wish I'd never sent him down here to this shit hole. He was better off in Detroit."
"Carlo, I'm sure that has nothing to do with it."
"Probably not."
"My God, Carlo, what else could happen to you? I'll be prayin' for you and Mikey."
"Thanks, Tony. I gotta get back in there to see Laura. She's really shook up."
"Carlo, be sure an' keep in touch. Gimme a call later and let me know how things are goin'."
"I'll call you, Tony."
* * *
Barnett checked the IV lines and injection syringe for evidence of air bubbles. The lines were clear. Marsha presented the tip of a long guide wire to the doctor, who inserted it through the needle into the femoral. The needle was removed and a Teflon sheath was passed over the wire, into Michael's arterial circulation. David removed the wire and inserted a left coronary catheter through the sheath. As he watched under fluoroscopic imaging, Barnett passed the catheter upward through the aorta and around the aortic arch, positioning the tip just above the heart.
* * *
The human heart has four chambers, two atria on top and two ventricles on bottom. The left ventricle (LV) is a strong, muscular chamber responsible for pumping oxygenated blood through the body. The LV receives ninety percent of the coronary arterial blood flow and is the site of nearly all myocardial infarctions. Occasionally, heart attacks occur in the right ventricle--virtually none in the atria.
Myocardial blood supply is derived from three coronary vessels: the left anterior descending (LAD), the circumflex (Circ), and the right coronary (RCA). The LAD and Circ branch off from the short, left main coronary, originating from the left aortic base, immediately above the heart. The origin of the RCA is above the heart at the right aortic base. In most cases, the LAD and RCA deliver a major portion of the blood supplying the left ventricle.
* * *
David cautiously aspirated blood from the catheter, flushed it with saline and made a final check for errant bubbles. The catheter was filled with x-ray contrast and a small test injection was made at the base of the aorta. He carefully positioned the catheter tip in the opening of the left main. His pager sounded.
"I'll get it, said Nikki. She called the number listed on the pager. "Dr. Barnett, you have a consult at Toledo CCU."
"Ask if it's urgent."
"The nurse says it can wait till later if you're tied up."
"Okay, write down the name and room number. Tell 'em I'll be there tonight."
* * *
Laura Conti decided to call her parents. She left the conference room to use a telephone at the receptionist's desk.
"Hello, Mom."
"Hi, honey. How are you?"
"Not so good. It's Michael. He's having a heart attack."
"What! How can that be? He's so healthy."
"I know, Mom. I can't believe it. I'm really worried. Mom, I'm scared!"
"Oh, Laura. I hope he's gonna be okay."
"Mom, what will I do? I can't make it without him."
"You have to be positive, honey. Medical care is miraculous these days. He's gonna be alright."
Laura wept quietly into the phone.
"Your father and I will be praying for you and Michael. Please call back as soon as you know more."
"I will. I gotta go."
"Goodbye, Laura."
* * *
Michael Conti's heart rate had risen to one-hundred-thirty. An intra-arterial blood pressure recording, obtained through the femoral sheath's sidearm, was visible on the hemodynamic monitor. His blood pressure still hovered at ninety millimeters of mercury.
"Mr. Conti, can you hear me?"
"Yeah, doc. I hear you."
"I'm ready to take a picture. You'll need to take a deep breath and hold it when I give the word. You can breathe when you here the camera stop."
"Okay. Tell me when."
* * *
Carlo Conti returned to the conference room to find Laura seated at the table.
"Laura, have you heard anything?"
"No!"
"What the hell's taking so long? Where's that goddamn doctor?"
"Carlo, he's working on Michael. I'm sure he's busy. We just have to wait and pray."
"Wait and pray. Wait and pray. I've been praying my whole life. What good has it done?"
Laura turned to her father-in-law with a look of disgust. Carlo started pacing the floor, muttering to himself. "Pray, pray, pray. Fuck it."
"Carlo! Please stop! Please, I'm terrified enough as it is."
* * *
Barnett stepped on the fluoroscope peddle. "Go ahead, Mr. Conti. Take a deep breath." The x-ray image improved as Michael's diaphragm dropped on inhalation. David quickly moved his foot to the cine peddle to take a permanent, moving picture as he injected contrast. He pushed the plunger on the contrast syringe. Dye flowed into Michael's left coronary system.
Marsha, watching the injection on a video monitor, exclaimed, "Oh, my God!" Her voice hung in the air.
The doctor was stunned by what he saw. He whispered to himself. "Holy shit." The contrast slowly trickled through numerous, tight constrictions in the LAD and Circumflex. Michael's left coronary system was replete with severe atherosclerotic plague. There were high grade narrowings everywhere. His coronaries looked like those of a ninety-year-old man, not a thirty-nine-year-old athlete.
Michael, hearing Marsha's remark, asked,"Is something wrong. Am I Okay?"
"You're fine, Mr. Conti," answered David. "The test is going well."
Wanting no more outbursts frightening his patient, he turned to Marsha, placed his gloved index finger close to his mask, and gave a soft "shh".
Marsha whispered, "I'm sorry."
X-ray contrast is mildly toxic to the heart. Barnett decided to limit his injections to two, instead of the usual five or six. In addition, taking a picture of Michael's left ventricular chamber was out of the question. In his case, the large volume of dye required would likely be fatal. He quietly spoke to his other nurse. "Jenny, we'll only take one more picture. Let's go sixty degrees LAO."
Jennifer moved the x-ray tower to a lateral position.
"Mr. Conti, one more deep breath."
Barnett hit the cine peddle and made a second injection. The left coronary vessels, viewed from a new angle, looked as bad or worse than before. David closely reviewed both pictures on a digital screen. A tight, ninety percent lesion in the proximal (early) portion of the LAD, had a tiny remnant of fresh clot. He pointed to that spot and softly spoke to Marsha. "Here's the culprit. He had a total thrombosis right here. The thrombolytics worked, partially dissolving the clot, but the damage was done. His atherosclerosis is just too severe."
Marsha acknowledged with a nod. David had to do whatever he could to keep the LAD lesion open. A balloon angioplasty would be much too hazardous. The time involved would not be worth the minimal benefit. The safest way to keep Michael's coronaries open would be with increased anticoagulation.
"Jenny, bolus him with another thousand units of heparin and increase his drip to twelve hundred an hour. Marsha, wait about ten minutes for the increased heparin to kick in, then draw some blood for a stat PTT."
David reviewed the coronary pictures again. To make matters worse, there were small collateral blood vessels connecting the distal (end portions) of the LAD to the right coronary artery. Collaterals develop slowly over time, usually years, only when there is demand for blood from an adjacent vessel.
This meant the right coronary had gradually closed off sometime in the past. The collaterals, supplying blood retrograde, backwards from left to right, had protected Michael from an infarction when total blockage of the right coronary occured. He probably had minimal, or no symptoms, at the time. However, when Michael's LAD occluded hours ago, blood supply to his collaterals was cut off. Consequently, he had two simultaneous infarctions--one in the distribution of the LAD, and a second in the distribution of the right coronary. Barnett thought, He's wiped out his anterior wall (front of the heart) and his inferior wall (bottom of the heart) Know wonder he's in shock.
* * *
Shock, in medical terms, occurs when blood pressure is too low to sustain life--usually below eighty systolic. At such pressures, the supply of oxygen to vital organs is inadequate. The kidneys shut down first, liver damage ensues and skeletal muscle starts to necrose. Continued muscle metabolism in the face of poor oxygenation leads to anaerobic breakdown of tissue. Lactic acid, produced by muscle necrosis, is released into the blood stream. Acidosis leads to dangerous electrolyte imbalance. Death follows soon after.
* * *
Barnett, to make sure his suspicions were correct, switched the left coronary catheter for one designed for right coronary cannulation. He injected a small bolus of contrast into the RCA. As anticipated, the artery was totally occluded near its origin.
A cell phone rang. Nikki answered. "Hey, doc, it's your daughter, Maddie. She wants to know if you liked the show?"
David chuckled. What a time for her to call. "Tell her I loved it. She was wonderful."
Nikki relayed the message. "Nikki, tell her I can't come to the phone right now. And remind her that it's past her bedtime."
Nikki laughed. "She said she stays up later now."
"I'm not surprised. Okay. Tell Maddie I'll call tomorrow afternoon."
He turned his attention back to his patient, noting that Michael's breathing was more labored. He checked the pulse-ox reading on the monitor. Michael's oxygenation was suffering the consequences of his extensive infarction. And, despite huge doses of dopamine, his pressure was falling--systolic BP hovering around eighty. His pulse-ox, on maximal nasal oxygen was critically low. David thought, we need an echocardiodgram to asses his left ventricular function and severity of mitral regurgitation. He needs more oyygen.
"Nikki, call for a stat echocardiogram. We'll do it right here in the lab. Jenny, please call respiratory. Start a non-rebreather mask at one-hundred percent oxygen. Barnett said to himself, he's developing pulmonary edema.
* * *
Pulmonary edema is the medical term for wet lungs--congestion in lung tissue. A damaged, failing heart causes increased back pressure, resulting in the accumulation of fluid in lung tissue. Mitral regurgitation adds to the problem. The congestion causes reduced up-take of oxygen in the pulmonary vessels. In Michael's case, it was an ominous sign.
* * *
"Mr. Conti, we've taken two pictures of your heart. How do you feel?"
Michael was fading. His speech was garbled. "I. . .I'm short of breath. I feel. . . dizzy."
"Okay, Michael. We're gonna fix that for you. Jenny, get me a blood gas syringe."
David aspirated arterial blood from the femoral sheath. It was dark red, not as bright in color as it had been. "Nikki, send this for a blood gas. Tell 'em to run it stat. Jenny, he's gotta be getting acidotic. Push one amp of bicarb, give him twenty of Lasix IV push and turn the saline drip down to keep open. He can't handle anymore fluids. And Jenny, please tell respiratory to get here now!"
Jennifer ran to the supply counter for an oxygen mask, Lasix and bicarb. Nikki, after sending the blood gas, returned to the lab. "Nikki, call anesthesia. I want him intubated. Then call cardiac surgery--ask for a pump tech. I need an intra-aortic balloon pump up here pronto.Jenny, please get that oxygen mask in place. We'll use that until he's intubated."
"I'm on it, doc."
"Nikki, I also need someone to talk with the family. We can't afford to have any of you leave. Call Karen in the ER. Ask her to bring the family up to the cath conference room. "
"Okay, right after I call for anesthesia and the pump tech."
Glancing up to the wall clock, David noted the time. It was ten after nine. They had been in the lab for nearly an hour.
Michael's pressure dropped to seventy-five systolic. Jennifer and Nikki were busy, scrambling around the room, giving meds and making phone calls. Barnett, exhausted from the weight of his lead, ripped off his blood smeared gloves, gown, and lead apron--dropping all of it to the floor. His scrubs were soaked with perspiration. "Mr. Conti, we have to put a breathing tube in your airway. It goes in your mouth, down in your trachea. It'll help you breathe."
Michael murmured something through the mask. David couldn't here what he said. He was getting frustrated. His patient was crashing. "Nikki, what's takin' anesthesia? Where are they?"
"Hey, doc, it's only been a minute since I called. They said someone would be right up. I'll call them aga. . ."
"Forget it. Pull the crash cart over here. I'll do it myself."
The doctor pulled Michael's mask off and used an Ambu bag to deliver three good inhalations of oxygen. "This is gonna be uncomfortable, Mr. Conti. I have to put some pressure on your jaw."
Michael Conti opened his mouth wide. David inserted a retractor blade and pulled up, peering down Michael's throat to locate his vocal cords. The tissue in his airway was swollen, edematous from fluid retention. Vocal cords came into view. "Jennie, hand me that number twenty-one ET tube with a wire trochar."
With his free hand, Barnett carefully slid the wire stiffened tube between Michael's vocal cords, removed the retractor and trochar, and immediately attached the Ambu bag to the tube emanating from Michael's mouth. More inhalations were given. "Jennie, secure the tube with tape. You'll have to bag him until anesthesia gets here. Nikki, call respiratory again for assistance with his airway. Marsha, what's his BP?"
"It's down a little more, bouncin' between seventy and seventy-five. His rates up to one-forty, sinus tach."
Barnett's pager went off. " Nikki, please answer that."
"Dr. B, its the CCU upstairs. You have another consult."
"Ask them what's going on with the patient."
"It's a fifty-five year old woman, doctor. She was admitted through the ER by Dr. Goetch. Her attending want's you to assess her chest pain."
"Okay, Nikki.Tell them I'll run up and check her out as soon as I leave the lab."
"Will do, doc."
David turned back to his patient. He walked to the opposite side of the table and increased the dopamine drip to thirty micrograms, an incredibly high dose. He yelled, "Nikki, where are you?"
"I'm right behind you."
"Oh, sorry. Check his Foley bag for me. See how much urine he's made."
Nikki reached under the long drape hanging from the table. "Not a drop of urine in here, doc."
"None?"
"I emptied the bag when we started. None since."
"Marsha, he's in renal shutdown. Draw blood for stat electrolytes, BUN and creatinine. Jenny, I'll take over bagging while you make up an Isuprel drip. Start it at ten mics. Nikki, give him another bolus of Lasix, eighty milligrams IV push."
A moment later the respiratory tech arrived. "Hi, Dr. Barnett. I'll take over for you."
David knew him. "Thanks, Doug. He's hypoxic as hell. Bag him at a good rate--twenty a minute."
"Okay, I got it."
A small Asian woman in scrubs entered the lab. Barnett had never seen her before. "I Dr. Kim, anesthesia. Sorry I late. I tied up in operating room. You need help?"
"No, we've got it under control."
"Okay, I go?
"Sure, thanks." David thought. Thanks for nothing. Get the hell outta here.
David turned to the digital screen to review the arteriograms once more. There's nothing I can do here. His thrombosis is dissolved and there's no need for an angioplasty. A balloon dilatation would be risky. Besides, I wouldn't know where to start. He has too much disease.
The doctor knew Michael's only chance was to support him mechanically, thereby buying time for his infarction to heal. Even then, the extent of his ventricular damage and the diffuse nature of his coronary atherosclerosis would preclude coronary bypass surgery. If, against all odds, he lived through the night, he would have a rough road of healing ahead. His only chance for a long, meaningful life, would be a heart transplant. The hard truth was that Michael's chance of survival, even for a few hours, was nil.
"Marsha, what's his BP?"
"Ninety to ninety-five systolic, Dr. Barnett. He's on dopamine at twenty micrograms."
Twenty mics of dopamine is a massive dose, thought Barnett. The cardiac monitor showed a sinus tachycardia at one-hundred-twenty beats per minute. His heart rate was climbing. Michael Conti was in a dire situation.
David put on a mask and head cover, quickly scrubbed in and had his scrub nurse, Marsha, help him don a sterile gown and gloves. It was eight-fifteen p.m.
* * *
In the ER conference room, Carlo Conti was pacing the floor. Laura remained seated at the table, starring down with tear filled eyes--head held in her hands.
"Laura, I can't stand this. I'm goin' out to my car to call my brother."
Laura nodded. She thought of calling her parents.
* * *
David walked to the head of the cath table to speak with his patient.
"Michael, are you okay?"
"I'm still here, doctor. My chest pain's gone."
"Good. We're going to start the procedure now. You'll feel a needle stick in your groin. I have to inject some anesthetic. It's gonna sting."
"I'm ready."
Barnett used his fingers to locate Michael's femoral pulse, injected Lidocaine in the overlying skin, and gently rubbed the area to dispense the anesthetic. He waited a minute to let the numbing effect set in, and inserted a sixteen-gauge needle through the skin toward the femoral pulsation. Michael was thin; hitting the target was easy. A stream of bright red blood shot from the head of the needle. Marsha, standing next to Barnett, called out, "We have arterial." Nikki noted the time of femoral puncture on Michael Conti's chart.
* * *
Carlo Conti was in the parking lot, sitting in his car, using his car phone.
"Hello."
"Tony, It's Carlo."
"Hey, Carlo. What's up?"
"It's Michael. He's in the hospital in Toledo. He's having a heart attack."
"Oh shit! You gotta be kiddin' me. Is he okay?"
"Apparently not. It sounds like he's in trouble. Tony, I'm really scared."
"What the hell happened? Did he collapse? I thought Mikey was in great shape."
"Laura says he's been having chest pain for awhile. He saw some doctor last week. I never knew about it. This afternoon his pain got real bad, so she took him to the emergency room."
"In Toledo?"
"Yeah. I wish I'd never sent him down here to this shit hole. He was better off in Detroit."
"Carlo, I'm sure that has nothing to do with it."
"Probably not."
"My God, Carlo, what else could happen to you? I'll be prayin' for you and Mikey."
"Thanks, Tony. I gotta get back in there to see Laura. She's really shook up."
"Carlo, be sure an' keep in touch. Gimme a call later and let me know how things are goin'."
"I'll call you, Tony."
* * *
Barnett checked the IV lines and injection syringe for evidence of air bubbles. The lines were clear. Marsha presented the tip of a long guide wire to the doctor, who inserted it through the needle into the femoral. The needle was removed and a Teflon sheath was passed over the wire, into Michael's arterial circulation. David removed the wire and inserted a left coronary catheter through the sheath. As he watched under fluoroscopic imaging, Barnett passed the catheter upward through the aorta and around the aortic arch, positioning the tip just above the heart.
* * *
The human heart has four chambers, two atria on top and two ventricles on bottom. The left ventricle (LV) is a strong, muscular chamber responsible for pumping oxygenated blood through the body. The LV receives ninety percent of the coronary arterial blood flow and is the site of nearly all myocardial infarctions. Occasionally, heart attacks occur in the right ventricle--virtually none in the atria.
Myocardial blood supply is derived from three coronary vessels: the left anterior descending (LAD), the circumflex (Circ), and the right coronary (RCA). The LAD and Circ branch off from the short, left main coronary, originating from the left aortic base, immediately above the heart. The origin of the RCA is above the heart at the right aortic base. In most cases, the LAD and RCA deliver a major portion of the blood supplying the left ventricle.
* * *
David cautiously aspirated blood from the catheter, flushed it with saline and made a final check for errant bubbles. The catheter was filled with x-ray contrast and a small test injection was made at the base of the aorta. He carefully positioned the catheter tip in the opening of the left main. His pager sounded.
"I'll get it, said Nikki. She called the number listed on the pager. "Dr. Barnett, you have a consult at Toledo CCU."
"Ask if it's urgent."
"The nurse says it can wait till later if you're tied up."
"Okay, write down the name and room number. Tell 'em I'll be there tonight."
* * *
Laura Conti decided to call her parents. She left the conference room to use a telephone at the receptionist's desk.
"Hello, Mom."
"Hi, honey. How are you?"
"Not so good. It's Michael. He's having a heart attack."
"What! How can that be? He's so healthy."
"I know, Mom. I can't believe it. I'm really worried. Mom, I'm scared!"
"Oh, Laura. I hope he's gonna be okay."
"Mom, what will I do? I can't make it without him."
"You have to be positive, honey. Medical care is miraculous these days. He's gonna be alright."
Laura wept quietly into the phone.
"Your father and I will be praying for you and Michael. Please call back as soon as you know more."
"I will. I gotta go."
"Goodbye, Laura."
* * *
Michael Conti's heart rate had risen to one-hundred-thirty. An intra-arterial blood pressure recording, obtained through the femoral sheath's sidearm, was visible on the hemodynamic monitor. His blood pressure still hovered at ninety millimeters of mercury.
"Mr. Conti, can you hear me?"
"Yeah, doc. I hear you."
"I'm ready to take a picture. You'll need to take a deep breath and hold it when I give the word. You can breathe when you here the camera stop."
"Okay. Tell me when."
* * *
Carlo Conti returned to the conference room to find Laura seated at the table.
"Laura, have you heard anything?"
"No!"
"What the hell's taking so long? Where's that goddamn doctor?"
"Carlo, he's working on Michael. I'm sure he's busy. We just have to wait and pray."
"Wait and pray. Wait and pray. I've been praying my whole life. What good has it done?"
Laura turned to her father-in-law with a look of disgust. Carlo started pacing the floor, muttering to himself. "Pray, pray, pray. Fuck it."
"Carlo! Please stop! Please, I'm terrified enough as it is."
* * *
Barnett stepped on the fluoroscope peddle. "Go ahead, Mr. Conti. Take a deep breath." The x-ray image improved as Michael's diaphragm dropped on inhalation. David quickly moved his foot to the cine peddle to take a permanent, moving picture as he injected contrast. He pushed the plunger on the contrast syringe. Dye flowed into Michael's left coronary system.
Marsha, watching the injection on a video monitor, exclaimed, "Oh, my God!" Her voice hung in the air.
The doctor was stunned by what he saw. He whispered to himself. "Holy shit." The contrast slowly trickled through numerous, tight constrictions in the LAD and Circumflex. Michael's left coronary system was replete with severe atherosclerotic plague. There were high grade narrowings everywhere. His coronaries looked like those of a ninety-year-old man, not a thirty-nine-year-old athlete.
Michael, hearing Marsha's remark, asked,"Is something wrong. Am I Okay?"
"You're fine, Mr. Conti," answered David. "The test is going well."
Wanting no more outbursts frightening his patient, he turned to Marsha, placed his gloved index finger close to his mask, and gave a soft "shh".
Marsha whispered, "I'm sorry."
X-ray contrast is mildly toxic to the heart. Barnett decided to limit his injections to two, instead of the usual five or six. In addition, taking a picture of Michael's left ventricular chamber was out of the question. In his case, the large volume of dye required would likely be fatal. He quietly spoke to his other nurse. "Jenny, we'll only take one more picture. Let's go sixty degrees LAO."
Jennifer moved the x-ray tower to a lateral position.
"Mr. Conti, one more deep breath."
Barnett hit the cine peddle and made a second injection. The left coronary vessels, viewed from a new angle, looked as bad or worse than before. David closely reviewed both pictures on a digital screen. A tight, ninety percent lesion in the proximal (early) portion of the LAD, had a tiny remnant of fresh clot. He pointed to that spot and softly spoke to Marsha. "Here's the culprit. He had a total thrombosis right here. The thrombolytics worked, partially dissolving the clot, but the damage was done. His atherosclerosis is just too severe."
Marsha acknowledged with a nod. David had to do whatever he could to keep the LAD lesion open. A balloon angioplasty would be much too hazardous. The time involved would not be worth the minimal benefit. The safest way to keep Michael's coronaries open would be with increased anticoagulation.
"Jenny, bolus him with another thousand units of heparin and increase his drip to twelve hundred an hour. Marsha, wait about ten minutes for the increased heparin to kick in, then draw some blood for a stat PTT."
David reviewed the coronary pictures again. To make matters worse, there were small collateral blood vessels connecting the distal (end portions) of the LAD to the right coronary artery. Collaterals develop slowly over time, usually years, only when there is demand for blood from an adjacent vessel.
This meant the right coronary had gradually closed off sometime in the past. The collaterals, supplying blood retrograde, backwards from left to right, had protected Michael from an infarction when total blockage of the right coronary occured. He probably had minimal, or no symptoms, at the time. However, when Michael's LAD occluded hours ago, blood supply to his collaterals was cut off. Consequently, he had two simultaneous infarctions--one in the distribution of the LAD, and a second in the distribution of the right coronary. Barnett thought, He's wiped out his anterior wall (front of the heart) and his inferior wall (bottom of the heart) Know wonder he's in shock.
* * *
Shock, in medical terms, occurs when blood pressure is too low to sustain life--usually below eighty systolic. At such pressures, the supply of oxygen to vital organs is inadequate. The kidneys shut down first, liver damage ensues and skeletal muscle starts to necrose. Continued muscle metabolism in the face of poor oxygenation leads to anaerobic breakdown of tissue. Lactic acid, produced by muscle necrosis, is released into the blood stream. Acidosis leads to dangerous electrolyte imbalance. Death follows soon after.
* * *
Barnett, to make sure his suspicions were correct, switched the left coronary catheter for one designed for right coronary cannulation. He injected a small bolus of contrast into the RCA. As anticipated, the artery was totally occluded near its origin.
A cell phone rang. Nikki answered. "Hey, doc, it's your daughter, Maddie. She wants to know if you liked the show?"
David chuckled. What a time for her to call. "Tell her I loved it. She was wonderful."
Nikki relayed the message. "Nikki, tell her I can't come to the phone right now. And remind her that it's past her bedtime."
Nikki laughed. "She said she stays up later now."
"I'm not surprised. Okay. Tell Maddie I'll call tomorrow afternoon."
He turned his attention back to his patient, noting that Michael's breathing was more labored. He checked the pulse-ox reading on the monitor. Michael's oxygenation was suffering the consequences of his extensive infarction. And, despite huge doses of dopamine, his pressure was falling--systolic BP hovering around eighty. His pulse-ox, on maximal nasal oxygen was critically low. David thought, we need an echocardiodgram to asses his left ventricular function and severity of mitral regurgitation. He needs more oyygen.
"Nikki, call for a stat echocardiogram. We'll do it right here in the lab. Jenny, please call respiratory. Start a non-rebreather mask at one-hundred percent oxygen. Barnett said to himself, he's developing pulmonary edema.
* * *
Pulmonary edema is the medical term for wet lungs--congestion in lung tissue. A damaged, failing heart causes increased back pressure, resulting in the accumulation of fluid in lung tissue. Mitral regurgitation adds to the problem. The congestion causes reduced up-take of oxygen in the pulmonary vessels. In Michael's case, it was an ominous sign.
* * *
"Mr. Conti, we've taken two pictures of your heart. How do you feel?"
Michael was fading. His speech was garbled. "I. . .I'm short of breath. I feel. . . dizzy."
"Okay, Michael. We're gonna fix that for you. Jenny, get me a blood gas syringe."
David aspirated arterial blood from the femoral sheath. It was dark red, not as bright in color as it had been. "Nikki, send this for a blood gas. Tell 'em to run it stat. Jenny, he's gotta be getting acidotic. Push one amp of bicarb, give him twenty of Lasix IV push and turn the saline drip down to keep open. He can't handle anymore fluids. And Jenny, please tell respiratory to get here now!"
Jennifer ran to the supply counter for an oxygen mask, Lasix and bicarb. Nikki, after sending the blood gas, returned to the lab. "Nikki, call anesthesia. I want him intubated. Then call cardiac surgery--ask for a pump tech. I need an intra-aortic balloon pump up here pronto.Jenny, please get that oxygen mask in place. We'll use that until he's intubated."
"I'm on it, doc."
"Nikki, I also need someone to talk with the family. We can't afford to have any of you leave. Call Karen in the ER. Ask her to bring the family up to the cath conference room. "
"Okay, right after I call for anesthesia and the pump tech."
Glancing up to the wall clock, David noted the time. It was ten after nine. They had been in the lab for nearly an hour.
Michael's pressure dropped to seventy-five systolic. Jennifer and Nikki were busy, scrambling around the room, giving meds and making phone calls. Barnett, exhausted from the weight of his lead, ripped off his blood smeared gloves, gown, and lead apron--dropping all of it to the floor. His scrubs were soaked with perspiration. "Mr. Conti, we have to put a breathing tube in your airway. It goes in your mouth, down in your trachea. It'll help you breathe."
Michael murmured something through the mask. David couldn't here what he said. He was getting frustrated. His patient was crashing. "Nikki, what's takin' anesthesia? Where are they?"
"Hey, doc, it's only been a minute since I called. They said someone would be right up. I'll call them aga. . ."
"Forget it. Pull the crash cart over here. I'll do it myself."
The doctor pulled Michael's mask off and used an Ambu bag to deliver three good inhalations of oxygen. "This is gonna be uncomfortable, Mr. Conti. I have to put some pressure on your jaw."
Michael Conti opened his mouth wide. David inserted a retractor blade and pulled up, peering down Michael's throat to locate his vocal cords. The tissue in his airway was swollen, edematous from fluid retention. Vocal cords came into view. "Jennie, hand me that number twenty-one ET tube with a wire trochar."
With his free hand, Barnett carefully slid the wire stiffened tube between Michael's vocal cords, removed the retractor and trochar, and immediately attached the Ambu bag to the tube emanating from Michael's mouth. More inhalations were given. "Jennie, secure the tube with tape. You'll have to bag him until anesthesia gets here. Nikki, call respiratory again for assistance with his airway. Marsha, what's his BP?"
"It's down a little more, bouncin' between seventy and seventy-five. His rates up to one-forty, sinus tach."
Barnett's pager went off. " Nikki, please answer that."
"Dr. B, its the CCU upstairs. You have another consult."
"Ask them what's going on with the patient."
"It's a fifty-five year old woman, doctor. She was admitted through the ER by Dr. Goetch. Her attending want's you to assess her chest pain."
"Okay, Nikki.Tell them I'll run up and check her out as soon as I leave the lab."
"Will do, doc."
David turned back to his patient. He walked to the opposite side of the table and increased the dopamine drip to thirty micrograms, an incredibly high dose. He yelled, "Nikki, where are you?"
"I'm right behind you."
"Oh, sorry. Check his Foley bag for me. See how much urine he's made."
Nikki reached under the long drape hanging from the table. "Not a drop of urine in here, doc."
"None?"
"I emptied the bag when we started. None since."
"Marsha, he's in renal shutdown. Draw blood for stat electrolytes, BUN and creatinine. Jenny, I'll take over bagging while you make up an Isuprel drip. Start it at ten mics. Nikki, give him another bolus of Lasix, eighty milligrams IV push."
A moment later the respiratory tech arrived. "Hi, Dr. Barnett. I'll take over for you."
David knew him. "Thanks, Doug. He's hypoxic as hell. Bag him at a good rate--twenty a minute."
"Okay, I got it."
A small Asian woman in scrubs entered the lab. Barnett had never seen her before. "I Dr. Kim, anesthesia. Sorry I late. I tied up in operating room. You need help?"
"No, we've got it under control."
"Okay, I go?
"Sure, thanks." David thought. Thanks for nothing. Get the hell outta here.
David turned to the digital screen to review the arteriograms once more. There's nothing I can do here. His thrombosis is dissolved and there's no need for an angioplasty. A balloon dilatation would be risky. Besides, I wouldn't know where to start. He has too much disease.
The doctor knew Michael's only chance was to support him mechanically, thereby buying time for his infarction to heal. Even then, the extent of his ventricular damage and the diffuse nature of his coronary atherosclerosis would preclude coronary bypass surgery. If, against all odds, he lived through the night, he would have a rough road of healing ahead. His only chance for a long, meaningful life, would be a heart transplant. The hard truth was that Michael's chance of survival, even for a few hours, was nil.
This chapter contains loads of medical jargon and technical information. Is it too much? Please let me know.-Doug
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