When the ambulance doors flung open, the 86-year-old female was lying on her right side, legs bent as if she had fallen onto the stretcher. Ashen, tachypneic, and diaphoretic, she responded only minimally to my greeting. A prompt ECG demonstrated a heart rate of 67 bpm, ST elevation in V1, RSR’ and ST depression in lead 1 and AVL. The possibility of a posterior MI came to mind but didn’t make sense because a fairly recent coronary calcium score was only 40. I considered pulmonary embolism (PE), but she wasn’t tachycardic. I requested an emergent echocardiogram but the ER had none. Assessing her rapidly with a borrowed stethoscope, I noted jugular venous distention (JVD) to the angle of the mandible. She rallied a bit to answer my questions and described severe epigastric pain radiating to her chest. In midsentence she lost consciousness and developed an odd blowing respiration followed by a loss of pulse. Thoughts of osteoporosis, kyphosis, rib fracture, and sternal flail cluttered my instincts, but my reluctant hands went onto her chest anyway. I began aggressive compressions noting that her chest was surprisingly but reassuringly spongy with good recoil.
After a minute into pulseless electrical activity, my mother’s hands went up toward the Ambu bag flailing, then again limp. Another 30 seconds of compressions and she opened her eyes. Her blood pressure was 67/40 mm Hg, and only 77 mm Hg systolic following a 500-cc saline bolus. Her heart rate lurched to a tachycardic 120 bpm. The last blood pressure before I stepped out to call another ambulance was 90/60 mm Hg. My father sat helpless in a wheelchair in the hallway sobbing. He had ignored my pleas not to watch my efforts at resuscitating his wife of 65 years. As I stepped by, I patted him on his back with no time for a more sympathetic gesture. My brother Shane and his wife Lori, a nurse practitioner, arrived just as we were getting ready to make the second transport. “Not intubated?” Lori asked, surprised. “Not yet,” I answered insecurely, thinking maybe she should be. We got to the cath lab in the neighboring town before the echo tech arrived. An urgent cath was efficiently performed showing predictably normal coronary arteries, then the excellent and astute echo technician told the tale.
Dr Walton-Shirley’s mother. Courtesy of Dr Walton-Shirley
Mom’s right ventricle was akinetic, bulging like an overinflated balloon at three times its normal size. Her squashed left ventricle had hunkered down and was running at full gate trying to maintain perfusion. Her right ventricular systolic pressure (RVSP) of 66 mm Hg confirmed this was not her first rodeo. A CT angiogram demonstrated severe bilateral pulmonary artery obstruction. We dismissed tissue plasminogen activator (tPA) as a treatment option because of a requirement for regular iron infusions. I had transfused her for severe gastritis 10 years ago when she was sneaking naproxen sodium tablets for a bad knee. Furthermore, her brother died 15 years ago of an intracranial bleed after I thrombolysed him at age 67 for a ST-segment-elevation MI (STEMI). We settled on a plan of heparin therapy followed by a novel oral anticoagulant (NOAC). Then my thoughts drifted to our daughter. Had anyone talked to Kate?
Kate sat 40 miles away in her bridal cabin sobbing. She had arrived there first thinking we weren’t far behind. Although all of the grandchildren adore their granny, Kate was the oldest grandchild and was looking forward to her grandparents attending her wedding. She had heartily approved the pictures of their wedding attire and loved the jewelry we chose for mom, but fate stole her rehearsal dinner that night. When she arrived at the ICU waiting room with her fiancé John, she blurted in a rush of emotion, “I don’t want to have a wedding anymore. I just want to stay with granny.” The expectant groom dropped his head in a mix of both understanding and disappointment.
As we all sat in the waiting area, not quite knowing what to expect, I began to recount the details of the past 2 hours. I felt guilty that all the plans Kate and her sister Aaron had made for the most important day in her life might have been for nothing. It was to be a gargantuan wedding because John is one of nine children. There were to be 11 bridal attendants dressed in their choice of pastels before the backdrop of a quaint barn of gray lumber. The beams were already adorned with sweeping tulle and twinkling lights on the background of a lush green meadow. Simultaneous to that image was my mother lying in ICU bed #4 fighting for her life. Then there was the practical consideration of whether to contact the guests and notify the wedding venue. “You’ll have your wedding,” I reassured Kate, as I draped my arms around her shoulders, not knowing how I could say that with any certainty at all.
The bride’s grandmother. Courtesy of Dr Walton-Shirley
Thankfully, the demon thrombi that sat cocked and loaded in mom’s deep leg veins declared a temporary truce. The following morning she was much more stable, so I dedicated the rest of the day to Kate. We had breakfast and later dressed in the bridal cottage, braving the Kentucky summer heat for pictures. My sister-in-law Lori insisted on staying with mom and dad the entire afternoon of the wedding. With the help of our friend and stylist Holly, mom and dad watched Kate’s wedding via FaceTime. After we reassured Kate that her grandmother was stable, she was radiant and joyful. I fulfilled Kate’s request to sing the song I had written for this very day when she was just 3 months old. Her handsome father and I walked her to her waiting husband-to-be and placed her hand in his. A ripple of guilt washed over me when she motioned for me to come dance with her at the reception. I thought of Scarlet O’Hara when she danced the Virginia reel uncaringly as a young widow, but I quickly dismissed those feelings in honor of our daughter who deserved all the joy we could muster. When it was time for Kate to leave on her honeymoon, she cried and hugged me, sobbing once again. “Take care of granny,” she said, “And let me know if anything changes.” On Monday at noon, everything did.
Reembolization after the third dose of NOAC was heralded by a heart rate of 120 bpm and a respiratory rate of 32 breaths/min. The rounding pulmonologist suggested we consider catheter-directed thrombolysis therapy with the EkoSonic Endovascular System (EKOS). We made the decision to hop again to a tertiary center. Frailty would prevent my mother from sustaining that kind of respiratory effort. I held her hand as we sped with lights and intermittent sirens for the entire 90 minutes. Through the side windows I saw glimpses of blue sky and clouds between tractor-trailers and cars. The 2 mg of morphine and 0.5 mg of Ativan helped relax mom, but she awoke for a short while and very sweetly said, “You have become everything I ever wanted you to be.” I stifled tears and said a prayer but tried not to close my eyes because, when I did, her blowing respiration, loss of pulse, and my reluctant compressions on her spongy chest replayed in my head. My thoughts were interrupted when I noticed that the paramedic suddenly looked concerned. Mom’s oxygen saturation had plummeted to 86% but was quickly addressed with another increase in nasal cannula oxygen. When we arrived at Vanderbilt University, a team was waiting.
Mom’s dementia prevents her answering most short-term recall questions. She can’t remember whether or not she ate breakfast or took a bath, but she can make good decisions in the moment. She was able to discuss her code status like an expert. Her answer was “Yes,” when asked if she wanted to undergo CPR again if necessary. It was also “Yes,” when asked if she wished to be a full code, but then she added confidently and with no emotion, “If you don’t think I can get well, don’t resuscitate me.” That’s the essence of my beautiful, intelligent, and very brave mother.
The following evening Dr Rob Piana, interventional cardiologist at Vanderbilt, placed an EKOS catheter into each pulmonary artery and began a slow infusion of 1 mg of tPA per hour per artery for 8 hours. At my request, he placed an IVC filter as well (my reasoning being that she had flunked full-on anticoagulation). The usually simple procedure was made difficult by mom’s confusion brought on by Versed and fentanyl. Dr Piana stopped three times because of sterile-field contamination. Later, mom woke to tell me she thought “some man was trying to embalm her.” In the 1940s, she worked in a funeral home part-time as a college student. All of that talk about catheters and fluid dripping into blood vessels took her back in time.
During the 8-hour infusion, mom’s heart rate decreased from 117 to 80 bpm and her respirations decreased from 32 to 18 breaths/min. Her blood pressure and creatinine remained normal. The postprocedure echocardiogram demonstrated an RVSP of 66 mm Hg (down from 80 mm Hg). In my wildest dreams, I would never have thought I could get away with dripping tPA into a vascular tree that contained only 8.7 g of hemoglobin, but her hemoglobin never budged. The most hopeful findings included an obvious awakening of the distal septal contractility and a slightly smaller RV dimension. Disappointingly, dyspnea upon standing for the first time in days brought her to a state of panic—proof that a ton of clot had assaulted her, forcing us to face the reality that some of it might be there forever.
The bride and groom. Courtesy of Morgan Worley photography
I’m ashamed to say that 10 days ago I knew nothing of catheter-directed thrombolysis despite being exposed to so much great late-breaking information. I knew only of mechanical thrombectomy, vacuum extraction, and lysis. I once sent a patient for a pulmonary endarterectomy with great success. I have since read the SEATTLE II trial, a single-arm, multicenter study which showed that ultrasound-facilitated catheter-directed fibrinolysis decreased RV pressures and anatomic thrombus burden with low bleeding rates in patients with acute massive and submassive PE. The approach is intuitive because the catheters vibrate at 2 million cycles per second, making the clots more porous, while multiple side holes drip tPA directly on them. The lytic surfs the waves more deeply inside the clot like a gnarly pipeliner. As with all new approaches in medicine, the outcomes are still being collected and scrutinized. I was warned that “it doesn’t work for everyone,” but it worked for my mother.
The scientist in me still bows to the emotional rollercoaster I experienced as a daughter. When I’m alone in quiet solitude, images of my mother slipping away still flood my thoughts. June 24, 2016 at 3:45 pm was the most terrifying moment of my life as a daughter. June 25, Kate’s wedding day, was the most poignant day of my life as a mother. I will also forever cherish that ambulance ride and the long night I sat at mom’s bedside. It was my honor and privilege to cradle her in my arms whenever she was turned, basking in the feel of her velvety warm cheek as it rested against mine. I can still taste the strong coffee that helped me stay on high alert to make certain those catheters weren’t accidentally pulled from her right jugular vein, which would have in essence pronounced “game over.” I will never forget the look on my mother’s face, at first confused and fearful but then comforted when her eyes met mine, softening as she would drift back into a calm and restful sleep.
Admittedly, this was my own personal trial cohort and a most important “N” of one; we await outcomes of larger trials. Meanwhile, I know that somewhere in the world, there are others whose chests are loaded with clot, fighting for air and for their lives. I regret that it took a whirlwind of a weekend—three PEs and a wedding—for me to learn about this treatment, but it is with an enormously deep gratitude to God and medicine that I can still hold my mother’s soft warm hand while I tell you about it.