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The ideal candidate for pulmonary vein ablation for atrial fibrillation is a relatively young, otherwise healthy person with occasional afib who has failed at least two anti-arrhythmic drugs. Pam was 47, otherwise very healthy, and the spin that Hugh Calkins put on her case is that she failed three anti-arrhythmic drugs. Her records show that in fact she had not failed drug therapy and a physician who was working in the best interests of the patient would have recognized that fact from chart notes.
While Pam was working as an ICU/CCU nurse at Anne Arundel Hospital in Annapolis in 1998, she went to see a cardiologist because of occasional fainting and dizziness.
It was determined from a series of tests that she had a condition called Syncope and that a pacemaker was in order. An electrophysiologist named Dr. Grant Simons would implant it. We met with Dr. Simons. He is a pleasant man with an easy smile, and the story on him was that he is an excellent violinist and would have preferred a career in music, but his mother insisted on Med School over Julliard – or something like that. We both liked him, and Pam took his advice.
“Successful implantation of a dual chamber pacemaker,” he exclaimed in his report of the procedure on July 2, 1998. And that’s definitely where he wanted to leave it.
Pam was doing fine in the hospital when I went to pick her up, all smiles and I’m glad that’s over with. I was going to take her to the Parthenon, a great neighborhood restaurant. She signed the forms, changed into into her street clothes, declined the wheel chair, and said thanks and good night to all. And then she walked out into the hallway and collapsed. Nurses and aides rushed over. We formed a circle around her there on the floor. I remember someone slapping her hand, saying “Come on honey, wake up…” And Pam did wake up and she said “I almost passed out.” The nurse said “you did pass out, honey,” and there on the floor, Pam began to cry. She raised her right hand to her left shoulder, which was covered by a sling. ” I thought this was all over,” she said.
A nurse got hold of a cardiologist on call who had them checkout the pacemaker. Upon hearing that it was working fine, the doctor said that it was OK with him if Pam went home. So I took her home. The first thing she did was run to the nearest bathroom in the house and start retching and heaving.
I called the cardiology group. A few minutes later, the covering doc was on the phone. He sounded like he’d been interrupted. He sounded annoyed. I said I just got Pam home from the hospital and she is violently ill. He said that wasn’t possible. He said that the only way Pam could be that sick would be if a pacemaker lead had perforated her heart — and no such thing had occurred here. Pam was probably ill from the anesthesia, get a prescription filled and she’ll be OK.
She rode out the night on swells of nausea. As for the reason she passed out while trying to walk out of the hospital, it turned out to be a precipitous drop in blood pressure due to over medication. In an effort to slow down an occasionally speedy heart rate previous to trying the pacemaker, Pam had been taking 12 or 25 mgs of Atenolol a day. Upon admittance to the hospital, Grant Simons had ordered 100 mgs of Atenolol. The vasodialators had worked well, bogging out her circulatory system when she stood up. Simons had apparently been thinking he was safe with such a high dose because the pacemaker would kick in if her heart slowed too much. But he wasn’t thinking about her blood pressure, which bottomed out when she stood up.
Meanwhile, as the nausea subsided with some medicine, Pam began feeling like she was being poked in her ribs by a hot needle with every beat of her heart – which was pretty much what was happening. The tips of pacemaker leads are designed to screw into the wall of the heart. If they get screwed in too far, they go through the heart and send little jolts to the chest wall muscles.
If you weren’t a nurse and knew better, you would have believed Grant Simons when he said that it was your diaphragm that was being jolted by the pacemaker — not the chest wall. If the chest wall muscles were being paced, that would mean that the Doc had poked a hole in your heart. And that just can’t be. So we’ll adjust the pacemaker and change the meds and the diaphragmatic pacing will go away.
I noticed a pattern with these doctors after a while. First of all, any complication that happened almost never happens to anybody – except you. This is made clear to you in a way that intimates that you are somehow at fault. You’re some kind of troublemaker. YOUR diaphragm is picking up signals from the pacemaker lead. Grant Simons wanted it to be diaphragmatic pacing because that’s not really a complication, not his fault. But if Pam were right, it would mean that the lead, having been screwed in too far, had punctured the heart wall and was pacing chest wall muscles.
Simons’s next office note reflected an upbeat assessment and an optimistic outlook: “Today I saw Pamela Walter in follow up. She states she is feeling much better since her pacemaker was placed and that she is almost never aware of her heartbeat anymore. She does have a bit of diaphragmatic pacing for which she has come into the office today.”
So he was still looking on the bright side, hoping the problem would go away.
***
Calkins writes repeatedly that “She failed treatment of a number of anti-arrhythmic agents… all of these agents were both unsuccessful and poorly tolerated.”
There is plenty in the record to indicate that Pam had not in fact failed anti-arrhythmic drugs. Rather, the pacemaker lead which had perforated her heart was shocking her chest wall muscles and the symptoms were exacerbated by taking anti-arrhythmics.
In a clinic note from August 2000, Calkins lists as “Reason for Visit” a “Second opinion regarding management of pacemaker lead malfunction” Calkins notes that the symptoms of the “pacemaker lead malfunction” become more severe when she takes her anti-arrhythmic drugs. His recommended course of action if the symptoms persisted was to “present the case to my associate Dr. Jeff Brinker in anticipation of possible lead revision. At that time… we can make a final decision regarding whether to extract her current ventricular lead or merely place a second lead…” If the pacemaker lead was making her anti-arrhythmics intolerable, they could have fixed the lead and tried drug therapy again.
Who’s Minding the Store?
After Pam and I were married, we moved to Annapolis. Lofty ideas about journalism had faded by that time and I had sunk to working for politicians. We figured it would be good for me to live near our nation’s capital.
We’d caught the tail end of the era when Annapolis was still a relatively small town, a very pleasant place to live where waterman worked the Chesapeake Bay for crabs and oysters, and you might run into the mayor while standing in line at the post office.
And so I managed to get a job in DC working for a US Senator and Pam began work as a nurse at the local hospital. We had a little condo, and a little boat, and on weekends we’d sail out Back Creek toward to the Naval Academy or the Chesapeake Bay Bridge.
But Annapolis began a rapid and massive spurt of growth, and Anne Arundel Hospital went from being a small community affair located downtown (where you could walk to work on a nice spring day) to a giant medical center with a sprawling campus on the edge of town. And it was no longer much fun to work there if you were a nurse. Pam started spending more time filling out forms then she did caring for patients.
When it came to giving out raises and keeping personnel in line, management took a page from Mao’s Little Red Book and instituted something called “Peer Reviews.” Once a year, each nurse was required to write a review on a colleague. You can imagine what a congenial climate that fostered among the staff. Of course, Pam didn’t have to tell me about bureaucracy – I worked in the US Senate -and you’d be surprised, but there’s a lot of politics goes on up there at Capitol Hill.
Pam was always saying how much the nurses complained that there was no place nearby to buy uniforms. These gals had a choice between driving to inner city Baltimore or into DC every time they needed a new outfit — as if they weren’t already risking their lives everyday at work.
So we spent a couple of weekends scouting out locations and by sheer dumb luck found a vacant store would turn out to be ideally situated for such a purpose. All of Pam’s retirement money from her years as a nurse in Florida went into the enterprise. We rented the place and purchased just enough goods to open for business. We first worked the store part time and with helpers, but within a few years we were both able to quit our other jobs and live by working our own business. We worked a lot and we weren’t getting rich, but we owned our own business. We drove nice cars and we dined out when we felt like it. We had Sushi a few times.
Now, for the first time in nearly nine years, the shop was dark and closed …
****
Fortified by rice wine, I made my way back to the hospital and started making phone calls to Pam’s relatives as I waited for the surgeons to announce their verdict.
“How’d it go?” Pam’s mother asked from Florida, on the other end of my pay phone in the Hopkins lobby. She was referring to the ablation procedure.
“Not so good,” I said and I explained about the “complication.” In the sharp intake of breath you could hear the bottom drop out. “She’s OK,” I said. I told her that Pam was undergoing surgery right now to repair the mitral valve. She asked if she should book a flight and come up. I said I would if I were you. “Don’t worry,” I told her.
Maybe I should have told her to sit tight for now, there’s no hurry. Summoning the relatives was the equivalent of breaking the fire alarm glass in case of emergency; certainly not to be done lightly. But it was one of the things I was pondering back there at the sushi bar. Between courses of Futomaki, I kept going over the demeanor of the players involved, especially the surgeons. While they affected confidence on the surface, it was clear from watching them communicate with each other that they were far from certain they could fix Pam’s broken heart in time to head off grim scenarios.
I was starting to get a bad feeling about the whole thing.
****
It was during the next call that I found about the Iron Law of School Bus Driving, which is this: You never back up – NEVER.
So when the foul mouthed fishwife who lived across the street from us got into a Mexican standoff on a narrow street with a rookie driver from a rival company and let fly most of her repertoire in front of the kiddies, her contract with the Marlowe Brothers School Bus Company was summarily terminated – never mind that she was in the right.
Now I had someone to look after our store while the siege was on up at Hopkins. I called her Doris Ziffle, and she chain smoked generic light 100’s, but you could trust her to open and close the store and sit behind the register — I hoped.
****
By and by Dr. David Yuh came to the waiting room. I’d never met the man before.
He said Pam had made it through O.K. He couldn’t repair her mitral valve, he had to replace that, but she’d come through it OK and I’d get to see her soon enough — and by the way, they went ahead and took out the pacemaker and all of the leads, it wasn’t doing any good anyway.
Pam first made Dr. Yuh’s acquaintance when he applied a bone saw to her chest. They never did shake hands. He seemed like a decent guy, friendly enough in a formal way. He said they like to get open-heart patients off the ventilator on the same day as surgery, and the patient should be out of bed by the second day.
I got to see her for a few minutes post-op. Although they do a good job of trying to prepare you for what someone looks like just after open heart surgery, that’s really not possible. Judging by the puffed-up head on the pillow, this person you laid eyes on just a matter of hours ago seems to have tripled in weight. Her lower face is mostly covered by the breathing tube apparatus and her eyes dart about like those of a trapped animal.
So what do you say? Everything’s OK. The worst is over. You came through it fine. You hold her hand and look into her eyes and give smooth reassurances.
Then you get back out in the hall and you exhale.
****
They got her off the ventilator late that night and I was in her room early the next morning. The nurse was gathering her notes and getting ready to write report, finishing up an 11p- 7a shift. This is part of what she wrote:
“Nurse’s note 06:20 Pt more restless and moving constantly in bed. Has received Ativan and Fentanyl… She is reporting stabbing back pains… she has repositioned herself repeatedly…”
“What kind of a night did she have?” I’d expected her to be awake.
“Well, she was restless all night, kept twisting and moving around. Seems like she couldn’t get comfortable.” She lightly stroked Pam’s cheek with the back of her hand. “Poor thing.” The nurse and I were standing on the same side of the bed facing the open door. An unshaven young man in scrubs walked in and, without looking at us, put his hands under the sheets covering Pam’s upper abdomen. The nurse and I looked at each other.
“Excuse me,” said the nurse.
The intruder paid no attention and kept rooting around under the sheets. I said Hey and he kept going and I said HEY again, loudly and sharply, and that got his attention and he looked up. The nurse and I both said: “Who are you?” He said he was from Cardiology and he was there to check on Pam’s pacemaker. Then he disappeared. The nurse said she’d never seen him before. She shrugged and went out.
Stabbing back pains…
I adjusted the pillow beneath Pam’s head. I slid my hand under her back to smooth out the sheet. I felt something and pulled from beneath the middle of her lower back a pair of curved forceps:
Here is a nurse’s note written after Pam got off the ventilator the first time, during the brief moments of lucidity before she started dying again and was re-sedated so that another vent tube could be snaked down her raw throat:
“Pt very anxious and angry regarding emergent nature of surgery yesterday. States “I’m gonna die in a minute.”
After turning in the forceps at the nurse’s station, I went to to the airport to pickup Pam’s mother, Jackie, who is a practical person, especially in a pinch. The women in her family would not abide incompetency in a man — husbands specifically. This did not apply to doctors.
Jackie was at the curb with her carry-on bag and got in the car as soon as I pulled up. I was able to report that Pam’s heart surgery had gone well and that she was off the ventilator and in a private room. She was asleep when I left, but most likely Pam would be sitting up in a chair beside the bed when we got there — and she could talk to us.
Jackie listened to me and did not ask questions until I was through, and when her questions were answered she went silent. Her people were German Catholics from Katherine, Kansas. They were immigrant tough to begin with, Volga Deutsch who endured, the people Tim Egan wrote about in The Worst Hard Time who made a stand on the prairie when others headed for California during the dust bowl years.
Jackie had an innate sense of how to survive a crisis. (My folks were German Catholic too and had dealt with their share of hardship, but didn’t venture too far from Port Elizabeth after they landed, and there weren’t too many locust plagues in New Jersey.)
I was glad that Jackie had come. After a few days we could take Pam home and her mother could look after her while I got back to business. Everything was going to be O.K.
But when we did get to her room, Pam was gone.
The sight of the empty bed was jarring, but before I could speak a nurse came and said that Pam had been sent back to intensive care and that they could tell us more when we got there.
Back up to the fifth floor.
The good news from the ICU was that Pam’s temporary pacemaker, the one the mystery man from cardiology had been checking on, was in fine working order. They could tell because when they turned it off, Pam’s 
heart didn’t work and the cardiac monitor showed flat lines – asystole. When they plugged it back in, the lines on the monitor resumed the rhythmic blips which normally produce the soothing lub dub, lub dub sounds of a human heart. Of course, from now on when Pam held an infant, it would hear the metallic sound of modern high technology — click click… click click… click click… a sturdy St. Jude Medical© Model MEC-102 27mm Mechanical Heart Valve made of pyrolytic carbon and tungsten.
It’s supposed to last forever.
As for why she had landed back in intensive care, extubation can be a hit or miss procedure — if you’re not careful.
A machine has been doing your breathing for you, and getting your lungs to take responsibility again is sort of like pulling the old table cloth trick. They’ve got to make sure that blood gasses are high enough so that the pump is primed and the lungs will gradually take over from the machine. A patient must be carefully and deliberately weaned off the ventilator. It’s a delicate maneuver.
Respiratory therapy note:
22:59 Pt was extubated… Was extremely anxious and was extubated per order before mechanic or CPAP gas was up… Acute confusion and anxiety increasing…
02:01 Re-intubation performed by Anesthesia resident…
03:37 ETT position migrated. Cuff above vocal cords. Significant air leak heard. 02 sat decreasing. Ambu bag used for ventilation…
04:59 Bleeding noted on pt. gown in mid ABD area …
As for why her heart was out of commission, it could be just normal, temporary post-op irritation. Or it could be that the circuit board of her heart had been accidentally blown, fried, toasted; in which case a permanent pacemaker becomes another souvenir from Johns Hopkins, like the St. Jude Mechanical Heart Valve and the attending scar tissue.
For the second time in her two days in the care of Johns Hopkins Medicine, Pam’s life was in free fall. Of course, I didn’t know any of this at the time. I’d been reassuring myself by reading the posters in the hall proclaiming Hopkins to be the best hospital in the land.
*****
“Fig Newton?”
I was peeling the lid from a coffee cup. I told Pam’s mother No, thanks.
We were on a bench in the hall right outside the ICU. There wasn’t much to say, so we fell into a trance watching the doors on elevators open and close. Sometimes people got out, sometimes they didn’t. Sometimes there were no people.
Hugh Calkins appeared, all lab coat and glasses — a timid presence.
He carried a medical instrument. He sat down next to Pam’s mother, Jackie. He was terribly sorry about what happened.
He said this to her:
“What happened was I was trying to reposition the catheter. I was going to ablate four areas. I got two done and I wanted to switch catheter sheaths. I turned away for a second and the mapping catheter – just like this one here – see how it’s coiled up there at the end like a lasso? And that’s what they call it, a Lasso catheter.
“Well, while I was moving the catheter, working toward the third area, I turned away because I wanted to use a different sheath, and the catheter went down into the mitral valve muscles.
“The mitral valve muscles, they’re like parachute strings. And you see how this catheter loop sort of coils up? When we retract it, it’s supposed to straighten out and it should have just slid off those muscles when we retracted it, but this catheter, you know, is a mapping catheter, which, they have these little electrodes on them.”
He held the tip of the catheter up and ran the thin wire straight through his finger tips before it snapped back to a curl. “Now this one, this mapping catheter is a new design. It has TWENTY sensors – electrodes. So what I think is… is that the extra sensors kept us from retracting the catheter. The electrodes of this catheter got snagged on these parachute string muscles of the mitral valve.
“This catheter,” said Hugh Calkins, “is a dangerous instrument.”
****
I’d already heard the story, minus the visual. He was operating the catheter. He was switching catheter sheaths. He ablated two sites, mitral valve destroyed, off to surgery.
Yesterday, I’d felt almost sorry for him. Just a decent guy, trying to do a good job. He seemed genuinely aghast and remorseful, and the younger doctor with him was noticeably shaken. You could see how much these two cared about Pam, and seeing as how she would make a nice recovery, I tried to take an expansive view of the situation. These things happen. I remember thinking how we all take these modern medical miracles in stride, and that perhaps we had come to expect too much of the medical community. Transplants and re-attached limbs and bypass surgery, all these things we take for granted.
But I was beginning to narrow my view now that the promised resurrection had failed. At first, I’d given Calkins credit for stepping up to the plate and taking responsibility. Whatever else, I had to admire the fact that he was being a stand-up guy.
Now I wasn’t so sure. Listening to him tell the story again, I found myself wondering how a man of his experience could have made such a rookie mistake.
“Let me ask you something, Doc,” I said. “When you’re moving the catheter around inside the heart and you want to move the lasso part from one site to another, why don’t you pull the catheter back into the sheath before you move it, then let it out at the new site?” It seemed like common sense to me. Calkins pushed his thick, rimless glasses back up the bridge of his nose and nodded.
“Oh, yes” he said, “That’s what we’ll do from now on.”
And thus I made my contribution to the annals of medicine. Here – for the record – is Hugh Calkins’ official description of the entire fiasco: Circular Mapping Catheter Entrapment in the Mitral Valve Apparatus: A Previously Unreported Complication, published in the Journal of Cardiovascular Electrophysiology a few months after the fact. Among the suggestions as to avoiding the disaster inflicted on Pam is this: “… it would be reasonable to withdraw the catheter into the sheath during repositioning or moving of the catheter between the inferior PVs.”
If only I’d thought of that sooner.
****
Except for the lighting, it was as bleak inside the 5th Floor ICU as it was out on the rain-swept streets of Baltimore. Fluorescent white shown upon the linens of the dying and the recovering alike — and upon Pam, who was stuck somewhere in between, in a world of bruises and stitches and blood and gauze. For all the chirping electronics and humming machines and dripping drips, she wouldn’t wake up. She was spiking fevers of unknown origin. Grim looking fluids oozed through a tube that had been inserted between her ribs.
All the while, her eyes were only halfway shut and she stared vacantly into the exam light that seemed to be always hovering overhead at full intensity.
Days passed, and a sort of routine emerged. Pam’s mother Jackie or I would drive to the airport to pick up Pam’s sister or her son or her daughter, and we would give them the latest on her condition, set them up in our new digs and then take them over to see her. Kristi is as much best friend and sister to Pam as she is her daughter, and it was Kristi who first suggested to the staff that perhaps Pam’s eyes should be lubricated or taped shut against the bright light and dry air.
Hugh Calkins would occasionally make an appearance to repeat the story he told Jackie and me; that he’d turned away momentarily and the catheter got caught in the mitral valve muscles. He told that same story to Kristi and to Pam’s sister Lisa on consecutive days — two sites ablated, mitral valve demolished — then off to surgery.
Sorry, he says, again and again, but now it was starting to have a ring of tough luck to it. Sorry. Oops. Oh, well. And as the days wore on, we began to see less and less of Hugh Calkins.
****
“ETT repositioned to right side of mouth by RT. Pt more awake and restless, coughing and gagging.”
I can see it as if it were happening right now, right in front of me. Gagging on the ventilator tube lodged in her throat, choking and gagging, wrists tied to the bed rails and she pulling against them, pulling herself up from the bed, heaving forward, straining, neck muscles taught, choking, the pressure popping her eyes open, red veined and raw, hot tears, and the fierce frantic struggle for air, for breath, for life itself.
Now I understood what she had sensed after the botched ablation — that sooner or later they will kill her. She would never get out alive and I’d been wrong to reassure her, I’d been wrong to believe in this place, wrong to bring her here.
****
ICU Subsequent Care Note: Delerium; pt remains very agitated on fentanyl and received dose of haldol this AM. Will again attempt to decrease fentanyl but we have not had any success. Once it is decreased she becomes agitated and has respiratory compromise. We will continue to attempt to wean fentanyl so that we may assess her for extubation. Neuro consult obtained.
So now they’re in a Catch-22 trying to wean Pam off a ventilator. When they reduce the sedatives so she can start breathing on her own, she becomes agitated to the point where it’s not safe to take the breathing tube out.
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We demanded to see the doc in charge.
He was a hard man to get a hold of, and this issue of The American Medical News explains why:
“Johns Hopkins Penalized for Resident Hour Violations”
“The Accreditation Council for Graduate Medical Education has disciplined its first resident program for work-hour violations since new rules went into effect for all programs July 1. Johns Hopkins Hospital’s internal medicine program was cited for exceeding the 80-hour work week and requiring call more than every third night in the intensive care, counter to ACGME work hour standards.”
Johns Hopkins Magazine dutifully reports that “Nine days into the new enforcement period, a new Hopkins intern sent an e-mail to ACGME officials stating that some Internal Medicine residents were working more than 100 hours per week.”
The person upon whom Pam’s life depended was working about 90 hours a week, maybe a hundred. I tracked him for days and finally snagged him at a nurse’s station. The man was obviously exhausted, but so was I, and I pressed him about why she wasn’t coming around. He had reached the point of exasperation and he told me more or less that he was a very busy guy with lots of patients and they all had families who wanted answers and he had a family of his own to worry about.
I decided to call Dr. Yuh, the surgeon who installed Pam’s mechanical heart valve. I was told that he was on vacation – in Hawaii.
