How a visit to "America's Best Hospital" turned into one patient's worst nightmare.
"A well-written study of one person’s experience at the hands of the most exalted research hospital in our country. The story of how one of the foremost teaching/research hospitals in the country practiced on his wife without disclosing that they were doing so."
Richard Wu turned the catheter handle counter-clockwise, transforming the instrument in to a corkscrew which he drove through the mitral valve of my wife's heart. He didn't realize it until later, when he tried to place the catheter elsewhere in the heart and he could not do it. It was stuck.
“Only the first 50% of the circular portion of the catheter tip could be withdrawn into the sheath and pulsatile motion could be appreciated” is what they wrote in Pam's chart.
They were pulling on the catheter wire, trying to cajole it off a snag, but it was tugging right back, like they’d hooked a five pound bass. A nurse notes that the “patient is waking and moving around with chest pain @ 7/10.”
By that time, Hugh Calkins had shown up. He scrubbed in. Taking hold of the controls, feeling in his fingertips the tautness of the wire and the pulsing tug of muscle from deep in Pam's heart, he turned the catheter knob this way and that, but he could not pull it free. To see what he could see, he called for a stat echocardiogram; and yes, the distal portion of a Biosense Webster Lasso® catheter was stuck deep in the wrong chamber of Pam's heart, entwined in the intricate webbing of the mitral valve muscles.
He had to stop the procedure, had to think a minute and try to figure out what to do.
He called his EP lab partner, Ron Berger, who was in the middle of supervising an ablation training session down the hall. Berger surveyed the situation, scrubbed in, and gave it a try. He turned the knob. He pulled and pushed and twisted. No good.
And the situation turned out to be like Chinese finger cuffs, where the more you tried to free it, the more it became entangled--and they tried for the better part of an hour, making a bad situation that much worse before finally giving up and calling in an expert, their EP colleague Jeff Brinker, who studied the echo film while an assistant helped him scrub in. The catheter was snarled tight in there all right, and Brinker saw only one chance to avoid the humiliating spectacle of having to wheel down to the surgeons a patient from the EP lab with a catheter wire tangled in her heart.
You might get lucky with a good hard yank. It says on the box to not do that because it is very likely to cause a lot of damage, but he figured it was worth a try. So, as if he'd been handed a stubborn bottle of ketchup to open, Jeff Brinker gripped the control knob tightly between thumb and forefinger and prepared to apply force. Feeling the twitching pulse of Pam's life vibrating through the wire, Brinker settled into the rhythm.
One, two, three...
According to the record, the catheter is “suddenly free” and it could not have been a good feeling for Dr. Jeff Brinker when he felt the line go slack. The sudden loss of tension meant that something had ripped or broken. Something wasn't right.
“Blood pressure dropping,” someone said.