by Cheney, Dick
• • •
As I rested in Casper over the next few weeks, for the first of what would be many times in my life, I had to contemplate heart disease as a political issue. Even after I got the go-ahead from the doctors to continue the campaign, I considered what the voters would think. Would they be concerned that I might not be physically up to the job? Would my opponents try to use my heart attack against me? How would I explain to the voters exactly what had happened—and why, in spite of the heart attack, I wanted to go forward and pursue my political aspirations to represent them in the US Congress?
I convened a number of people I trusted to discuss the way forward. Bob Teeter was my pollster. We had met on the Ford campaign, and he would remain a close confidant until his untimely death in 2004. Bob Gardner, another Ford campaign veteran, was my advertising director. The best man at our wedding and my campaign chairman, Dave Nicholas, also joined us. And of course Lynne was my most trusted adviser. We got together and explored the idea of conducting a statewide poll to ascertain what impact the heart attack had on public attitudes toward me. We realized pretty quickly, though, that we didn’t know what questions to ask. No one had ever tried to measure the impact of a candidate’s heart attack in the middle of a campaign. We decided to try to put together an ad to address voters, thinking the direct approach would be best. There had been plenty of coverage of my heart attack in the Wyoming media, so the ad took the issue head-on. We gathered a group of friends and supporters, and we all sat on the lawn in our backyard. With the cameras rolling, we discussed famous political leaders who’d suffered heart attacks. We talked about Lyndon Johnson and Dwight Eisenhower and how they’d continued in the highest office in the land after their coronaries. When we showed the finished product to a small group of friends, it bombed. People said it was way too depressing and jarring. We scrapped it.
While we thought of other ideas and approaches, Lynne spent a good deal of time filling in for me on the campaign trail. She spoke at Republican events all across Wyoming. She was so good that many of my supporters suggested, only half-jokingly, that we might be better off if she were the candidate.
We finally settled on the idea of writing a letter that we’d send to every registered Republican voter in Wyoming explaining the facts of my heart attack and why I had decided to continue my campaign for Congress. I addressed why I had decided to run in the first place, laying out the issues that had initially inspired my candidacy. Then I continued:
A man’s political beliefs are only a part of what motivates him, and in June an event in my life gave me reason to evaluate why I am running for Congress from a different perspective. While I was campaigning in Cheyenne, I suffered a mild heart attack.
I explained that I’d been given a green light by the doctors to go ahead with my run, that there was no health reason I couldn’t run for and serve in Congress. Then I wrote:
An event like a heart attack, however mild it might be, causes a man to reflect upon himself and what is important to him. I must admit that when I found out what had happened, it occurred to me that there are certainly easier ways for a man to spend his life than in running for Congress and being a public official, ways of life which are easier on his family, on his privacy, and on his pocketbook.
But as I talked to my family, it became clear to me that while public life is sometimes difficult, it is also, for the Cheneys at any rate, immensely satisfying. All of us, Lynne, our two daughters, and myself, like being involved in an effort which goes beyond our own personal interest. Trying to achieve goals which benefit many people gives all of us a good feeling, an uplifting sense of purpose.
On July 11, 1978, I invited a few members of the Wyoming press to our home in Casper and announced that I would be continuing the race. I explained that I would continue to rest for the next few weeks and then would be back out on the campaign trail.
I traded in the Ford Mustang I had been using to drive myself to campaign events for a large motor home. My dad joined us as our driver, and my mom came along as our cook. Both of them, along with Lynne, made sure I got plenty of rest in the back of the RV between campaign events and I had healthy food to eat. A note from Dr. Hiser to Dr. Davis on July 26, 1978, indicates how closely they were watching my progress:
Dick Cheney returned to this office on 25 July 78. He looks extremely well and feels as well. Because he is doing well I have permitted him to have two short appearances in his campaign this coming weekend. Overall I think he is doing nicely and I will keep you informed.
Dr. Hiser had some specific instructions for me:
We will permit him to have two short appearances this weekend in Douglas and Torrington. He is to ride there in an air-conditioned travel van. He is to rest while going there, he is to maintain his exercise program, and he is to assure that he will get 8 hours sleep each night.
With my wife and parents along for the ride, I am confident we followed Dr. Hiser’s orders to the letter.
The heart attack, as daunting as it was, probably helped my campaign. The letter gave me an opportunity to communicate with the voters of the state without asking for anything other than their understanding. And it allowed me to talk to them as a husband and a father, not as a politician. A congressional candidate suffering a heart attack midcampaign was big news, and the event probably increased my name recognition across the state. When primary day rolled around, I won the three-way race with 42 percent of the vote.
DR. REINER
On September 23, 1955, President Dwight David Eisenhower developed what he thought was indigestion while playing golf at a country club outside Denver. The president had already completed eighteen holes and was in the middle of his second round when the discomfort convinced him to leave the course and return to the home of his mother-in-law in Denver, Colorado, where President and Mrs. Eisenhower were staying. The president, who was sixty-five, had no prior history of heart disease, but he had been an avid smoker, at one point consuming four packs of cigarettes per day. Eisenhower painted for a few hours, ate a light dinner, and went to bed around 9:30 p.m., but at about 2:45 a.m., he awoke with pain in his lower chest. When milk of magnesia failed to provide relief, the president’s physician was summoned to the Doud residence. Major General Howard Snyder, an army surgeon, arrived at 3:11 a.m. and noted that the president’s blood pressure was 160/120 and his pulse was 90 beats per minute, both elevated, typical for a patient in pain. Although there are conflicting accounts of what occurred next, a handwritten note, which Major General Snyder maintained he wrote at the president’s bedside, states:
As soon as I arrived, listened to the president’s heart and took blood pressure, I realized it was a heart injury.
This would have been an impressive diagnostic achievement for a physician not trained in cardiology and not having ready access to an EKG. Nonetheless, Snyder asserted that the president was immediately treated with amyl nitrate, an inhaled vasodilator; papaverine, also a vasodilator, this one administered in an injection; morphine for pain; and heparin, an anticoagulant injected intramuscularly. Because the patient was sweaty, cold, and restless, Snyder asked Mrs. Eisenhower to get into bed with the president in the hope that this would calm and warm him (a curious strategy not currently recommended for a patient with a suspected heart attack). Snyder later administered a second dose of morphine, which eased the president’s pain and lowered his blood pressure to a closer-to-normal 140/80. The morphine allowed the president to fall asleep around 5:00 a.m., but when he awoke at 11:00 a.m., his chest pain was still present. At 12:30 p.m. (ten hours after the president’s chest pain began and about twenty-four hours after his initial discomfort), Dr. Snyder requested an EKG machine; forty-five minutes later he documented an anterolateral myocardial infarction (a heart attack involving the front wall of the heart). The president was then walked downstairs and transported by car to the hospital.
In his exhaustive book Eisenhower’s Heart Attack, from which this chronology is obtained, Clarence Lasby ca
sts doubt about whether Snyder’s note was indeed a contemporaneous depiction of the events that night and instead suggests that Snyder wrote the memorandum much later to cover up for misdiagnosing the president’s symptoms and for erroneously treating him many hours for a presumed gastroenteritis.
After arrival at Fitzsimons Army Hospital, President Eisenhower was placed in an oxygen tent, not permitted to see his cabinet for two and a half weeks, ordered to remain at bed rest for a month, and kept out of Washington for seven weeks. Two hundred thousand people lined the streets to view the motorcade when he returned to the nation’s capital. After only a weekend in the White House, Eisenhower left Washington to continue his recovery at his farm in Gettysburg, Pennsylvania, and didn’t return to work at the White House until after the New Year.
• • •
Regardless of whose version of events one accepts, Eisenhower’s case illuminates the standard of care for a heart attack at midcentury. For the first eight decades of the twentieth century, the standard therapy for a heart attack mostly involved bed rest and pain control, usually with morphine, palliative treatments intended to keep the patient quiet and comfortable in the hope that no further catastrophe would befall the damaged heart. In the 1950s, oxygen was introduced as a standard therapy and papaverine and nitroglycerin, blood vessel dilators, were often given to prevent coronary spasm. Sometimes warfarin (an oral anticoagulant) or heparin (an injectable anticoagulant) was prescribed to prevent another heart attack or pulmonary embolism (a real hazard because of the prolonged bed rest); however, no strategy was employed to reopen the culprit vessel and limit the damage to the muscle. Patients spent on average four to six weeks in the hospital, and 30 percent died during the hospitalization, a toll reflecting the dismal progress achieved in the management of this disease through much of the twentieth century.
• • •
The term infarction, derived from the Latin infarcire, “to stuff,” refers to the death of tissue resulting from interruption of nutrient-rich blood. In 1880, Karl Weigert, a German pathologist, first made the association between an occluded coronary artery and a myocardial infarction, but most physicians of the time, including the legendary Sir William Osler, considered a heart attack a nonsurvivable event. In his classic 1892 textbook, The Principles and Practice of Medicine, Osler incorrectly noted, “Complete obliteration of one coronary artery, if produced suddenly, is usually fatal.” Twenty years later, at the 1912 meeting of the Association of American Physicians, Dr. James Herrick, a master clinician who two years earlier was the first to describe sickle cell anemia, proposed the revolutionary idea that a patient could survive an MI:
Obstruction of a coronary artery or any of its large branches has long been regarded as a serious accident. . . . But there are reasons for believing that even large branches of the coronary arteries may be occluded—at times acutely occluded—without resulting death, at least without death in the immediate future.
Not only did Herrick understand that a myocardial infarction need not be fatal but he also suggested that it was caused by a thrombus (blood clot) and was among the first to suggest strategies that might ameliorate the damage:
The hope for the damaged myocardium lies in the direction of securing a supply of blood through friendly neighboring vessels so as to restore so far as possible its functional integrity.
Although the concept that a heart attack results from obstructed coronary blood flow was accepted as fact by the early 1900s, Herrick’s notion that a newly forming blood clot was the cause of that obstruction was the subject of continuing debate for most of the century. As recently as 1974, only four years before Dick Cheney’s first heart attack, Dr. William Roberts, head of cardiac pathology at the National Heart, Lung and Blood Institute at the National Institutes of Health, wrote an editorial in Circulation, the journal of the American Heart Association, in which he rhetorically asked, “Which comes first, coronary thrombosis or myocardial necrosis?” (Which comes first, a blocked coronary artery or the heart attack?) His answer, like that of many physicians before him, that coronary thrombosis was the consequence rather than the precipitating cause of acute myocardial infarction, would soon be proven incorrect.
Without a clear consensus in the cardiology community that the usual culprit during a heart attack was a thrombus, a dynamic and potentially reversible problem, treatment was mostly limited to prodigious amounts of rest. In his brief remarks to the five thousand well-wishers who greeted him at the airport upon his return to Washington after his heart attack, President Eisenhower acknowledged the caution of his doctors and the torpid pace of his recovery:
I am happy the doctors have given me at least a parole if not a pardon. I expect to be back at my accustomed duties, although they say I must ease my way into them and not bulldoze my way into them.
The treatment administered for Dick Cheney’s myocardial infarction was remarkably similar to that received by Eisenhower twenty-three years earlier, both focusing mostly on rest. After an uneventful eleven days in the hospital, Cheney was advised by Dr. Davis to remain “homebound with in-house activity” for an extended period of time.
Dick Cheney’s care did differ in one important aspect from that delivered to President Eisenhower: Mr. Cheney was monitored in a coronary care unit, an innovation introduced just a few years after Eisenhower’s hospitalization and the first advance in the treatment of heart attacks that actually lowered mortality.
• • •
In the 1920s, as electrical power was being disseminated throughout homes and businesses in the United States, it was becoming common for utility linemen to die after accidental electrical shocks. It had been known since the mid–nineteenth century that electricity could cause a chaotic and fatal arrhythmia called ventricular fibrillation, but the prompt restoration of a normal heart rhythm remained an elusive problem. Ventricular fibrillation, also a dreaded complication of acute myocardial infarction, causes cardiac output to cease and blood pressure to drop to zero, halting the delivery of oxygen to the tissues, a condition called anoxia. While some organs can tolerate anoxia for an extended period of time, the brain cannot, and after just a few minutes, irreversible brain damage occurs.
In 1933, William Kouwenhoven, an electrical engineer, and colleagues at Johns Hopkins University reported experiments, funded by the Edison Electric Institute, in which for the first time they were able to reverse ventricular fibrillation and restore a normal rhythm by applying a “countershock” of electricity to the thorax of a fibrillating dog. The first successful defibrillation of a human patient occurred in 1947, but only after the chest of the fourteen-year-old boy was opened and electrical current was applied directly to the surface of the quivering heart. The boy made a full recovery.
In the years that followed, more patients were resuscitated from in-hospital cardiac arrest in this manner but only after enduring an emergency thoracotomy in which an incision was made along the left side of the chest, the ribs spread to expose the heart, and defibrillator paddles placed directly against the muscle. Although a step forward, this technique was hampered by two major drawbacks. First, it required an around-the-clock in-house team of skilled surgeons to “crack” the patient’s chest, and second, and just as important, it was time-consuming, a major disadvantage when the time window for resuscitation is a very few minutes. There was thus a need for technology that could promptly detect life-threatening arrhythmias, enable defibrillation of the heart without having to open the chest, and, perhaps of paramount importance, keep the patient alive until defibrillation could be accomplished. Within several years, all three pieces would come together.
In 1956, one year after President Eisenhower’s heart attack, Dr. Paul Zoll, a Harvard cardiologist, successfully resuscitated a sixty-seven-year-old man using a new external defibrillator, for the first time obviating the need to open a patient’s chest.
One year later, Zoll developed a method to display a patient’s cardiac electrical activity on an oscilloscope equipped
with an alarm capable of detecting a cardiac arrest. This revolutionary technology permitted real-time surveillance of cardiac patients for life-threatening arrhythmias.
The final piece of the resuscitation puzzle came in 1960 when researchers at Johns Hopkins University described a method of “closed-chest massage” capable of pumping blood in and out of the heart without opening the chest. William Kouwenhoven (who twenty-seven years earlier pioneered defibrillation), James Jude, and Guy Knickerbocker, in a landmark paper published in 1960 in the Journal of the American Medical Association, reported their simple method to squeeze the heart between the sternum and spine by compressing forcefully with the heel of a hand. Kouwenhoven and colleagues wrote:
Cardiac resuscitation after cardiac arrest or ventricular fibrillation has been limited by the need for open thoracotomy and direct cardiac massage. As a result of exhaustive animal experimentation a method of external transthoracic cardiac massage has been developed. . . . Anyone, anywhere can now initiate cardiac resuscitative procedures. All that is needed are two hands.
The stage was set for a new way to monitor and resuscitate cardiac patients, and at the meeting of the British Thoracic Society at Harrogate in North Yorkshire, England, on July 15, 1961, Dr. Desmond Julian presented a paper in which he described the rationale for the first coronary care unit:
