Complex cardiovascular surgery often involves a team including surgeons and nurses from several departments. Read more at massgeneralmag.org
By the time an ambulance rushed Kerry Kearn Kawai to Massachusetts General Hospital, doctors at two other hospitals had done all they could for the young mother from Winchester, Mass. The 34-year-old had suffered a massive blood clot on her lung that morning. A heart-lung bypass machine was keeping her alive but that wasn’t likely to last.
Joshua Baker, MD, was waiting in a Mass General operating room that evening in January of 2011. The cardiac surgeon was confident in the skills of the array of Mass General experts he had begun to mobilize for Kerry. But her cardiovascular system had suffered the sort of enormous shock that is usually fatal. “I thought there was a less than 1 percent chance that she would make it,” Dr. Baker recalls.
Saving Kerry would test the skills of Mass General caregivers and draw deeply on their emotions. But they knew such challenges well. Through the years, Mass General had always been willing to tackle the most complex and risky cardiovascular cases. Part of the process had always involved learning from each case, keeping an eye out for lessons that might improve the delivery of care for the next patient.
In recent years, Mass General has been systematically reassessing how it treats cardiovascular disease, the leading cause of death in the United States, accounting for about 800,000 deaths annually. There are compelling reasons to do so. As people live longer, they are developing more complex cardiovascular disorders. Few individual physicians can master the intricacies of each, and patients are hard pressed to choose among treatment options. Meanwhile, insurers and government payers are demanding greater efficiency and more emphasis on prevention.
For Mass General leadership, such factors point to the need for greater interdepartmental collaboration and an even sharper focus on early detection of cardiovascular issues. “The goal is to have a team-based approach where we really evaluate all of their risk factors and try to be proactive,” says G. William Dec Jr., MD, co-director of Mass General’s Corrigan Minehan Heart Center. Adds Lee Schwamm, MD, vice chairman of Neurology: “Every emergency admission is a failure of prevention.”
The goal is to provide cardiovascular patients with care that is more seamless and readily understood. “At the very beginning of a patient’s entry into the system, there needs to be a comprehensive, multispecialty network that provides the backdrop for all of that patient’s care,” says Michael R. Jaff, DO, director of Mass General’s Vascular Center. “And it can’t be the patient’s responsibility to figure that out.”
Such thinking has prompted Mass General to launch the new Institute for Heart, Vascular and Stroke Care. Although separate heart and vascular centers will continue to exist, they will pursue more joint research and work together to better educate the community about cardiovascular disease. Meanwhile, caregivers across the cardiovascular spectrum will redouble their efforts to provide disease-specific patient care that is unfettered by departmental boundaries. “It is a wonderful step in making sure that all the disciplines understand what the others are doing,” says Ann Prestipino, senior vice president of Surgical and Anesthesia Services and Clinical Business Development.
The institute isn’t starting from scratch. As the Kawai case shows, the sort of collaboration it is designed to foster has been underway for some time within many of the participating departments and centers.
Growing up in Medford, Mass., Kerry Kearn Kawai almost never got sick. She was a varsity athlete in high school and captain of her swim team at Columbia University. She and her husband, Paul, both attorneys, surfed and competed in triathlons together early in their marriage. Kerry’s only times in a hospital had been for the Mass General deliveries of her daughter Emma, in 2007, and son, Owen, in 2010.
Except for digging out from the previous night’s blizzard, Jan. 27, 2011, began as another workday for the Kawais. Kerry was six months pregnant with their third child but woke up feeling fine. Before driving the kids to daycare and then to her job at a Boston law firm, she headed for the shower. It was around 6:30 a.m. and the kids were just waking up. While waiting for the water to get hot, Kerry began to feel dizzy. The sensation intensified quickly.
When Paul came in from shoveling the driveway, Kerry was lying on a bed, gasping for breath. After calling 911, he held her in his arms. She was having seizures and drifting in and out of consciousness. Unable to imagine what might be happening, Paul pleaded with his wife to keep breathing.
A pulmonary embolism is a sudden blockage, often a blood clot, of one of the arteries supplying the lungs. The condition can strain the heart, kill lung tissue and cause brain damage. It often strikes without warning. The U.S. Centers for Disease Control estimates that between 60,000 and 100,000 Americans annually die from pulmonary embolism and a related clotting disorder called deep vein thrombosis.
After relatives rushed over to watch the couple’s children, Paul drove to Winchester Hospital, where the ambulance had taken Kerry. Only a few minutes had passed but, by the time Paul arrived, doctors had already performed an emergency Cesarean section to save the baby, who had been rushed to Boston’s Children’s Hospital.
“I walked into the emergency room and there was a line of people doing CPR on my wife,” Paul remembers, his voice quivering. “She was on the table. She wasn’t conscious. She had no pulse.”
After tests detected a large pulmonary embolism, Kerry was transferred to Lahey Clinic for more specialized care. With little time to spare, surgeons there opened Kerry’s chest, attached her to a heart-lung bypass machine and surgically removed the clot. But while the blockage was gone, the complications had begun to spiral.
A traditional bypass machine diverts blood away from the heart and lungs so doctors can perform certain cardiovascular surgeries. Through tubes, the blood is pumped out of the body and into a reservoir. Oxygen is added before it is pumped back into the patient. Surgeons try to wean patients off bypass machines as soon as possible because of potential complications. They include infection, blood clots and brain damage. Internal bleeding is also a concern because of the anticoagulants typically used. Because of the emergency Cesarean, such bleeding was a major risk for Kerry.
After the operation, her heart was too weak to pump anywhere near the amount of blood necessary to keep her alive. Unable to disconnect their patient from the machine, Lahey doctors reached out to other area hospitals for assistance.
Joshua Baker, MD, arranged for Kerry to be brought to Mass General, then the only Boston hospital offering adult cardiovascular patients a technology called extracorporeal membrane oxygenation, or ECMO for short. Dr. Baker had been championing the use of ECMO, which is similar to traditional bypass machine but with a shorter circuit of tubes and a pumping system that was less likely to damage the blood itself. Patients don’t require as much anticoagulant and can safely stay on the system longer.
Dr. Baker told Stephanie Ennis, NP, to get ready. The veteran nurse practitioner advised operating room nurses Kerry would be coming there first and alerted the cardiac surgery intensive care unit (CSICU) to stand by. Ms. Ennis coordinates care for Mass General cardiovascular patients needing ECMO or other forms of mechanical support. Skilled in operating the devices themselves, she keeps in close touch with transplant candidates living at home and makes certain hospitalized patients understand the treatments in store for them every day.
Kerry’s abdomen was badly distended from internal bleeding when her gurney arrived in the operating room. After examining her, Dr. Baker decided the weight and mass of the blood pooling inside her abdomen was likely to impede the ECMO machine from doing its job.
Dr. Baker made an incision to find the source of the bleeding, The abdominal cavity was drained and packed with absorbent surgical sponge. Dr. Baker kept working. Mass General trauma surgeons and obstetricians were called in for consultation. With the ECMO up and running, the medical team painstakingly searched for the sources of the bleeding. After Dr. Baker repaired some damaged blood vessels, the incision was closed.
Kerry’s chances were still grim. Although the ECMO machine was giving her heart and lungs time to rest, much of the blood it was pumping was being delivered via transfusion. Her internal bleeding had slowed, but Dr. Baker would need to operate two more times to stop it completely. In all, Kerry would need more than 90 units of blood, enough to replace the entire blood supply of an average adult more than five times. Meanwhile, unless and until she regained consciousness, no one would know whether the circulatory disruption had caused significant brain damage. Kerry might never wake up.
The hours of uncertainty were excruciating for Paul, who was stationed with Kerry’s family in a waiting room outside the CSICU. While his wife’s life hung in the balance, their prematurely-born daughter, Ava, was across town at Children’s Hospital beginning a survival struggle of her own. He hadn’t seen their child yet.
It was the middle of the night by the time Kerry was stable enough to be transferred up to the CSICU. Paul went to her bedside. With monitors and tubes everywhere, he leaned over and began speaking softly to his still-sedated wife. Months later, Paul would not remember his words that night but others who were there would not forget. “He was whispering in her ear, just talking to her, giving her all the reasons she had to pull through this,” Ms. Ennis recalls. “Everyone in the room was crying.”
Although the viability of Kerry’s heart and lungs was still a huge concern, Mass General specialists began moving to head off other potential impediments to her recovery. Vascular surgeons and orthopaedic specialists checked for circulation problems in her hands. Renal experts examined Kerry for potential kidney damage. Ken Rosenfield, MD, section head for Vascular Medicine and Intervention, installed a small catheter to bolster circulation to Kerry’s right leg.
“When you have a patient like this, whose life is hanging in the balance, it is very difficult,” says Dr. Rosenfield, who worked closely with Dr. Baker throughout the case. “You are focused on the heart and the lungs but you also need to think about all of the other things that could go wrong and try to prevent them from happening.”
Driven and intensely focused, Dr. Baker kept Paul apprised of what he thought he needed to do next and then went off to do it. The doctor was not a chatty sort but Paul didn’t care. He sensed his wife was in good hands. That feeling was reinforced in a big way less than a day after Kerry was admitted. With her sedation turned down, Kerry was able to respond to simple questions from Dr. Baker by raising her thumb. Amid signs that Kerry’s heart was once again capable of supporting her, Dr. Baker detached her from the ECMO machine. Paul says Dr. Baker gave his family something it desperately needed that day. “There was hope,” he says.
For Kerry, consciousness came back slowly in disconnected snippets. Fearful and confused, she was initially hesitant to ask any of the doctors and nurses what had happened.
But Stephanie Ennis appeared at her bedside again and again. When there was blood to be drawn or another test to be taken, the nurse practitioner was there to explain what was going on. After Kerry suffered several hallucinatory nightmares, the nurse practitioner assured her that such things were common for patients in her shoes. Ms. Ennis called staff at Children’s Hospital for updates about Kerry’s newborn daughter and brought her a framed picture of baby Ava. “Stephanie was this amazing guardian angel that they gave to me,” Kerry says.
Thomas MacGillivray, MD, also became a welcome visitor. As surgical director of Mechanical Surgical Support at Mass General, the cardiac surgeon oversees the ECMO program but had no direct role in caring for Kerry. Even so, as a surgeon, a husband and a father, he felt drawn to this patient and her situation. In the evenings, he would stop by to chat, albeit seldom about the nitty-gritty of her care.
“You go into medicine so that you can help people,” Dr. MacGillivray explains. “Sometimes you help them by doing a heart transplant. Sometimes you help them by sitting down and trying to relieve the tension by telling a joke. Sometimes you just reassure them that everything is going to be OK.”
Even as her heart and lungs slowly gained strength, Kerry faced other medical hurdles. She required intensive therapy for her left arm, which the trauma had left weak and painful. An ear, nose and throat specialist helped deal with a persistent cough. A Mass General psychiatrist visited to make certain she had the coping skills to deal with such a traumatic, near-death experience.
Three weeks to the day after she arrived at Mass General near death, Kerry was discharged. She left with a list of instructions and appointments. In the ensuing weeks, therapists visited and other Mass General staff checked in by phone. On her first follow-up visit with Dr. Rosenfield, who became her cardiologist, he gave her his personal cell phone number and implored her to use it. “It wasn’t like the cord was cut,” Kerry says. “They helped me have the support I needed to make a comeback.”
Earlier this year, Kerry returned to work at the Boston law firm where she specializes in corporate transactions. Monitoring herself closely, she works out for 45 minutes every day. She marked the first anniversary of the pulmonary embolism that nearly killed her by going to a day spa with her mother. She and Paul also had family and friends over to celebrate the first birthday of their daughter Ava, who has made a medical comeback of her own.
Meanwhile, demand for adult ECMO services at Mass General has surged and many of the doctors who treated Kerry are part of the hospital’s new Pulmonary Embolism Response Team (PERT), an initiative planned under the auspices of the Institute for Heart, Vascular and Stroke Care. With PERT, Mass General cardiovascular specialists will be simultaneously alerted and asked for input about high-need patients like Kerry.
For his part, Dr. MacGillivray says her case is an inspiration. “The experience of watching someone like that get better is what keeps you coming to work every day,” he explains. “When someone comes in who is really, really sick, you think to yourself, ‘We got Kerry through and we can get this person through, too.’ ”
To find out about ways to support cardiovascular programs at Massachusetts General Hospital, please contact Elizabeth Drolet at (617) 726-5561 or firstname.lastname@example.org.