My Hurricane Diary: September 1st, 2008

9:30 am. September 1st, a day I will never forget. It was Labor Day. It started as a very windy day with a lot of cloud cover. The sun was nowhere to be seen. I had just started my rounds. Standing next to a patient in the ICU, I called Jason, our cath lab director. I was apprehensive, having just seen the news on television that Hurricane Gustav (Figure 1) was about to make landfall. My patient was a 41-year-old male with ongoing chest pain and ST-segment elevations in lateral leads just admitted to the ICU. After Jason answered the phone, I explained to him the need to open the cath lab before the hurricane. Most of the cath lab crew lives within 30 minutes of the hospital. I was confident that we could do the PCI and have just enough time to get the crew back home before the hurricane hit. Jason agreed, so we sent the call out. “Let’s see some more patients before the lab opens,” I told Stephanie, our nurse practitioner. She and her family had just “moved” into the office with a great deal of food, some flashlights and a radio. She said they didn’t want to take any chances, as Gustav would be taking a direct hit on us as a Category 2 or even 3 hurricane. “Gustav is the real deal,” she said. It so happened that I had also “moved” into the hospital the night before for the same reasons. I had just finished my interventional training in Brooklyn, New York, and moved into small-town practice in Opelousas. I was working under the umbrella of a nationally-known cardiology group and was starting to enjoy the change and the southern way of living. We are three interventionalists in the lab with a small bunch of exceptionally trained support staff. But, I wasn’t ready for Gustav. This was my first real-life awakening in south Louisiana. 10:00 am. I got an email alert from the National Hurricane Center on my Blackberry. Gustav has made landfall with sustained winds of over 110 miles an hour, with even higher gusts possible. Well, we have the landfall, I thought. I looked out the window and could see that the wind was picking up. It had just started raining, and looked grim and cloudy. The hospital had power and the air conditioners were working. “Steph, this could be fun…” I said. “I don’t think so, Dr. Deepak. We got hit pretty badly with Rita and we lost power for six days. Katrina wasn’t fun either. They say this is worse.” We kept on rounding. 10:10 am. I walked in to a patient’s room. It was Mrs. B. I had known Mrs. B for a week. She was elderly and had a diagnostic cath a week before to evaluate her coronaries. She was admitted for heart failure and had history of severe peripheral vascular disease. She had “bypass” for the legs. We were planning to discharge Mrs. B after some rehab once the shortness of breath resolved. “Mrs. B, aren’t you glad you are here? It’s bad out there,” I told her as I entered the room. She gave me a horrified look. “I wish someone could do something. My leg is hurting so bad and I can hardly move it,” she said. “I am sorry to hear that,” I said. “Let me take a look.” I moved the blanket. She was crying and was clearly upset. I looked at her leg and looked at my watch. I came out of the room and looked outside. It was quiet, just the wind and the rain. It was getting dark. The parking lot was empty and there was no one in sight. “Steph, we are in deep trouble,” I told our nurse practitioner. “We have a cold, pulseless leg. Mrs. B can’t move her leg.” 10:17 am. I got paged from the lab. “We are ready, doc!” I ran to the lab. My patient with acute myocardial infarction (MI) was on table, prepped and ready. I had Kevin, Gary and Kurt. Three strong LSU (Louisiana State University) football fans. I was getting worried. I had just summoned these three staff members to the hospital in 30- to 40-mile-an-hour winds. I was most worried about Kurt, as he drove over 25 miles from Lafayette to reach the hospital. Lafayette is south of Opelousas, towards the Gulf Shore, and closer to the hurricane, which had already made landfall. I was happy to see Kevin, as he was our most experienced scrub tech in treating acute leg ischemia. With Kevin around, I have a shot, I thought. Then I broke the news before I gained access. “Guys, I have a cold leg. If we don’t do something, she is going to lose that leg,” I said. “It could be days before we get power.” I made my case. 10:28 am. I got access. The young man with chest pain had strange anatomy. There was visible thrombus in a fair-sized ramus intermedius very close to the left main. I decided to primary stent. 10:49 am. A 2.5 x 16 mm stent was deployed. We had good flow. 11:03 am (Figures 2-3). The patient was out of the lab. As I came out of the lab, my phone rang. It was my wife, from New York. “Are you ok? I am watching horrible things on TV. Do you still have power?” She was understandably nervous. “Well, what now?” I asked the guys as I was dictating the procedure. I was told that Gary has gone to fetch Mrs. B. The wind looked bad now. I was trying to see Mrs. B’s angiogram. My heart sank again. “It’s aorto-bifemoral grafts!” I exclaimed. The grafts came at an acute angle, resembling a Chinese alphabet (Figure 4). There was no way I could cross over this. “Man, it is just not my day,” I told Kevin. 11:50 am. Mrs. B was lying on the table, clearly unaware of what was happening around her. I tried to explain to her that we needed to work from the arm and that we had no other choice but to try and open up the blockage in her leg that was causing all the pain. I also warned her that we could lose power any moment. She didn’t want to know any of this. “Do something,” she said. She looked at me as if I was wasting time. 11:52 am. One last look at my Blackberry to open a mail alert. I saw a new message from the National Hurricane Center. ...CENTER OF GUSTAV APPROACHING MORGAN CITY LOUISIANA... MAXIMUM SUSTAINED WINDS HAVE DECREASED TO NEAR 105 MPH... 170 KM/HR...WITH HIGHER GUSTS. GUSTAV IS A CATEGORY TWO HURRICANE. I knew the storm was coming at us fast. Soon it will be Lafayette, then Opelousas. 11:57 am (Figures 5-6). I took left brachial access. I brought in a pigtail catheter all the way down to the bifurcation and parked it. I then took a shot and followed it down. The flow stopped right under the knee. There it was, looking at us. It was a long thrombus, occlusive, with almost no distal runoff. She also had a significant proximal superficial femoral artery (SFA) stenosis. Could it be any harder? I thought to myself. “There is something with hurricanes and thrombus,” I told Kevin. 12:03 pm. We parked a long sheath as far down possible. The Glidewire went through the thrombus pretty easily. We tried to aspirate the thrombus with a long Quick-Cross catheter, as none of the designer “aspiration catheters” or “devices” were long enough to aspirate thrombus from popliteal artery. Well, we aspirated thin air! 12:20 pm (Figures 7-8). The hurricane had crossed Morgan City. The National Weather Center confirmed our worst fears. It was aimed at Lafayette and moving towards the north. That put Opelousas in the eye of the hurricane. I could hear gusty winds outside. It was raining cats and dogs by now. I only hoped that the power stayed on a little bit longer so that I could give Mrs. B a fair shot of keeping her right leg. Kevin gave me the longest balloon we had in 3.0 mm. We wanted to get some flow trickling down. The tip just crossed the thrombus. We could see a trickle going down after a gentle inflation. This is not good, I thought. 12:40 pm (Figures 9-10). Kevin handed me a 5.0-mm balloon. We dilated the SFA lesion at nominal atmospheres. We had a non-flow limiting dissection with a good runoff. “Let’s leave it alone,” I said. 1:00 pm. We had been working on Mrs. B for over an hour. She was sleeping like a baby. We had only one thing left to do — put an infusion catheter through the thrombus and infuse a thrombolytic. I scrubbed out for a moment and called Kal Veerina, my senior colleague. He concurred. “That’s the only choice you have,” he said. 13:07 pm (Figure 11). We inserted a perfusion catheter and wire, and started infusing urokinase. 13:08 pm. We sutured the long sheath on the slim, frail left arm of Mrs. B and closed the case. 13:18 pm. Mrs. B was out of the lab. I came out and looked outside to see nothing like I have ever seen before. Ferocious winds packed with rain were smashing on to the glass windows of the cath lab. The wind gusts sounded like a train howling past you at high speeds. It seemed like nature was taking some kind of revenge. 13:30 pm. Mrs. B is nicely tucked away in the ICU. Kurt hops into his truck. He starts his drive back home to Lafayette. He wanted to be with his family. “I had the motorway all to myself,” he later told me. He reached home just 20 minutes before Gustav made its landfall in Lafayette as a Category 2 hurricane. It was almost at the same time that we lost power. It took six hours for the wind to settle; just the same amount of time it took Mrs. B to get the pulse back on her leg. The author can be contacted at dkthekkoott@aol.com.

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