Working swiftly, Sanders and Hartz spread iodine over the area of the mayor`s right groin, walled off the area with dressings, made an incision, spread aside the fatty tissue with their fingers and fastened it out of the way with metal retractors, located the femoral artery and vein, punctured these two blood vessels with a needle, inserted a guide wire into each and connected the machine`s plastic tubings, or cannulae, directly to the vessels. Northwestern clinicians have worked with the manufacturers of the CPS machine to try to develop the best cannulae, Sanders explains. ”The trick is to have the tubing flexible enough not to rupture the vessel and yet strong enough to flare back and force the needle hole in the vessel into a width about the thickness of a lead pencil.”
The principle of the heart-lung machine is simple. Venous blood returning to the heart is diverted into the machine, where carbon dioxide is exchanged for oxygen. Then the freshly oxygenated blood is warmed and returned by the machine into the patient`s arterial system. The machine acts as a ”heart” by pumping the blood, and as a ”lung” by exchanging carbon dioxide for life-sustaining oxygen. The portable ECMO system is about one-half the size of the typical operating-room heart-lung machine, and it can be set up and connected to a patient in about one-third the time. Future models of the machine are expected to be only one-third its current size and to fit at the end of a bed rather than being supported on a cart.
Within seconds after the CPS system was first ”purged” by circulating a saline solution to prime the patient`s system-to ensure that an air embolus would not occur-it was providing circulation. By 11:45 the mayor of Chicago was on full life support.
Initially, the medical team was guardedly optimistic. ”This machine does a better job of pumping blood than does your own heart,” Kramer says. Hartz recalls that the previous-and sixth-patient on the CPS system, a woman who arrested during an obstetrical procedure, ”made a full recovery. Although she did not, like the mayor, have a true heart attack, she did suffer an arrest of the heart.”
For his part, Sanders knew that if there were to be good news, it would come quickly. ”If the patient is going to recover,” he explains, ”he will usually awaken within a few minutes of having his circulation restored, and he will need anesthesia while we continue our work on the heart.”
But on this morning the anesthesiologists would not be needed. Harold Washington never awoke, and the next medical services to be required were those of the neurologist, Dr. Onur Melen, who during the two hours the mayor was on the machine, performed a series of standard tests to ascertain if he was brain-dead. While Melen was assessing just how bad things were, nurse Meg Kloster was setting up a bed on the fourth-floor cardiac surgery suite in the hope that the mayor would be transferred there for a possible surgical procedure. Sanders had put everything and everyone in the suite ”on hold”-
just in case-but it was not to be.
”To be blunt,” Kramer summarizes, ”there were no signs of recovery. We were able to restore circulation and color, but we were not able to get a cardiac or neurological response.” Mathews adds, ”The only spontaneous movements the mayor made were a few agonal breaths, or dying gasps.”
When the patient did not revive within 30 minutes of being placed on bypass, Sanders was ”about 99.9 percent certain that he was dead.”
Nevertheless, the artificial circulation was continued for another 90 minutes, until Sanders pronounced Washington dead at 1:36 p.m. He explains: ”Had the patient not been the mayor, we might have stopped the resuscitation effort after 30 minutes. But we wanted to make absolutely certain that everything possible was done. The CPS machine is licensed by the FDA to provide bypass for up to six hours, but after two hours, there was no doubt that the mayor was irreversibly brain-dead. We were able to achieve full blood flow and convert his heart rhythm from defibrillation into an electrical standstill, but we were unable to achieve a normal heartbeat or any signs of brain activity.”
He adds: ”In our series of 16 runs with the CPS, we have occasionally achieved cardiac response but not neurological, or neurological response but not cardiac. On four occasions we achieved both, but only one of those, the young woman, made a full recovery. With the mayor, we were unable to achieve either (response).”
After one hour on bypass, Sanders began to tell members of the mayor`s entourage, including Edwards and Senat and Washington`s family members, that the outlook was dim. Washington`s pastor, Rev. B. Herbert Martin, and-at the request of the mayor`s companion, Mary Ella Smith-a Catholic priest were called to administer last rites.
”Once the patient is hooked up,” Sanders says, ”we`re essentially operating on automatic pilot, and I had time to talk to the mayor`s people who had been allowed in the room. I told them how bleak things looked and that if he were a member of my family, I would not want to artificially prolong life after all hope was gone. We decided that we would run the machine only for two full hours. It was a very emotional scene when I disconnected the CPS hookup. In the confusion, I forgot to dictate notes, and someone had to remind me to check the time the machine was turned off.”
The official time of death was given as 1:36 p.m, but Los Angeles Mayor Tom Bradley had offered his condolences earlier, a discrepancy that infuriated many people. Sanders believes that ”Bradley called Washington`s office that day for another reason, and when he was told that Washington had suffered a heart attack, he mistakenly assumed that the mayor was already dead. I do not believe that one of the mayor`s people told Bradley that Washington was dead before I pronounced him dead.”
During the two hours the mayor was being worked on in the hyperacute room, the main ER treated an additional 16 patients, including three who came with chest pains and were admitted to the hospital to be checked for possible heart attacks. For the day, 15 patients were admitted to the hospital, including five who had signs of possible heart attacks. ”We were able to carry on the normal routine of the ER as well as treat the mayor,” Mathews says. ”Our security, working with the mayor`s bodyguards and Chicago police, did a pretty good job of weeding out the bystanders who had drifted into the ER.” Sanders was well aware that he was keeping a pack of reporters at bay outside the ER doors, but he concludes: ”First things first. We did everything we could for the patient. Then we told his family the bad news. Then we met the press.”
After calling Cook County Medical Examiner Dr. Robert Stein to confirm his hunches about the cause of death, Sanders spent the rest of the night on a ”media tour,” explaining to various reporters what had happened. Then he drove to his Wisconsin cottage, arriving at 4 a.m. Thanksgiving Day, and found his family still up and waiting for him. He recalls wryly: ”My wife, Karen, was very supportive and asked, `How ya doin`?` My father, John Sr., who is a surgeon in Cleveland and who knows too well how personally we feel about the death of a patient, called the next morning at 7 to say, `0 for 2, huh?`
(Sanders had also taken part in the unsuccessful attempt to revive Mayor Richard J. Daley after his heart attack on Dec. 20, 1976). That`s the way it goes.”
Kramer adds: ”I still get very keyed up just talking about our effort to save the mayor. At the actual moment, I tried to be very cool and to suppress my excitement, but it still is a very vivid memory. For a few moments the mayor was my patient, and I did everything I could to try to save him. We`ve been able to bring patients back from the brink of death, and whenever you do, the feeling is almost overpowering. I wish that could have happened with the mayor. Anytime you lose a patient, you have two basic feelings-sadness that there has been a death, and disappointment that you could not prevent it. Whenever I lose a patient, I feel lousy, and I felt very lousy after the mayor died.
”That`s why the autopsy was so reassuring. It documented that this patient was unresuscitable.”
”Let conversation cease,
let laughter flee.
This is the place
where death delights to help the living.”
This passage, in Latin, is on a plaque hanging on the wall outside the office of Cook County Medical Examiner Stein, who has held the post since the county voted to establish it in 1976. He had earlier spent 20 years as a consultant to the coroner and now has a staff of 100 with jurisdiction over all violent or unexplained deaths in Cook County. This means 15,000 bodies a year, and Stein himself performs 500 autopsies a year, as well as supervising the rest.
As a forensic pathologist, Stein is eminently qualified for this grisly but indispensable job. His new state-of-the-art facility was built just a few blocks from the old grim Cook County Morgue in the shadow of the vast Cook County Hospital complex on the city`s West Side. Through the halls of the old morgue have passed the mortal remains of John Dillinger, the seven St. Valentine`s Day massacre victims, the eight nurses killed by Richard Speck and the 29 young men murdered by John Wayne Gacy. Stein supervised the pathology work on the 1979 Gacy case as well as the identification of the 274 victims of the DC-10 disaster that occurred only six months later. But he is quick to emphasize that his work is much more than simply ascertaining the cause of sudden death.
”What we do here,” he explains, ”is for the living. The living learn from the dead. I don`t want to be known as a doctor of death. I think of myself as a teacher.”
The teaching lesson from the death of Harold Washington is very simple, he says. ”Harold Washington was a victim of his hypertensive heart disease
(one resulting from high blood pressure), his lifestyle and his diet. The message is that we all have to find the time to take better care of ourselves physically.”
There are two kinds of autopsies-the simple hospital autopsy that merely lists a cause of death and the definitive medicolegal autopsy performed by medical examiners like Stein. The medicolegal autopsy consists of two parts-findings and interpretations-and it lists both cause and manner of death.
Based on his findings, Stein says that he is ”100 percent certain” of his interpretation that the mayor died of a sudden heart attack that was due entirely to natural causes. The mayor`s autopsy is a brief document that is
”a simple, straightforward exposition of death by heart attack,” he says.
The official cause is described as ”acute coronary thrombosis due to coronary atherosclerosis with 90 to 95 percent occlusion.” What this means, he explains, is that the three major arteries supplying life-sustaining oxygen to the mayor`s heart were all blocked by as much as 90 to 95 percent. One of these arteries, the left anterior descending artery, which provides 40 percent of the blood supply to the left ventricle, the heart`s main pumping chamber, suffered an acute thrombus, or blood clot, and this triggered a fatal irregular heartbeat. Stein listed as a contributing cause ”concentric hypertrophy of the left ventricle.” This means that the heart`s main pumping chamber was grotesquely swollen from years of having to pump against the greatly increased resistance of clogged blood vessels. The mayor`s long-standing high blood pressure caused his hypertensive heart disease, resulting in a swollen heart and narrowed blood vessels. Although it is not listed as a cause or contributing cause of death, the mayor`s obesity figured prominently in the autopsy. ”Right in my first sentence,” Stein says, ”I noted that the mayor was about 100 pounds overweight and that this helped to compromise his health.”
Stein adds, ”The autopsy specimens are so grossly obvious that any sophomore medical student would have quickly diagnosed the mayor`s death as I did.” Waving his hand toward a microscope in an adjoining room, he says:
”Since it was the mayor, we took slides of everything-heart, blood vessels, brain, kidney, spleen. I can send them to any qualified pathologist in the world and have my findings confirmed.”
The objective findings of an autopsy can sometimes cloud the interpretation of the cause of a death. In the case of Elvis Presley, for instance, evidence was found both of heart disease and of near-toxic levels in the blood of prescription drugs. The Memphis medical examiner, Dr. Jerry T. Francisco, acknowledged the presence of the drugs but concluded that Presley`s death was due to heart disease and heart disease alone, with the drugs neither causing nor contributing to the singer`s dying at age 42. Other physicians present at the autopsy apparently believed that the death was due to
”polypharmacy,” or a fatal mixture of the several prescription medications found in the autopsy toxicological tests, but since the autopsy was a sealed document, they were precluded from arguing this view. Only Francisco was empowered by law to state a cause of death, and he chose heart disease. Most experts familiar with the case support his line of reasoning, but controversy nonetheless has surrounded his report.
By contrast, the drug tests on Harold Washington were totally negative. Stein emphasizes, ”Our mass-spectrometry drug tests can detect the presence of any one of 30,000 toxicological compounds listed by the National Bureau of Laboratory Standards, and these drug tests were absolutely negative.”
Stein rests his case on what he calls the ”overwhelming evidence found in an objective autopsy. I had been following the TV reports all day, and the mayor`s body was brought in about 4 p.m. I performed a very routine autopsy, requiring maybe 90 minutes, and I knew within about 20 minutes that the clot had caused the arrest.
”The mayor had a huge heart, what we call a `bovine heart,` weighing 600 grams (a ”normal” heart weighs 250 to 300 grams) and indicating the many years his heart had overworked itself pumping against the resistance of severely clogged blood vessels. He also had severe three-artery disease, with the left anterior descending artery, or LAD, which supplies the front wall of the heart and the left ventricle with blood, occluded 100 percent; and with the circumflex artery and right coronary artery, which supply the back wall of the heart with blood, both occluded 90 to 95 percent.
”His atherosclerosis (hardening and narrowing of the blood vessels) was so severe that even the arterioles, or small branches of the circulatory system, were occluded 50 to 60 percent. We found that the blood vessels at the base of the brain were also hardened and narrowed. We also found a small amount of fat in the liver.
”He was only 70 inches tall, and he weighed 284 pounds, which is about 100 pounds overweight. (Nineteen of those pounds, however, may have been due to the intravenous fluids he received during treatment.) This obesity created miles of new capillaries that his heart had to supply with blood. His adipose (fat) tissues were at least three inches thick.”
