Blog | Thursday, December 30, 2010

Richard Holbrooke: a terrible way to die


Veteran U.S. Diplomat Richard Holbrooke died of an aortic dissection. The man considered largely responsible for the Dayton Peace Accords, which ended the war(s) in the former Yugoslavia, had an outsized personality in a world usually replete with protocol and bureaucracy (don't let those wikileaks cables fool you).

One thing Holbrooke seldom gets credit for is the way he negotiated a settlement on the billions in dues owed by the U.S. to the United Nations when he was U.N ambassador during the Clinton Administration. Imagine having to convince 192 or so foreign governments to cut you some slack, one-by-one.

Sadly, his death was unexpected, and will leave incomplete what he probably hoped would be his biggest legacy: some type of lasting peace and stability in Afghanistan and Pakistan.

The news stories report he was meeting with Secretary of State Hillary Clinton when started to feel ill. The next thing we're told is he was rushed to George Washington Hospital (very close to the State Department in Washington) and taken to a 20+ hour operation to repair the tear in his aorta.

Over the weekend we were told he was in "critical" condition, and by Monday his obituaries ran.

Image from Wikimedia CommonsThink of the aorta as a huge muscular pipe that takes blood pumped from your heart and streams it to the rest of your body. That pipe is constructed in layers, the innermost of which is called the intima. For unknown reasons, that inner lining can sometimes tear away from the rest of the pipe, causing the blood to go haywire, clotting in the pipe, and causing there to be a significant diminution of blood going where it's supposed to go. Imagine your legs going numb. Or your arms.

The strange thing is, even though we think of the aorta as a pipe, it's well innervated (connected to our nervous systems). So the tear is exceedingly painful--classically described as chest pain that radiates through to the back.

It's a nightmare to diagnose, and as you can tell by the effort to save Holbrooke, a bloody mess to treat.

To diagnose it you first have to think of it. The test of choice is something called a CT angiogram, a specialized CT scan that looks at the blood vessels in the chest and/or abdomen. (Wait! Didn't I just read something interesting about CT scans recently? Where was it?)

If you actually make the diagnosis of a big tear like Holbrooke had, it's off to surgery. As fast as possible.

Though I wrote that we don't truly understand what causes dissections, we do know some things that increase the risk: High blood pressure. Smoking. For some reason, being male. Atherosclerosis.

John Ritter is said to have died from a dissection. Famously, Dr. Michael DeBakey, the pioneering cardiovascular surgeon, suffered a dissection at age 97. He supposedly knew what was happening to him, and his young second wife, in spite of his protests, called paramedics and got him medical attention. He managed to survive to age 99.

I can imagine the scene in the GW emergency room as Holbrooke "presented." Utter chaos. The news accounts make the hospital look clean and efficient, as though there was no trouble diagnosing this horrible condition and rushing this famous diplomat off to a heroic life-saving operation.

Sadly, neither image jibes with reality.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.