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Dr Lloyd Rudy and "that night": From chicken soup and bed rest to anticlot therapyMar 9, 2011 22:31 EST
As he spoke, he was relaxed and confident, towering over most average folks. I spotted him across the room while attending the Bale/Doneen course in Vegas. He is lithe, gray-haired, and has a ready smile. He made a few comments and answered some questions during the first hours of the morning and then obliged the speaker by coming to the front of the room. He was asked specifically to talk about "that night." Quickly, I grabbed my MacBook and transcribed his short talk as best I could. To think I would not learn of such impactful events for decades struck me as very odd. As a 12-year-old, awakening to the early-morning sounds of a Kentucky farm in 1972, I had no idea that at that moment, far away on the Western seaboard, a new chapter had unfolded in the world of heart-attack care. It was a story that would influence my destiny and would change the lives of so many patients and physicians forever. In his words, Dr Lloyd Rudy told his story:
"We analyzed the mortality for acute MI in coronary care units across the country. It was around 17%, but those MIs that involved the 'widow maker,' or the LAD, were large MIs. Their mortality rate was around 30% to 35%. We still did not know exactly what was happening," he continued. "We knew about atherosclerosis and ruptured plaque. We were asking ourselves, 'What is happening with that totally blocked anterior descending?' As surgeons, our [mortality for elective operations] was only 1.5% to 2%, so we finally talked our cardiologists into letting us operate on acute MIs. We wound up with the lead paper at the AHA because out of the first 100 patients, we lost only one . . . and those were all giant heart attacks. We didn't operate on 'little ones,' " he quipped. Then he said, sadly, "The patient we did lose was in [electromechanical disassociation] EMD. We did not save him."
The timing of the surgery for a large acute MI was a concern for Rudy and his colleagues. "We asked ourselves, 'When exactly are we going to cut it off?', " referring to a proposed time frame for an emergency bypass operation. "What if his pain started 12 hours ago? Are we going to operate on someone like that?" he asked rhetorically. He then said, "Spokane, Washington, with a surrounding population of 300 000, is actually a small town of 10 000. Anybody who worked for us had to live within 10 minutes of the hospital, because we were going to say the golden period is six hours." We said, "If they have pain starting within six hours and if it's a large enough heart attack, let's operate. That's how this all came about."
Rudy smiled, stepped back a moment, then began again. "Heart attacks do not occur at noon. Anybody can tell you that. It's the firefighter dragging a hose who has an MI, and it's always at 2 am when you're asleep. We were in there in the operating room all the time, all night," he recalled. He then went on to describe his colleague who coaxed him into one of the most impactful moves any surgeon ever made in the field of coronary pathology. "Marcus De Wood is a brilliant cardiologist who was more interested in research than anything," he said. "He was in there with us at 2 am when we were doing this stuff. He was always writing it all up, taking it down to Henry Swan in LA, and checking all the stats. We were in the trenches, and he was getting all the credit!" Rudy said with a big guffaw. Then he continued, "The proximal LAD on this patient was totally plugged. He was 48-ish and in real trouble. Then Marcus said, 'We gotta prove what that is. What's actually in there? What's closing that artery?' Then I said, 'Yeah, right, Marcus, I've got him on bypass and I'm just gonna go ahead and do this vein graft.' But he wouldn't give up. He asked again, 'Can you find what that is? You have to find what that is!' He was so persistent."
Then Rudy, with a look of determination that likely mirrored the same serious countenance hidden behind his surgical mask that very evening, said, "I took that Fogarty catheter . . ." Then he hesitated, seeming to play back the entire event in slow motion, thinking aloud, coaching himself. "If you take it and put it up in there, you take a risk of pushing that clot or whatever it is into the main stem and then, goodbye. That was the real squeezer. But Marcus was insistent. I got the catheter by this clot, blew up the balloon, pulled it out, dragging it slowly, and it [the clot] trailed off like a big long snake, completely intact! It was amazing! I handed it to Marcus, who absolutely went nuts! He was back there on the blue towels, jumping around, taking pictures and going crazy. . . . And so I put in the graft," Rudy said, his voice trailing off. He began again, "We had a mortality rate of only 2.5% in our first 1000 patients." He shook his head, accentuating how difficult it was to convince his colleagues to take acute MIs to the OR. "We literally had to put our hands around the cardiologists' necks." After the procedure was complete, Marcus De Wood made the understatement of the century: "We are going to revolutionize coronary care forever." Lloyd Rudy stopped, reflecting upon the enormity of the moment, and then said, "I think we did."
I had never heard a firsthand account of "that night." Only those who've treated a heart-attack patient, researched the mechanism of infarction, or experienced an MI can really appreciate the implication. Liters of heparin later and enough IIb/IIIas, enoxaparin, lytic, aspirin, clopidogrel, prasugrel, and ticagrelor tablets to fill the ocean, many of us will now finally understand where it all started. Because of the daring of Dr Lloyd Rudy, the persistence of Dr Marcus De Wood, and the dedication of their team of anesthesiologists, anesthetists, nurses, EMS personnel, and techs, we now understand it is a "snake of a clot" that stands between life and death for so many. "That night" fostered the dawn of a new day for AMI therapy. Thanks to you, Dr Rudy and Dr De Wood, for saving the lives of countless patients, some you knew, many you have never met, and scores of whom are not yet born. You transformed standard ACS orders from chicken soup and bed rest into a sophisticated cocktail of anticlotting medications forever.