Saving Tom Kadesch
A seemingly healthy man experiences terrifying chest pain—and two doctors at Suburban Hospital experience a horrific sense of déjà vu.
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By that Thursday night, Tom Kadesch had already put in more than 40 hours at DRS Technologies in Gaithersburg and was looking forward to having the next day off. He had been to the grocery store, putting the frozen foods in the garage freezer next to his 21-speed Schwinn. And now he was at the kitchen table in his home near Damascus.
But as he set up his “lazy man’s Christmas tree”—a 3-footer from a box—something seemed off. Pressure was concentrating in his chest, just as it had during exams 16 years earlier at the University of Maryland, and later at George Washington University. It felt as if something was moving inside of him.
Kadesch, an engineer who designs intelligence equipment for military use, set down the tree base and walked slowly out to the porch for air, then back in to the sofa. There was a dull pain as he paced past his bass guitar and music stand, then returned to the open door. Sitting felt uncomfortable. Can’t drive, he thought. Lights off at the neighbors’.
Kadesch’s small family had always tended to handle problems on its own, so calling an ambulance didn’t occur to him. Instead, he hunched over his cell phone, head swirling. Concentrate. Hit 4, hit 2...
In Kensington, Charles Kadesch was online in the basement, his wife, Bobbi, up knitting in front of the TV. Icing in Frederick, the news said. The phone rang. Caller ID showed it was their only child.
“Mom,” said a weak voice.
“Tom, is that you?”
“Mom. Can you and Dad come up? Something—” he paused—“wrong in my chest.”
Bobbi Kadesch yelled for her husband, grabbed her keys and ran into a torrential rain. It was Dec. 11, 2008, two weeks before Christmas.
In the emergency department at Bethesda’s Suburban Hospital, then-32-year-old Dr. Matt Leonard of Arlington, Va., had the 11-to-7 overnight shift. While in med school at the University of Virginia, he had watched the television show ER “religiously” and become enthralled by emergency medicine. “You’re a jack-of-all-trades,” he says. “It’s exciting because you see and treat every single thing.”
In blue scrubs rather than the white coat some colleagues preferred, the 6-foot-4-inch specialist was revved up despite having worked an early shift the day before. The emergency room was quiet as the Kadesches drew near.
Bobbi and Charles had driven about 25 miles to get their son and had brought him to their house before realizing he needed to get to a hospital. Wipers on maximum, Bobbi Kadesch had negotiated I-270 with her son in back, alternately alert and slumped over. “Mom, you’re a good ambulance driver,” he said once. Now Charles parked the car while Bobbi guided her son through the emergency room entrance.
Thirty-seven years old, she told the triage nurse. Chest pain. Never sick except two long-ago sinus surgeries.
The nurse noted the time—1:10 a.m.—and the patient’s appearance: sweaty; conscious but woozy. By the time his father hurried in, Kadesch was getting an EKG just steps from the entrance. The test indicated decreased cardiac output. Still, his blood pressure was 137 over 74, pulse 65.
The triage staff wanted him to lie down to have blood drawn and a saline IV hooked up in case it was needed later, but growing pain made Kadesch insist on standing. Hurry up, he thought.
Nurses noted his agitation. “Hey, this guy doesn’t look right,” one of them said, handing Leonard the chart outside the exam area. “Central chest pain...can’t find a comfortable position...no shortness of breath,” it read.
Kadesch was leaning on a gurney—I’m not going to make it, he thought—as Leonard entered the curtained-off area and began to examine him. While methodically asking questions, the doctor noted a weaker pulse in Kadesch’s left arm than in his right. Leonard’s eyebrows shot up. I can’t believe this, he thought. Again?
The doctor ordered a spiral CT scan even before getting results from a chest X-ray taken by a portable machine. The IV in Kadesch’s arm now held Dilaudid and esmolol to relieve pain, control his blood pressure and keep his heart from racing. A high-resolution CT scan of soft tissue and organs would show exactly what was wrong and where, Leonard explained. He calmly outlined the possibilities: It could be inflammation of the heart or, more dangerous, a pulmonary embolism or aortic dissection. Kadesch became calm himself as the drugs took effect.
As Kadesch was being prepped for the scan, Leonard assured his parents: “He’s in the best place.” Out of their hearing, he turned to a nurse: “This is crazy. I bet this guy has an aortic dissection. That would be the second one in a week for me.”
“You’ve got to be kidding,” she said.
Leonard sat beside the CT tech, watching the black-and-white screen intently. The body’s largest artery leaves the top of the heart, arches north like a candy cane, then comes down the back to feed the major organs. But this aorta, which should have looked like a garden hose where it exited the heart, looked instead like the double barrel of a shotgun. The aorta was split from the heart valve up through the arch and down along Kadesch’s spinal cord. With every beat, blood flowed between layers of the artery wall.
At the control desk, the secretary turned at Leonard’s approach. “I need Keith Horvath now,” he said.
Dr. Keith Horvath, 52, chief of cardiothoracic surgery at the National Institutes of Health Heart Center at Suburban, was asleep six miles away in Washington, D.C. Heading back to the hospital is not automatic for a surgeon on call; he or she has to trust the ER physician’s diagnosis and make a decision. “But I’d rather come in to confirm or deny it—and know we did the right thing—than stay home and wonder,” Horvath says.
Leonard and Horvath both had been soccer players, and in Leonard’s 10 months at Suburban the two had developed a rapport. Just days before, it was Leonard who had sent Horvath an acute aortic dissection. Over several weeks, a tear had developed in one layer of a Bethesda woman’s aorta. Eventually, surging blood had ripped open the second layer and threatened a full rupture, which would have caused catastrophic internal bleeding. Leonard’s diagnosis, followed by Horvath’s immediate five-hour surgery, had saved her life.
Having done between 100 and 200 of these operations over the course of 16 years, Horvath knew that aortic dissections are often misdiagnosed as everything from heart attack to heartburn, and most commonly found in autopsies. The mortality rate with surgery is 20 to 30 percent. Without surgery, it’s close to 100 percent.
As Horvath drove in, the three Kadesches were getting an update from Leonard. An aortic dissection means leakage of blood, he said. Leakage means the blood isn’t getting where it needs to go. Though an aortal tear beyond the arch or in the abdomen can be managed with medicine and lifestyle changes, a tear in the first several inches outside the heart requires surgery.
The condition is rare enough that a physician can go a lifetime without seeing a case, Leonard said. Causes include hypertension, diabetes and connective-tissue diseases, and the peak ages are 50 to 65. Kadesch didn’t fit the profile, but his symptoms were classic for men. Women, on the other hand, tend to suffer fatigue, shortness of breath and nausea. In both cases, signs can mimic a heart attack or stroke. There may be no obvious symptoms until it’s too late.
Remember the actor John Ritter? Leonard asked. Five years earlier he’d had the same condition: sudden chest and back pain and a split in the lead artery. Ritter died, Bobbi Kadesch knew, but “it was a good thing to say, like a reference point. It helped us put a finger on what this was.”