Aortic Dissection Quotes

He ran long at the White House, and arrived late to his next meeting with Hillary Clinton, Jake Sullivan and Frank Ruggiero—their first major strategy session on Taliban talks after the secret meeting with A-Rod. She was waiting in her outer office, a spacious room paneled in white and gilt wood, with tasseled blue and pink curtains and an array of colorfully upholstered chairs and couches. In my time reporting to her later, I only ever saw Clinton take the couch, with guests of honor in the large chair kitty-corner to her. She’d left it open for him that day. “He came rushing in. . . . ” Clinton later said. “And, you know, he was saying ‘oh I’m so sorry, I’m so sorry.’ ” He sat down heavily and shrugged off his coat, rattling off a litany of his latest meetings, including his stop-in at the White House. “That was typical Richard. It was, like, ‘I’m doing a million things and I’m trying to keep all the balls in the air,’ ” she remembered. As he was talking, a “scarlet red” flush went up his face, according to Clinton. He pressed his hands over his eyes, his chest heaving. “Richard, what’s the matter?” Clinton asked. “Something horrible is happening,” he said. A few minutes later, Holbrooke was in an ambulance, strapped to a gurney, headed to nearby George Washington University Hospital, where Clinton had told her own internist to prepare the emergency room. In his typically brash style, he’d demanded that the ambulance take him to the more distant Sibley Memorial Hospital. Clinton overruled him. One of our deputies on the SRAP team, Dan Feldman, rode with him and held his hand. Feldman didn’t have his BlackBerry, so he scrawled notes on a State Department expense form for a dinner at Meiwah Restaurant as Holbrooke dictated messages and a doctor assessed him. The notes are a nonlinear stream of Holbrooke’s indomitable personality, slashed through with medical realities. “Call Eric in Axelrod’s office,” the first read. Nearby: “aortic dissection—type A . . . operation risk @ > 50 percent”—that would be chance of death. A series of messages for people in his life, again interrupted by his deteriorating condition: “S”—Secretary Clinton—“why always together for medical crises?” (The year before, he’d been with Clinton when she fell to the concrete floor of the State Department garage, fracturing her elbow.) “Kids—how much love them + stepkids” . . . “best staff ever” . . . “don’t let him die here” . . . “vascular surgery” . . . “no flow, no feeling legs” . . . “clot” . . . and then, again: “don’t let him die here want to die at home w/ his fam.” The seriousness of the situation fully dawning on him, Holbrooke turned to job succession: “Tell Frank”—Ruggiero—“he’s acting.” And finally: “I love so many people . . . I have a lot left to do . . . my career in public service is over.” Holbrooke cracked wise until they put him under for surgery. “Get me anything you need,” he demanded. “A pig’s heart. Dan’s heart.

Aortic dissection results from an intimal tear in the aortic wall. The primary morbidity and mortality results from extension of the tear. This extension is promoted by factors that increase the rate of change of aortic pressure (dp/dt), including elevation in BP, heart rate, and myocardial stroke volume. Blood pressure should be reduced promptly to near-normal levels. Aggressive control of BP with a vasodilator can trigger reflex tachycardia, leading to increased dp/dt.