Sometimes a pain in the foot is much more than a pain in one’s foot. This statement has never been truer than it was for Brian McNeill.
The afternoon of July 21, 2018, Brian, 37, had helped wife Kelsey lay down a blanket and set up folding chairs on the lawn below the band shell at Riverside Park in their hometown of Salida. Their daughters Kinnie and Ellie, ages 8 and 4, played in the grass and snacked with their parents as the Salida Arts & Music Festival rolled on. McNeill’s right foot started to throb.
Having hiked, mountain biked, and snowboarded for much of his life, Brian knew foot pain well enough. This was different. A trip to the local hospital led to a helicopter flight to a Colorado Springs hospital and the erasure, with clot-busting tissue plasminogen activator (tPA), of a blood clot in his popliteal artery.
This had been an alarming turn of events, but an isolated one, the McNeills hoped. Even had it not been, they could hardly have imagined that Brian would survive the next few months only if he beat long odds more than once, and then only if first responders; neurologists; radiologists; electrophysiologists; ER doctors; vascular, infectious-disease, intensive-care medicine, and rehabilitation specialists; scores of nurses and hospital staff; and, foremost, a surgery team led by UCHealth cardiac surgeon Dr. Muhammad Aftab , an assistant professor of cardiothoracic surgery at the University of Colorado School of Medicine, got just about everything right.
Seven weeks later, on Sept. 10, a second clot, this time in the brachial artery of Brian’s right arm, led him to UCHealth University of Colorado Hospital at the Anschutz Medical Campus, where he was admitted as an inpatient. Two clots in less than two months – plus fatigue, chills and some cognitive problems – hinted at a deeper issue, one that might have had to do with the only health problem McNeill had ever had. He had been born with an abnormal (bicuspid, with two flaps rather than the usual three) aortic valve, through which the heart’s powerful left ventricle supplies the body with oxygen-rich blood. In early 2016, he had had successful surgery to implant a prosthetic aortic valve replacement.
Removing the arm-artery clot, this time with a surgical procedure, was straightforward. Harder was answering the question of where these clots were coming from. The UCHealth team zeroed in on the prosthetic aortic valve. Echocardiograms and CT scans showed that it had become infected, and that the infection – endocarditis – had blossomed into “vegetations,” a considerable euphemism for a microbial mass feasting on his vasculature and threatening his heart, his mind, and his body with clot-causing cast-offs. Those cast-offs had not only lodged clots in his arm and leg, but also in his brain, and they were to blame for the cognitive problems Brian had experienced. These had been a series of mini-strokes, the team recognized.
The infection had to be cleared out and the aortic valve replaced, which brought Aftab into the care team. He explained to the McNeills that his big worry was that a chunk of vegetation could lodge in the coronary artery that branched off right next to the bacterial mass and trigger a major heart attack. He was immediately scheduled for surgery while waiting for more brain imaging and results.
A tough choice
The next night, at about 10 p.m. on Sept. 15, Brian experienced “pain like an elephant sitting in my chest. It was the most incredible pain I’d had in my life,” as he described it later. Aftab’s worry had come to pass. Kelsey, who had been sleeping on the pullout, summoned nurses. Within minutes, several physicians – cardiologists, neurologists and others – crowded the room. They settled upon two options. One was to use a catheter to enter the coronary artery and remove the clot. The other was to use clot-busting tPA to dissolve it.
Both carried big risks. The catheter would have to snake past the aortic valve and could knock loose chunks of vegetation, possibly causing a massive stroke. The clot-busting tPA could, because of multiple mini-strokes Brian had sustained, lead to serious bleeding in his brain. The McNeills decided the tPA would be the lesser evil.
The team administered the tPA, doing neurology checks every 15 minutes. “And at one point – they were having Brian read these three letter words – all of a sudden he couldn’t read them,” Kelsey recalled. The care team stopped the infusion, rushed Brian to a CT scanner, and found bleeding in a couple of places in his brain. Fortunately, the tPA had already done its job in dissolving the coronary-artery clot. But the aortic-valve surgery would now have to wait until the bleeding in Brian’s brain stopped.
He spent the two weeks recovering and receiving antibiotics in the UCH Neurological ICU. The morning of Monday, Oct. 1, Aftab started an aortic-replacement surgery that often takes perhaps six hours. This one took more than twice that. The infection had destroyed much of the aortic root – the section of the big artery just above the aortic valve – and damaged the right and left coronary arteries branching off from the aortic root. Aftab faced, as he described it, “one of the more challenging surgeries I’ve done.” Perhaps six in 10 patients with such damage survive, he estimated.
Aftab removed the infected aortic valve and cleaned out the infected, abscessed aortic root, then replaced the valve and sewed the refreshed aortic root back in place with a prosthetic graft. Recognizing that Brian’s left coronary artery had to be bypassed, Aftab and the surgical team harvested a leg vein, did the bypass, and reimplanted both left and right coronary arteries into the cleaned-out, grafted, and sewn-up aortic root. By the end of it all, Brian’s heart had all but stopped.
Home, for now
Aftab had, before the surgery, talked the McNeills through various contingencies. Among the darker possibilities would be Brian’s heart stopping from the combined insults of a serious heart attack a few days earlier and what would end up a 14-hour surgery. Aftab had told them that, should that happen, Brian would be put on ECMO (extracorporeal membrane oxidation), a machine that takes over for the heart and lungs. Aftab massaged Brian’s heart directly as the machine was being hooked up. Another complication – all the sutures from the surgery, combined with the blood thinners needed to do the surgery in the first place – brought bleeding through all those little holes. So, Brian stayed in the ICU, chest temporarily closed, a vacuum pump doing its work, for the better part of two days as his heart strengthened and his breathing improved. Only then did Aftab close him completely.
By that Friday, Brian was off ECMO and doing baby-step rehabilitation in the UCH cardiothoracic ICU – going from bed to chair, doing slow laps around the ICU. As his mind cleared, he asked himself what lessons he might derive from his brush with death. Brian had, as an educator and education administrator at the Buena Vista Correctional Complex, always made an effort to bring a sense of optimism and positivity to an often-dark place – he thought of it as “carrying the light.” He told Kelsey that carrying the light would be his mission henceforth.
About two weeks later, Brian had come along to the point that he could leave the hospital. It had been more than a month since he had arrived with a blood clot in his arm. The entire time, Kelsey was, as she put it, “pretty much living in the hospital, and the girls were living across the street with my parents, Brian’s parents or with my aunt.” The family spent another two weeks in a Denver rental, just in case, before finally going home to Salida again on Nov. 2.
Most health care stories would wrap up right about here. And indeed, given the successful surgery, the young, strong patient, and the supportive family, Brian’s tale might well have hewed to that rubric, too. It would not be so simple.
On Nov. 10, the family was home in Salida. It was a Saturday afternoon. Kelsey and Brian had gone grocery shopping earlier. Brian and his dad now shared the couch as they watched the Washington State football team bully the CU Buffs. Then Brian slumped over, eyes open but unconscious, his breathing a series of gasps. Something was seriously wrong.
Kelsey started CPR; Brian’s parents continued it. The ambulance crew arrived, continued CPR with an automated CPR machine and launched into what would, all told, amount to 18 defibrillation attempts. They transported him to the hospital in Salida. There, 45 minutes after Kelsey had started pressing on Brian’s chest to sustain a trickle of blood flow to his vital organs, Brian’s heart started beating again.
Aftab had been involved from afar. Brain’s dad had called the UCHealth DocLine; the on-call surgeon reached Aftab at home. Aftab called Kelsey, who explained what was happening. Aftab said that, once Brian was stabilized in the hospital in Salida, they should airlift him to UCH. Prior to the flight Brian doesn’t remember, Aftab spoke with the ER physician, offering guidance as far as tests and labs, electrolytes and potassium levels, medication to support the heart function – all to ensure that Brian didn’t go into cardiac arrest again on the flight to UCH. Once he arrived at the UCH cardiothoracic ICU, his body was cooled to decrease metabolism and limit additional damage to a brain that, nearly starved on the meager rations of CPR, could well have been damaged already.
At UCH, Aftab asked the ICU team to keep Brian off sedatives so they could evaluate his neurological function.
“I told the family that we’ve got to be cautiously optimistic because I didn’t know what the outcome would be,” Aftab said. “With 45 minutes of CPR, probably 80 percent of patients die of irreversible brain injury.”
Carry the light
Brian finally awoke 48 hours later. He recognized Aftab and his family. His brain had survived the famine. What had caused his heart to stop? Aftab and colleagues think scarring from the heart attack prior to his surgery had led to an electrical problem, ventricular fibrillation, and ultimately cardiac arrest. On Nov. 20, UCHealth electrophysiologist Dr. Matthew Zipse, assistant professor of cardiology at the University of Colorado School of Medicine, placed an implantable defibrillator (ICD) to keep the terrifying cascade from happening again.
Five days later, Brian walked out of the hospital. There were still problems that would prove temporary – kidneys hobbled by low blood flow during CPR, lungs and legs with excess fluid. But he was alive. The McNeills stayed in Denver until Dec 28, just to be safe. When they got home, a surprise awaited Brian: Kelsey had ordered a wooden sign. The words “carry the light,” were etched in white cursive above the GPS coordinates of their home.
Kelsey, a child and family therapist, had been diagnosing children with post-traumatic stress for years. It now applies to her. She’s working through it, she says – no longer terrified of Brian’s heart stopping at a given moment, she now just worries quietly about it. In early February, she was back at work for the first time since September (a GoFundMe campaign and tremendous help from friends and family have helped keep them afloat). Daughter Kinnie, who missed six weeks of school during her father’s 53 days of hospitalization, caught up fast. Ellie, when she sees an ambulance, now says, “I hope that person is OK.” The emotional recovery will take time.
Ellie’s and Kinnie’s dad, is, against the odds, OK, and getting stronger every day. He is, as Aftab put it “crushing cardiac rehab,” which Brian does three times a week. He aims to return to work soon, and carry the light with him.
“I think that’s the whole idea for me moving forward,” Brian said. “I was in a pretty dark place and able to come out of it, to all the people and things I care about.” His voice broke; he gathered himself. “I’m fortunate to have so much of that light that I just can’t imagine not sharing it.”