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President Clinton Recovers from Successful Surgery
Aired March 10, 2005 - 14:30 ET
THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
KYRA PHILLIPS, CNN ANCHOR: "Now in the News," Michael Jackson's accuser back on the stand after an hour and a half delay. The pop star arrived late for today's session of his child molestation trial, complaining of a back problem. The judge threatened to revoke his bond and send him to jail.
Authorities are investigating whether a suicide is linked to the killing of a Chicago federal judge's husband and mother. Police sources tell CNN a man who shot himself to death in a traffic stop outside Milwaukee last night left a note confessing to those slayings.
Former President Clinton's office says that he's resting comfortably after surgery. Live pictures right now as we wait to hear from the doctors.
We want to take you quick, though, to Santa Maria, California. Just barely missed him there. Michael Jackson leaving the courthouse, going back and forth between attorneys and the shot inside the courtroom. We just want to let you know he is leaving the courtroom now on a quick break. This is the unusual break during trial. We'll, of course, continue to follow the trial as it resumes. Jackson, once again, on a break, as well as the jurors.
Now a horrific carnage scene today from a suicide bombing at a funeral in Mosul, Iraq. Hospital officials say at least 26 people are dead, 27 wounded. The U.S. military says more than 100 may be hurt now. The bomber blew himself up as a Shia Muslim procession for a university professor who had died.
MILES O'BRIEN, CNN ANCHOR: As we told you a few moments ago, Former President Clinton is recovering from follow-up surgery from last year's heart bypass. that was in September. More now about what kind of operation Clinton needed and why.
Dr. Randy Martin joining us from Atlanta's Emory University Hospital, he teaches cardiology. Dr. Martin, good to have you back with us.
DR. RANDY MARTIN, EMORY UNIVERSITY HOSPITAL: Good to be with you, Miles.
O'BRIEN: All right, let's -- just out of curiosity, over the course of your career, how frequently have you done this surgery?
MARTIN: Well, I'm a cardiologist, I'm not a thoracic surgeon, so unfortunately, I've never done this on a patient. But this is not a -- this is -- what you really want to know is that is after open heart surgery, after bypass surgery like the president had, it's very common to have a collection of fluid in the space between the lungs and the ribs called pleural effusion early on, but to this kind of complication, where you have scar tissue that compresses or collapses, that is very unusual. Less than one percent of the time it occurs.
O'BRIEN: All right and the fact that it is that unusual, does that, in any way, make you think that his prognosis might not be as good as it would be for other patients?
MARTIN: No, absolutely not. I mean, I think that if he had had a recurrent inflammation or even infection in there, it would have made the surgery today a little bit more difficult, a little bit more tedious to pull off all that scar tissue. But I would anticipate that he is in otherwise good health and that he should have a good recovery. It will be -- he will have a fair amount -- that's doctor speak for pain -- after this, because this is an area where there are a lot of nerve endings and it certainly could be pretty sensitive.
O'BRIEN: And does it ever occur more than once? Does a patient have to undergo one of these another time?
MARTIN: Not this particular type of stripping procedure, called decortication, Miles. But if he had a collection of fluid there, a lot of patients after open heart surgery or bypass will have a collection of fluid and some of them have that fluid literally drained with a fine needle, something that I understand the president did not have. So what they would do would be most likely remove the fluid and then remove the scar tissue. And then they may have done something called pleurodesis, which is actually putting talc in the space between the reexpanded lung and ribs to actually make a fine scar so the fluid doesn't reaccumulate so they wouldn't have to go back in.
O'BRIEN: Interesting. Walk us through, if you would -- and this is a little bit of supposition here, so we should warn our viewers about that. Of course, we don't know the precise way. But on a typical surgery like this, what would happen to a patient on this day?
MARTIN: Yes, it's quite interesting for the audience. What -- the president would have arrived in the pre-op holding area, they would have called it. They would have started a large I.V. in his vein and may have put a line in one of the arteries in his arm called an arterial line to measure his blood pressure.
And then they would have taken him into the operating room. And they may have then, with him still awake, done an epidural. I'm sure that many of the viewers know people who have had epidurals. That's putting a line fine catheter around the nerves in his spine to actually give him post-operative pain relief. So they would have done that when he was awake so he could tell them if it was effective or not.
Then they would have draped him and, obviously, prepared his skin, washing him with anesthesia and then put his left side, which is the side they're going to operate on, up. And then they would begin the procedure. And as I understand it, they were going to try to do it with a video assisted device, what's called a thorascopical (ph) aid to do it, a little endoscope to look in, drain the fluid. And then if they could -- and they do that through one small incision -- then if they could, they'd make another couple of incisions and put in instruments to begin the peeling.
If he had a lot of scarring or if he had a lot of fluid there, then they would have probably converted that to an open incision, a thoracotomy that would be called, not thorascopically (ph). And that's a little bit more of a procedure. This -- if he has a lot of scarring, this takes -- is very tedious to peel that scar off the deflated lung.
One of the interesting things they would have done -- if you or I needed to have a breathing machine helping us during surgery, the breathing machine would be inflating both lungs. In the president, they put in what's called a double lumin (ph) type breathing machine -- tube -- so that they can inflate his right lung, the one that's not collapsed, and keep the left lung collapsed while they operated on it on the outside.
So they would remove that tissue. Hopefully, they would reinflate the president's lung, maybe do that thing called the pleurodesis to scar it down, and then leave him with chest tube to make sure that his lung stays reinflated.
O'BRIEN: It sounds as if he's going to be in, as you said, discomfort is that euphemism. Given the way you talk about, you know, literally scraping off scar tissue. By the way, we should just note to our viewers, we're about two minutes away from the news conference. You see the live picture there from Columbia University Medical Center in New York.
The whole procedure there sounds like it's going to leave him extremely sore. How long will it take -- of course, you mention sort of degrees of this surgery. We don't know how far they had to go. But typically, sort of the baseline surgery, how long before he is going to be back, you know, swinging golf clubs and going to the tsunami regions?
MARTIN: Yes, Miles, I think that either way they did it, after six weeks, most of the pain will be gone. Most of the discomfort. I think it would be a good six to eight weeks before he could really swing a golf club because that does move a lot of the ribs and rib muscles. If they did an open incision or thorascopically (ph), it may take -- and he may have a little bit more discomfort post-operatively than if they did it with the video assisted or the endoscopic approach.
But, you know, if anybody's ever had a broken rib, and they did not break his rib, you know that the muscles and all that is pretty tender. So this is an operation that is not life-threatening. It is a relatively common operation. But it can have a fair amount of discomfort post-operatively.
O'BRIEN: And I think it's worth pointing out -- Dr. Sanjay Gupta a little while ago pointed this out, probably a little bit of a misunderstanding about this. This really wasn't heart surgery today, was it?
MARTIN: No. Absolutely not. And I think that's very important point. They did not go back in through his breast bone, through a -- what's called a median sternotomy. This was well outside of his heart, in the area between his rib space and his collapsed lung. So this is called thoracic surgery, very different in both the risk to the patient and very different in the recovery. A lot of people -- I've not had open heart surgery, but I actually know zillions of patients and had many patients, and actually, people get over that fairly quickly. This is going between the ribs and can actually be a little bit more painful to get over.
O'BRIEN: Oh really? That's interesting. More painful than actually, you know, splitting the sternum and open heart surgery?
MARTIN: Again, there may be many of your viewers that might have had both and they would disagree with me, but having dealt with lots of patients, if they had to do an open incision and actually separate the space between his ribs, that can be a little bit more painful than patients have told me than even having an open heart surgery. Because you actually get over that pretty quickly. But in any eventuality, the president obviously will, I would envision, go to the ICU after this. If we had the president in our hospital, we certainly would take him to the ICU.
O'BRIEN: All right. Dr. Randy Martin, who's at Emory University Hospital. Let's switch now to Columbia University Medical Center. This is the surgical team as they get all their place cards in the right place there. I don't know the order that everybody's sitting. But on that team is Dr. Joshua Sonett, Dr. Allan Schwartz, Dr. Herbert Pardes and Dr. Craig Smith, who is...
(BEGIN LIVE EVENT)
DR. HERBERT PARDES, CEO, NEW YORK-PRESBYTERIAN HOSPITAL: Good afternoon, my name is Dr. Herbert Pardes, president of New York Presbyterian Hospital. I am very pleased to let you know that former President Clinton underwent successful surgery this morning. Senator Clinton and Chelsea arrived with him. They are with him now. He is awake, he is resting comfortably. I would like to now introduce -- I think we -- that's good. Let's do it.
I would like to now introduce the members of the medical and surgical team. Dr. Alan Schwartz to my left, chief of cardiology, Dr. Desmond Jordan to my immediate left, President Clinton's anesthesiologist. To my right, Dr. Joshua Sonett, President Clinton's operating surgeon. To his right, Dr. Craig Smith, chief of cardiothoracic surgery. And to his right, Dr. Bob Kelly, senior vice president and chief operating officer of this institution.
We're now open for questions.
QUESTION: What did President Clinton say to you prior to his surgery and did he say anything in recovery?
DR. JOSHUA SONETT, OPERATING SURGEON: This morning he was ready and optimistic to look forward to getting to a full recovery, and already post-operatively he is feeling well and looking forward to getting on with things.
QUESTION: How long did the surgery take?
SONETT: The surgery started at 7:00 a.m. and lasted almost four hours.
QUESTION: Is that unusual? You had originally said it was going to be between one to three hours, I believe.
SONETT: It was as expected. The dissection was meticulous, and we really don't worry about the time it takes to perform an operation as long as we try to perform it to the best extent.
QUESTION: Can you tell me if the risk factors -- what are the risk factor profiles, and did President Clinton meet this profile?
DR. CRAIG SMITH, CLINTON'S PHYSICIAN: I'm not sure which risk profile...
QUESTION: The risk factors for his condition. I understand that this is extremely rare. Did he have any sort of characteristics that fit some sort of risk profile for this?
SMITH: Well, I guess by the nature of its rarity, in a sense, we don't know what the risk profile factors are, but he fit the syndrome to a T. He had a trapped lung encased in inflammatory scar tissue, and he does fall into that fraction of a percent who end up in this situation. But I'm not sure I could say there are risk factors that would allow us to isolate who will develop this from someone who won't.
QUESTION: How long do you expect him to stay?
PARDES: How long do you expect him to stay? Dr. Sonett, do you want to comment?
SONETT: We're still -- as expected, going to say three- to 10- day recovery time, and we'll see how he does.
QUESTION: Did you find what you expected to find in surgery, or were there any surprises?
SONETT: No, we found -- as expected. We began the case, myself and Dr. Steinglass, my surgical partner, performed the case, and we started with a thoracoscopy. The thoracoscopy showed that there was significant inflammatory peel entrapping, the lung that would prevent us from proceeding with the case using the videoscopic technique. So we performed a limited thorachotomy so they could fully and effectively release the lung.
QUESTION: Could you describe what that is actually like in layman's terms?
SONETT: Sure. You want me to show the graphic? All right. So here is normal lung, on the left side. And here's lung -- this is as President Clinton's lung looked like. There was a large fluid collection, compressing the left lower lobe, basically taking up half that space, so the left lower lobe was not working, 25 percent of his entire lung. And you see this thickened white area. That's a peel or rind around the lung so that if the fluid is removed, the lung would not expand on its own. I'll show you the next graphic.
So, in the beginning of the case, what we did is enter the chest cavity with a small videoscope, look in, remove the fluid. At that time we saw it was clear there was a large, thick rind, a rind that was thick enough that would take significant dissection, open dissection, to remove it, safely. Something that could not be handled with a videoscope. So, a limited thorachotomy was created. As you remove the peel, like peeling an orange, basically, the lung will expand and refill the chest cavity. We were quite delighted by the end of the case, President Clinton's lung was very healthy, pink- appearing and looked excellent, and we expect full functional recovery of that lung.
QUESTION: Was this found on a routine chest x-ray or was this found because he was having symptoms? Did he come to you or was this just a routine follow-up?
DR. ALLAN SCHWARTZ, CHIEF OF CARDIOLOGY, NEW YORK-PRESBYTERIAN HOSP.: This was a routine follow-up because of the planned trip. He was brought back for stress testing. And at that time, history and physical revealed that he had some new complaints -- in terms that I outlined last time -- had some discomfort in the left chest and, also, a subtle exercise in his -- a subtle limitation in his exercise when he was doing steep hills on his daily four-mile walks and, also, his physical examination showed some decrease in the breath sounds that was not present on the last examination. Because of those things, he had a chest x-ray. Once the chest x-ray was done, it was apparent there was a worsening of the chest x-ray, and then a C-T scan was done, which delineated the problem. He was on aspirin as part of his post by-pass therapy, and now he's on prophylactic subcutaneous heprin, and also we've resumed his aspirin.
PARDES: Other questions?
QUESTION: Oh, I'm sorry. Was he opened up through a chest cavity or was he operated on through -- microscopically?
SONETT: Again, we began the operation with a videoscope, and it became apparent that the case was too complex to perform through a videoscope, so there was a limited opening of his chest cavity.
QUESTION: What does that mean now that he has been opened up twice in the last six months? Is that going to affect his overall -- is that going to slow down his overall recovery?
SONETT: Well, the place where we operated was a completely different place where Dr. Smith performed the open heart surgery, so it was a different section, and the two recoveries are quite independent. PARDES: Back there. Go there.
QUESTION: Is he at high risk for this happening again or something similar happening in the right lung?
SONETT: No. He's at low risk for recurrence, and we have no expectation of any other changes in either lung.
PARDES: Second row, that gentleman.
QUESTION: Who was present in the operating theater during the surgery, and where were -- exactly where was Senator Clinton and Chelsea during the surgery?
SONETT: Senator Clinton and Chelsea were upstairs during the case, awaiting information about the operation. At the operating room table was myself and Dr. Ken Steinglass, my surgical partner, and there was a resident, helping, and anesthesiology and nursing techs, operative room techs for the videoscopic equipment. A really, a whole host of people that made every point critical.
SMITH: There's a group of people for a procedure such as this.
QUESTION: How long is the recovery going to take, and is this going to limit any activity on his part?
SONETT: Everybody's recovery time is variable. However, a normal -- normally we quote people four to six weeks of recovery or four to six weeks before they go back to work, if it does not require significant manual labor. So, that's the kind of recovery we expect. It could be faster, could be slower, depending on how he progresses. And a full functional recovery with not only no limitations but improved function is expected.
PARDES: Let's get that guy there.
QUESTION: Do we -- in millimeters, how thick was this layer, and what's the consistency of it that was on his lung?
SONETT: In millimeters, on pre-operative C-T scan it was measured 2 to 4 millimeters. Intra-operatively there were sections that were closer to 5 to 8 millimeters and a thick, almost rubbery, plaque-like -- hard rubber -- peel. Really quite remarkable.
PARDES: Let's get that gentleman there.
QUESTION: Typically, at academic institutions, residents do part of the operation. Was this done the same way? Was the President treated differently given he is a former president?
SONETT: There was a resident helping out on this case. There was two surgical attendants helping each other out on this case, given it was President Clinton. But no different.
QUESTION: Isn't there some risk of permanent scarring following a decortication? SONETT: We removed the visceral and parietal peel around the chest wall and the lung, so recrudescence of that scarring shouldn't happen, cause that lining has been removed.
PARDES: Let's get that lady back there.
QUESTION: Mr. Clinton himself has made a big point out of saying this was nothing serious. When you hear 25 percent of lung capacity lost, some people might think that's a bit serious. Can you just explain the level of severity here in terms of his condition leading up to the surgery?
SONETT: I consider any problem with any patient serious to that patient, and I can't comment on how they speak to it themselves. So, we take any problem seriously. We considered it a serious problem and took care of it in that way. I'm not sure if that answers it.
QUESTION: Was it life-threatening or non-life-threatening? I mean, was this something that if it wasn't taken care of quickly, it could have gotten much more severe?
SONETT: Non-life-threatening, absolutely non-life-threatening. He -- he was walking four miles a day and, clearly, playing golf just yesterday with it. So, this was a procedure to maximize his lung function and get it back to where he should be, but it was an elective procedure in that respect, that he was getting along fine out it. But he could be better.
QUESTION: Could any of you tell us where Senator Clinton and Chelsea are now, and how they're doing and what they've said to you?
SMITH: They are with the president right now and they are very pleased.
PARDES: Go back here again.
QUESTION: A couple more questions about the operation. Does he have a chest tube in? What was blood loss, and did have any changes in blood pressure or anything unusual at all during the operation?
SONETT: He was stable throughout the operation. He had minimal blood loss requiring no transfusions of significance. And he does have a chest tube. When it's ready to come out, anywhere from two to five days.
PARDES: Take that one there.
QUESTION: Can you help us understand the mechanics a little more? For the open heart surgery, I presume you went through the sternum. Today did you go through ribs, did you under the rib? How did you get into the area?
SONETT: Initially the videoscope is inserted between the ribs without spreading the ribs. And we can look in. We remove the fluid and then we can look inside the chest. It became quickly apparent that more was going to be needed. So then we find the best place to enter between another set of ribs and we go between ribs and gently spread the ribs so that -- does that sort of answer it? They kind of lever apart. Patients usually have rib pain and that will be his major functional limitation initially. But that should resolve rather rapidly. Larry?
QUESTION: Was the fluid bloody or (UNINTELLIGIBLE)? And if it was bloody...
SONETT: Can you get the microphone closer to his mouth.
QUESTION: Was the fluid that was compressing the lung, was that bloody fluid?
SONETT: There was evidence of old blood, yes.
QUESTION: Old blood?
SONETT: Yes.
QUESTION: Could this have been related to the fact that he was on Plavix before he had his bypass surgery?
SMITH: You know, it would be interesting to speculate. But I don't think we know enough about the relative contributions of blood or non-bloody fluid to the development of this particular problem enough to know whether it's worth speculating. He certainly was at higher risk for oozing and collecting blood in his heart surgery because of the Plavix.
But you could argue that we know he had a collection of some sort under the right and a collection under the left lung. And the one under the right lung was completely cleaned up. And we have no basis for believing it was any different in composition from the one in the left lung.
So what seems to be different is the way the body reacted to the collection on the left and whether it started as excessive oozing because of Plavix, I guess we'll never know.
PARDES: We'll take three last questions, here, here, here.
QUESTION: Could you just go into a little more detail on why a minimally invasive technique you deemed too complex?
SONETT: The inflammatory peel around the lung was so thick and so well-organized that it took an open, meticulous dissection of gently peeling off the lung and other mediastymal (ph) structures to free it up. Having performed many decortications (ph), and having known many other thoracic surgeons have performed many decortications, I can assure you that this could not have been performed safely and effectively through a videoscope.
PARDES: Let's take this lady and then that gentleman, and we're done.
QUESTION: I just wondered if he had any last-minute instructions for you, jokes for you, anything like that before you put him under?
DR. ROBERT KELLY, CFO, NEW YORK PRESBYTERIAN HOSPITAL: I actually walked him into the operating room. And as we were walking into the operating room, he was in very good spirits and was actually talking about his golf game, was a little upset it was raining in Florida yesterday and was anxious to get back out and golfing again.
PARDES: Last question.
QUESTION: What form of pain medication was the president taking before and now after the surgery? And, secondly, could you say generally in the short term what the president will be prevented from doing as a result of the surgery?
SCHWARTZ: So before the surgery, there was no pain medicine. When I use the word "discomfort" I meant discomfort. He had a sensation that he noticed in his left chest. He was not having pain. It was more something that shouldn't be there and was one of the alarms that lead to the diagnostic test. But he was not on pain medicine before the operation.
DR. DESMOND JORDAN, ANESTHESIOLOGIST: During the operation we placed a thoracic epidural, which should give a nice band of pain relief across the area of the incision which actually occurred at the end of the case. He was awake and alert and pain free.
PARDES: I might add that we expect Mr. Clinton to be walking tomorrow. In lieu of flowers or gifts, the Clintons have requested that anyone wishing to do so can donate to the American Heart Association at americanheart.org. People may offer their good wishes online at clintonfoundation.org. Thank you very much. We do not expect to have any further updates. Thank you.
O'BRIEN: President Clinton's medical team there at Columbia University Medical Center offering a briefing, listening along with you, was Dr. Randy Martin of Emory University here in Atlanta.
And Dr. Martin, good to have you back with us. What struck me was the thoracic surgeon saying it was a 5- to 8-millimeter thick, rubbery, plaque-like substance, referring to the scar tissue. As he put it, quite remarkable. How do we interpret that?
MARTIN: Well, it's -- Miles, first thing is, you know, he has an excellent surgical team. And when they come in and sit down smiling, you know that there's been good results.
I'm not surprised by the thickness of this. He probably had recurrent bouts of inflammation. And he may be one of those individuals that actually forms very dense scar tissue. So this was a very thick layer of scar tissue on top of the lung. And that's why they did the open incision, the thorachotomy, and actually had to take time to peel that off. So this is just a sign that he probably had recurrent bouts of inflammation that caused a lot of scarring.
O'BRIEN: Yes. As you had pointed out, just before we came in, there was some hope that you could do it completely microscopically with a camera. As they pointed out, they couldn't do that. As a matter of fact, they have to lever apart the ribs which to me sounds about the most painful thing about this, long run; anybody who has had injury to their ribs.
MARTIN: Well, you know, I don't mean to overplay, it is to be expected that he's going to have some discomfort. And you noticed that the anesthesiologist did say that they did the epidural. And that's to aid with pain relief during the procedure even while he's asleep because the body can still sense pain, and then post- operatively.
So yes, when you spread apart the ribs, even though you do it gently, it is very uncomfortable, it is painful. And I think that will probably be the president's main limitation, although he's such a positive person, that he will probably minimize that. And they are going to have him up walking as fast as possible to prevent any blood clots forming in his legs. So it is a -- as I surmised, a fairly painful post-operative recovery.
O'BRIEN: Dr. Randy Martin with Emory University Hospital, thanks for your time and insights -- Kyra.
PHILLIPS: All right. Straight ahead, yes, it was quite a crazy day at the Michael Jackson trial. What else do you expect? You saw it here live on CNN, Michael Jackson arriving more than an hour late for court. Not in his usual clothes. His usual pajamas? The latest at the top of the hour.
And the Chicago Police Department is going to hold a news conference in just a few minutes, it's about that traffic stop that could be connected to the murders of Judge Lefkow's family. We're going to have a live update for you in a minute. Let's take a look at the Big Board, the Dow is up 49 points. We'll take a quick break, we'll be right back.
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Aired March 10, 2005 - 14:30 ET
THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
KYRA PHILLIPS, CNN ANCHOR: "Now in the News," Michael Jackson's accuser back on the stand after an hour and a half delay. The pop star arrived late for today's session of his child molestation trial, complaining of a back problem. The judge threatened to revoke his bond and send him to jail.
Authorities are investigating whether a suicide is linked to the killing of a Chicago federal judge's husband and mother. Police sources tell CNN a man who shot himself to death in a traffic stop outside Milwaukee last night left a note confessing to those slayings.
Former President Clinton's office says that he's resting comfortably after surgery. Live pictures right now as we wait to hear from the doctors.
We want to take you quick, though, to Santa Maria, California. Just barely missed him there. Michael Jackson leaving the courthouse, going back and forth between attorneys and the shot inside the courtroom. We just want to let you know he is leaving the courtroom now on a quick break. This is the unusual break during trial. We'll, of course, continue to follow the trial as it resumes. Jackson, once again, on a break, as well as the jurors.
Now a horrific carnage scene today from a suicide bombing at a funeral in Mosul, Iraq. Hospital officials say at least 26 people are dead, 27 wounded. The U.S. military says more than 100 may be hurt now. The bomber blew himself up as a Shia Muslim procession for a university professor who had died.
MILES O'BRIEN, CNN ANCHOR: As we told you a few moments ago, Former President Clinton is recovering from follow-up surgery from last year's heart bypass. that was in September. More now about what kind of operation Clinton needed and why.
Dr. Randy Martin joining us from Atlanta's Emory University Hospital, he teaches cardiology. Dr. Martin, good to have you back with us.
DR. RANDY MARTIN, EMORY UNIVERSITY HOSPITAL: Good to be with you, Miles.
O'BRIEN: All right, let's -- just out of curiosity, over the course of your career, how frequently have you done this surgery?
MARTIN: Well, I'm a cardiologist, I'm not a thoracic surgeon, so unfortunately, I've never done this on a patient. But this is not a -- this is -- what you really want to know is that is after open heart surgery, after bypass surgery like the president had, it's very common to have a collection of fluid in the space between the lungs and the ribs called pleural effusion early on, but to this kind of complication, where you have scar tissue that compresses or collapses, that is very unusual. Less than one percent of the time it occurs.
O'BRIEN: All right and the fact that it is that unusual, does that, in any way, make you think that his prognosis might not be as good as it would be for other patients?
MARTIN: No, absolutely not. I mean, I think that if he had had a recurrent inflammation or even infection in there, it would have made the surgery today a little bit more difficult, a little bit more tedious to pull off all that scar tissue. But I would anticipate that he is in otherwise good health and that he should have a good recovery. It will be -- he will have a fair amount -- that's doctor speak for pain -- after this, because this is an area where there are a lot of nerve endings and it certainly could be pretty sensitive.
O'BRIEN: And does it ever occur more than once? Does a patient have to undergo one of these another time?
MARTIN: Not this particular type of stripping procedure, called decortication, Miles. But if he had a collection of fluid there, a lot of patients after open heart surgery or bypass will have a collection of fluid and some of them have that fluid literally drained with a fine needle, something that I understand the president did not have. So what they would do would be most likely remove the fluid and then remove the scar tissue. And then they may have done something called pleurodesis, which is actually putting talc in the space between the reexpanded lung and ribs to actually make a fine scar so the fluid doesn't reaccumulate so they wouldn't have to go back in.
O'BRIEN: Interesting. Walk us through, if you would -- and this is a little bit of supposition here, so we should warn our viewers about that. Of course, we don't know the precise way. But on a typical surgery like this, what would happen to a patient on this day?
MARTIN: Yes, it's quite interesting for the audience. What -- the president would have arrived in the pre-op holding area, they would have called it. They would have started a large I.V. in his vein and may have put a line in one of the arteries in his arm called an arterial line to measure his blood pressure.
And then they would have taken him into the operating room. And they may have then, with him still awake, done an epidural. I'm sure that many of the viewers know people who have had epidurals. That's putting a line fine catheter around the nerves in his spine to actually give him post-operative pain relief. So they would have done that when he was awake so he could tell them if it was effective or not.
Then they would have draped him and, obviously, prepared his skin, washing him with anesthesia and then put his left side, which is the side they're going to operate on, up. And then they would begin the procedure. And as I understand it, they were going to try to do it with a video assisted device, what's called a thorascopical (ph) aid to do it, a little endoscope to look in, drain the fluid. And then if they could -- and they do that through one small incision -- then if they could, they'd make another couple of incisions and put in instruments to begin the peeling.
If he had a lot of scarring or if he had a lot of fluid there, then they would have probably converted that to an open incision, a thoracotomy that would be called, not thorascopically (ph). And that's a little bit more of a procedure. This -- if he has a lot of scarring, this takes -- is very tedious to peel that scar off the deflated lung.
One of the interesting things they would have done -- if you or I needed to have a breathing machine helping us during surgery, the breathing machine would be inflating both lungs. In the president, they put in what's called a double lumin (ph) type breathing machine -- tube -- so that they can inflate his right lung, the one that's not collapsed, and keep the left lung collapsed while they operated on it on the outside.
So they would remove that tissue. Hopefully, they would reinflate the president's lung, maybe do that thing called the pleurodesis to scar it down, and then leave him with chest tube to make sure that his lung stays reinflated.
O'BRIEN: It sounds as if he's going to be in, as you said, discomfort is that euphemism. Given the way you talk about, you know, literally scraping off scar tissue. By the way, we should just note to our viewers, we're about two minutes away from the news conference. You see the live picture there from Columbia University Medical Center in New York.
The whole procedure there sounds like it's going to leave him extremely sore. How long will it take -- of course, you mention sort of degrees of this surgery. We don't know how far they had to go. But typically, sort of the baseline surgery, how long before he is going to be back, you know, swinging golf clubs and going to the tsunami regions?
MARTIN: Yes, Miles, I think that either way they did it, after six weeks, most of the pain will be gone. Most of the discomfort. I think it would be a good six to eight weeks before he could really swing a golf club because that does move a lot of the ribs and rib muscles. If they did an open incision or thorascopically (ph), it may take -- and he may have a little bit more discomfort post-operatively than if they did it with the video assisted or the endoscopic approach.
But, you know, if anybody's ever had a broken rib, and they did not break his rib, you know that the muscles and all that is pretty tender. So this is an operation that is not life-threatening. It is a relatively common operation. But it can have a fair amount of discomfort post-operatively.
O'BRIEN: And I think it's worth pointing out -- Dr. Sanjay Gupta a little while ago pointed this out, probably a little bit of a misunderstanding about this. This really wasn't heart surgery today, was it?
MARTIN: No. Absolutely not. And I think that's very important point. They did not go back in through his breast bone, through a -- what's called a median sternotomy. This was well outside of his heart, in the area between his rib space and his collapsed lung. So this is called thoracic surgery, very different in both the risk to the patient and very different in the recovery. A lot of people -- I've not had open heart surgery, but I actually know zillions of patients and had many patients, and actually, people get over that fairly quickly. This is going between the ribs and can actually be a little bit more painful to get over.
O'BRIEN: Oh really? That's interesting. More painful than actually, you know, splitting the sternum and open heart surgery?
MARTIN: Again, there may be many of your viewers that might have had both and they would disagree with me, but having dealt with lots of patients, if they had to do an open incision and actually separate the space between his ribs, that can be a little bit more painful than patients have told me than even having an open heart surgery. Because you actually get over that pretty quickly. But in any eventuality, the president obviously will, I would envision, go to the ICU after this. If we had the president in our hospital, we certainly would take him to the ICU.
O'BRIEN: All right. Dr. Randy Martin, who's at Emory University Hospital. Let's switch now to Columbia University Medical Center. This is the surgical team as they get all their place cards in the right place there. I don't know the order that everybody's sitting. But on that team is Dr. Joshua Sonett, Dr. Allan Schwartz, Dr. Herbert Pardes and Dr. Craig Smith, who is...
(BEGIN LIVE EVENT)
DR. HERBERT PARDES, CEO, NEW YORK-PRESBYTERIAN HOSPITAL: Good afternoon, my name is Dr. Herbert Pardes, president of New York Presbyterian Hospital. I am very pleased to let you know that former President Clinton underwent successful surgery this morning. Senator Clinton and Chelsea arrived with him. They are with him now. He is awake, he is resting comfortably. I would like to now introduce -- I think we -- that's good. Let's do it.
I would like to now introduce the members of the medical and surgical team. Dr. Alan Schwartz to my left, chief of cardiology, Dr. Desmond Jordan to my immediate left, President Clinton's anesthesiologist. To my right, Dr. Joshua Sonett, President Clinton's operating surgeon. To his right, Dr. Craig Smith, chief of cardiothoracic surgery. And to his right, Dr. Bob Kelly, senior vice president and chief operating officer of this institution.
We're now open for questions.
QUESTION: What did President Clinton say to you prior to his surgery and did he say anything in recovery?
DR. JOSHUA SONETT, OPERATING SURGEON: This morning he was ready and optimistic to look forward to getting to a full recovery, and already post-operatively he is feeling well and looking forward to getting on with things.
QUESTION: How long did the surgery take?
SONETT: The surgery started at 7:00 a.m. and lasted almost four hours.
QUESTION: Is that unusual? You had originally said it was going to be between one to three hours, I believe.
SONETT: It was as expected. The dissection was meticulous, and we really don't worry about the time it takes to perform an operation as long as we try to perform it to the best extent.
QUESTION: Can you tell me if the risk factors -- what are the risk factor profiles, and did President Clinton meet this profile?
DR. CRAIG SMITH, CLINTON'S PHYSICIAN: I'm not sure which risk profile...
QUESTION: The risk factors for his condition. I understand that this is extremely rare. Did he have any sort of characteristics that fit some sort of risk profile for this?
SMITH: Well, I guess by the nature of its rarity, in a sense, we don't know what the risk profile factors are, but he fit the syndrome to a T. He had a trapped lung encased in inflammatory scar tissue, and he does fall into that fraction of a percent who end up in this situation. But I'm not sure I could say there are risk factors that would allow us to isolate who will develop this from someone who won't.
QUESTION: How long do you expect him to stay?
PARDES: How long do you expect him to stay? Dr. Sonett, do you want to comment?
SONETT: We're still -- as expected, going to say three- to 10- day recovery time, and we'll see how he does.
QUESTION: Did you find what you expected to find in surgery, or were there any surprises?
SONETT: No, we found -- as expected. We began the case, myself and Dr. Steinglass, my surgical partner, performed the case, and we started with a thoracoscopy. The thoracoscopy showed that there was significant inflammatory peel entrapping, the lung that would prevent us from proceeding with the case using the videoscopic technique. So we performed a limited thorachotomy so they could fully and effectively release the lung.
QUESTION: Could you describe what that is actually like in layman's terms?
SONETT: Sure. You want me to show the graphic? All right. So here is normal lung, on the left side. And here's lung -- this is as President Clinton's lung looked like. There was a large fluid collection, compressing the left lower lobe, basically taking up half that space, so the left lower lobe was not working, 25 percent of his entire lung. And you see this thickened white area. That's a peel or rind around the lung so that if the fluid is removed, the lung would not expand on its own. I'll show you the next graphic.
So, in the beginning of the case, what we did is enter the chest cavity with a small videoscope, look in, remove the fluid. At that time we saw it was clear there was a large, thick rind, a rind that was thick enough that would take significant dissection, open dissection, to remove it, safely. Something that could not be handled with a videoscope. So, a limited thorachotomy was created. As you remove the peel, like peeling an orange, basically, the lung will expand and refill the chest cavity. We were quite delighted by the end of the case, President Clinton's lung was very healthy, pink- appearing and looked excellent, and we expect full functional recovery of that lung.
QUESTION: Was this found on a routine chest x-ray or was this found because he was having symptoms? Did he come to you or was this just a routine follow-up?
DR. ALLAN SCHWARTZ, CHIEF OF CARDIOLOGY, NEW YORK-PRESBYTERIAN HOSP.: This was a routine follow-up because of the planned trip. He was brought back for stress testing. And at that time, history and physical revealed that he had some new complaints -- in terms that I outlined last time -- had some discomfort in the left chest and, also, a subtle exercise in his -- a subtle limitation in his exercise when he was doing steep hills on his daily four-mile walks and, also, his physical examination showed some decrease in the breath sounds that was not present on the last examination. Because of those things, he had a chest x-ray. Once the chest x-ray was done, it was apparent there was a worsening of the chest x-ray, and then a C-T scan was done, which delineated the problem. He was on aspirin as part of his post by-pass therapy, and now he's on prophylactic subcutaneous heprin, and also we've resumed his aspirin.
PARDES: Other questions?
QUESTION: Oh, I'm sorry. Was he opened up through a chest cavity or was he operated on through -- microscopically?
SONETT: Again, we began the operation with a videoscope, and it became apparent that the case was too complex to perform through a videoscope, so there was a limited opening of his chest cavity.
QUESTION: What does that mean now that he has been opened up twice in the last six months? Is that going to affect his overall -- is that going to slow down his overall recovery?
SONETT: Well, the place where we operated was a completely different place where Dr. Smith performed the open heart surgery, so it was a different section, and the two recoveries are quite independent. PARDES: Back there. Go there.
QUESTION: Is he at high risk for this happening again or something similar happening in the right lung?
SONETT: No. He's at low risk for recurrence, and we have no expectation of any other changes in either lung.
PARDES: Second row, that gentleman.
QUESTION: Who was present in the operating theater during the surgery, and where were -- exactly where was Senator Clinton and Chelsea during the surgery?
SONETT: Senator Clinton and Chelsea were upstairs during the case, awaiting information about the operation. At the operating room table was myself and Dr. Ken Steinglass, my surgical partner, and there was a resident, helping, and anesthesiology and nursing techs, operative room techs for the videoscopic equipment. A really, a whole host of people that made every point critical.
SMITH: There's a group of people for a procedure such as this.
QUESTION: How long is the recovery going to take, and is this going to limit any activity on his part?
SONETT: Everybody's recovery time is variable. However, a normal -- normally we quote people four to six weeks of recovery or four to six weeks before they go back to work, if it does not require significant manual labor. So, that's the kind of recovery we expect. It could be faster, could be slower, depending on how he progresses. And a full functional recovery with not only no limitations but improved function is expected.
PARDES: Let's get that guy there.
QUESTION: Do we -- in millimeters, how thick was this layer, and what's the consistency of it that was on his lung?
SONETT: In millimeters, on pre-operative C-T scan it was measured 2 to 4 millimeters. Intra-operatively there were sections that were closer to 5 to 8 millimeters and a thick, almost rubbery, plaque-like -- hard rubber -- peel. Really quite remarkable.
PARDES: Let's get that gentleman there.
QUESTION: Typically, at academic institutions, residents do part of the operation. Was this done the same way? Was the President treated differently given he is a former president?
SONETT: There was a resident helping out on this case. There was two surgical attendants helping each other out on this case, given it was President Clinton. But no different.
QUESTION: Isn't there some risk of permanent scarring following a decortication? SONETT: We removed the visceral and parietal peel around the chest wall and the lung, so recrudescence of that scarring shouldn't happen, cause that lining has been removed.
PARDES: Let's get that lady back there.
QUESTION: Mr. Clinton himself has made a big point out of saying this was nothing serious. When you hear 25 percent of lung capacity lost, some people might think that's a bit serious. Can you just explain the level of severity here in terms of his condition leading up to the surgery?
SONETT: I consider any problem with any patient serious to that patient, and I can't comment on how they speak to it themselves. So, we take any problem seriously. We considered it a serious problem and took care of it in that way. I'm not sure if that answers it.
QUESTION: Was it life-threatening or non-life-threatening? I mean, was this something that if it wasn't taken care of quickly, it could have gotten much more severe?
SONETT: Non-life-threatening, absolutely non-life-threatening. He -- he was walking four miles a day and, clearly, playing golf just yesterday with it. So, this was a procedure to maximize his lung function and get it back to where he should be, but it was an elective procedure in that respect, that he was getting along fine out it. But he could be better.
QUESTION: Could any of you tell us where Senator Clinton and Chelsea are now, and how they're doing and what they've said to you?
SMITH: They are with the president right now and they are very pleased.
PARDES: Go back here again.
QUESTION: A couple more questions about the operation. Does he have a chest tube in? What was blood loss, and did have any changes in blood pressure or anything unusual at all during the operation?
SONETT: He was stable throughout the operation. He had minimal blood loss requiring no transfusions of significance. And he does have a chest tube. When it's ready to come out, anywhere from two to five days.
PARDES: Take that one there.
QUESTION: Can you help us understand the mechanics a little more? For the open heart surgery, I presume you went through the sternum. Today did you go through ribs, did you under the rib? How did you get into the area?
SONETT: Initially the videoscope is inserted between the ribs without spreading the ribs. And we can look in. We remove the fluid and then we can look inside the chest. It became quickly apparent that more was going to be needed. So then we find the best place to enter between another set of ribs and we go between ribs and gently spread the ribs so that -- does that sort of answer it? They kind of lever apart. Patients usually have rib pain and that will be his major functional limitation initially. But that should resolve rather rapidly. Larry?
QUESTION: Was the fluid bloody or (UNINTELLIGIBLE)? And if it was bloody...
SONETT: Can you get the microphone closer to his mouth.
QUESTION: Was the fluid that was compressing the lung, was that bloody fluid?
SONETT: There was evidence of old blood, yes.
QUESTION: Old blood?
SONETT: Yes.
QUESTION: Could this have been related to the fact that he was on Plavix before he had his bypass surgery?
SMITH: You know, it would be interesting to speculate. But I don't think we know enough about the relative contributions of blood or non-bloody fluid to the development of this particular problem enough to know whether it's worth speculating. He certainly was at higher risk for oozing and collecting blood in his heart surgery because of the Plavix.
But you could argue that we know he had a collection of some sort under the right and a collection under the left lung. And the one under the right lung was completely cleaned up. And we have no basis for believing it was any different in composition from the one in the left lung.
So what seems to be different is the way the body reacted to the collection on the left and whether it started as excessive oozing because of Plavix, I guess we'll never know.
PARDES: We'll take three last questions, here, here, here.
QUESTION: Could you just go into a little more detail on why a minimally invasive technique you deemed too complex?
SONETT: The inflammatory peel around the lung was so thick and so well-organized that it took an open, meticulous dissection of gently peeling off the lung and other mediastymal (ph) structures to free it up. Having performed many decortications (ph), and having known many other thoracic surgeons have performed many decortications, I can assure you that this could not have been performed safely and effectively through a videoscope.
PARDES: Let's take this lady and then that gentleman, and we're done.
QUESTION: I just wondered if he had any last-minute instructions for you, jokes for you, anything like that before you put him under?
DR. ROBERT KELLY, CFO, NEW YORK PRESBYTERIAN HOSPITAL: I actually walked him into the operating room. And as we were walking into the operating room, he was in very good spirits and was actually talking about his golf game, was a little upset it was raining in Florida yesterday and was anxious to get back out and golfing again.
PARDES: Last question.
QUESTION: What form of pain medication was the president taking before and now after the surgery? And, secondly, could you say generally in the short term what the president will be prevented from doing as a result of the surgery?
SCHWARTZ: So before the surgery, there was no pain medicine. When I use the word "discomfort" I meant discomfort. He had a sensation that he noticed in his left chest. He was not having pain. It was more something that shouldn't be there and was one of the alarms that lead to the diagnostic test. But he was not on pain medicine before the operation.
DR. DESMOND JORDAN, ANESTHESIOLOGIST: During the operation we placed a thoracic epidural, which should give a nice band of pain relief across the area of the incision which actually occurred at the end of the case. He was awake and alert and pain free.
PARDES: I might add that we expect Mr. Clinton to be walking tomorrow. In lieu of flowers or gifts, the Clintons have requested that anyone wishing to do so can donate to the American Heart Association at americanheart.org. People may offer their good wishes online at clintonfoundation.org. Thank you very much. We do not expect to have any further updates. Thank you.
O'BRIEN: President Clinton's medical team there at Columbia University Medical Center offering a briefing, listening along with you, was Dr. Randy Martin of Emory University here in Atlanta.
And Dr. Martin, good to have you back with us. What struck me was the thoracic surgeon saying it was a 5- to 8-millimeter thick, rubbery, plaque-like substance, referring to the scar tissue. As he put it, quite remarkable. How do we interpret that?
MARTIN: Well, it's -- Miles, first thing is, you know, he has an excellent surgical team. And when they come in and sit down smiling, you know that there's been good results.
I'm not surprised by the thickness of this. He probably had recurrent bouts of inflammation. And he may be one of those individuals that actually forms very dense scar tissue. So this was a very thick layer of scar tissue on top of the lung. And that's why they did the open incision, the thorachotomy, and actually had to take time to peel that off. So this is just a sign that he probably had recurrent bouts of inflammation that caused a lot of scarring.
O'BRIEN: Yes. As you had pointed out, just before we came in, there was some hope that you could do it completely microscopically with a camera. As they pointed out, they couldn't do that. As a matter of fact, they have to lever apart the ribs which to me sounds about the most painful thing about this, long run; anybody who has had injury to their ribs.
MARTIN: Well, you know, I don't mean to overplay, it is to be expected that he's going to have some discomfort. And you noticed that the anesthesiologist did say that they did the epidural. And that's to aid with pain relief during the procedure even while he's asleep because the body can still sense pain, and then post- operatively.
So yes, when you spread apart the ribs, even though you do it gently, it is very uncomfortable, it is painful. And I think that will probably be the president's main limitation, although he's such a positive person, that he will probably minimize that. And they are going to have him up walking as fast as possible to prevent any blood clots forming in his legs. So it is a -- as I surmised, a fairly painful post-operative recovery.
O'BRIEN: Dr. Randy Martin with Emory University Hospital, thanks for your time and insights -- Kyra.
PHILLIPS: All right. Straight ahead, yes, it was quite a crazy day at the Michael Jackson trial. What else do you expect? You saw it here live on CNN, Michael Jackson arriving more than an hour late for court. Not in his usual clothes. His usual pajamas? The latest at the top of the hour.
And the Chicago Police Department is going to hold a news conference in just a few minutes, it's about that traffic stop that could be connected to the murders of Judge Lefkow's family. We're going to have a live update for you in a minute. Let's take a look at the Big Board, the Dow is up 49 points. We'll take a quick break, we'll be right back.
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