Ashraf Abou el ela, MD, stood at the foot of the bed in a University Hospital intensive-care room so full of life-preserving technology that the 10 people tasked with monitoring the equipment were wedged in elbow-to-elbow.
Abou el ela, an MU Health Care cardiothoracic surgeon, stared intently at a video screen showing Richard Byrd’s beating heart. Byrd had been hooked up to an extracorporeal membrane oxygenation device — a miniature heart and lung machine known as ECMO — for four days. But for the last 15 minutes, the ECMO was off and his heart was beating on its own.
“We’re winning,” Abou el ela announced.
It didn’t look like Byrd was winning anything, unless it was a contest for the most tubes and monitors attached to a limp human being. But he was still alive. That alone was a victory.
Byrd, 57, was a heavy equipment operator in the Lake of the Ozarks area until he was forced into an early retirement after suffering two brain aneurysms. His passion for construction continued. On Nov. 29, 2017, he was building a garage at his home when a gust of wind blew a wall onto his back.
Byrd was treated for a concussion at Lake Regional Hospital and went home. Two days later, he called his wife, Cheryl, at 11:35 a.m. He dialed 9-1-1 complaining of shortness of breath 21 minutes later. Byrd was taken back to Lake Regional. After a few hours, his condition had deteriorated and it was decided he needed to be flown to University Hospital.
“His last words to me were: ‘I love you. I’m scared,’ ” Cheryl said.
Late that afternoon, Abou el ela was ready to leave the hospital for the weekend when he got an urgent call from the emergency room. Byrd had just arrived via the Staff for Life helicopter.
An air bubble led to a large clot that clogged the main vein from his upper body — the superior vena cava. Byrd was intubated and thrashing wildly. He was blue from the chest up. His heart was beating just 20 to 40 times a minute. Because of the low pH levels in his blood, multiple attempts to electrically pace his heart had failed.
In all likelihood, Byrd would be dead in less than an hour.
Abou el ela was asked if he knew any way to save him. Actually, he did. Abou el ela and an interventional cardiology team would use the ECMO machine that University Hospital had acquired just three months before to buy Byrd time until his heart could function on its own.
The device works as follows: Cannulas are inserted into the patient at two points, often the femoral artery and femoral vein; blood is drained from a vein and pumped through an oxygenator; the oxygen-rich blood is pumped back into the body, usually through an artery.
University Hospital has a state-of-the-art ECMO machine with a magnetic levitation centrifugal pump, which relieves the patient’s blood from the stress of being squeezed around the axis of a standard pump.
“There is a broad spectrum of temporary mechanical support devices — ECMO is the highest end,” Abou el ela said. “It provides much more support for somebody who is very sick. When somebody goes on ECMO, the therapy could be a bridge to recovery, or a bridge to transplantation if they’re eligible for a transplant, or a bridge to a decision.”
Byrd’s bridge to recovery was more like a twisting road. Just when it seemed he was in the clear, another issue arose that required a medical save.
After he was successfully weaned off ECMO for 15 minutes, Byrd was scheduled to be removed from the device the next day. But that evening, a small intubation wound led to massive airway bleeding — a problem exacerbated by the blood thinners needed to prevent clots while he was attached to ECMO.
“Usually it is a fatal complication, especially when someone’s heart is not working well,” Abou el ela said. “He’s getting therapy for the heart function, and now the lungs are also down because of clotting in the airway.”
A team of surgeons and pulmonology critical care experts — including Abou el ela and Ramez Sunna, MD — spent six hours employing a cryotherapy scope that uses liquid nitrogen to freeze the clots so they could remove them. After that, Abou el ela’s only choice to save Byrd was to keep him on ECMO without blood thinners to prevent further airway bleeding.
“This was taking things farther than the edge,” Abou el ela said.
It worked. Within a few days, Byrd stabilized, and Sandeep Gautam, MD, an electrophysiology expert, was able to implant a semi-permanent pacemaker for more dependable pacing.
The team switched Byrd from the veno-arterial version of ECMO to the veno-venous version that would support his lungs while his heart beat on its own. That required repairing Byrd's artery when the cannula was removed — again, without blood thinners — and the resulting clots threatened his leg and led to kidney damage.
As the family waited out another dangerous surgery, Byrd’s son and daughter picked out a country-music themed prosthetic leg that would suit their dad’s taste.
“That’s how we coped,” Cheryl said. “We had to have some laughter to break the tension.”
Byrd didn’t wind up needing the prosthetic leg. After 12 days, he finally came off ECMO for good.
Byrd slowly recovered in the intensive care unit throughout the month of December. He has foggy memories of Abou el ela repeatedly coming into his room — usually accompanied by acute care nurse practitioner Brittany Stone — and asking for a high-five.
“I could barely raise my hand,” Byrd said. “But once I started to hear his voice, before he even came in the room, I was trying raise my arm up for him. I just associated that voice with the high-five. It eventually got to where I could give him a high-five.”
After five weeks at University Hospital, Byrd was sent to Rusk Rehabilitation Hospital, an affiliate of Encompass Health and MU Health Care, where he spent 19 days. His kidneys recovered. He got back on his feet. Although his weight had dipped from 215 pounds to 165, Byrd would rectify that once he was off his mandatory low-potassium diet.
“I asked him, ‘When you leave the hospital, what is the first thing you want to drink?’ ” Abou el ela recalled. “He said, ‘A dark chocolate milkshake.’ I said, ‘The first one is on me.’ ”
On Feb. 28, Byrd returned to University Hospital for a checkup. Abou el ela met him at Essentials restaurant and bought him that milkshake.
Later, Byrd was introduced to a few of the dozens of health-care professionals that helped rescue him from the brink of death. Caring for a patient on ECMO requires a team of nurses, perfusionists and respiratory therapists ready to react to emergencies at any hour. The meeting ended with a meaningful high-five between Byrd and Abou el ela.
"This hospital and Dr. Ashraf and his team," Byrd said, "I owe my life to them."