That autumn day in Nashville, Tennessee, had been breezy and sunny. Now
at midnight, a full moon stood tall in the sky, casting its golden beams
earthward and creating reflections of the skyline in the swirling waters of
the Cumberland River as it patiently carved its way through the downtown
area. Even at this late hour, the din of heavy traffic echoed along the shores
of the Cumberland.
The relative tranquility was shattered by the sound of gunfire. Bursting
from the shadows two hundred feet from the shores of the river, a solitary
figure ran from a four-door burgundy Cadillac sedan. Outstretched arms
brandishing handguns protruded through the car’s open windows. The young
man barely escaped death as he jumped down the stairway leading to the river.
With a fierce effort, he landed aboard a river taxi just leaving its dock. Two
men emerged from the Cadillac and chased the young man. Their bullets had
failed to hit their mark.
Five months earlier, a mid-May morning starts out much as it always had for
Butch Kennedy. The air is unusually cool and damp when he arises, chilling
him as he pushes aside the warm bedcovers. While he showers, his wife, Elinor,
prepares breakfast; later, she sits beside him during his meal. Before leaving for
work, Butch reaches for a lightweight jacket and a thermos of freshly brewed
coffee. At the back door, he kisses Elinor, still dressed in her bathrobe and
floppy slippers, and tells her he loves her. On the way to his well-worn pickup
truck sitting in the driveway, he notices that the darkness is just beginning to
fade as the sun’s first light appears on the horizon. Butch’s warm breath fogs
the air as his gloved hand reaches for the steering wheel of his truck.
On the way to work, Butch travels along a series of winding country roads
that, up until recently, have gone mostly unpaved. Passing one sprawling farm
after another, Butch waves to some of his early rising neighbors, many of whom
are already out on their tractors or tending to their cattle. The morning air
coming in through the truck’s ventilation system is ripe with the fresh scent
of pollen, mixed with the pungent aroma of cow manure. Small flocks of birds
dot the fields on either side of the roadway.
As Butch approaches his workplace, the Nissan plant in Smyrna, Tennessee,
he thinks ahead to the schedule and hopes it will be an uneventful day. Slightly
behind on their monthly production quota, the laborers have been grumbling
to him about having to work longer hours for the past several weeks.
After finding a parking spot in the employee lot, Butch wastes little time
getting inside. He reaches his locker and quickly changes into the familiar
attire of blue coveralls and an orange baseball cap. Before leaving the locker
room, he pulls a clipboard from the wall with the day’s work assignments and,
over his first cup of coffee, sits down to briefly review the list. Satisfied that
everything seems to be in order, he stands and hurries to organize his team.
Butch then walks toward the large manufacturing portion of the facility.
The cavernous interior is initially dark, with some early daylight streaming
in through the windows on the south side of the building. Upon entering, he
reaches up to throw the main breaker on the inside wall; the room becomes
brightly illuminated by long rows of humming fluorescent lights. The air
within the facility, heavy-laden with the scent of machine oil, paint fumes,
and metal dust, instantly permeates Butch’s sinuses.
Several of the men and women who assemble the passenger cars and light
trucks are already gathering their tools and getting situated. Butch briefly
inspects each station before allowing any work to commence. For the past
fifteen years, Butch has served as the line foreman for the Japanese company’s
large facility in Smyrna. To those he supervises, he is known as tough but fair.
They greatly respect him. Because of his dedication to the job, he has won
more productivity awards than any other Nissan employee.
Noel C. Scidmore, M.D.
After another thirty minutes or so, all the workers have arrived and
taken their positions on the floor. Once Butch determines that everything
is in place, he visually scans the floor one final time. With a nod, he reaches
upward to pull a long cord hanging from the ceiling. A horn blares, and the
steel automobile shells begin their slow, linear march forward. Teams of two
or three men and women perform a single task at each stopping point. They
work ceaselessly; the only hint of their fatigue is the perspiration that falls
uninterrupted from their foreheads. From all across the building, mechanical
wrenches sound out a type of crude melody as bolts are snuggly fit into
place. Loud hammering and high-pitched metal sanders add to the clamor.
As Butch strides back and forth to check on his laborers, showers of sparks
are sent high into the air beside him, with huge robotic arms swinging into
place to weld the steel frames.
Suddenly, Butch catches a glimpse of something that greatly concerns
him. As he sprints across the concrete floor, his cap blows off, but that doesn’t
slow his progress. Just in time, he reaches one of the newer employees, who
was in the process of installing a steering column. The young man had gotten
his pant leg caught in one of the machines and was about to fall backward
before Butch caught him. Acting quickly, Butch releases the man’s foot, which
a moment later would have been crushed. Remarkably, the assembly line has
to be halted for only a moment. With Butch’s assistance, other workers guide
the long metal tube into place. Shaken but grateful, the man peers over at his
boss. Butch pats him warmly on the back and gives him a couple of suggestions.
He then retrieves his cap and continues his surveillance.
As the morning wears on, Butch begins to feel slightly nauseated, and
soon an ache develops in the left side of his chest. For the past two weeks, this
pain had been nagging at him. It seemed to strike him at nearly the same time
each day, which confused him. Believing he had an ulcer, Butch had been
gobbling up antacids. He had even made an appointment with the company
doctor for later in the week. Today, however, the pain is much more severe
than it has been before, and it is accompanied by some lightheadedness. He
waves at the plant supervisor, who is standing in one corner of the building.
The man immediately walks over to Butch.
“Harvey, I’m not feelin’ so good. Could you take over my shift for a few
minutes so I can see the nurse?”
“Sure, Butch. You go and get seen. You don’t look so good. What’s the
“I think I’ve got an ulcer, and it’s just killin’ me today. I’m feelin’ a little
“You hurry on, Butch; I can take over for the rest of the day if I need to.”
“Thanks, Harvey; you’re one great guy.”
Butch turns and walks toward Employee Health. After only a few steps, the
ache in his chest dramatically escalates to an excruciating pain that squeezes
the breath out of him. Without uttering a sound, he falls to the floor, gasping
for air. He grimaces as he feels his face strike the cold concrete floor. Lying
on his side, he rocks back and forth, hoping to find relief from the crushing
tightness in his chest. He mumbles loudly to himself as he struggles to
comprehend what is happening to him, “Oh God, I can’t breathe. Let me get
some air before I suffocate. Please, please, Lord, stop the pain! Why does my
head hurt so bad? Am I dying? Dear God, am I dying?”
While Butch writhes around on the floor, he can barely hear the alarms
ringing or the cries of his coworkers as they rush to his side. Harvey is the
first to reach him. Butch can feel Harvey’s hands on his side as he rolls him
over onto his back. Then, feeling another set of hands support his head, Butch
strains to look up to see who it is. The fuzzy image of braided red hair comes
into focus. He slowly recognizes the face of one of his longtime friends and
coworkers, Linda, who is sitting beside him. Next, he feels his coveralls being
pulled down to his waist and his T-shirt being raised to his neck. He hears
Harvey yell at the workers, “Come on, everyone, stand back and give Butch
some room to breathe!”
Butch’s brain is swimming at this point, and everything seems to be happening
in slow motion. Butch’s thoughts drift to his family.
Where’s Elinor? I want to see my wife! Where is she? Someone please call her!
What about David and Suzie? I want to see my children!
By now, Butch can barely hear anything. He futilely struggles to listen to
the conversation of several men who stand over him. Without warning, their
discussion ends and his pain worsens as one of the men begins to vigorously
Noel C. Scidmore, M.D.
compress his chest to get his heart back in rhythm. The compressions are
initially uncomfortable, but then Butch’s chest pain begins to wane and his
breathing becomes easier. It seems dark inside the plant. He wonders why
he can only make out the shadowy outlines of the people who stand nearby.
At about that time, the circle formed by the crowd of factory workers
around him opens. So profound is Butch’s weakness that he doesn’t hear the
wailing siren or see the flashing red lights when the ambulance arrives. He
does, however, notice two large male paramedics when they kneel beside him.
Unbeknownst to Butch, the men work at a furious pace. There is, at first
a pinch in one of his arms as they insert an intravenous line, and then comes
the feeling of something cool running into his vein. Next, beneath his nostrils
they place plastic tubing containing oxygen, relieving his struggle for air. He
barely notices when the paramedics lean over him to strap electrodes across
his chest that they will use to check his heart’s rhythm. Then, after prying his
eyelids open, they shine a bright light into his eyes.
Butch’s next sensation is of being hoisted up onto a gurney and then
being wheeled briskly across the plant floor. For the first time, he opens his
eyes to look around. In close proximity are the anguished faces of his friends
and coworkers. They are quickly left behind as he is rushed to the waiting
ambulance. As soon as the back doors are securely fastened, the driver quickly
accelerates. Butch now looks up at the men who are working furiously to save
his life. John, the younger of the two paramedics, continues to check Butch
over carefully, while his older and bearded partner, Charlie, calls into the
Deaconess Hospital in Nashville by two-way radio.
“Let me speak to Dr. Sterling.”
A moment passes. “Yes, Charlie. I’m here. Whatcha got?”
“Late-forties black male. Collapsed while at work. Severe chest pain.
Looks like an mi. Initial pressure 220/118. Pulse 110. Mental status: intact
but lethargic. Rhythm regular. st-segment elevation in anterior leads. We’ve
given two milligrams of morphine iv and three inches of Nitropaste with
good reaction in both systolic and diastolic bps. We’re running five liters O2
through binasal cannula. I’m sending the rhythm strip to you right now by fax.”
“You got any tpa on board?”
Dr. Sterling pauses as he reviews the ekg tracing that is now coming off
the fax machine. After his analysis, he returns to speaking to the paramedics.
“Charlie, you’re right, looks like an anterior mi. Give a fifteen-milligram
dose of tpa over two minutes’ iv, and then start a drip at two milligrams
per minute. We’ll aim for a total dose of one hundred milligrams.”
“Got it. Our eta is about ten minutes. I’ll see you then, unless something
John then instills an initial dose of the lifesaving tissue plasminogen activator
through the line in Butch’s vein, hoping to break up the clot that has formed
in the arteries of his heart. As the loud siren wails and the countryside races
by in a blur, Butch stares out the back window of the ambulance, wondering
what will happen to him. The morphine and nitroglycerin go to work in his
body, and his pain begins to subside. He turns his head to watch the clear
bag of fluid that drips slowly into the vein of his left arm. In his sleepy state,
the trip passes quickly. Closing his eyes, Butch prays silently to himself: Dear
God, let me live. You’ve gotta let me have more time with my family. I’ve gotta
see my children grow up. Please, Lord, don’t let me die.
Moments later, the automatic doors of Nashville’s Deaconess Hospital’s
emergency room fly open as two young paramedics propel Butch swiftly inside.
The loud commotion of the er startles Butch. Off to his left, a young girl
screams, while from all over the room, doctors and nurses yell to one another.
Meanwhile, multiple patients stream in the doors beside him. Along one
hallway, a long line of people sit with their families, waiting to be seen by a
doctor. On a stretcher just in front of Butch a young man is groaning loudly.
He wears a rigid neck collar, his body strapped to a long wooden board. Over
his face and chest are several large bruises and lacerations, and on his torn
trousers are multiple dark bloodstains. Beside the man are two firemen, who
describe how they had to cut the young man out of his crushed automobile.
Stopping only momentarily, the paramedics wheel Butch directly into
patient room number one. Paramedic Charlie hollers loudly, “Kennedy in one!”
Dr. James Sterling, tall and thin, with black hair, runs into the room
with two nurses alongside him as they transfer Butch to a hospital bed.
Sterling wastes no time in shouting out orders. “O2, six liters a minute—
oxygen sat monitor—twelve-lead ekg—cardiac isoenzymes—Troponin
Noel C. Scidmore, M.D.
I—electrolytes—magnesium—fibrin splits—fibrinogen—and pt, ptt, and
cbc—stat! Get Dr. Peters down here!”
The team works rapidly. While the ekg technician places more leads
across the chest, Butch is taken off the portable monitors and transferred to
stationary wall-mounted devices. Dr. Sterling compares the ekg tracing to
the rhythm strip obtained at the Nissan plant. He, too, notes the presence of
an anterior heart attack, but he is delighted to see there has been dramatic
improvement with the clot-busting therapy. As the two paramedics get ready
to depart, Dr. Sterling lifts his head briefly. “Nice work, Charlie, John. You
did a great job with Mr. Kennedy.”
The men wish their patient the best of luck as their dispatcher sends them
on their next task. Knowing the paramedics have saved his life, Butch struggles
to get out the phrase thank you before they are gone. By now, Butch’s mind is
clearer and he is beginning to hope that he might live.
After quickly assessing Butch’s status, Dr. Sterling performs a cursory
physical exam that includes a neurologic check, listening to his lungs and
heart with his stethoscope, and an abdominal exam. He notes Butch’s slightly
overweight physique and then begins Butch’s patient interview.
“Mr. Kennedy, I’m Dr. Sterling. I will be taking care of you here in the
emergency department. Can you tell me how long you’ve been having chest
Butch stares up at Dr. Sterling before he answers, noting the look of
concern in the doctor’s eyes. “A couple of weeks.”
“What about this episode?”
“It came on about twenty minutes before I got dizzy and fell down.”
“Did it radiate into your jaw or shoulder, or cause numbness in your left
“This time it hurt my left shoulder.”
“Do you have any history of high blood pressure, prior heart attacks, or
“Do you have a history of high cholesterol or triglycerides?”
“Not that I know about.”
“Anyone in the family with heart disease?”
“My father died of a heart attack when he was sixty-two.”
At that moment, the cardiologist, Dr. Leonard Peters, walks in. He and
Dr. Sterling initially move to a corner of the room to discuss the case.
“Thanks for coming down, Leonard.”
“What’s the story, Jim?”
“Forty-eight-year-old black male with a history of chest pain for two
weeks. Anterior mi forty minutes ago while at work. Pain into left shoulder.
Paramedics on scene in eight minutes. One hundred milligrams tpa given,
with subsequent improvement in ekg and pain. Lab work pending. O2 sat
on six liters 95 percent. Normal neuro and cardiac exam.”
“Where’s the rhythm strip and ekg?”
Dr. Sterling hands the chart to his associate. After reviewing the data,
Dr. Peters examines Butch thoroughly, holding his stethoscope against Butch’s
chest for a long time. After that, he compliments Dr. Sterling on his management
of the case and asks for Butch to be transferred emergently to the cardiac
lab, where he’ll undergo a cardiac catheterization to document the extent of
atherosclerotic blockages of the arteries of his heart. At the same time, an
angioplasty might be performed, where the blockages will be reduced by an
inflatable balloon to improve blood flow.
Transported briskly by two attendants, Butch arrives in the cardiac suite
a few minutes later. Following a thorough explanation of the procedure, he
is transferred to the cold, hard surgical table. The initial preparation is skin
sterilization of the right groin, followed by injection of a local anesthetic. After
a small skin incision is made, Dr. Peters inserts the long metal and plastic tubeshaped
heart catheter into the main artery of the leg and guides it into position
with the help of a fluoroscopic X-ray machine. Once the catheter position has
been verified by Dr. Peters, contrast dye is released, appearing dark gray on the
black-and-white fluoroscopy screen. Plain X-rays are then taken as the dye runs
the gauntlet of vessels. The study shows that Butch has significant narrowing
of the main artery to the heart, the left anterior descending artery. There is
also significant obstructive plaque formation in one of the other major arteries.
Proceeding swiftly, Dr. Peters is able to successfully perform angioplasty on
both arteries. Without sustaining a single complication, Butch is soon on his
way to one of the coronary care units for close monitoring.
Noel C. Scidmore, M.D.
Having been called by one of the Nissan plant managers shortly after
Butch’s heart attack occurred, Elinor Kennedy arrived at the Deaconess
Hospital only a few minutes behind Butch. There, she sat anxiously in the
cardiac intensive care unit waiting for Butch’s procedure to be over. When
the nurses informed her that Butch was in his room following the angioplasty,
she ran in and threw her arms around her husband, shouting out; “Butch, you
look so good! I’ve been so worried. Are you okay?” Stoically, Butch nods to
the affirmative, as he is still groggy from the anesthesia; “Elinor, I love you! I
think things are goin’ to be all right.” Elinor then takes a seat beside Butch’s
bed and grasps one of his hands between her two.
Because of the extent of Butch’s disease, Dr. Peters feels that consideration
should be given to cardiac bypass grafting. Luckily for Butch, one of the most
eminent cardiothoracic surgeons in the nation practices medicine at Deaconess
Hospital in Nashville. Dr. Edward Westmoreland happens to be on duty today.
Dr. Peters calls him personally to review the case with him. Dr. Westmoreland
arrives late that evening after finishing his scheduled surgeries for the day. Prior
to evaluating his new patient, he spends a great deal of time reviewing Butch’s
angiography films and chart. Somewhat abrupt, but extremely professional,
the silver-haired Edward Westmoreland introduces himself to Butch and his
wife upon entering their room. First, he asks a series of questions and then
performs a thorough examination. His initial assessment is that Butch may
be a candidate for surgery, but he recommends that a few additional tests be
run first. Next, he pulls out a detailed anatomical diagram of the heart from
his pocket and shows Butch and Elinor the sites of Butch’s significant arterial
disease. He explains that the heart attack was severe, adding that fortunately
the clot-busting therapy given to him in the ambulance has made a significant
impact, thereby minimizing the damage to the heart.
Dr. Westmoreland then explains that the first test, an ultrasound of
the heart, will provide a rough measurement of the functional strength and
anatomy of the heart. If all goes well at that step, then bypass surgery could be
considered. Just before Dr. Westmoreland departs, he asks one final question:
“Most insurance companies now require authorization before I’m allowed to
order any tests. If you can tell me who your carrier is, I’ll get my nurse working
on the approval process right away.”
Elinor answers, “We’re insured with AmericaHealth. All the workers at
the Nissan plant have been transferred to that insurance company.”
With a nod of his head, Dr. Westmoreland dashes off to see his next
consult. The clock on the wall of Butch’s room now reads 10:00 p.m.