President Dwight Eisenhower’s 1955 admission to hospital heart attack was as dramatic for Americans as that of President Donald Trump for COVID-19, write Harvard's Dr Thomas Lee in the New England Journal of Medicine.
Lee, at Harvard Medical School, and Press Ganey write: One reason to study history is to avoid repeating past mistakes; another is to understand what went right. For both reasons, it is worth stepping back from the flood of information surrounding the hospitalisation of President Donald Trump for COVID-19 and recalling the events surrounding the heart attack of President Dwight Eisenhower in 1955.
The news of Eisenhower’s heart attack was as dramatic for Americans as the revelation that Trump had COVID-19. “Two events in my lifetime shook me severely,” wrote Dr Leonard Scheele, the US surgeon general at the time. “One was the announcement of the president’s coronary thrombosis, and the other was the announcement of the raid on Pearl Harbour.”
Eisenhower’s myocardial infarction began on Friday, 23 September, 1955, while he was playing golf. At first, he attributed his discomfort to the hamburger he’d had for lunch. He went back to the house and continued to have what he thought was intermittent “indigestion,” then awoke around 2am with severe chest pain. His wife, Mamie, called Eisenhower’s personal physician, who arrived about 3am.
Multiple accounts of Eisenhower’s initial care were later provided, some conflicting, but it seems clear that the physician treated the president with multiple shots of morphine because of the severity of discomfort, while hoping the diagnosis was indigestion. Then Eisenhower fell asleep, and an ECG was performed only after he awoke at 1pm on Saturday afternoon. That ECG revealed an extensive anterior myocardial infarction.
The decision was made to hospitalise Eisenhower. He walked with assistance to his car, which took a circuitous route (to avoid the press) to Fitzsimons Army Medical Centre. Under an oxygen tent, Eisenhower began receiving the few medications available for patients with myocardial infarction at the time: morphine (for pain), papaverine (an antispasmodic used in hope of dilating coronary arteries), atropine (used in hope of preventing arrhythmias), and both heparin and warfarin to reduce blood clots.
Eisenhower’s physician might have been slow to recognise his heart attack, but his staff immediately grasped the need to share information with the country. The first of 11 press briefings that Saturday was held at 2:30 p.m., just as Eisenhower was being transported to the hospital.
The reaction to the news of Eisenhower’s heart attack was panic, and the thirst for more information was intense. In some ways, myocardial infarction was even more frightening to Americans than COVID-19 is today. Heart disease had become the leading cause of death because of cigarette smoking and decreased “competition” from infectious diseases and wars. Mortality among patients with myocardial infarction who reached the hospital was 30 to 40% because there just wasn’t much to offer patients beyond bed rest. The first coronary care unit would not open until 1962. Cardiopulmonary resuscitation and direct-current cardioversion to treat refractory arrhythmias would not be described until 1960.
Despite the multiple press briefings that first day, the initial inclinations of Eisenhower’s physician and staff were to play down the seriousness of the unfolding events and to deflect questions about delays in his initial care. But the press and the public wanted more information, and for good reason – no president had been hospitalised for a major heart attack before.
The next day, Eisenhower’s press secretary, Jim Hagerty arrived, and interactions with the press improved. Hagerty was a former New York Times reporter who was respected by the White House press corps for his competence and integrity. Hagerty was also extremely close to Eisenhower and was confident in his instinct that the president would want him to share information freely with the public. Both had been troubled by the lack of candour about President Woodrow Wilson’s medical problems.
Despite his reputation and good intentions, Hagerty knew that trust could not be assumed. He was aware of rumours that Eisenhower had had a previous small heart attack that had been kept secret and that newspapers were already questioning whether Eisenhower’s initial care had been bungled and then covered up.
Trust in Eisenhower’s care rose with the arrival of Dr Paul Dudley White, a cardiologist from Massachusetts General Hospital who was arguably the most respected physician in the country. White had been selected as an external consultant by the team of military doctors caring for Eisenhower.
White’s plane landed at 1:30pm, and he immediately went to the hospital, reviewed clinical information, examined Eisenhower, and met with his family. Late in the afternoon, he issued a brief bulletin with his assessment: “The president yesterday had a moderate attack of coronary thrombosis without complications. His present condition is satisfactory.” He asked Hagerty to stress to the press that “moderate” meant “neither mild nor serious.”
White agreed to give an extended press conference the next day at 10am He and Hagerty understood that the press was already asking critical questions about why it took so long to recognise that Eisenhower did not just have indigestion and why he was allowed to walk downstairs and out to the car. White went to the home where Eisenhower had been a guest and verified that bringing the president down the narrow stairs on a stretcher might have been more stressful for him. He decided he should move attention away from questions about what had happened and focus instead on teaching the nation about heart attacks.
White’s press conference on 26 September was, by all accounts, breath-taking in its sweep and effectiveness. He spoke to the press, and by extension the public, as if they were medical students interested in understanding the heart and myocardial infarction. He explained how heart attacks were caused by the build-up of atherosclerosis in the coronary arteries and the formation of blood clots that blocked the vessels. He described how the damage was repaired the same way that cuts on the skin healed and that over about 2 weeks the scar on the heart would become “strong.”
He anticipated and addressed questions about whether golf or high altitude had contributed to Eisenhower’s heart attack and about whether he’d had a previous heart attack. He provided detail on Eisenhower’s treatments and laboratory results. He revealed that Eisenhower had had more pain on Saturday night but none since. He included the comment that Eisenhower had had “a good bowel movement” that morning because he thought it important, but also because “the country is so bowel-minded anyway.”
He dodged questions about whether Eisenhower could run for a second term, later saying that he’d never had a patient with presidential responsibilities but that many patients survive heart attacks and resume normal activities for many years after. After he was done, he got on a waiting plane and flew back to Boston.
The press coverage the next day showed that White had found an ideal combination of expertise, optimism, and transparency. He had dispelled fears of impending catastrophe. He earned trust by sharing information and insights. Hagerty told him “the newsmen covering here unanimously agree that yours was one of the best, if not the best, conference they have ever attended.” The editor of an antismoking newsletter wrote him that nothing published by any association had had impact comparable to what he had accomplished that day.1
Heart attacks became less mysterious and less frightening to millions of Americans that day, and White gave them the message that they could take steps to reduce their risk.
So, what can we learn from Eisenhower’s heart attack 65 years later – beyond humility from realising that some of our COVID-19 therapeutics will probably amuse future generations?
Certainly, everyone should aspire to achieve the trust that Eisenhower’s press secretary had from much of the press corps. That trust is built over time by being humble, listening, and maintaining one’s integrity in every interaction. It cannot be created abruptly during a crisis just when it is needed most.
And it would be wise for everyone in health care – not just Trump’s caregivers – to reflect on how Paul Dudley White managed his 24 hours in Denver. He acknowledged and addressed concerns not by swatting them away but by doing his homework (such as going to see for himself the stairs Eisenhower had walked down). He was transparent, honest, and optimistic. And he recognised and seized the teachable moment and was able to shift the conversation from what had happened to what should be learned.
Epitomising expertise, empathy, and judgment, White found a way to play the role of physician for not just the patient but also the country: he eased fears, provided accurate information, and defined a credible path forward for both. And if he were doing so in 2020, he would do it wearing a mask.
[link url="https://www.nejm.org/doi/full/10.1056/NEJMp2031046?query=TOC"]New England Journal of Medicine article[/link]