Cardiac arrest coming in!
Mona, our ward clerk, cradled the red ER phone against her shoulder, her hands busily sorting lab slips. She pushed her ear into the receiver, hard, then announced, Two minutes out.
In plain English cardiac arrest means heart stopped. Every year 300,000 Americans succumb to sudden cardiac death--and they are often walking, talking, and feeling fine when it strikes. The most common cause is ventricular fibrillation, the irregular electrical misfiring that can result when something throws the heart’s carefully synchronized rhythm off- kilter. That something might be a heart attack, a potassium imbalance, scarred heart muscle, or something as seemingly innocuous as a burst of ill-advised activity.
Whatever the cause, a heart in V-fib no longer pumps blood to the body but lies as helpless and quivering as a bag of worms. Unless normal rhythm is restored within four minutes by shocking the heart and reimposing normal electrical activity, the brain--our most oxygen-hungry organ--begins to die.
Four minutes. Where I work, in New York City, it often takes paramedics over eight minutes to fight their way through congested streets to a victim’s side. Nor do New Yorkers, wary of contagion and inclined to mind their own business, tend to start the cardiopulmonary resuscitation-- CPR--that can hold off death for a few precious minutes. In less congested and more congenial cities like Tucson and Seattle, between 15 and 35 percent of people felled by cardiac arrest due to V-fib will live. In New York City, just 5 percent will survive.
To ER doctors in New York City, Cardiac arrest coming in almost always means Nothing more to do.
Even so, the nurses were at their positions in the resuscitation room when the ambulance bay doors slammed open. A stocky, red-faced man led the rush. It was Zachary, my favorite paramedic.
Fifty-year-old white female, he huffed. Walking with her friend by the ferry terminal. Said she felt dizzy, then went down. While he talked, he and his partners hoisted their patient onto the table and unraveled the tangle of IV lines, electrode wires, and backboard straps.
We were parked right there. She was in V-fib. We shocked her twice, he concluded, just catching his breath.
The nurses slapped cardiac monitor leads onto the patient’s chest. Across the monitor’s green screen marched spike after spike of normal heartbeat. I pressed my fingers deep into the woman’s upper thigh, where the femoral artery lies, and felt a brisk, rhythmic pulse. I turned to Zachary in surprise.
Oh, I forgot to tell you. He smiled. She’s had a pulse since the second shock.
A nurse announced that the patient’s blood pressure was a reassuring 130 over 60. The respiratory therapist was busy supplying oxygen through the tracheal tube Zachary had inserted on the way to the ER. I stood back, surveying the bustle.
Doesn’t look to me like anybody here needs a doctor, I said. You guys brought her back.
The four paramedics beamed. Just then our patient moved her right hand. Then her left. Some deep-seated reflex stirred; she was resisting the breathing tube and telling us that her brain had survived the V-fib.
She’ll be up eating breakfast tomorrow, I said, exultant. Great save, folks.
Zachary came up and nodded at the surgical scars running down her chest.
Pete’s still interviewing the friend, so I don’t know her history yet, but what do you think of those?
Through my stethoscope I’d already heard the clicks of artificial heart valves.
Sounds like she’s had valve surgery. And in a woman her age in New York City that can mean...
Endocarditis, Zachary said. I was afraid of that.
Addicts who inject drugs have an astronomical rate of endocarditis, or infections of the heart valves. Bacteria hitch a ride into the bloodstream on dirty needles and lodge on heart cells. If not treated, infections can become so severe that the chewed-up valves must be replaced.
Well, maybe she’ll use the borrowed time to clean up her act, huh? he went on.
Maybe, I answered, though I thought we both knew better.
Once before, Zachary had shown me that I didn’t know better. A year ago I had just started as the new emergency room director. During a get-acquainted meeting with the ambulance crew, their chief had asked, Any questions for Dr. Dajer?
Yeah. Zachary’s arm and voice rose together. Why is it that whenever we bring a patient into the ER you look right through us? It’s as if we don’t exist.
He was looking at me, ready to detect the slightest dodge. I’d been on the job for three months, and the pace still felt breakneck. A paramedic wheeling in a patient meant only one thing--more work. There was no way to make that sound like anything but what it was: whining.
You’re right, I finally answered. I’ve been a jerk. What can I do to change that?
Ride with us. Every other medic around the table nodded in agreement.
Three days later Zachary and his partner, Matt, buckled me into the back of their ambulance. We headed out on our first call: a man in a nearby fast-food restaurant was having a seizure. Though the restaurant was just seven blocks away, it took that many minutes to get there. Despite the blaring sirens and flashing lights, no one gave us a second glance, much less got out of the way.
We found a stout, well-dressed man of 60 sprawled faceup beside the counter. His face had already darkened to a deep, impossible blue. Zachary and Matt scrambled to hook him up to their portable cardiac unit. I dropped to the floor and tried to insert a tube that would feed oxygen down his windpipe.
V-fib, Zachary read off the unit. He grabbed the monitor’s two defibrillating paddles and pushed one against the man’s upper chest, the other against the left rib cage. If all went well, the electric current between the two paddles would flow through the man’s chest and jump-start a normal electrical rhythm.
All clear! He hit the discharge button on each paddle, firing 300 joules of electricity into the man’s chest. The huge torso lifted in a spasm, then sagged. I felt the neck for a pulse.
Still V-fib, Zachary said, then shocked him again. Still no pulse.
Matt and I tore off the man’s coat and shirt and started IV lines. While Zachary kept shocking the heart, we gave oxygen and shots of lidocaine to help coax it into a normal rhythm.
Again and again we tried to bring that dying heart back. Through it all, barely four feet away, the lunch crowd lined up at the remaining cashiers.
Zachary and Matt worked like demons until there was nothing more to do. And then there was nothing more to say.
When we got back to the ER, I phoned the man’s son, a doctor who worked in the city. When I explained what had happened, he broke down, sobbing uncontrollably. Shocked, I realized that I had expected him to react like a doctor, not a son. I then wondered if I was any different from the lunch crowd.
Later that day Zachary and Matt told me about the two years they’d spent answering calls in the Bronx. They told me about taking occasional sniper fire in some areas. They told me about a paramedic who was crushed between two trucks while helping an accident victim. They told me about the man they found wedged between a subway car and the platform who came apart at the waist when the train pulled back. They told me about scooping up the remains of a man who had jumped from a 20-story building.
Zachary and Matt had no emergency room walls to hide behind, no high salaries to pay for exotic, soothing vacations, nobody to dress the wounds before they saw them, nothing to slow the buildup of burnout.
Yet a year later here was Zachary, rooting for his patient--drug abuser or no drug abuser.
Dr. Dajer, her mother’s on the phone, Mona shouted across the ER.
Mrs. Ferman? I asked, surprised at how quickly she’d been found.
Yes, Doctor. Diane’s friend called me. Is my daughter all right?
She had a cardiac arrest, ma’am. But the medics brought her back. Thankfully, she’s stable right now. At this point it’s the best we can hope for. I cleared my throat. Mrs. Ferman, do you know anything about your daughter’s medical history?
Oh, she’s had so many operations, Mrs. Ferman cried. But she’s always been very positive through it all.
What were they for?
Rheumatic fever. Her valves were terribly affected. The aortic and the mitral have been replaced twice. Do you need a list of her medications? Here, I’ll read them to you.
I caught Zachary’s eye, then pointed at my chest, mouthing Rheumatic fever . . . I’m an idiot.
Only some of the time, he mouthed back.
Diane Ferman had come down with strep while still an infant, just a few years before the penicillin that could have cleared her infection became widely available. In a cruel case of friendly fire, the very antibodies that the body manufactures to attack the strep-causing bacteria can sometimes attack proteins in heart tissue. Rheumatic fever, or inflammation of the heart muscle, ensues, as does scarring of the heart valves.
Blood flows smoothly through the heart because of hingelike flaps of membrane in the valves that open in only one direction. When, for example, the left atrium contracts, blood is forced through the flaps of the mitral valve into the left ventricle below. When blood is pushed back against the flaps during a contraction in the left ventricle, the pressure forces the flaps shut, closing the mitral valve and preventing the blood from flowing back into the left atrium.
Though the heart muscle usually heals following rheumatic fever, often the delicate valves do not. In cases of repeated bouts with strep, these normally supple conduits of blood become scar-encrusted choke points. Damage is most common in the mitral valve, which allows oxygenated blood into the left ventricle, and the aortic valve, which allows blood into the aorta, the large artery that carries oxygen-rich blood out of the heart.
Complications of rheumatic fever unfold with time. In Diane’s case, her left atrium had grown large and flabby because of the damage to her valves. In the upper right chamber of her heart, where the heart’s pacemaker cells reside, abnormal electrical impulses now jounced about in a rhythm called atrial fibrillation. And because her heart was scarred and beat irregularly, pressure built up in blood vessels in the hardworking right side of the heart. That pressure could force fluid out of the vessels and into her lungs. Diuretics can clear the fluid, but they disrupt the regulation of potassium, and depletion of potassium, in turn, can cause more rhythm irregularities, such as V-fib. And all for want of a little penicillin some 50 years ago.
We will take very good care of your daughter, Mrs. Ferman, I said.
I’m sure you will, Doctor.
We moved Diane into a hospital bed. She seemed to be sleeping lightly, a perfectly normal condition following cardiac arrest. In response to commands, she moved her arms and legs and even squeezed her eyelids tight. But what unknown event had kicked her heart into V-fib? Was it something as random as scarred heart muscle? Or was it something as easily treated as low potassium? In any case, the likelihood of the V-fib’s recurring in the next 24 hours was high. We had to make sure it didn’t.
As Lynn, Diane’s nurse, and I watched the heart monitor, Diane’s pulse suddenly dropped into the twenties.
What would you like me to give her? Lynn asked, keeping the alarm out of her voice.
As I deliberated, Diane’s pulse came back up on its own.
Oh, boy. Now, where is that potassium level? Mona, could you tell the lab I need to know stat?
I just called them.
Well, call them again. Please.
Zachary came up to me. He’d just brought in another patient.
How’s she doing?
Just dropped her rate. I’m not sure why.
Methinks she would do with the blue pill and a spot of the black draught, he said with a reassuring wink. Zachary was quoting from Master and Commander, one of 15 Patrick O’Brian novels he and I had both devoured. In the novel, Dr. Maturin, an Irish surgeon in England’s Royal Navy, has an almost shamanlike reputation for reviving sailors knocked on the head or nearly drowned in the drink. The blue pill and the black draught was Dr. Maturin’s favored cure.
Actually, I’m somewhat more interested in her potassium right now, I said.
Ah, just a product of your times, Doctor dear, Zachary replied as he headed out the door.
Diane’s potassium level came back low. Lynn immediately prepared some IV fluids. Then Diane stopped moving. Her left side seemed weaker than before. According to her mother, Diane had once suffered a stroke because of a clot in her left atrium. Clots tend to form where blood flow is poor, as it was in Diane’s left atrium. To prevent this from happening again, she had been taking anticlotting medication. Unfortunately, that also put her at much higher risk of serious bleeding from blows to the head. I didn’t know if Diane had hit her head hard enough to cause a brain hemorrhage when she collapsed. There was only one way to tell. Diane needed a CT scan right away.
Lynn, make sure she goes straight to the coronary care unit after the CT scan. Don’t bring her back down here again. An arrest in the elevator would be a disaster. Can you alert the nursing supervisor?
She’s not going to like that. Last I checked, the CCU bed wasn’t ready.
I don’t care. Tell her we’re coming.
Diane’s scan didn’t turn up any hemorrhage. I suspected that her immobility was caused by a swelling in the brain. If the heart is stopped for a time, the lack of oxygen stuns the brain cells, briefly upsetting their control over how much water they absorb. The swelling would probably subside within a few days. Once again we bundled Diane up and headed for the elevator. The coronary care unit, when we arrived, was in turmoil. I explained to the CCU staff, This patient needs to be here, not up and down in the elevator. The medics pulled a miracle. Let’s give her the best shot possible.
That evening Zachary made one more pass through the ER. I flashed him a thumbs-up.
The next morning I raced up the stairs to the CCU, expecting to meet Diane Ferman over her breakfast tray.
How is she doing? I chirped at the bleary-eyed residents. But the look on their faces stopped me like steel cables.
At 2 A.M. her blood pressure dropped again, the senior resident explained. We brought it up, but then her heart rate destabilized. We shocked her and went round and round with meds and shocks, but she never stabilized. We worked on her for hours. Sorry, Dr. Dajer.
I tried to stifle my disbelief by putting a hand on his shoulder.
Maybe if we’d gotten a pacemaker in sooner, he said.
Maybe. There are always maybes, I replied, the what-ifs tumbling through my head. You gave her every chance. She had a very sick heart.
Of course, Diane’s mother already knew.
She fought so hard for so long, Doctor. Diane was full of life-- she never wasted a minute of it. I know you all did your best. Mrs. Ferman spoke with the bravery of those who have loved deeply and well in the face of death.
An hour later Zachary strolled into the ER.
Well? he asked, beaming.
I spoke slowly. She coded this morning. They couldn’t bring her back.
Oh. Zachary stepped back, stunned. I’m very sorry to hear that, Dr. Dajer.
We stared at each other a moment. Then he headed off, to try again.