Allan’s cardiothoracic surgeons can’t work on his delicate coronary arteries while his heart is still beating. That would be a little like trying to take apart the engine of a 1978 MG while it’s running. So with his chest open, and with his blood flowing through a bypass pump, the surgeons stopped his heart by flooding it with a solution that contains potassium chloride. This prevents his heart muscle from conducting a normal rhythm, paralyzing it. That’s why no one around me is freaking out about a heart that isn’t beating.
Next, in what seems like an eternity but is really just a matter of minutes, they graft a vein to make a detour around the blockage. Then they disconnect the bypass machine and apply a shock to Allan’s heart. Allan and his heart get a second chance.
The seconds during which Allan’s heart stalled and then roared back to life were probably the simplest part of the entire procedure. It certainly looked simple. Just a quick shock, and all was well.
And yet it took an amazingly long time for would-be resurrectionists to figure out how to pull off this little trick. As far back as the eighteenth century, members of the resurrection club were trying to restart the heart. Some of the earliest research even stumbled on the value of electricity.
Back in 1775, for instance, the Danish physician Peter Abildgaard announced proudly that it is possible to use electricity to resurrect . . . a chicken. “With a shock to the head,” he reports, “the animal was rendered lifeless, and arose with a second shock to the chest.” That, one would think, would be the point at which most people would stop. But not Abildgaard.
“However,” he goes on, “after the experiment was repeated rather often, the hen was completely stunned, walked with some difficulty, and did not eat for a day and night; then later it was very well and even laid an egg.” (One can only assume that if Mary Shelley had heard of this poultry reanimation, she would have been unable to resist the temptation to make Frankenstein’s monster a Red Bantam.)
Birds seem to have borne a disproportionate share of these early experiments. In another example, from 1796, the German naturalist Alexander von Humboldt was working in his study when a bird collided with a windowpane and fell to the ground. Humboldt ran to fetch a Leyden jar—essentially a homemade battery that stores an electrical charge across a glass-walled container that serves as an insulator. He applied one wire to the bird’s beak and—for reasons that are known only to Humboldt himself—inserted the other wire into the bird’s anus. The bird, Humboldt reports, was revived for at least a few minutes. Then it died.
Apparently Humboldt was so impressed by this dramatic albeit temporary reversal that he tried the same maneuver on himself, placing one electrode in his mouth and the other in his anus. It’s not clear what he hoped to accomplish, given that he had not just hurled himself at a window. However, he reports happily that a shock resulted in “vivid flashes.”
Fortunately for all of us, this obsession with shocking chickens and otherwise healthy people was short-lived. Soon science moved on to humans who might benefit. As with much early science, though, a neat chronology is elusive. But the physician and historian Mickey Eisenberg has pieced together a timeline of events that makes as much sense as possible of these early days. Eisenberg places the first possible resuscitation using electricity as far back as 1774, more than twenty years before Humboldt was stimulating his private parts. In that year, the Royal Humane Society’s report describes the case of one Ms. Greenhill, who fell out of a window. She was taken to Middlesex Hospital, where the surgeons and an apothecary all shook their heads sadly and declared that nothing could be done to save her. At this point a certain Mr. Squires decided to try electricity. Because, I guess, why not?
Apparently he applied wires to various parts of Ms. Greenhill’s anatomy that are probably best left to the imagination. All to no effect. Eventually, though, by design or chance, he applied those wires to her chest, causing her to breathe and eventually to wake up.
The next decade saw other examples, which were summarized by Dr. Charles Kite in 1788, along with a more detailed report of his own adventures with electricity. In that instance, Kite tried the same thing on a young girl who had suffered a fall. The good news is that, as with previous subjects, a shock delivered by a homemade battery seemed to revive her.
The bad news is that Kite’s detailed description of his impromptu experiment does not inspire a high degree of confidence that he had even the faintest idea what he was doing. “Electricity was then applied,” he reports proudly, “and shocks sent through in every possible direction. . . .” One can only imagine what this scene must have looked like, as Kite pushed his way through a crowd of bystanders and applied wires to any visible skin.
Kite goes on to describe how those shocks caused muscle contractions and how, eventually, the girl woke up. He’s often given credit for the first use of defibrillation, but the truth is that it’s not at all clear that those shocks actually restarted the girl’s heart. It’s possible that they stimulated breathing. And of course it’s entirely possible that the girl was merely unconscious, and that these shocks accomplished nothing more than a vial of smelling salts would have, albeit with significantly more dramatic flair.
Despite initial advances with chickens and people, these ideas were just a little ahead of their time. Abildgaard and Kite were on the right track, but they hadn’t yet figured out how to support the victim’s breathing. That science was more than 150 years away, and we’ll see those advances in chapter 6. In the meantime, the idea that a heart could be shocked back to life simply sat there, fully charged, waiting until it could be used.
The next big breakthrough came in 1947, when the American surgeon Claude Beck showed that a dose of electricity applied directly to the heart could correct the sort of disorganized, chaotic electrical activity (fibrillation) that is often the last flicker of activity before a heart becomes inanimate. Beck had been working for several years on a defibrillator that could be used during surgery, and he’d even reported two cases where his invention was used. Defibrillation had been successful, but those patients only went on to live for several hours.
But in 1947, Beck’s patient was a fourteen-year-old boy undergoing surgery to correct a chest deformity. He was otherwise completely healthy.
That’s important because this boy was about to become one of many otherwise healthy patients who led Beck to coin the phrase “a heart too good to die.” He meant that this patient was so otherwise healthy that Beck couldn’t in good conscience let him succumb to a little thing like a non-beating heart.
As Beck was ending the operation and sewing up the chest, the boy’s pulse and blood pressure dropped to zero. As was standard procedure at the time, Beck reopened the chest and performed a manual massage of the heart, squeezing it in a way that should have re-created its normal pumping action.
More than forty minutes passed, with Beck manually pumping away, unwilling to give up. Finally, an experimental defibrillator was brought into the operating room from Beck’s lab, and after some trial and error, he succeeded in restarting the boy’s heart. Apparently the boy recovered, none the worse for wear.
Allan, by the way, did almost as well. He left the hospital about a week after the open-heart surgery I observed, weak and tired, and unable to walk more than a few steps at a time. But he was alive and grinning the last time I saw him, being pushed in a wheelchair out the hospital’s front door, with his wife walking beside him.
To be fair, Allan’s procedure was carefully orchestrated. Step by meticulous step, the surgeons and anesthesiologist stopped his heart and restarted it with the proficiency and certainty of trained mechanics. Watching their calm professionalism in the presence of a heart that’s not beating, it’s tempting to conclude that there’s really nothing complicated to it. Just a little shock—that’s all you need.
In order to appreciate the magnitude of what the science of resuscitation has achieved, we need to step outsid
e the controlled environment in which Allan’s heart was restarted. He had the benefit of an open chest and a heart that had been stopped on purpose as part of a careful, well-choreographed plan. But we need to see what happens when a patient—suddenly and without warning—ceases to be alive and starts being dead.
The “suddenly and without warning” part is going to be a challenge, though. How do we anticipate when and where one of these events will take place? And how can we predict which patient is about to have a very, very bad day? Waiting for a cardiac arrest to occur is a little like waiting for lightning to strike.
Fortunately, there’s one place I can think of where I know—with absolute confidence—that someone is going to try to die. I know the time down to the minute when someone’s heart is going to stop, and I know exactly when a team of physicians and nurses will descend to try to bring that person back to life. What is less certain is whether they’ll succeed.
THE LONG-DISTANCE RUNNER AND HIS VERY, VERY BAD DAY
Allan’s cardiac arrest was part of a plan, but for our next patient—Mark—the cessation of his heartbeat was an unwelcome surprise. Mark is lying on the operating table right in front of me, and it is obvious that his day isn’t going too well. Which is too bad, because his day started out great.
About three hours ago, this forty-two-year-old scientist and seasoned long-distance runner went into surgery to have a malignant thyroid tumor removed. Following an uneventful procedure, the surgeon closed up the wound, and now the tumor is sitting peacefully on a table not three feet from me. Aside from the fact that he’s short one thyroid gland, Mark was otherwise hunky-dory.
Now, however, Mark is not doing so hot. Truth be told, he’s dead.
I know this because Mark is not moving, breathing, or performing any one of a number of common and recognizable behaviors that are usually reliable signs of life. I also know this because there’s a monitor to my right that displays all of his vital signs, which are conclusively absent. For instance, I’m watching his respirations (nil), heart rate (zero), blood pressure (zip), and EKG tracing (flat). It’s a textbook case of someone who is undeniably and incontrovertibly deceased.
And yet, despite the tragically premature death of this forty-two-year-old man, the crew of eight doctors and nurses gathered around the operating table is giggling nervously. An anesthesiologist is trying mightily to force air into Mark’s lungs, but those lungs do not seem to be cooperating. A surgeon is unenthusiastically poking at Mark’s neck with a scalpel in much the same way that you might poke a beehive with a stick.
Unless something miraculous happens, it’s looking increasingly likely that our weekend athlete will never run another marathon. Still, the giggling continues. This, I’m thinking, is going to be difficult to explain to Mark’s bereaved family.
Fortunately, that conversation won’t be necessary. This isn’t a real operating room, and Mark isn’t a real patient. I’m actually in the University of Pennsylvania’s simulation center, which is designed to re-create the circumstances, confusion, and anxiety of real medical emergencies. All of this—the EKG tracings, the history, and even the trappings of the operating room around us—are the set and props of an elaborate drama that helps OR teams learn to respond to the unexpected.
At the center of this simulation is our patient, known today as “Mark.” He’s actually a metal and plastic mannequin. His history is fabricated and his physiology is simulated.
However, he’s designed with careful attention to detail, so that the team of doctors and nurses surrounding him can do virtually anything they would to a real patient. For instance, when the anesthesiologist inserts a breathing tube into Mark’s lungs, a sensor displays the resulting increase in oxygen on a monitor over the operating table. Or a nurse can announce she’s drawing blood for a test and, after a suitable interval, the results will be supplied by a disembodied voice. It is a truly amazing arrangement that gives the team real-time feedback, telling them what they’re doing well. Or not, as the case may be. At the end of this scene, everyone in the group will critique themselves, and one another, so no one wants Mark to die. But the certainty of his demise, if you ask me, is looking very, very likely.
Suddenly, though, Mark’s future begins to brighten. A nurse has wheeled in an automatic defibrillator—a plastic box the size of a milk crate. It’s equipped with handy wires that the team attaches to pads placed on Mark’s chest. The room is quiet for a moment, and then the defibrillator springs to life.
We all breathe a sigh of relief. It’s like everyone’s favorite extrovert has just made a grand entrance at a hopelessly dull party. Now, people’s expressions suggest, we’ll have fun. But it takes only about two seconds for me to wish that this particular guest hadn’t been invited.
As soon as it’s powered up, the new arrival demonstrates that it has the capacity for speech. (This isn’t unusual. Most defibrillators, particularly those used in public settings, provide a computer-generated voice that describes the heart’s rhythm, as well as instructions for bystanders.)
Unfortunately for all of us, this defibrillator’s voice somehow manages to be both abrasive and dripping with ennui. It reminds me of the disinterested voice that flight attendants use to admonish us—for the millionth time—to use care in opening overhead bins because articles may have shifted during flight. And the defibrillator is using that voice right now to tell the team to “continue CPR.”
This advice is greeted with more than a little eye rolling by the doctors and nurses who have been doing exactly that, for the past five minutes with no discernible results.
The defibrillator continues to babble woefully unhelpful instructions. The team continues CPR. And Mark continues to make the gradual transition from temporarily dead to permanently dead.
As the defibrillator drones on, I begin to think of it as Adam, the nom de guerre that Frankenstein’s creation bestowed upon himself. With the same exasperating patience, Adam tells the team again and again: “No shock advised.” That’s because Mark’s rhythm is asystole, and there’s no impulse that would produce a contraction of the heart. Asystole is essentially a flat line, and this EKG tracing means that the heart is not conducting any meaningful rhythm. And asystole, Adam knows, doesn’t respond to shocks.
He knows this, presumably, because he doesn’t watch movies. If he did, and if he’s an old-enough model, he might have seen the 1990 film Flatliners, in which otherwise well-adjusted medical students line up to have their hearts shocked into asystole and then, after varying amounts of drama, back into a normal rhythm. The first part, shocking your way into asystole, at least has some basis in reality. (Although, for the record, this is really not a very good idea.) But once you’re there, another shock won’t help. You need chest compressions, artificial ventilation, medications, and lots of luck.
This is why we’re all listening to Adam suggest again and again in a bored voice that the team should continue CPR. Which they do. Alas, no one has yet found the nerve to tell him to shut up.
As far as I can tell, the only person in the room who is not particularly bothered by Adam’s tone-deaf and entirely superfluous advice is Greg Marok, who is standing just to my left. Greg is the simulation coordinator and master of ceremonies for this show, and I’m here as his guest. He’s blond, baby-faced, and extra-friendly, doing everything he can to put the simulation participants at ease.
It’s Greg’s job to orchestrate this simulation in a way that inspires maximum learning—namely by cooking up scenarios that will flummox even the most seasoned teams.
And this team is in danger of being flummoxed, because Mark is still in asystole. Of all of the EKGs that code teams see, asystole is one of the worst because it’s very hard to reverse. It’s also, not coincidentally, the last thing EKGs show as a patient dies.
What is even more concerning is the fact that Adam seems to have given up. Every thirty seconds or so he’s been mournfully t
elling everyone that there’s nothing he can do.
Fortunately for Mark, though, the team is not so pessimistic. Even if Adam can’t use the charge he’s stored up, the team has a few tricks left. And so, ignoring Adam’s gloomy proclamations, they start to do whatever they can.
Since Mark is a mannequin, he won’t actually respond to medication. But the members of the team can call out what they’d give a real person, and the computer simulation adjusts Mark’s heart rhythm and blood pressure accordingly.
First, they “give” epinephrine. Epinephrine improves the heart’s contractility and it also prompts blood vessels to clamp down, which helps to maintain blood pressure. They also give atropine, which blocks acetylcholine receptors, in hopes of lighting a fire under the heart’s SA node and getting it to produce a rhythm.
Much to everyone’s surprise, the simulation responds and those tricks work. According to the monitor in front of me, Mark’s heart is now in ventricular fibrillation. (Fibrillation, which we saw when Allan’s chest was open to the world, is the chaotic electrical activity that happens when impulses circle around and around without any recognizable pattern. On an EKG, fibrillation looks like a very fine sawtooth—essentially electrical white noise.) That’s still a problem, but it’s a better problem to have than asystole, because those little squiggles of electricity mean that Mark’s heart is now trying to beat. It’s a little like when you’re trying to start a car and the engine turns over and then dies. That’s bad, but it’s a whole lot better than turning the key in the ignition and hearing nothing but ominous silence.
Of course, the onset of ventricular fibrillation has not escaped Adam’s keen attention. It seems he’s having trouble restraining his enthusiasm. This development injects new life into his electronic voice.
“Ventricular fibrillation!” he announces excitedly. He sounds about as elated as a mechanical voice can sound. It’s as if the team has suddenly handed him a task that is worthy of him.
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