Shocked

by David Casarett

  SHOCK IN A BOX

  John died yesterday. At least, he looked pretty dead to his buddies on the seventh green of the suburban golf course where he’d been playing just a few minutes before. In the space of a couple of seconds, his handicap went from a respectable 14 to something close to infinity.

  But then he was back.

  And now he feels fine.

  John didn’t endure the indignities of his golfing buddies pounding on his chest or providing mouth-to-mouth resuscitation. Even better, he didn’t suffer any of the usual CPR side effects of a bruised chest or cracked ribs.

  That’s because his buddies didn’t do CPR. In fact, they didn’t do anything. For all I know, one of them snuck in a surreptitious short putt, hoping no one would notice the extra stroke.

  The truth is that John’s buddies did exactly what they needed to do. Nothing.

  John is a big, affable guy in his late fifties. He’s easily six feet tall, with close-cropped gray hair, broad shoulders, and a dense web of freckles that he’s earned through years of outdoor work as a commercial construction contractor. I’m meeting him in a clinic that specializes in the care of people who have a tendency to die suddenly. That is, they all have a history of ventricular fibrillation and other fatal arrhythmias. With expansive gestures, he’s telling me about what happened yesterday. But his story, he says, actually began much earlier.

  Two years ago, he’d been sitting in the bleachers at his grandson’s first Little League game. It had been hot that afternoon. He started feeling woozy but chalked it up to the insufferably muggy Philadelphia summer weather.

  “Then the next thing I remember,” he says, “I’m in an intensive care unit. I’m lying flat on my back, with these straps tying my arms and legs down. I’ve got tubes and wires running every which way. I looked like a construction site when the electricians and plumbers just walked off the job, you know?”

  Apparently he’d had a cardiac arrest. It was a close call, but John had been lucky. He’d had his cardiac arrest in a public place. It turns out that you’re much more likely to have someone start CPR if you die in public than you are if you die at home. Even though your family members arguably have a greater incentive to do CPR than a stranger would, in a public setting there are simply more people around, and so it’s more likely that someone will take the initiative.

  In John’s case, two people sitting nearby started CPR, and someone else called 911. Fortunately, the fire station was only two blocks away, so the paramedics arrived in about five minutes. They were able to shock his heart back into a normal rhythm immediately, and they hustled him to the nearest emergency room.

  The next day, when a cardiologist offered him an implantable cardiac defibrillator (ICD), John didn’t hesitate. He just said, “Sign me up.”

  Also, John explains, he’s divorced and lives alone. He knew there was a good chance that the next time his heart walked off the job there wouldn’t be anyone nearby to make that 911 call. An ICD was really his only option.

  ICDs have become remarkably sophisticated, but the basic premise is essentially what the name implies. Just like an AED, an ICD has the ability to sense a rhythm, and to shock the heart if that rhythm is abnormal. The basic design consists of wires that are embedded in the muscle of the heart, and those wires lead to a box that analyzes the rhythm and delivers a shock if needed. The box in some of the earlier devices was about the size of a hefty paperback, but they’ve shrunk over years of evolution to about the size of a pack of playing cards.

  There have been advances in the way these devices are designed and implanted, too. Some of the earliest versions required open-chest surgery. That technique gave way to the use of electrodes that were threaded through veins. More recent versions don’t touch the heart directly, but rather use electrodes under the skin of the chest.

  They are, you have to admit, pretty nifty. For someone like John, who has just realized that his heart is not the dependable buddy he’d always thought it was, these devices seem like a gift. And so patients decide, as John did, that there really isn’t much of a choice. “Sign me up,” they say.

  But not everyone shares John’s enthusiasm. Many people refuse the offer of an ICD. Some don’t understand the risks of an arrhythmia, and others aren’t urged by their physicians to consider it. It doesn’t help, either, that these devices have had a somewhat spotty track record of quality issues and recalls. They’re still safe, but some people are turned off by stories of devices that fail to work as advertised. In fact, it may be that a majority of patients who could benefit most don’t actually get the devices, particularly women and African Americans.

  As John and I are talking, the clinic technician knocks on the door and lets himself in. He looks like he’s about fourteen—too young to manage something as delicate and as important as an ICD. I’m tempted to ask to see his driver’s license, but he and John seem to know each other. John asks the technician about his girlfriend (who is now his fiancée) and the technician asks John about his golf game.

  They’re chattering away as the technician places a device over John’s chest to scan the ICD. In a matter of a minute, the tech has downloaded its history, including a record of the shock it delivered. He can also see the rhythm that convinced it that a shock would be the right thing to do.

  “Yup,” the technician says. “Sure looks like it fired once.” He nods. “Ventricular tachycardia.” He nods again, then starts putting his gear away.

  I can’t help thinking that there’s something oddly nonchalant about this interaction. John has just died, and the technician’s reaction is: “Well, it looks like you died. Here, let me validate your parking stub. See you in three months.”

  But perhaps it’s not so strange. If you were a patient with asthma, for instance, and you began to feel a little short of breath, you’d use your inhaler. Then you’d feel better. But you wouldn’t call your doctor to set up an appointment, would you? No, because that’s what your inhaler is for. You use it when you need it, and then you go on with your life.

  In the same way, that’s how ICDs are meant to work. Granted, their function is a little more spectacular. And although it’s possible to take a quick, surreptitious puff on an inhaler when no one’s looking, it’s a little harder to die and be resurrected without disrupting the flow of a golf game. Although I suppose anyone stuck behind you at the seventh hole could just play through if he’s in a hurry.

  It’s the ability to adopt this attitude of nonchalance that has made these devices so popular. According to one of the largest ICD surveys anyone’s ever done, as of 2009, there had been more than 300,000 ICDs implanted. Implantation rates rose in almost all of the countries surveyed, especially in the United States.

  But do they work? They do. In one study of patients with heart failure who were at risk of the sort of arrhythmias that ICDs treat, an ICD decreased the risk of death by 23 percent.

  That figure gives a sense of the potential benefits of ICDs, as well as their limitations. This reduction in mortality is impressive, particularly if you’re one of the people—like John—who is alive because he has an ICD. But 23 percent isn’t 100 percent. That is, an ICD isn’t going to save the life of everyone who gets one any more than CPR can save the life of everyone who receives it. For starters, as we’ve seen, an ICD can’t treat every abnormal rhythm. Also, people may develop other health problems that could kill them before their heart does. Still, it’s possible that ICDs are particularly beneficial for people with very bad heart disease, perhaps because those are the people who are very likely to die of a shockable arrhythmia.

  Even though I’m pretty sure I know the answer, I ask John if getting an ICD was the right decision for him.

  “No question,” he says simply. “I’d do it again”—he pauses—“in a heartbeat.” He smiles.

  What John doesn’t say, at least not immediately, is that although ICDs are effective, t
hey come with a cost. Some of that cost is financial. Estimates are hard to come by, but studies suggest that ICDs cost somewhere between approximately $37,000 and $138,000 per year of life saved. The actual costs depend on the population, how sick people are, and how long they live. Since most of the costs are for implantation, the benefit in terms of years of life saved per dollar spent is greatest for younger, healthier patients. These are patients like John. Looking at these numbers, it’s hard not to agree with John’s assessment that there was really no question of whether to get an ICD.

  The technician is gone now, and we’re done. There’s nothing John needs to talk to his cardiologist about. The cardiologist will review the results of the ICD’s data scan and will be in touch with John if there’s anything he should know.

  We’re walking out of the clinic together, but there is more that John wants to talk about, so we stop at the hospital café down the hall from the clinic. John colonizes a free table and I buy us two cups of coffee.

  “You know,” he says when I get back, “it’s not quite as automatic as they make it seem.” He pauses. “I don’t want to make it sound like I’m complaining, but it’s not a cakewalk.”

  I’m not sure what he means, but already I’m getting the sense that this is a conversation he wanted to have outside the confines of the clinic. He’s not exactly furtive, but it seems as though these are opinions that he’d rather the technician and his cardiologist didn’t hear. It’s almost as if he thinks he’s about to be disloyal.

  “When it works, you know, it’s amazing. Like a miracle.” His ICD, he says, has fired about ten times in the past two years. Several of those times were just like what happened on Sunday. He was standing there, and then all of a sudden, he wasn’t. Sometimes he doesn’t remember passing out.

  But that doesn’t mean his ICD is invisible. In fact, he thinks about that ICD every minute of every day. It’s a comfort, but a source of anxiety, too.

  “You know, it’s strange. I’m always grateful when it goes off. Because I know I’m going to be around a little longer. But . . . it changes life in between.”

  I ask him what he means.

  “There’s a sort of . . . panic. I even get a little superstitious.” He smiles sheepishly. “I mean, I know this sounds crazy, but once when it went off, I’d just walked by this air-conditioning vent in my study. And just a few seconds after I walked by it, I was down on the ground. And I swear, I know it sounds nuts, but ever since, I give that vent a wide berth.”

  What John is getting at is that while ICDs save lives, they can erode patients’ quality of life. Patients with ICDs have a lower quality of life than the general population, and also a lower quality of life than people with pacemakers. Although, interestingly, people with ICDs report a better quality of life compared to people who are only taking medications to control an arrhythmia.

  This loss of quality of life seems to be greatest for people like John, whose ICDs are very active. For instance, patients who receive a shock within the first year of having an ICD report increased anxiety, fatigue, and psychological distress compared to those whose ICDs are quiet. Some patients experience symptoms of post-traumatic stress disorder, too.

  “That’s the tradeoff,” John says as he finishes his coffee and stands up to leave. “You live longer, sure. And I’m all for that, believe me. You gain extra years. But you lose minutes and hours along the way worrying about what’s next.” He shrugs. “But you know it’s worth it.”

  CPR ON THE FRONT LINES

  As our four-ton ambulance plunges through light afternoon traffic, scattering smaller vehicles like minnows, the most convincing evidence of the urgency of this run is not our wailing sirens or our flashing lights, or even the near misses at crowded intersections. No, it’s the upturned faces that line our route. On either side of us, the pedestrians and drivers offer a mute testimony to the importance of our mission that is more convincing than all of our sound and spectacle.

  I don’t know where we’re going. And I have no idea what we’ll find when we get there. But those looks that are directed at us are my assurance that this must be a matter of life and death.

  You’d never guess that, though, if you just looked at the two paramedics I’m with. Jason and Garrett have maintained an otherworldly calm since we left their home base. I’m only a “rider” on this trip—an observer—and I’m crammed like a bag of groceries into a small cubby behind them. Yet I’m probably more anxious than they are.

  Jason is tall, impossibly thin and long-limbed, and sports a low-maintenance sandy crew cut. He looks like a weekend triathlete—which is exactly what he is—who works as a paramedic to pay the rent and maintain a decent supply of running shoes. But he’s brought the energy of an athlete to every call we’ve been on today, leaping out of the truck first and charging ahead with unrestrained enthusiasm. Now, though, Jason is starting to fidget. He’s just started tapping on the dashboard in time to some inaudible rhythm in his head, and is plainly getting on Garrett’s nerves.

  But Garrett just takes a deep breath every time Jason’s palm slaps the dashboard. He’s an old soul, apparently. He’s also just plain old, at least for this work. A stocky African American man in his fifties, he has graying sideburns and a weekend’s stubble on his cheeks. Garrett used to work as an ER aide, he told me, but about ten years ago he decided that he wanted the freedom to work when and how he wanted. He cycled through a variety of jobs until he completed the two years of training required to become a paramedic, and he’s been working steadily ever since. (Paramedics are the most advanced category of emergency medical technicians [EMTs], and can perform many of the procedures that you’d undergo in an emergency room.)

  The three of us are racing through the suburbs of a small Midwestern city toward an address that Garrett tells me with typical terseness is a “CCRC.” He means it’s a continuing care retirement community, like the one that Lorraine Bayless was in, made up of independent homes, apartments, assisted-living facilities, and a nursing home. These guys get only bits of information from a dispatcher who is even more pinched with words than Garrett is, but I’ve learned a little more from Jason. He knows only that there is an eighty-two-year-old female who has been “found down.” That is, on the floor.

  That description covers a lot of ground, and indeed I suspect it’s the ambiguity of this call that is bringing out Jason’s tendency to fidget. She may have had a stroke, as Lorraine Bayless did, or a seizure. Maybe her heart has stopped, or maybe she’s only fainted. We don’t know, and that uncertainty is making him nervous.

  The other piece of this story that is unknown is where on the CCRC spectrum this woman is. She could be a healthy, vibrant woman living in her home. Or she could be a nursing home resident with advanced dementia and multiple medical problems. Despite the availability of trained medical staff, nursing home residents who suffer a cardiac arrest don’t have a much better chance of survival than someone who collapses on the street does. So this call could end in a miracle, or it could end very badly.

  Weaving through traffic that thins as we make a fast right turn onto a smaller street, Jason taps faster and Garrett gives the truck a little more gas, shooting a glance at the monitor that keeps a running log of how long we’ve been traveling. This will be the measure of our door-to-door response time, and it already reads 8:54. Not bad, but if this eighty-two-year-old female doesn’t have a heartbeat, then every second counts. Garrett drags his eyes back to the road, and the truck lurches forward.

  When we pull into the CCRC complex, we follow a pleasant tree-lined street that meanders gracefully as if it were paved to follow the course of an ancient river. It winds past redbrick and white-sided bungalows, each with its own driveway and carport. Then we’re in front of a three-story apartment building, which I’m guessing is the assisted-living facility, where people with functional limitations or cognitive decline can get extra help.

  There i
s a woman in a nurse’s uniform holding a door open for us. She’s looking toward us with the same expression with which someone on a life raft might look at the silhouette of a ship that appears on the horizon. She nods vigorously when she sees us. Then she waves, as if to eliminate any doubt, and to ensure we won’t drive on past. But she doesn’t leave the door to greet us; she actually seems tethered to her post, turning every few seconds to look through the open door behind her.

  Caught up in the excitement of the drive, and infected, perhaps, by Jason’s nervous energy, I find myself anticipating that Garrett will stop any second now. Jason will hop out and I’ll be right behind him. There’s no time to lose. We’ll be in the building with the defibrillator pack and stretcher in a minute. And we’ll save a life.

  But this afternoon, what should be a heroic moment of arrival is when things start to go very wrong.

  Jason is out the door as we’re rolling to a stop, a red nylon backpack slung casually over one shoulder. I’m right behind him until Garrett reaches over and puts a hand on my shoulder. When I turn around impatiently, he tells me, “These calls aren’t the easy ones.” Unsure what he means, but knowing that Jason is already inside, I nod uncertainly and follow him.

  By the time I reach the door, Jason and the nurse have disappeared. I make my way down a short hallway to a door about halfway down on the right, which is hard to miss. There are half a dozen people crowded around, and I assume they’re residents.

  I follow Jason into a cozy living room whose wide bay window offers a panoramic view of the street outside. There’s an overstuffed blue velvet sofa facing the door, and an antique mahogany credenza against the far wall. It’s heavily laden with family pictures in a bewildering assortment of frames. There are what appear to be siblings and children and grandchildren, and timeless baby photos that could be of anyone. That’s what I notice first.