Shocked

by David Casarett

  Another glance reveals a wide bare swath across the top of the credenza. That’s when I notice that more portraits—perhaps a dozen—are flung across the floor. A few frames are still intact, but most have broken and there are shards of glass glinting wickedly in the sunlight.

  A second later, I can see that the cast of a hundred or so family members still on the credenza is looking down on a strange scene in which Jason is bent over a very pale, thin woman in a flowered housedress who is lying flat on her back. She’s wearing threadbare green ankle-high slippers with pointy toes that seem to tower over her.

  There is a young, clean-cut man doing chest compressions that I can’t help noticing are too shallow and much too slow. He stops, and Jason kneels and checks for a pulse and breathing. And somewhere in the flurry of efficient activity, as he’s taking the defibrillator out of his bag, he finds a second to catch my eye and shake his head, pointing his chin toward the man next to me. He’s also in his eighties, with a narrow face and a wild shock of white hair that hovers over his creased forehead.

  Jason’s message is clear: No heartbeat. No respiration. Take the husband and get him out of the way.

  It doesn’t take more than a moment to reconstruct the events that have brought us here. An elderly woman, in the middle of dusting the family portrait gallery, feels faint. Maybe she has chest pain, or maybe she’s just lightheaded. In her panic, she reaches out in search of a handhold, but her frail fingers find only the portraits. Her flailing hands sweep across the credenza’s surface, bringing a dozen of her family members with her as she slumps to the floor.

  Imagining that scene, or something like it, I take the stunned man by the elbow and we move over to the window. As much to distract him as in hopes of gleaning useful information, I ask him what happened. His name is Richard, he says, and he begins to explain that the woman on the floor is his wife, and that they’ve been married for sixty-one years. He repeats this fact several times, as if somehow that number will serve as a charm, holding any bad luck at bay.

  Her name is Florence, he says. Then, a little louder so Jason can hear him, he emphasizes that it’s Florence, not Flo. She hates being called Flo, he says, more softly. But Florence isn’t hearing anything.

  In a flurry of activity, the young man doing CPR has stood up and stepped away. Garrett has joined Jason with another red nylon backpack, which he seems to set down and open simultaneously. Then everything happens too fast for me to follow, even though I know what I’m looking for. Garrett has opened Florence’s housedress, baring her bony chest while Jason continues CPR. Now there’s an oxygen mask in place and Garrett’s ropy forearm is bulging as he squeezes the bag with a hubcap-size hand to inflate her lungs.

  Garrett turns the defibrillator on, and from my vantage point by the window I can see the jagged white line of ventricular fibrillation racing across the small screen. That line is an urgent call for someone to apply the defibrillator paddles, but they don’t do this. Instead, they continue doing chest compressions, and delivering breaths through the oxygen mask.

  Jason and Garrett know what most impatient bystanders don’t—that CPR by a paramedic is as good as an immediate shock from a defibrillator. They’re being careful and methodical. I know this too, and yet as the seconds tick by I start to worry. What are they doing? I’m increasingly feeling the urge to leave Richard’s side and pick up the defibrillator pack myself.

  Soon, though, just as I knew he would, Garrett applies one shock, followed by a second. With each jolt, Florence’s limbs move and her chest rebounds as if a small animal is trapped inside her chest and is butting its way out. One of them—Jason?—has started an IV in Florence’s left arm. There’s a third shock, and then a fourth. They push saline solution through the IV, then a dose of epinephrine, then lidocaine.

  As this drama unfolds, I’m trying to get a little more information about Florence, which I pass on to Garrett and Jason as they work. She has severe heart failure, Richard says, for which she’s taking a long list of medications. She has diabetes, too. Her heart failure has been getting much worse, and she’s been in the hospital three times in the past three months. And she has liver disease. But it’s not because of drinking, Richard hastens to add. It’s something to do with her heart.

  Out of the corner of my eye, it seems as though the tempo of Jason and Garrett’s efforts has slackened just a little. They both sit back for a second and I can see the monitor showing something like a regular rhythm. Glancing up, Jason confirms with a curt nod that Florence’s heart is back in sinus. She has a normal rhythm, and his nod to Garrett, who has two fingers on Florence’s neck, confirms that she also has a pulse. Without saying another word, they both seem to come to a consensus: it’s time to go.

  In what seems like only a few seconds, he and Garrett have Florence positioned on a stretcher. The defibrillator is nestled on top of her. Now Jason is squeezing the ventilator bag, manually pumping oxygen into her lungs. Neither of them looks at me as they pass.

  In the county morgue where I did a rotation as a medical student, I met a technician who used to be a medic in the Marine Corps. One of his morgue duties was to sew up bodies after an autopsy, and he performed that task with a speed, efficiency, and economy of movement that was truly striking. In no more than a minute, he’d restore the contours of a body that the pathologist had torn apart, readying it for the undertaker. He was so quick and sure that even the pathologists would stop whatever they were doing to watch him. But what I remember most vividly is that despite his technical prowess, he never revealed any pride, pleasure, or satisfaction in his work. In case after case, he would sew, knot, and cut the heavy nylon thread with the same blank, vacant expression.

  I saw that same look on Jason’s and Garrett’s faces as they wheeled Florence out the front door. Although they’d achieved something undeniably remarkable—they’d brought a woman back to life—there was no pride and no excitement. No more than there was for that ex-medic sewing up a patient whose days were over.

  Five minutes later, Garrett and Jason have loaded Florence into the ambulance, and we’re racing toward the nearest hospital. Garrett is driving and Jason is in the back with me, tending to Florence. Through the back window, I can see the suburbs flashing by, and although I can’t tell where we are, I count three turns in quick succession.

  Whenever Garrett slows suddenly for those turns, Florence slides forward just a bit and her head bumps the stretcher’s metal railing with a soft thud. It’s a little thing, not enough to cause any discomfort if she were awake. But each time, those bumps offer a monotonously gloomy counterpoint to the monitor’s optimistic chirping.

  Soon we stop abruptly and back up to the emergency room’s trauma bay. When the ambulance doors open, the quiet of our little world splinters and Florence’s stretcher is whisked out by a dozen strong hands. Now this is for real. There’s no room for observers, regardless of what letters I might have after my name. My only job is to get out of the way.

  Florence is handled with a cool efficiency, and a team of blue-scrubbed staff wheel her at a controlled jog through the oversize sliding doors and into one of two trauma bays. A nurse is performing chest compressions as they move. I follow cautiously to find the team placing a large IV line in a vein in her neck, a catheter in her bladder, and an endotracheal tube down her throat. A lead-aproned X-ray technician is hunting for space around the table, and jockeying for a few seconds in which to snap a chest image. And all around Florence, there are tubes and wires and monitors and eight or nine people all focused intently on bringing her back to life, one more time.

  There is nothing in this scene that’s new to me. I’ve done everything that the team is doing. I’ve run codes, and I’ve applied defibrillator paddles and placed intravenous lines in the jugular vein.

  But this is the first time I’ve seen those things done on someone I’ve “met,” whose image from an hour ago is as vivid in my memory
as the scene playing out right now is. Although I’ve secured an endotracheal tube in place with the same ubiquitous fabric tape that the respiratory technician is applying diligently, now I’m watching the process with a clear image in my mind of Florence’s face as it had been only moments before, free and unencumbered. As that tape obscures Florence’s sharp cheekbones, I’m thinking of the dozens of photographs on the credenza back at the CCRC that display the same vaguely Nordic family resemblance. Although I anticipate Florence’s galvanic hand-twitch in response to a 200-joule shock from the defibrillator paddles, it’s strange indeed to visualize those hands an hour ago, busy rearranging her family photo gallery.

  Half an hour later, Florence is stable. She has a normal heart rate and her blood pressure is OK. She’s not awake, but that’s because she’s been heavily sedated. She’s still on a ventilator that is breathing for her, so it’s too soon to declare a victory. It’s too soon, even, to try to predict whether she’ll ever wake up. But she’s stable enough to transfer from the ER up to the ICU.

  Word comes in that Richard is in the waiting room, with their daughter. I go out first, as the team is finishing up, and the family resemblance is strong enough that I recognize the woman at the registration desk—tall, blond, in a crisply tailored business suit—as Richard and Florence’s daughter, Carla. I introduce myself, and we sit down to talk until the ER physician can come out.

  Almost immediately, Richard asks me how Florence is. I start to explain that her doctor is on his way out, but he interrupts me, asking whether she’s alive. That’s all he wants to know, he says. I wonder, Can I tell him that much?

  I tell them that she is. Yes. That much I can say.

  Richard and Carla’s response is oddly mixed. There’s relief, of course. I can see it plainly on both their faces. But it’s relief tempered by the realization that if Florence is alive, then the real roller-coaster ride is just beginning.

  The physician comes out then and introduces himself. We all sit down and he tells Richard and Carla what he knows at this point. But that’s not much, he’s quick to clarify. It’s far too soon to say anything definitive about how Florence is doing, or—he pauses—about how things will turn out.

  First he tells them a few things about which he’s certain. For instance, he says that for the past twenty minutes in the emergency department her heart’s been in a stable rhythm. Still, she’s not breathing on her own, he cautions them, so she’s on a breathing machine. And she’s unconscious.

  It’s clear to me from the facts that the physician has selected, and from his steady tone, that he’s hanging crepe. He’s giving Richard and Carla all the signals he can that Florence is in very serious condition. And he’s warning them—subtly, and without making a formal prediction—to prepare for the worst.

  Then Carla asks point-blank whether Florence is going to live, and the physician frowns. It’s a difficult question. He thinks for a moment, and then answers that every hour she’s alive, her chances are a little better. Take one day at a time, he says finally, laying one hand on Richard’s shoulder.

  But he’s not describing Florence’s chances for a total recovery. The most basic fact is that fewer than 10 percent of patients who suffer a cardiac arrest outside a hospital survive to leave the hospital. Based on that fact alone, Florence’s chances are slim.

  That’s an oversimplification, though, which glosses over numerous factors. Indeed, the equation that will determine Florence’s survival is much more complex than a simple number would suggest.

  Florence has other factors in her favor. For instance, Jason and Garrett arrived quickly, and they worked fast. So did the young man who started CPR. (I learned later that he was an activities coordinator—ironically the same position that Colleen held at Glenwood Gardens, where Lorraine Bayless lived.) Also, it’s good that Garrett and Jason were able to restore a heartbeat before they transported her. She’s also at the best hospital in the region.

  The conversation is beginning to wrap up when Carla asks whether, if Florence wakes up, her brain might be . . . damaged?

  The physician pauses only a split second before retreating to the only answer he can offer.

  “It’s too soon to tell,” he says. “Let’s try to get her through tonight, then the next couple of days. Then we’ll see.”

  Garrett looks up as I open the door to the break room, where he and Jason are finishing the paperwork for their shift. He seems tired. Tired and about ten years older than he’d been when I met him that morning.

  Although I have some questions for them, Garrett’s haggard look reminds me that they’re officially off duty. It’s seven p.m. and they’ve just finished a grueling twelve-hour shift. They probably want to get their paperwork done so they can leave, so I figure I’ll just thank them for letting me hitch a ride.

  But Garrett looks up and smiles. Then Jason kicks a chair out from under the scuffed Formica table that is strewn with spreadsheets and checklists. He gestures for me to sit, and I do. I’m wondering what’s on their minds. I don’t have to wait long.

  Garrett flicks his pen onto the table, where it lands on their shift call list, spinning crazily in an arc that flicks among the diagnoses we’ve seen that day like some morbid game of spin-the-bottle.

  “Motor vehicle accident.”

  “Bicycle accident.”

  “Fall.”

  And, of course, “Cardiac arrest.”

  Garrett breaks the silence by asking me what I thought of Florence’s case.

  I say I’m not sure what he means.

  “What do you think about how it turned out?” he asks. “And what we did?”

  I’m still not sure what they’re probing for, but I’m beginning to get an idea. So instead of answering, I ask how they think it turned out. They see these cases all the time, I point out. They know better than I do what the possibilities are. What did they think? And then, because it seems like a little extra prompting might help, I ask them if they think they did anything wrong. That, it turns out, is exactly what they need to start talking.

  Garrett goes first, wading in with the studied intensity of someone who, I’m guessing, has spent a long time—and a lot of futile calls—thinking about what he was doing, and why.

  “We have to try,” he says. But as he says that, he’s also shaking his head with a strange intensity. It seems as though he’s trying to reconcile an internal disagreement.

  “That’s the thing,” he continues. “When we’re there, whether it’s a kid who’s choked on something, or an old lady with dementia and cancer in a nursing home, we have to do everything. Doesn’t matter. When we first walk in that door—hell, when the call comes in, mostly, we know what’s going to happen. It’s not like it’s a mystery. The choking kid? No problem. He’ll be fine. But the lady in the nursing home? No way. Never. We know when we get the call that it’s going to be a waste of time. But we have to do it. We have to go. And we have to go fast.”

  He’s not shaking his head anymore, and I can’t help thinking that, somehow, in that short explanation, he’s reached some sort of internal compromise.

  Jason has a slightly different take. He’s been tapping his fingers furiously on the tabletop for the past thirty seconds, like he’s waiting to have his say. But as he starts speaking, he’s not voicing an opinion so much as he’s trying out an idea. Thinking out loud.

  “Really,” he says, “people don’t want this, you know?” He looks at Garrett, who shrugs. Then he looks at me. “A lot of people don’t, anyway. They don’t want some stranger storming into their home, pounding on their chest, and doing all sorts of invasive things to them while their family is watching. They don’t want to be thrown in the back of a truck and carted to a hospital. And they sure as hell don’t want to die in an ICU, unconscious and connected to all those tubes and wires.”

  He turns to Garrett. “Remember that lady back about two mon
ths ago? The tomato lady?” Garrett nods and Jason turns back to me. “Same neighborhood as the call we just did. But a private home—big house. Older lady, lots of health problems. Collapsed in her garden one morning—she was out watering her tomatoes. So her husband called us. We did what we could and we brought her back, but she died in the ER. And you know what her husband said to me? He said he felt awful, because he was certain that if she had to die, she would have wanted to die right where she was, in her garden.”

  Jason shakes his head. “You see what I’m saying? A lot of the time we’re not actually letting people live any longer, we’re just changing how they die.”

  “And we’re giving them all kinds of hospital bills up along the way,” Garrett adds.

  I ask them about so-called out-of-hospital do not resuscitate (DNR) orders. The order is actually a form—like a living will—that a patient and doctor fill out together. It’s usually accompanied by a bracelet that tells EMTs and bystanders not to do CPR. But Garrett says they never see these forms. Do they see bracelets often? I ask.

  “No one wants to think about these things, you know?” Jason says. “I mean, you don’t think about it until you have to. . . .”

  “And then it’s too late,” Garrett finishes the thought.

  I think that’s a pretty good summary about the way we make most end-of-life decisions. We avoid making any decision until we have to, and often at that point we’re too sick to make a decision at all. Then our families have to make a decision for us.

  “But there’s no alternative,” Jason says. “Either someone says they don’t want to be resuscitated, or they’ll have us working on them. Those are your only choices.”

  Jason seems frustrated by this, but Garrett is more philosophical. “That’s just the way it is,” he says. “We can’t make the call. And I for one don’t want to. Wouldn’t want to. I’d quit before I took on that kind of responsibility. Make a decision in the field about whether to resuscitate someone? No way.”