We later learned this wonderful gentleman had volunteered to donate his Saturday as a chaperone for a group of New Jersey high school students who had come to perform their class play, The Wizard of Oz, for our hospitalized children, providing a little good fun and distraction from their illnesses. He was accompanying his longtime partner, a lovely woman who was one of the school’s math teachers and also assisting the senior class play director.
The group entered the elevator on the first floor and planned to exit on the eighth floor where they were going to entertain the patients. The elevator was very stuffy, packed with the students and chaperones. Our patient had taken a nitroglycerin tablet (for chest discomfort) before entering the elevator. When the elevator door opened on the destination floor, he fell face down in the elevator and stopped breathing. He never made it out of the elevator and someone started CPR immediately. The high school students exited the elevator, the hospital representative greeting the students used the elevator phone to contact the hospital emergency operator, and the elevator went back down to the first floor where we, the ER team, met our patient for the first time. He was in full cardiac arrest, without a discernable heartbeat. We continued CPR as we lifted him onto a gurney and wheeled him back to the ER. There, we quickly attached wires to leads taped on his chest to obtain an electrocardiogram (EKG) assessing his heart function, and placed a breathing tube into his main airway, the trachea, to provide rescue breathing.
We found him to be in ventricular fibrillation, the most serious of all abnormal heart rhythms. In V-fib, the heart muscles in the pumping chambers quiver rather than contract as they normally should, and as a result no blood is pumped to the body. We continued performing CPR, as well as giving him emergency heart medicines and using paddles to try shocking his heart back into a normal rhythm, for almost an hour. He repeatedly—at least ten times—would seem to have a return of a weak pulse, suggesting some return of a heartbeat, but it would last only a few seconds, and then quickly revert back to his life-threatening V-fib rhythm.
As the team leader of this resuscitation effort, I found myself to be in an increasingly difficult situation, despite having directed dozens of pediatric resuscitation efforts over my years in practice. Many of the nurses at the bedside had come to think that we had lost this patient, and that prolong-
ing a “futile” effort was becoming disrespectful of the (presumably) newly deceased patient’s body, as well as cruel to his partner, who was with us in the resuscitation bay the whole time all of this was going on. I was asked several times if it wasn’t yet time to “call the code,” meaning stop the resuscitation. But I had my doubts that it was time to let go. The recurrence of even a faint pulse, though very briefly, suggested some life was yet there in this man’s heart. And perhaps my hesitation was furthered by a sense of insecurity, given my relative lack of experience with treating adult heart disease, and yet being in charge of this situation.
Fortunately, one advantage of working on a team in a teaching hospital medical center is that we always have a variety of staff participating. We had already called our affiliated adult hospital next door, describing the situation and asking if any other approaches might help; they really didn’t have much more to offer. Still, I asked if one of the team there might be able to make the five-minute dash across the alleyway, and of course they offered to send someone right away. But just as we were getting closer and closer to ending the resuscitation effort, one of the bright young physicians-in-training who was already assisting us at the bedside had an idea. He was a resident in adult emergency medicine, assigned for a month to our children’s hospital to become more familiar with pediatric emergencies. Before coming to us, back at his home hospital, he had recently seen the senior physicians try a new drug to treat V-fib victims who were unresponsive to the standard battery of medicines. This new medicine was amiodarone, a drug that was rapidly gaining usage in the adult cardiology world and, as it happened, even by pediatric heart specialists for certain special cases. It turns out our cardiologists had arranged for amiodarone to be stocked in our hospital’s main pharmacy, but it was so new and reserved for such special cases that we did not even stock it in our emergency department yet! I didn’t hesitate once the trainee in adult ER medicine made the suggestion—what was there to lose? We rushed a request to our pharmacy, and within minutes it was “special delivered” to us in the ER.
Remarkably, our patient had a great response to the amiodarone. Almost immediately after the infusion was completed, he returned to normal heart rhythm, with a strong pulse and nearly normal blood pressure. This time, his improvement persisted, not relapsing to V-fib. Just then, our adult emergency medicine colleague from next door arrived and arranged for urgent transport from our ER to their cardiac intensive care unit. We all breathed a deep sigh of relief and hoped for the best. I still had the sense that several of my coworkers thought we had gone on too long, that surely after more than an hour of being kept barely alive by CPR, his prospects for meaningful recovery were dismal.
Later that day those fears were only heightened. I had dispatched one of our pediatric ER trainees to visit the cardiac unit next door to find out what was happening. She reported back to me that the cardiology team had immediately performed a procedure to diagnose the condition of the man’s heart’s arteries and expand a small balloon within them to improve blood flow. They discovered he had several severely blocked heart arteries and intended to take our patient directly to the operating room to try to surgically “bypass” his clogged heart arteries.
Alas, as per the cardiologists’ routine after a prolonged resuscitation, a comprehensive neurologic evaluation was done first, which revealed signs of massive brain injury. His partner later recalled to me that the heart surgeon arrived with another physician, introduced as the neurology specialist, who told her that “It was worse than they thought,” that likely not enough blood had gotten to his brain during the nearly hour-long absence of normal heart function, and that he had suffered irreversible brain damage. The neurologist cautioned her that the probability of his ever awakening was next to nil, and the heart surgeon had therefore decided he was no longer a surgical candidate.
I went home that evening with very mixed emotions. I had for a brief few hours believed we may have saved a man’s life, and I was proud of being “stubborn” about my instincts and refusing to quit the resuscitation. But now I was left to wonder if my decision, and all our efforts, had only resulted in a man having to “live” on a breathing machine, in a vegetative state. It did occur to me that during his resuscitation we had used multiple doses of powerful drugs for his abnormal heart rhythm, which often have a deeply sedating effect. I wondered if that might have impacted his later neurologic exam, yet still wear off eventually. But surely the neurologists had taken that into account.
And yet, despite this grim turn of events, the story of our Good Samar-itan volunteer had a happy ending. His partner never lost hope, despite the grim prognosis. She and other friends and family members kept a vigil at our patient’s bedside and applied several alternative medicine healing techniques to him that they felt comfortable with. He did require considerable traditional medical support for the first day or two, with multiple medications for his heart and blood pressure, as well as sedatives to keep him from “fighting against” the breathing machine that was keeping him alive. His heart function improved dramatically, and after being kept in deep sedation for several days, the cardiac care team let his sedating medications wear off, to see what would happen. Was there any brain function left?
To everyone’s amazement, he rapidly woke up! Soon, his doctors were able to take him off the breathing machine entirely. To this day, I have a picture on my desk of him sitting up in bed just four or five days after the ER encounter, with his loving lady by his side, her arms around him. They were home within two weeks. Six months later he thoughtfully came back to look me up and say thanks to all of us. We visited the resu
scitation room in our ER, met the nurses who’d been there that day, and then I took him back to the adult hospital next door to revisit that site.
We spent most of that afternoon together, and I had a strong impression that this man was intellectually 100 percent intact. He had a charming sense of humor, cautious optimism about his life to be, and a sense of wonder and gratitude for having survived. It also gave me the chance to tell him it wasn’t really me who saved his life. Rather, it was a cluster of small miracles, serendipitously aligning just in the nick of time. He suffered his deadly abnormal heart rhythm while in a hospital where there were many skilled health professionals only a few feet away. One of those skilled people, still in his training and on a most fortuitously timed tour of duty with us, happened to have used a new medicine none of us had experience with. That medicine was available right in our own hospital (if not quite yet in the ER) and accomplished what none of our efforts up to that point had been able to accomplish. In the years since, amiodarone has become a staple in the management of severe abnormal heart rhythms, but for us, on that day, it seemed heaven sent. And then, perhaps most miraculous of all, his “irreversible brain damage” wasn’t really irreversible after all.
This lovely couple both retired, and married, five years after these events. They wintered in Florida and bought a second home there a year later. They traveled the world, and he joined several barbershop quartet singing groups. He had the profound blessing of living to see three grandsons join the family, and to see his second son engaged. Then one day, eleven years after our story began, he quite suddenly felt dizzy for a few seconds and collapsed. He was gone, from a large brain hemorrhage. His manner of passing is one I’d venture to say many of us would choose for ourselves.
I’ve spoken with his wife since then, and she tells me that he always referred to those eleven years as his “bonus” time, and that he and she were very grateful to have had them together.
And I’m very grateful I was such a “stubborn” ER doc that day, and that the stars aligned just the way they did.
Date of event: July 2008
Please, God, I Have So Much More to Do
Benjamin Honigman, MD
As emergency physicians, we begin to form a mental picture of patients as soon as we get the ambulance call, well before the patient actually arrives in our emergency department. The typical image of a patient who has had a cardiac arrest is an older man, overweight, with a history of high blood pressure, smoking, and a sedentary lifestyle. Never did we imagine the ambulance bringing a buff eighteen-year-old football player from a local high school, a hometown hero who had already secured academic scholarships to college and hoped to also play football at a Big Ten university.
The young man was working out with his high school’s track team to stay in shape for his upcoming football season. After a vigorous workout in ninety-degree heat, which was his norm, he passed out. A classmate who was the first one to notice him lying face down on the grass saw that he was not breathing. He screamed for help and two coaches responded. Not only had he stopped breathing but he also had no pulse: a true cardiac arrest. How could this be—a star athlete in great physical condition?
But this was not destined to be his time to die. One of the coaches, a medical technician, began chest compressions and the other coach began mouth-to-mouth breathing. The second coach, retelling the events for a news-
paper reporter, said of his player in no uncertain terms, “He was dead,” and remembers whispering between resuscitation breaths: “No. No. No. You’re not going out like this.” The young man’s high school friend who was standing nearby told the reporter he prayed silently as well: “Lord, don’t let him die. He’s got a future. He never gives up. He’s a good person. He’s a role model.”
Because of his coaches’ heroism and skill, and the good fortune that they were present and knew exactly what to do when he went down, our patient started breathing again just as the paramedics and ambulance arrived.
The ambulance crew rapidly inserted an IV line (a tube for fluids and medicines) into his vein, placed him on a gurney, and lifted him into the back of the ambulance. He recalled praying in the ambulance as it sped away, “Please, God, I have so much more to do.” Moments later, his heart started beating erratically and he had to be shocked with electricity en route to the hospital to regain a normal heartbeat. Once again the skill of those around him saved his life.
Our young football star arrived at the emergency department in dire shape, with severe oxygen deficiency. His lungs had filled up with fluid, a potentially fatal condition called pulmonary edema, and he was nearly chok-ing on the pink frothy liquid that was coming from his lungs. It was clear that he was fighting for his breaths and fighting for his life.
We recognized that this was no routine cardiac arrest. Such an event in a fit young person requires immediate investigation for a congenital heart abnormality, something he might have been born with but didn’t cause problems until now. While we were waiting for the heart specialist to arrive, our patient asked me through his labored breaths whether he had HOCUM. HOCUM is an acronym for hypertrophic cardiomyopathy, an affliction that causes an en-
larged heart and takes the lives of many young people, especially athletes after exertion. I remember being taken aback by the insightfulness of his question, particularly coming at a time when he was struggling to breathe. How did he know about HOCUM? Our patient was clearly an aware and bright young man who had read tragic stories about young athletes dying on their playing fields. I believe he was trying to help us help him by suggesting a diagnosis, making sure we were thinking about heart conditions that are present at birth. HOCUM was certainly one of the abnormalities we had thought about, but we wouldn’t know until the heart specialists could do their sophisticated testing.
We used medications to treat the excess fluid in his lungs and rapidly transported him to the cardiac catheterization lab, where the heart doctors could do their specialized tests. These studies showed that he did not have HOCUM, but rather had been born with another type of heart abnormality. In his case, one of the heart arteries, the left coronary, opened into the aorta (the main artery of the body) in the wrong position. This location created pressure and cut off some of the blood supply to the heart. Our patient was rushed to the operating room, where he had an open heart procedure to correct the placement of this artery into a normal position.
He could have died at each step along the way that day. From the track where he collapsed, to the ambulance where he developed a potentially fatal heart rhythm, to the emergency department where the fluid in his lungs threatened to suffocate him, to the heart catheterization lab and the oper-ating room where potentially life-threatening emergency procedures were undertaken. Perhaps, as his coach had concluded, he even had died at one or more of those moments. But miraculously, at each of those stages, he seemed to have a guardian angel at his side directing skilled individuals who were at exactly the right place at exactly the right time to save his life. Why did his heart finally give out that particular day, near coaches skilled in CPR? Our young athlete had exerted himself on many occasions prior to this with no difficulty, often in workouts when no one was around. Why did tragedy not strike on a day when no one was around?
We later learned more about his background and the odds he had already beaten to even get to this point in his life. Our patient grew up in a poor home with the threat of gangs to deal with along the way. He had lived in foster homes and at one point in a homeless shelter. He became interested in sports and school and had outstanding mentors who cared deeply about him, guardian angels even before that fateful day on the track.
In his speech at his high-school graduation ceremony, our college-bound senior, the hometown hero, said: “There’s no such thing as a self-made individual. You do as much as you can, but you can’t do it all by yourself.”
For the complete newspaper story from which some of the
details and quotes were taken, see:
“Lord, don’t let him die.” J. Bunch, Denver Post, July 18, 2008; http://www.denverpost.com/ci_9916358
Date of event: 2015
A Bona Fide Miracle
Jeremy Garrett, MD
Teenagers make choices and take chances—some of them unwise. That’s what teenagers do. But on an unseasonably warm January day in the middle of a freezing winter, fourteen-year-old John Smith and two of his friends almost made their last choice ever. They decided to walk out on an icy lake.
At first things seemed great as the three posed for an impromptu picture with John’s cell phone that went straight to social media. In an instant, their joy turned into terror when, moments after taking the photo, the ice gave way and all three boys plunged into the frigid water. The boys struggled to hang on to the crumbling icy ledge. One of the boys eventually managed to crawl out onto the surface; the other two clung to the ledge as best they could. One was able to make it until help arrived, but the other, John, lost his grip and eventually went under. He remained underwater for fifteen minutes.
When the rescue crew arrived, they at first didn’t even know John was there. After rescuing his two friends, they donned protective gear, entered the water and began a search for John, probing the lake bottom with long blunt poles. Only days earlier, this same first-responder team had completed their ice-water rescue training. Miraculously, one specially trained paramedic felt a telltale thump with his probe; it was John. They acted quickly and retrieved the teen from the water. He was completely limp as they dragged him across the ice to shore, where they initiated cardiopulmonary resuscitation (CPR). Time was of the essence and they desperately continued CPR for fifteen minutes while transporting him to a local emergency room.
There, CPR continued with aggressive warming efforts for nearly a half hour longer, without response. As John remained pulseless, blue, without signs of life for well over an hour, doctors were about to stop resuscitative efforts and called his mother to the boy’s side. As she prayed loudly and fervently, inexplicably his heart started beating on its own. While spontaneous circulation had resumed, no other signs of normal organ function were present.
Miracles We Have Seen Page 15
