Following is an excerpt from Patient Care: Death and Life in the Emergency Room by Paul Seward, recently published on July 3 from Catapult. Seward, a debut author at 75, was one of the first wave of doctors in the country to specialize in emergency medicine. Patient Care offers medical professionals and interested readers alike a glimpse into “the unconditional compassionate care extended by a seasoned physician who put his heart and soul into every human encounter. A volume brimming with humanitarian lessons in medicine and life alike” (Kirkus Reviews). Each chapter explores ethical questions that spotlight the humanity of patients, nurses, coroners, pharmacists, and, of course, doctors—caring for their patients, and for themselves.
The Heart Is a Pump
1.
It’s a simple idea for something so miraculous.
When I began my medical school course in cardiovascular physiology, “the heart is a pump” were the first words the professor wrote on the blackboard, and I have heard them—and spoken them—hundreds of times since.
The heart is a pump. But it is not an ordinary pump. First of all, it is a pump that is made up entirely of muscle. Moreover, that muscle is unique. It is not like the skeletal muscle found in your arms and legs and other moving body parts. Nor is it like the smooth muscle found in your intestines, around your blood vessels. Instead, cardiac muscle is made of a special kind of muscle cell that is found nowhere else in the body.
Cardiac muscle cells do look a lot like skeletal muscle cells. The principal difference is that skeletal muscle cells line up together to form a long series of parallel fibers that all pull in essentially the same direction. They are designed to pull on bones and bring them closer together.
Cardiac muscle fibers are, for the most part, not attached to anything but each other. Instead of parallel lines, they form a branching web of thousands upon thousands of crisscrossed muscle fibers linked together to form what is essentially a hollow ball of muscle, inside of which are four separate chambers. That muscle, like the piston in a gasoline engine, is not designed to pull on those chambers but to squeeze them and make them smaller.
But how does simply squeezing on those chambers pump the blood around?
First, the squeezing of the heart muscle is not like the hand of a boxer, squeezing all his fingers at once to make a fist. It is instead like the hand of a farmer milking a cow, who squeezes the teat first with his index finger, then his middle and finally his ring and small fingers, to push the milk down and out and into the bucket.
Similarly, in the heart, the squeezing starts first in the two upper chambers—the atria—which thereby push blood into the two lower chambers—the ventricles. Then, when the atria have finished squeezing, it is the ventricles’ turn, pushing the blood out of the heart and on its way. Finally, just to be sure the blood goes in the correct direction, each chamber has a valve at the exit that opens when the blood pushes outward and closes when it tries to push back.
But why four chambers; why not just two? Because the heart doesn’t pump the blood in a circle—out to the body, back to the heart. It pumps it in a figure eight, with the heart in the center, exactly where the circles touch…. It’s as if we have two hearts pumping in two circles. One circle is to the lungs and back; the other circle is out to the body and back. But both circles originate from a single amazing ball of muscle.
Why amazing? It is not simply that its construction and mechanism permit this single small pump to push our entire blood supply through our lungs, then through our body and back again. It is also that, beginning well before we are born, it does that exercise approximately once every second for our entire life. That means that if we live roughly seventy years, our heart will have squeezed once a second, without a single moment of rest, considerably more than two billion times. If it were to stop for more than a second or two, we would quickly lose consciousness. If it did not start again within five or six minutes, our brains would die. We all know this. Yet like most everyday miracles, we take it for granted.
Until it doesn’t happen.
2.
My recollection is that he was fifty-three years old.
I don’t know why I should remember something so specific; perhaps it’s because he seemed too young to have such a terrible heart problem. After it was all over, I learned that until a few months prior, he had been perfectly normal and healthy. Then with no warning, he had suddenly suffered a severe heart attack, which, though he survived it, had left him with major damage to his left ventricle.
I also think I recall that he had required open-heart surgery on his coronary arteries—at the time a new and radical procedure. But that might be a false memory. After all, during our time together, I had more than ample time to look at his chest, and I don’t recall seeing the long scar that is the badge of such surgery.
It doesn’t matter. What does matter is that the damage to his heart left him with permanent and severe heart failure. It also left him with the knowledge that he was a prime candidate for further problems. It was as if one day a bomb had gone off in his chest, nearly killing him, and then had left another bomb ticking inside him, waiting to explode.
I didn’t know all that when he came in. When I first learned of his existence, all I knew was that the paramedics were bringing in a middle-aged male in cardiac arrest due to ventricular fibrillation.
At this point I’m sure I don’t need to review what we did on his arrival. Either I or the paramedics intubated him, IVs were placed, drugs were given, and the customary electrical shocks were applied, to defibrillate him.
Then suddenly, surprisingly, it worked. On the monitor, in place of the random jagged lines of ventricular fibrillation, we saw the orderly peaks of a normal heartbeat marching across the screen.
But that was all. The patient remained unresponsive and we could not palpate a pulse.
There is a name for this. It’s called pulseless electrical activity, or PEA. It’s not that uncommon a situation for a badly damaged heart. It means that even though the heart is capable of normal electrical activity, and therefore produces a relatively normal heart tracing, the muscle fibers in the heart are so damaged that they cannot contract strongly enough to pump the blood around. In short, the monitor looks fine, but the patient has no functional heartbeat.
What one does in that case is simple: resume cardiac compressions, then try to figure out if the reason for this problem is something that we can fix. Perhaps he isn’t getting enough oxygen; perhaps there is too much acid in the blood; perhaps there is fluid around the heart; or any of a number of things. So we started going through the list of possibilities. At that moment, I happened to be the person whose turn it was to do the compressions (they are hard work), so I started doing them again. That was when something totally unexpected happened.
He woke up.
His eyes abruptly opened, he began to move his arms, first up to his chest where I was pushing, and then toward his face.
I stopped chest compressions at once and grabbed his hands so that he could not pull out his endotracheal tube. Then I started to explain to him that he was in the hospital, that he had had a heart attack, that we had needed to put a tube into his windpipe to help him to breathe and . . . I realized he was no longer listening. Within a few seconds of my stopping chest compressions, he once more lost consciousness.
So I started them again. And once again he woke up.
It was obvious that he was awake. His eyes opened. He looked at me. His lips moved as he tried to speak, but he could not because of the ET tube. Once more, this time while continuing to compress his chest, I began to explain to him what had happened.
He understood me. I know that because over the next hour he nodded and shook his head appropriately (the ET tube still attached, as he was clearly on the brink of another full arrest, and I did not want to take the chance of not being able to breathe for him should that happen) as we talked about what was happening to him, what the possibilities were, and, ultimately, what we were going to do. I don’t remember if he signed the consent forms, but his nods and shakes were very clear.
He understood what was happening to him. The question was, did we?
Almost immediately it was clear what the situation was. The tracing on the monitor was normal; his heart was electrically normal. And—probably—it was contracting a little bit. Our best guess was that heart valves were opening and closing correctly, making sure that blood flowed in the right direction. And his lungs were working. All that the heart needed to do its job was a little more force. And that was what our chest compressions seemed to be supplying.
Even so, he was clearly living on a knife edge. Whenever we stopped—which happened once or twice more before we fully realized what was going on—he lost consciousness, became unresponsive, and stopped trying to breathe. If we had stopped for more than a minute or two, he would have died. But otherwise he was awake, reasonably alert, and not in too much pain. We gave him some morphine, for which he expressed gratitude. After all, not only was his heart muscle hurting from the heart attack, but we were pushing on his chest about once a second. His brain, his lungs, and the rest of his body were working fine. His only problem was that his heart didn’t work. And there was nothing we could do to fix that.
But there was one thing we could do. We could call for help.
I don’t remember making the calls, or who I talked to. I know that it was the larger of the two hospitals in Santa Rosa, a small city south of Ukiah, which had the closest major hospital. I must have spoken to the cardiologist on duty. I am sure that he was as surprised as I was at what was going on. But I remember being told that they would take him and see what they could do to help. They thought that perhaps an intra-aortic balloon pump might work. This is essentially a balloon at the end of a catheter that can be slipped into the aorta (the main artery coming out of the heart) via an artery in the groin. It can be made to inflate or deflate in time with the heart in such a way as to help the heart pump the blood.
But now we had another problem: how to get him to Santa Rosa? We knew that, however we did it, it had to be set up so that somebody could continue to do chest compressions nonstop all the way.
Our first idea was a helicopter. I’m not sure why that didn’t work out. Perhaps it was unavailable, or perhaps the working space was not big enough. Both could have been true.
That left only one other choice: the ambulance in which he had arrived. The paramedics were available; it was full of gas. All that was needed was someone to push on his chest all the way down.
That was going to be me. After all, he was my patient. He was my responsibility. I was legally the highest-level medical person present. I needed to go.
And I wanted to go. How could I not?
I have thought of that trip often since then. The distance was sixty miles or so down a winding road, and I think they did it in a little over forty-five minutes. During that time, I must have taken turns doing compressions with one of the paramedics, but I can’t be sure.
After all, my memory of that ride is not like a movie; it is like a photograph. I am kneeling beside the stretcher, my arms straight, and my hands on his breastbone, rhythmically compressing his chest. But I am not looking at my hands; I am looking at his face. He has reddish-blond hair. His eyes are open. They are blue. He is looking at me. I am talking to him, reassuring him, letting him know that I will not stop, that we will get him to Santa Rosa safely and that there would be experts to care for him, things that they could do. He is nodding, still looking at my face.
When we got there, he was still alive. They did take him to the ICU. There they did put in an intra-aortic balloon pump. And it worked: they were able to stop pushing on his chest, and they could take out the ET tube so he could talk.
He lived two more days. Later I learned that during that time, his family could see him, talk to him, and perhaps hold him. And they could say goodbye.
Paul Seward has been a physician for nearly 50 years, and has spent the majority of those years working in emergency rooms on both coasts. He is a graduate of Stanford University and Harvard Medical School, and did his internship and residency in pediatrics at UC San Francisco. Seward is an Emeritus member of the American Academy of Pediatrics and the American College of Emergency Physicians. Now retired, he and his wife live in Vermont.
Image, “Heart, illustrated as a pumping machine,” courtesy of Wellcome Collection
Homepage image, “Heart,” by George Kirtland, courtesy of Wellcome Collection
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