“New patient looks okay,” Baio said of Gladstone a few minutes later as he grabbed two chairs and led me to the back of the unit. “His wife is coming in shortly. Needs to wake up a bit, so I stopped the sedatives.”
“Got it, I’ll put in the order.”
“I already took care of it. Okay, let’s play a game.”
Our last conversation had ended with a shit-stained scrub top landing in my face; I shuddered to think how a “game” could turn out.
“A year from now, you’re going to be in charge of running a cardiac arrest. Dozens of doctors, crammed in a room, looking at you while a lifeless patient lies in the middle. This year you get off easy—you just do chest compressions or draw blood or put in an IV. But next year you’re the conductor.”
“Fantastic,” I deadpanned. Running a cardiac arrest was not a scenario that had been covered much in medical school. And perhaps with good reason—the mere thought of it would have given many of us nightmares. We had been more focused on learning and perfecting the basics of listening to patients and examining them.
“I’m going to throw scenarios at you and I want you to tell me how you’d handle them. Ready?”
I laughed. “I think we both know the answer is no. But…yes.”
“Okay, it’s six A.M., you show up for work and start checking on your patients. You enter a room and the patient is unresponsive. Twenty-four-year-old black girl. Go.”
He pointed at me, and I slowly exhaled. Beeping ventilators and vital signs monitors were momentarily ignored. “Unresponsive?”
“Unconscious, unresponsive. Whatever. She doesn’t move when you shake her. Go.”
“I suppose…I suppose I’d start with the ABCs.”
“Fine. She has a patent airway, but she’s not breathing and her heart’s not beating.”
I smiled, trying to buy time. “We should fix that.” My mind was in overdrive, desperately trying to draw on the events of the one cardiac arrest I’d witnessed at Massachusetts General.
“Indeed.”
“I would intubate her,” I said, “and start chest compressions.”
“Good, and can you do both of those things?”
“No. Not at the same time.”
“So…” he said, jutting his chin forward.
“I’d get help. I’d yell for help.”
“Excellent!” Baio patted my arm. “In this case, your inclination to react like a small child is correct. Everything in medicine is based around teamwork. Never forget that. So, what else?”
“I’m not sure.”
“You’ve started CPR, you’re giving her oxygen. But why would a young girl’s heart stop?” His green eyes narrowed slightly, focusing on me intently.
It shouldn’t, I thought. “Congenital something or other?” I offered.
“I said she was a twenty-something black girl. Does that help?”
“Maybe she overdosed?”
“Easy”—he laughed, leaning away from me—“not all black kids are on drugs.”
I was aghast. “No, no, no, I just—”
“I’m kidding—drugs are a reasonable thought. What would you do about it?”
“I could give something maybe to reverse the drugs.”
“Yes. Narcan. It’s incredible. Turns someone from a stuporous zombie to agitated and annoying in seconds. What if I told you she had a fistula on her arm?”
“She could have a kidney disease.”
“Go on…”
“Maybe she missed dialysis or maybe her electrolytes are off. I’d ask someone to draw labs. Maybe the potassium…”
He shook his head. “The woman’s heart isn’t beating. Do you have any idea how long it would take our lab to process her blood and tell us about the potassium?”
“No.”
“She’d be in the morgue before you had your answer.”
I rubbed my forehead. “Shit.” I had reached for the textbook again and the patient was dead. So when was I supposed to reach for the textbook? How could I know what to do if I didn’t know what to do?
“You have to be one step ahead,” said Baio. “Treat empirically. Assume her potassium is off and treat it. You have to be comfortable flying blind. And please stop grinding your teeth.”
“I’m trying.”
“Let’s do another. You enter the room, and this time it’s a banker that’s unresponsive.”
“What kind of banker?”
“I don’t know,” he said, waving his hand, “a banker. Shuffles paper around, makes a lot of money. A banker.”
“Let’s see,” I said, looking at the ceiling, “could be…cocaine?”
“Everyone’s on drugs with you,” he said, smiling, as he reached for a small carton of apple juice. “I like it. Keep going.”
As he took a large sip, a nurse sprinted in our direction. Her heavy footfall broke my concentration, and we both looked up as she reached us.
“It’s Ms. Franklin!” she said.
Baio stood up and reactively tugged on my sleeve. “Let’s do this,” he said, beaming, and started to sprint down the hallway. I followed him as quickly as I could. As we ran, he said over his shoulder, “Do everything I say. Everything.”
We quickly arrived at the bedside of an elderly woman on a ventilator. She was so frail and thin that you could make out the individual muscle fibers in her neck.
“What happened?” Baio asked a nurse standing at the bedside. Before she could answer, Baio turned to me. “Matt, disconnect her from the ventilator.”
A team of nurses went to work on the woman. “She just flatlined,” one of them said.
I looked at the breathing machine and my stomach turned. I suddenly had an overwhelming urge to move my bowels. Disconnecting a patient from a ventilator was a scenario I had only read about in medical ethics textbooks. Terri Schiavo came to mind.
“Disconnect,” Baio repeated calmly while reaching a hand under her gown and onto her groin, searching for a pulse.
I tugged the breathing tube away from the ventilator, but nothing happened. I tried again but still nothing. A nurse half my size lunged in front of me and pulled the breathing tube off of the ventilator in one quick motion as Baio rattled off a series of questions while assigning each nurse a specific role in the resuscitation. Someone began squeezing a bag of oxygen into her throat as I rapidly glanced back and forth at the flurry of activity, looking for something to do. Baio briefly closed his eyes while again feeling under the gown. “No pulse. Matt, start chest compressions.”
I positioned myself on the left side of the bed and placed one hand over the other. I had performed CPR dozens of times on Janet, the Mass General crash test dummy, but never on a human before. A moment of terror shot through me as I pondered the implications of my 190-pound body descending upon this 87-pound woman.
Baio sensed my hesitation. “Just accept that you’re going to break her ribs. Just do it. She’s dead. Let’s go.”
With the first thrust, ribs cracked as easily as uncooked spaghetti. “Aah,” I muttered. With my second compression, more ribs cracked. By the third compression, her chest cavity had become soft and I could feel the sharp edges of broken ribs under her skin.
To the nurse beside him, Baio said, “I will need one round of epinephrine and one round of atropine.” Placing his hands in sterile gloves, he reached for a large needle and again mashed on her groin, searching for a pulse. “Slow down, Matt, you’re pumping too fast. One hundred beats a minute.”
He began to insert a large tube into her pelvis.
“Staying alive,” he said.
“Yeah, she is…” I said, becoming short of breath.
“No, she is dead. But the song ‘Stayin’ Alive,’ remember? Do compressions to that beat.”
I didn’t remember because I’d been in the restroom earlier that day while the team discussed that chest compressions should be performed roughly one hundred times per minute. In the heat of the moment, it’s nearly impossible to keep track of the pace, but the Bee Gees’ song “Stayin’ Alive,” which happens to play at 103 beats per minute, could be used to help keep the pace.
“Stop chest compressions,” Baio said firmly.
I stopped and caught my breath. The patient’s chest was sunken where I’d been pounding away. We looked at the defibrillator monitor. I desperately wanted to do something else, anything. I was not ready to see the second patient I’d touched die in front of me after I cracked her body open performing chest compressions.
“The monitor shows a heartbeat,” I said between breaths.
Baio placed his hand on her neck. “No pulse. Resume compressions.”
The heartbeat I’d seen was not really a heartbeat, rather something called pulseless electrical activity. Her heart was spasming as electrical currents raced across cell walls; to the inexperienced eye (mine) it would appear like beats on a heart monitor. But without a pulse there was not sufficient blood flow to the body. Baio was right: CPR had to continue.
I resumed my assault on her chest cavity as a nurse injected one medication after another into her. The sharp edges of her broken ribs felt like they were about to slice through her skin.
Baio kept his eyes trained on the monitor. “Hold compressions, and Matt, feel for a pulse.”
I placed my hand on her neck and felt nothing. My heart sank. “I don’t—”
Baio simultaneously felt the other side.
“Oh, yep”—he smiled—“there’s a pulse. Congratulations. You just saved your first life.”
He moved my hand several inches higher, where indeed, there was a vigorous, bounding pulse.
“Holy shit!” I said as we locked eyes.
“Holy shit, indeed. Now, put her back on the ventilator.”
This was it. After years of preparation, I had just helped bring someone back from the dead. My heart raced, and I could feel my own pulse pounding through my neck. This was the sensation I had been seeking, the one that was missing for me in surgery. Granted, I had done exactly what Baio told me to do, and it had involved damaging the patient in ways that seemed to create a new set of problems, but she had pulled through. She was stayin’ alive, and would live to see another day with her spouse, kids, whomever. Medicine was messy, but it was fucking incredible. As we stood together at the bedside, I looked over at Baio with a measure of pride. He seemed to sense this.
“You know,” he said, patting me on the back, “there is nothing more rewarding than bringing a ninety-five-year-old demented woman with widely metastatic lung cancer back to life. Well done.”