As people streamed into the room to help with the code, Posey’s heart monitor changed from ventricular tachycardia to ventricular fibrillation. The monitor bonged more rapidly with the change in rhythm, and the numbers began to flash red with each bong of the alarm – to show to the senses an elevated urgency.
Ventricular tachycardia was a bad rhythm, but at least it was organized and trying – ventricular fibrillation was just a bag of wormy muscles just trying to get out of the bag to run amuck alone and without a plan.
The treatment for both arrhythmias were the same – shock and awe, better living through electricity.
Just as the heart is divided left and right, it’s divided up and down as well. The upper chambers of the heart are the atria’s, the waiting rooms. Low pressure, and fairly thin walled (left thicker than right) they are the areas where the blood pools before getting passively sucked, through the opening and closing of valves, into the ventricles -- which then do the actually work of pumping – or contracting.
The sino-atrial node is where the pathways that conduct the electricity that’s used to initiate the contraction are located – it’s between the upper and lower chambers. When the impulses that go up get irritated or blocked, you get atrial arrhythmias -- when the pathways that go down get irritated or blocked, you get ventricular arrhythmias. They are both caused by the same kind of problem, but the consequences are much different.
If you lose the function of the top chambers of the heart – the atria – you lose up to 20% out the output. If you lose the bottom chambers, you die.
Ventricular tachycardia after a heart attack usually happens because of irritability – the leaks of acids and other poisons from the dead areas of the heart cause inflammation and irritability, making the trigger threshold for ventricular tachycardia low.
Imagine the heart as an organized group of drug addicts – all in acute withdrawal. The addicts are all lined up for a race, and all scheduled to start when the green flag starts. The prize for winning the race is a bag of dope.
It’s that kind of irritability – and individual muscles either irritated by leakage or just poisoned by floating debris, tend to jump the gun and the race from an organized starting point becomes a free for all. But in ventricular tachycardia at least most of the muscles are aiming in the right direction.
Ventricular fibrillation is like that, but everyone’s a winner, and they get the bag of dope before the race starts, so when it starts, no one can know which way they might go.
Electricity, though untested as a treatment program for drug addicts, works wonders on heart muscles. Like a cattle prod, it gets their attention and allows them to take a time of quiet, stunned reflection and then restart in unison as a happy and coordinated whole. Make no mistake though, they may be lashed together and working as a chain gang as they contract, but they are still individual cells that are mighty pissed off.
Posey’s heart arrhythmia was approached in two different ways. I immediately got the defibrillator charged to its maximum, and after spreading conductive gel on the usual spots on his chest, I shocked him with the paddles three times in rapid succession. After each shock, I checked the monitor – after the third shock, he converted to a normal rhythm -- although it was still crazy fast.
Another nurse gave him an IV injection of Lidocaine, while still another mixed up a solution of it and hung it from an IV stand and plugged it into a stopcock connected to the central line.
Lidocaine is a member of the ‘caine’ family – you may know other members of the family better – Cocaine and Novocain. All of them work the same, though some are more fun than others. It’s all about side effects.
Lidocaine numbs things up, and when given internally through an IV, it numbs up everything it comes into contact with. When it gets to the irritated parts of the heart, it numbs them up as well. The cells are still irritated and pissed off, but stop complaining because they can’t feel anymore.
There are side effects – sometimes it numbs the brain up as well and makes people stupid, and sometimes, when the levels get too high, it becomes toxic and starts killing the cells instead of numbing them.
And, it’s a cover up – it doesn’t fix anything, it just hides it, and when it wears off, the problems it was covering up roar back with a vengeance.
When the rhythm changed after the shock (defibrillation) the other nurses and doctors who had come in for the code began to drift off. The Balloon pump began hissing again more regularly and the franticness of the monitors alarms and flashing lights dimmed. I was left in the room with Dr. Lee, and a big mess.
I stood there and considered things. Posey lay in front of me on the bed, motionless and covered with goo. Blood was splattered in small splotches, and all the splotches could be traced to different causes. His heart rate was 120 beats a minute, and his blood pressure was 90/40. He had no spontaneous breathing – the ventilator was doing all the breathing for him. Hanging from his central line were medications – all maxed out at their maximum dose, and as I looked at them, I could think of nothing more to add that would help.
I stood there and looked at Posey and had a moment of clarity. I had no idea what to do next.
Without the clarity, I would have started something – cleaned him up, adjusted the lines or documented events in my notes. In the clearness of the moment, I found myself seeing the big picture – that it was over and that he was gone, and everything I did from this point on was just going to be a mechanical grinding – a going through the motions movement of wasted time, and compulsive busy work to keep me distracted and unfeeling.
I’d like to say that this made me do something I didn’t do. I’d like to tell you a tale of acceptance and loss – that I used the moment to reflect on the man who laid in front of me, of his life and the loss of it. I’d like to tell you I said goodbye and left him go.
I turned to Dr. Lee and said, “How about Dr. S. – is he available?”
I remember that Dr. Lee looked at me in the same way that I had just finished looking at Mr. Posey. You could see in his eyes that he was having his own moment of clarity, and that this clarity was about me. In that moment he was having a complete change in how he saw me – my motivations, fears, and seriousness. He saw that I not only cared, but, perhaps, that I cared too much. In his eyes, I saw that the thought seemed repellent to him.
Our relationship, Dr. Lee and myself, was based on distance. Neither one of us got too close to our patients, we both maintained a distance from them, and we both felt that our real skills came from maintaining this distance. Lee knew from his experience with me, that I could walk away from death without looking back, and that my caring ended when I walked out of a patient’s room to go home at night. He knew that I showed neither empathy nor sympathy for my patients, and that I treated them as a professional, and not a friend.
When I asked him about the availability of Dr. S., he knew what I was really asking – for him to call Dr. S and get him to come in and do something – something interventional – something surgical and drastic. I was drawing a line and asking him to step over it with me.
Dr. Lee looked at me for a long minute, then turned away and picked up his lab coat from the linen holder, and walked out of the room. He didn’t say anything to me as he left because he didn’t need to. I knew he would make the call.
Dr. S was a cardiac surgeon who worked with another cardiac surgeon, Dr. R, in a two-man practice that contracted with several hospitals in the area.
Dr. S was from Australia, and was obvious about it. He was what I called a slash and burn surgeon – the best kind as far as I was concerned. He saw things simply, as problems and solutions – you saw the problem then applied the solution. He saw no complications – he was too busy addressing problems.
And he also had a cute way of using the word ‘mate’ as a pejorative, and was married to a beautiful nurse who treated him like something found on the bottom of a shoe.
His partner, Dr. R, was from Texas, and gay. Dr R walked, talked and wore boots like a Texan. He also flirted with the female nurses shamelessly, like all surgeons are wont to do, but always stopped before sneaking away with them for torrid weekends of sex and other thing’s debauched. He was as big as all of Texas, except for the gay thing.
The fact that S was a cuckold, and R was gay, were not something any of us on the unit talked about, except in whispers and giggles when they were not around. Back then, neither of these parts of their personalities were considered fashionable or trendy, and if made common knowledge they would have severely impacted their ability to practice their skills or make money.
Both of them were good surgeons – fast, meticulous and detail oriented, all things you want in a cutter. In cardiac surgery, you wanted all three skills, but speed was the key. Both Dr. S an R got in and out quick, and their patients did much better because of this.
When I asked Dr. Lee about getting Dr. S to see Posey, I didn’t do it randomly – he was the guy I would have used if I need surgery. I wouldn’t want to sit around a room and discuss great literature with him, unless we were drinking, but, like a master mechanic, he had the goods when using his hands to speak for him. He was an artist in the operating room.
There were other cardiac surgeons that I worked with that didn’t have the goods. Dr. Cat was one – he had sausages for fingers, and a brain that ruminated on several levels of meaning before instructing his hands to move. He was slow and clumsy, and these things were not attractive in a cutter.
Dr. Cat was a great talker and teacher; he would spend hours sitting at the nurse’s station explaining the latest in medical thought. Most of his talking came in the form of lectures, complete with footnotes, pauses and summary statements, but it was all interesting stuff, if that was what you were interested in.
When I first heard the word pedantic, and then looked it up in a dictionary, I thought of Dr. Cat – but with affection, not derision – He wasn’t phony with his talk – it was clearly the way he processed thoughts and organized information.
I liked him, but hated taking care of his patients after he operated on them – they spent too much time on the by-pass machine, and leaked too much after coming back, because Dr. Cat tied poor sutures with his sausage fingers and took too long when doing it. A great person but a poor surgeon – he needed to focus on things that involved more talking and less cutting.
There were other cardiac surgeons available, but all had weaknesses, and none had popped into my head when thinking about Posey. Dr. B was female, and you just knew she had to be good to get where she was, but had an unfortunate combination of attention deficit disorder with obsessive-compulsive tendencies. She was also slow – molasses slow, and had yelled at me more than a few times, when yelling at me once would have been too much.
Dr. M was adequate – he seemed up to date with his knowledge, and used all of the latest and best techniques, but his patients all did poorly for some reason and I had my doubts about him because of this, and the way his eyes looked at something distant when he talked to me.
When you got Dr. S, you got Dr. R with him – they worked together like a well-oiled team. The only time that you got one without the other was when they took call at night – one would be available to answer questions, while the other did whatever they were rumored to do, in the privacy of their own, and expensive, home in the foot hills.
They were like the cartoon classic, Heckle and Jeckle, when together. You knew abstractly that they were different, but couldn’t tell which one was which when they were standing next to you. They had different personalities, and each took different roles in the conversations they were part of, but it was never clear who was who or what was what. They fed off each other in this way – completing the others jokes, cutting what the other held out to be cut – all without asking or apparent discussion.
I knew that Dr. S had several patients on the unit – one of them had coded a few hours earlier when I came in. I figured he’d be in to see Posey fairly soon, and spent some time trying to figure out what I’d say to him that would make the difference. Without surgery, there was no hope for Posey, but I kept telling myself that with surgery he might have a chance.