Christmas (2)
The patient's ECG, which had been showing chaotic electrical activity, flattened into a straight line with a long, piercing tone right after the shock. I held my breath. Damn it. No pulse returned. The machine kept droning its grim, steady note. I charged the defibrillator again. Thump! Another shock. One second stretched into what felt like ten. Still nothing.
Should I start CPR again? That wasn't good. No matter how well you performed it, the longer a patient went without spontaneous circulation, the greater the chance of irreversible damage—
“We’ve got a pulse!”
Beep. Everyone in the room exhaled at once. Normal sinus rhythm had returned. Beep. Beep. Beep. The monitor settled into its steady rhythm, and soon spontaneous breathing followed. Blood pressure was still low but climbing toward normal range. Yet consciousness had not returned. Would it come back quickly, or had we already lost too much time?
We had cleared the immediate crisis. At least the most urgent one. That bought us a little breathing room to think. I pulled the ECG strip and studied it again. Classic myocardial infarction. Now what? We had kept the patient from dying on arrival, but treating the infarction itself was the only way to restore consciousness.
In the 1970s, acute MI management was still primitive. Aspirin was the cornerstone—modern coronary care revolved around it. Platelet aggregation drove most coronary events, and aspirin blocked that process. I remembered that tissue plasminogen activator existed to dissolve clots directly, but it hadn’t been invented yet.
Wait—there was something new this year. A machine for coronary angiography and intervention. Those procedures had only just begun in the late seventies. Stanford had received one this year, though I doubted anyone here had used it. I had, though. In a modern hospital you saw dozens a day. Back in Korea I had watched hundreds and performed quite a few myself.
Finally, a plan.
Christmas Day. Tragedies rarely arrive at convenient moments, and I couldn’t help thinking this one had chosen the worst possible time. Still, we had bought ourselves a few precious minutes with the return of circulation. I stood at the emergency department station reviewing the orders when Professor Edwin Alderman of Cardiology walked in. He looked across the room at my patient.
“Good afternoon, Professor.”
“I was watching from the back… You did well. Any neurological deficits?”
I nodded. The patient remained unresponsive, and the other signs were not encouraging.
“Doesn’t look good so far.”
The professor sighed. “Usually they don’t come back. When the vessel stays blocked the heart can’t pump properly, so blood flow to the body and brain drops. Most of them just drift off like that.”
A commotion erupted on the far side of the ER. Nurses were escorting a family member toward the bedside. I blinked hard, trying not to hear the raw sobbing that followed. It was still too early to give up. We had options left.
“Professor, the radiology lab has a fluoroscopy unit for coronary work, doesn’t it?”
“We have one of those?”
“It arrived this year. We can give aspirin to stop further clotting and use a balloon catheter to open the blocked artery directly.”
“Ah… that procedure.”
I nodded. “Yes.”
“Does anyone here even know how to do it? Coronary intervention is still experimental, isn’t it? It was only described last year.”
How to answer that? I scratched the back of my head. “I read about it.”
“You’re not going to kill the poor man, are you?” The professor exhaled, but his eyes said he wanted to believe. “We can do it.”
Professor Alderman looked deeply uneasy, yet he had no real choice. Letting the patient die without trying was not an option. “All right… If there’s one person in this hospital who could pull something like this off, it’s probably you.”
At least he had agreed. He gave me one last worried glance before turning away. There was no time to waste. Even if I wanted to think things through more carefully, every second counted. I grabbed the clipboard and headed for the bedside to obtain consent. Several family members were already waiting.
“Hello.”
Questions poured out like a waterfall. Please save him. Is this safe? Will he wake up? How dangerous is it? I started to speak, then simply raised both hands and nodded. The area around the bed fell quiet. Nearby, nurses were already preparing to move the stretcher.
“The situation is serious,” I said. “We’re going to attempt an experimental procedure. The sooner we start, the safer it will be.”
“What exactly are you planning…?”
“In simple terms, we’ll thread a wire into the coronary artery and open the blockage.”
“On Christmas, of all days… Please save him. He can still make it, right?”
“We’ll do everything we can. There’s still a real chance.”
Signatures were obtained. There was no time for lengthy explanations. We rushed the stretcher toward the radiology lab.
The procedure began in the radiology suite. After administering aspirin intravenously, we positioned the patient on the coronary angiography table. The professor let out another long breath.
“You’re sure you can do this?”
“The equipment is commercially available, at least.”
Professor Alderman still looked doubtful, but the catheters and fluoroscopy unit were real products with instruction manuals. Inserting the catheter and repairing the vessel was something only a physician could do, yet I had done it many times before. We donned lead aprons over sterile gowns and prepared the catheters. Everything was ready.
I accessed the femoral artery and advanced the catheter. Its tip soon reached the aortic root. Smooth so far. The professor stared at the X-ray screen with a deep frown.
“Did the book cover this part too?”
Now isn’t the time, Professor. I carefully maneuvered the catheter toward the narrow ostium of the coronary artery.
“Yes.”
“Where are we?”
“Aortic root. The coronaries arise just above the aortic valve. I’m going to engage them here.”
It was far more difficult than modern procedures. Contemporary catheters required far less skill. Still, progress was being made. Almost there…
“This is the left coronary ostium. Could you inject contrast, please?”
“All right.”
The professor pushed contrast through the catheter. The coronary arteries finally appeared on the screen. We could see the blockage.
“There… that’s it.”
We were almost done. I advanced the catheter gently until the balloon sat across the lesion, then inflated it. Click. The balloon expanded. We injected contrast once more. I watched the flow while waiting for the next heartbeat. One long second. The contrast moved freely through the vessel. Normal flow had been restored.
Professor Alderman pressed his fingers to his temple, unable to believe what he was seeing. Had he not been wearing a sterile gown, he probably would have rubbed his eyes. He had heard the rumors—the youngest Lasker laureate, multiple papers in major journals, the strange stories among the faculty about a resident who could read a brand-new CT scanner as if he had invented it himself. So it had all been true?
And now this—performing a coronary intervention that had only been described the previous year, a technique most Stanford physicians had never even heard of, let alone attempted. He was executing it with complete competence. It was almost demonic talent. Or perhaps “demonic” didn’t even begin to cover it. How on earth had he learned this?
Relief at the successful procedure finally allowed the senior physician’s mind to register just how extraordinary the situation was. The resident turned toward the ECG monitor with quiet satisfaction, as if to say, I told you we could do it.
The tracing that had shown a textbook infarction only minutes earlier was now markedly improved. Blood pressure had climbed to 120. It had actually worked.
“Coronary flow looks restored. Let’s see if consciousness returns.”
“Y-yes…”
“I expect it will, and soon.”
Even seeing it with his own eyes, Professor Alderman could not make himself believe what had just happened.