by Ray Fowler, MD
Copyright Jan 1, 1988

(Time in Space Home)

            The "Code" announcement came without warning, as always. The usually calm voice of the operator over the paging speaker became strident, exclaiming "Code Blue, CCU ... Code Blue, CCU". In Emergency, we went to "instant on". Pulse racing, heart pounding, intense anticipation, and off down the hall like a shot; white coat blousing in the wind, sprinting up the stairs, off down the third floor hallway, past the worried family standing by the door: Into the unit.

            "Where is it?!?!" I bellowed as I jogged into the CCU, now fairly winded from the four flights of stairs, taken three at a time. "In here!", was yelled from around the corner in the unit, and on down to room 306 I ran.

            This scene had been repeated so many times that I could imagine it unfolding in my mind's eye. The acutely ill, struggling victim had given way to one who had stopped breathing and had no pulse. At this point the poor creature became limp and blue, lying back into the arms of the assistant that was trying to bring some measure of aid or comfort.

            Such was the case of Mrs. Washington. As I bolted into the room, she was stiffening, gasping, flailing her arms for a moment, and then lying slowly back on the bed, crushed beneath the squeezing weight of chest pain which was taking her life.

            It was in this scenario that I first met this old woman. The nurses were Nancy and Gwen, both tough veterans of many such events with me in Intensive Care. The patient was new to them as well as myself, a recent admission of the morning with an acute myocardial infarction, a "heart attack". The case was already a difficult one, the heart so weakened by disease that even with a pacemaker aboard, the strength of the heart's contraction was so weak that the blood pressure slipped away moment by moment. The staff had been waiting for and expecting the worst, and sure enough it had come.

            Briskly into this crisis we plunged. The initial responses by critical care specialists in such situations are simple enough. We gained access to her airway and breathed for her. She had no pulse. The monitor showed a paced rhythm. The pressure gauge indicated that the heart's impulse of contraction was almost gone. Solid, strong pressure spikes burst out of her heart when we initiated cardiac compression, and nothing remained to move blood from her heart when we stopped.

            It was the worst of imaginable situations. Mrs. Washington had had a long history of heart disease and was nearly seventy. She had had a pacemaker inserted years ago, and had sustained a heart bypass operation over a decade before. In a way, she had led the charmed life of someone preserved by the magic of medical technology, who'd been given a few more years to spend with her family; a few years of extra time that had been granted to her and her loved ones.

            As so often we've seen, the life of many patients has been prolonged by the grace of our modern technology, by the careful focusing on control of life style and habits, and by the pursuit of a state of grace and peace. With these elements cooperating in unison, many full and productive years of life have been added in abundance to those with proper pursuit of care, and the right amount of good luck.

            Yet, the horseless shay must, in time, crumble to dust nonetheless. When this tragedy comes about, as it must with all people and as it has in all times throughout history, it seems to me that the end of the life of those who have been specially preserved is quicker, more precipitous.

            Certainly for Mrs. Washington events had reached a frightful climax on this weekday morning. Feeling well the evening before, a full supper under her belt, she had had the fulminant onset of smothering chest pain that took her breath. The family, accustomed now to the extended length of life that she'd been granted, wilted before this sight of the patriarch of their family lying upon the sofa, gray, sweating, vomiting, and struggling for air. It took a concerted will for the daughter to dial 9-1-1 and call for help.

            Mrs. Washington had been brought to Emergency and thereon to CCU. Hour by hour, in spite of everything that had been done for her, she slipped away. This heart attack had ruined her heart muscle. Before this, her heart was a tight fist that squirted out a strong stream of nourishment throughout the body. Now, the heart was a shocked mass of mush that labored for each stroke in spite of chemical support and oxygen. By morning the cause was lost, and the nurses merely awaited the hour.

            In the short time that the girls in the unit had been given to get to know her, Mrs. Washington had been cooperative, sweet, deeply grateful, and scared out of her wits. These nurses are simply wonderful people, and they ministered to all of her needs, and, as nurses do, they also drew strength from the patient's own courage and resilience, from her own will to fight for life. And, even though they sensed that she was losing the battle, they hoped and feared and prayed right along with her. They were her support structure in these terrible few hours: This awful period in which she couldn't catch her breath or shake off this awful pain.

            She'd tried one last time to simply go to the toilet. The girls eased her up onto the pan, and as they held her in their arms, her heart lost its last strength, and she suddenly lost consciousness.

            I've worked so many hours with the staff of the CCU. They have such commitment to the cause of excellence. Every heart rhythm; every acute disease process; all medical crises of modern man: These they know. But, the right to care and the privilege of compassion still belongs to them as well. In this case, they were shocked and sobbing while we worked on the little lady.

            And for all this intense labor of this awful moment, we gained no ground. Her heart was flaccid, exhausted. While we did CPR, she would blink her eyes at us, her brain awake and sharp. And, when we hesitated for a moment, her eyes would glaze over. She was there, with us, and we couldn't do a thing for her.

            I did everything that I could do. I know all those books backwards and forwards, but I got them out anyway looking for anything that might help. The cardiologist gave me no solace on the phone. We were on our own.

            I went to the hallway to speak to the family. They were absolutely devastated by all this, and they took hold of my coat and leaned against me, sobbing. I told them I would do everything I could, but that they should go sit in the waiting room, hold each others hands, and pray that we would all have strength through this.

            I returned to Mrs. Washington's beside. Nancy, Gwen, and I labored along without success. After awhile, when we had nothing else to offer, when her poor, tired frame had made no sign of recovery for a long time, we ceased cardiac compressions, and watched for a final time as that bright light went out of her eyes. All electrical activity of her heart had already ceased. All that remained was for us to pass a few moments at her bedside and see that in fact all was as it was, that this sweet little lady had died.

            I get so saddened at such times. The brief period that exists when I know what the family does not is very stressful for me personally. I use this time to write on the chart, make my observations, thank the staff for their effort, and get up my courage to face the family.

            Finishing my notes, I stood up to go once more to Mrs. Washington's room. I approached the curtain quietly and was not observed by those within. And, as I leaned against the door frame, I witnessed one of those peculiar, special moments that are permitted for me to see.

            There at her bedside stood Nancy and Gwen. Nancy was stroking Mrs. Washington's head and speaking softly to her. Gwen held the old woman's hand and just looked at her face. Mrs. Washington’s eyes were now lightly closed. Their patient was still their patient, their new friend their new friend. Her grief was theirs, her burden their burden.

            They knew, as I have long known, that angels hover nearby in times such as these. The soul of the newly departed lifts up from the body as a mist that seems to still the air. And, as the spirit drifts away to infinity, those that are left behind help the spirit along the way.

            Yes, angels hovered near Mrs. Washington's bedside that morning: The angels in white standing guard beside her, and the angel that rose up on their strength.

            Thus strengthened myself, I went outside to talk to the family.