When a Heart Stops

It was the summer of 1987 and the beginning of my last year of residency. Having easier rotations, I felt rested and wanted to earn some money. Northwest Emergency Physicians offered me a 24-hour shift at Moses Lake emergency room. It was a chance to earn good money and to travel to eastern Washington, the arid part of the state I had not seen since driving across the country 2 years earlier to begin my residency. Loving explorations, I accepted their offer.

The night before the journey my mind swam in excited and apprehensive thoughts as the minutes sped by. What cases would I see? Was I fully trained for my work? What were the people like in rural Washington? Finally, I dozed off. Three a.m. arrived before I knew it.

The lights of the city were low, and thick clouds covered the silent black Seattle sky. A cool breeze brushed my bare skin as I started my car and headed for the highway. I rolled the window down to wake up, rolled it up to warm up, and down again to feel alive and alert in the cold night air. After driving through mountain passes in total darkness, the soft rolling acres of farmland were a pleasant surprise in the morning light. Sprinklers filled the sky with a fine mist as cows grazed and tractors plowed. The Columbia River snaked through the countryside and I-90 stretched on forever.

I arrived at the small rural hospital just before 7 a.m. The staff greeted me warmly and gave a quick tour of the ER. They showed me their fully equipped treatment room, where the supplies were stored, and how to fill out billing slips. The nurse asked if I was tired from the drive and said, “It's usually quiet in the morning. Why don't you rest?”

I headed upstairs to the doctors' room for a nap. I was drifting off to sleep when the telephone rang.

“Get down here stat. We have a head injury.” Click. I shoved on my shoes, popped in my contacts, and raced down the stairs to the treatment room.

The scene was terrifying. One nurse pounded out chest compressions on a ghostly white boy while the respiratory technician squeezed the oxygen bag. I looked over my shoulder hoping to see another doctor. The hall was empty. I wanted to run away. The glaring hospital room with its whirring ventilator and anxious staff working on the boy filled me with dread. My heart and head began to pound.

“Page the pediatrician and the surgeon!” I shouted.

I placed my hand on the boy's cold wrist. I couldn't find a pulse. I came to my senses and started running his code.

I had never resuscitated a child before. This blond-haired boy looked about ten or eleven. Frantic—desperate—to revive him, I placed the paddles on his chest. The monitor showed a flat line.

“Everyone back,” I shouted and delivered the shock. His small body jerked. There still was no heart rhythm.

“Continue CPR,” I commanded. I recharged.

“Everyone back,” I said and delivered another shock. He jerked again. Still no life rhythm.

“Epinephrine,” I yelled. I called for intubation. The respiratory technician looked at me as though I were crazy. As air was pressed into the boy's lungs, half of it bubbled out of a huge crack in his skull. What could be left of his brain? I had to do something! As I watched his chest move up and down with the breaths delivered, I decided to start an IV line. Unable to feel a femoral pulse, I placed a large-bore needle into his cold, pasty skin, searching for a vessel. My needle came back dry. Maybe a subclavian! The chest compressions stopped me. I looked at the boy's outstretched form, then at the nurses. Three faces stared back at me. The senior nurse shook her head.

“What's the use?” I thought. I knew in my heart his soul had already left.

“You can stop now. Thank you for your help,” I said. Everyone sighed—except me. I felt a pain I had never known before. My chest felt empty, as if my own heart had stopped … . I thought about his family. I had to tell his parents that their son was dead. Too late, the pediatrician came running in. She took one look at the boy, looked away, and left. She did not speak to me. She was gone, leaving me alone in this sterile room filled with antiseptic solutions.

Finally, I asked for the story. There had been a car accident 20 miles away on I-90—that long stretch of road that seemed so romantic to me earlier this morning. The same morning a family of five left Spokane on a trip with their two daughters in the back seat (wearing their seat belts) and their son on a mattress in the back of the van. Mom was driving while Dad slept in the passenger seat. The mother dozed. The van veered off the road and rolled over, throwing the boy from the van. His father ran to him and held him until a motorist stopped and sped them to the nearest hospital. The ER staff moved the boy, who had breathed his final breath in his father's arms, into the treatment room and began CPR.

The child was dead on arrival, and resuscitation was a long-lost dream. Could another doctor have saved him? This was the first time in my experience that an unstable patient arrived without an ambulance, without EMTs calling out vital signs and IVs running, without any hope of success.

I finally left the treatment room. The father was waiting in the counseling room across the hall. I did not know how to share my grief or express the adequate sympathy for his loss. I went in. The boy's father was a thin, fairly young man, with dark brown hair just starting to gray. He looked up at me with pain in his eyes.

“I am Dr. Kasman. We did all that we could, but it was too late. I'm sorry.” He already knew. I gently touched his arm and asked if he wanted to see a pastor. “No, but thanks,” he replied as he stared at his hands. His wife and daughters would arrive soon.

“Let me know if you need anything,” I said quietly and left.

The staff now had several patients in exam rooms. I was it, “the doctor in charge,” and I had more patients to see. Work waited as sick patients peered out of their rooms. These problems were easily handled.

After I saw a few patients, the automatic doors opened and the boy's mother, heavy with fear and loss, walked in. She saw her husband and ran to him and asked if he was all right. They clung to one another and cried. They held each other without blame, sharing only their sorrow. I showed the wife and daughters to the counseling room and asked if anyone was hurt. The wife had a few facial lacerations. The girls were uninjured.

I saw more patients. When the mother was ready, she was placed in a room. She lay still on the examining table with tears welling up. She bit her lip and whispered, “I fell asleep.” I wanted to comfort her, but not finding the words, I busied myself. I numbed her skin with lidocaine and asked her to tell me if she was not fully anesthetized. She winced as I placed the first stitches but said nothing. She seemed to want to feel the pain. I injected more lidocaine to ease her physical pain.

“It's not your fault. I'm not here to hurt you,” I said. She bit her lip harder and wept quietly. She asked me to check her daughters. Both were scared and shocked but physically unharmed. They returned to the counseling room to wait for their grandparents.

More patients. Six hours had passed since this tragedy began. Still, I was numb. The nurses mentioned lunch but I had neither the time nor the desire. I saw more patients. Finally, the grandparents arrived. The grandmother was a short, white-haired woman wrapped tightly in a long gray coat. She looked at me with inquiring eyes. She could not bring herself to hug her daughter. (Or was it her daughter-in-law?) The tension rose. Someone had killed her grandson. Was it me or the mother? Fortunately, they brought their own pastor to comfort them.

I saw more patients. Shortly after 1:30 the automatic doors opened again and the family began to leave. The parents embraced their daughters as they walked into the bright afternoon light. The glass doors slowly closed as they left their son's body behind, taking only his spirit home.

As I write this now my eyes fill with tears … tears I could not release then. There were more patients to see. My ordeal might be over but the day, and the anguish, were not. In the 17 hours to come, I slept only 2 hours and saw 40 patients. A 20-year-old man walked in with his scalp lifted from his forehead after he had playfully jumped into a river bed that was too shallow. I secured his neck and applied pressure to his bleeding wound. I directed a nurse to start an IV as I clamped bleeder after bleeder. Finally I had the staff call a surgeon. The patient bled more; I clamped more. The surgeon arrived just as the field was dry. But now my ER was full. In the evening, a Hispanic migrant worker arrived in labor. Her only English was, “It's my time.” She was only 29 weeks along. I stopped her contractions and had her airlifted by helicopter to a high-risk neonatal center.

“Will it ever end?” I wondered. Another patient was placed in a room.

The pace slowed as the night dragged on. I sunk more stitches, tended more coughs, and treated more stomach flus. The police brought in a rowdy drunk. My body craved sleep. I no longer cared about the money earned. The dark hours passed and morning finally came. My shift was finally over.

Despite the bright sunshine, I had to struggle to stay awake on the drive back to Seattle. I thought of my own vulnerability as my eyes tried to close and stopped only one-half hour from Seattle to buy soda and candy to keep me awake until I safely returned home. When I arrived, I called my parents, explained I had just completed a 24-hour ER shift, and quickly said good-bye. As I lay on my bed and stared at the ceiling, I saw that beautiful young boy, cheated from Little League games, from being teased by his sisters, from fishing with his dad, and from his first-date jitters. I wanted to be held. I seemed to cry for hours. Warm tears ran down my face and neck as I wept. Finally, sleep won, trapping my sorrow for years.

Yes, I talked about the boy's death. I shared it with other residents and with faculty. In the even light of day, we discussed how the boy was already dead and how I had done all that was possible. We reviewed the steps to have taken if the boy had had a pulse: how to intubate him and how to protect his spine. We learned the procedure for defibrillating a child and how to start an interosseous IV when indicated. Everyone said I had managed the situation well. They gave me their best support.

But no one asked how I felt.

• Copyright ©2004 by the American College of Physicians