From a distance, the building could be anything—offices or a factory, out in the scrub north of the city. You can see it for miles as you drive down the two-lane road, with mountains in the distance and the big sky overhead. At night, lit up from one end to the other, it gleams like a ship at sea.
But it’s only up close that you can tell what it is—a hospital, built in the middle of nowhere, where the land was cheap. From the windows of its higher rooms, you can look a long way out into the desert.
The hospital is brand-new. It was built to lure the health insurance of the suburbs. But the projections were off, and the money has come in a trickle rather than a gush. So other calculations have been made, services have been cut, and now the hospital feels shiny and bright and strangely empty at the same time.
When I work there, as I sometimes do, I’m always wary. It’s part of the endlessly uneasy solitude of medicine in small hospitals.
He’d driven in alone, a large man in his 50s, with a belly and a white goatee and wide, faintly startled blue eyes. He wore clean jeans and a T-shirt. Chest pain. But he wasn’t gasping or sweating, or clutching himself. Instead, he looked nervous and shy, like a student suddenly called on in class.
“I was on the job,” he said, like an apology. “Something doesn’t feel right.”
Sometimes our bodies only give us signs, and ask us to guess.
A foreman on a road crew, a construction site on the outskirts of town. He didn’t go to doctors much.
They handed me his EKG.
EKGs are magical and uncertain. They have a long history in medicine. They’re from another era, when antibiotics did not exist and the heart seemed endlessly mysterious. Like x-rays, they are throwbacks.
In the deepest sense, our lives are electrical currents. Charged elements—sodium and potassium and countless others—flow back and forth across membranes with impossible complexity.
The heart, unlike the brain, is simple enough to invite understanding. It’s dumb and brutal, charging itself up again and again like a firefly.
All our hearts beat the same way. The impulse begins high up, near our throats. It flows down through the muscle, causing it to contract in a ripple rather than all at once. Blood is forced from the four chambers in an ancient and elegant order. All of this is reptilian, primeval, beyond the conscious mind.
By the late 19th century, the first tracings of the heart’s electrical activity were made. That initial curiosity led to a great discovery: when heart tissue is damaged, electricity flows through it in different patterns. Those patterns are distinct and leave tracings on a page that can reveal an astonishing amount of information to the practiced eye.
Ten electrodes are applied to the body in precise places. Each electrode measures the current between it and the other electrodes. Taken together, they record the currents of the heart in three dimensions. An EKG, most basically, is a two-dimensional graph of three-dimensional space.
After a while, when you’ve looked at thousands of EKGs, you forget the technicalities. You forget the answers to the questions they asked you on the tests. You just see the patterns, like familiar faces on the street.
I wasn’t sure about his EKG. It didn’t look quite right, yet it also didn’t look quite wrong. It’s another of the mysteries of EKGs: they are often opaque. They do not always reflect what they are supposed to reflect. Instead, they speak to probabilities rather than certainties, suspicions rather than knowledge.
I’m old enough to remember cartloads of heavy paper charts brought hours late from the depths of medical records, like books in a library. All those rows of files, all those x-rays labeled with the Dewey Decimal System and slid into thousands of paper sleeves—all gone, burned in incinerators, in the landfill, so many stories and terrors and struggles among them.
Now, of course, the records are only a few keystrokes away.
I entered his name and date of birth in the computer. I searched for him for a few seconds. But nothing came up.
Then a nurse cried out, and I turned.
He lay twitching and gasping on the gurney. A moment earlier he had been speaking to me.
Ventricular fibrillation is something you can tell at a glance. It’s a lethal heart rhythm, a tiny saw-toothed pattern on the screen. Instead of an elegant ripple, the current spins in incoherent circles, and the heart stops pumping. You have to act immediately.
A normal heart beating in real time looks like a machine. It has a prehistoric quality, glistening with yellow fat, deep and dark and red. I’ve held a beating heart in my hand a few times, and I’ve always been struck by the immense impression of strength it gives—a knot of muscle, bearing down again and again.
I’ve also seen ventricular fibrillation in an exposed heart. I’ve seen it in people who were shot and stabbed, when the surgeons have opened their chests in the trauma room. Opening the chest in the trauma room is a bloody rite of passage in surgery, and it almost never works. But it is exciting and stark and astonishing, and afterward, everyone feels as if they have done something profound, and they talk about it for a few minutes.
The heart trembles like a fish left on the bank too long. The impression is the same because the forces are the same: muscle, deprived of oxygen, shakes.
Defibrillation is an old trick, nearly as old as the EKG itself. It’s become famous—“Clear!” everyone shouts, as the lifesaving shock is given.
Shocking the heart fires all of its cells at once. For an instant, the slate is wiped clean. Then, one hopes, the inherent, mysterious, automatic nature of the heart will begin again on its own. It will charge itself up like an animal and try to follow the well-worn path it always has.
If the heart is too badly damaged, or too much time has passed, then the shock does nothing. Death comes quickly, and it looks painless. Its speed is both terrifying and reassuring because there is no time for fear or plans or regrets. Just a strange fluttering sensation, and we’re gone.
But if the damage to the heart is not yet too great, defibrillation can seem like the work of God. It comes down to the thinnest of lines, just a minute or two either way.
So we fumbled, and rushed for the defibrillator, and ripped up his shirt, and slapped the sticky electrical pads onto his pale hairless chest, and charged the capacitor as his lips turned blue. Everyone’s hands were shaking, and no one was entirely calm.
A shock from a defibrillator sounds like the crack of a tiny whip. It hardly seems electrical. The arms jerk; the body recoils. The body will do this for a while even after it’s dead. We shocked him, once. For a moment, the green tracing on the monitor above his head went flat, as all the cells in his heart went off together. And then, just like that, his heart started beating normally again.
The life flooded back into him. His face pinked up, and he began to blink. A few seconds later he was full of sudden strength, struggling to sit upright, ripping off the oxygen mask we’d put on his face. It was only then that we rolled him out of the cubicle to the resuscitation room, glistening and empty and full of equipment. Everyone—the nurses in triage, the nurses in the ER itself, and me—had been wrong. We hadn’t sensed the urgency at all.
“What happened?” he asked. “Where am I?”
I didn’t answer. I was paging the cardiologist. He’d looked okay. The EKG had chosen to hide the truth rather than reveal it.
At that time of day, during that particular week, a cardiologist was in the hospital doing elective cardiac catheterizations. The crew was there, the equipment was ready, no one had yet gone home. I didn’t have to call for a helicopter and wait those long minutes for the rumble of rotors on the roof, as time passed.
For the moment, poised between life and death as he was, the patient had raw emotional power over us. He had everyone’s complete and perfect attention. You know the stakes are real, and they fill you up. Later we would all forget about him, but that moment of power, when you are thinking of nothing else, feels pure and athletic and cleansing. It has a terror to it, but also a kind of joy, and it’s one of the privileges of medical practice, when the world is heightened and full of significance.
We gave him a drug that quiets electricity in tissue—amiodarone. It works a little bit. We gave him drugs that resist blood’s endless compulsion to clot—aspirin, heparin. They work a little bit, too. But he was having a heart attack in front of us nonetheless: an artery was plugged, and his heart could descend again at any moment. He needed an open vessel, and fresh blood to the muscle.
Another EKG. I stared at it. And it still didn’t reveal its secret.
The cardiologist walked in a few minutes later, introduced himself, and listened for perhaps 30 seconds. He glanced at the EKG, and he glanced at the rhythm strip, and then he shrugged.
“Okay,” he said, casually, to no one in particular. “Let’s take him.”
Take him. It’s one of the more resonant phrases in medicine. It means action, doing rather than thinking or debating.
The man lay there on the gurney, listening to the cardiologist go through the details in his practiced way—a catheter into his heart to open the blockage we suspected was present. The risks, the benefits. The form to sign. The minutes were passing.
“I don’t know,” he said. “I want to talk to my wife. Do I really need that?”
He scratched his chest, nervously and absently. I remember that—a man with blue eyes and short gray hair and a white goatee, scratching his chest. Why the gesture stood out to me I don’t know, but it did. It seemed human, I suppose, something I could understand. The electrodes itched, and he scratched at them without thinking.
He had no idea, I realized. He did not understand how much danger he was in. Everyone else in the room understood this perfectly. Only that man, bewildered, could not quite believe what was happening to him.
“There’s really no time for that,” the cardiologist said, and we all looked at the man in silence.
When that many eyes are on you, and everyone is waiting, and there are needles in your arms and lights above you, and drugs are running into your veins, almost no one can refuse. The fullest weight of authority is upon you.
“Okay,” he said, finally, and then he signed the form, and looked truly afraid for the first time.
“I want to call my wife,” he said. But no one answered. They just rolled him away, down the hall to the elevators, at a speed that suggested urgency without panic. That speed is distinctive and unconscious in hospitals. It’s a brisk walk, and you can see it at a glance.
My shift was only beginning.
Progress in medicine follows a predictable path. The first step is diagnosis. The second is the performance of treatment. The third is treatment that works.
The first two, inevitably, occur together. But we wait for the third, sometimes for hundreds of years.
So much of medicine is empty ritual. People live, and die, as they always have. The minor illnesses of life get better on their own. The terrible ones get worse. There are only a few moments, and a few conditions, where medicine earns the faith we want to place in it.
But often the knowledge is mystical. Blood, for example, changes color with every heartbeat. Venous blood, its oxygen consumed by the body, is a deep bluish-red to the naked eye.
The right side of the heart pumps venous blood back into the lungs, where it is transformed by the air we breathe. When blood pours out of the lungs into the left side of the heart, then flows through the aorta and its tributaries, it is scarlet again, full of oxygen and power.
The first of the aorta’s tributaries are the coronary arteries. Two little holes in the aorta, just above the aortic valve, one to the left, one to the right, each supplying a net of vessels that wrap the muscle of heart and keep it bathed in endlessly scarlet, oxygenated blood.
Those vessels are hardly larger than a straw. They are always working, because the heart is relentless and thirsty. And so they are vulnerable, and when they become caked by time, by modern life, as they narrow with plaque, which feels hard to the touch, like gravel rather than flesh, our lives begin dangling from them. If the plaque cracks and is opened by the current, the blood around it responds as it does to a wound.
It clots. It plugs the vessel. And in an hour or two, all the downstream muscle will be dead.
When I was a child, heart attacks could only be watched. Drugs were given that did not work. Blockages could not be opened. Hearts died, sometimes quickly, sometimes slowly, as everyone stood there, adjusting irrelevant drips.
But then in the 1980s, the third step came.
Cardiac catheterization is astonishing and delicate and beautiful. The thinnest of catheters, a little prehensile tail with an intelligent tip that bends and twists, is threaded through a needle into the arteries of the wrist or groin. It slides effortlessly, into the aorta, and finally up to the heart itself.
The heart beats, shadowy, on a black-and-white screen. The catheter is visible, inching forward, waving like a tendril in the current. The cardiologist is quiet and intent. All of the movements are gentle.
The catheter rises inside the aorta until it seems to be above the heart. But then it begins to bend of its own accord, following the arc of the vessel, descending toward the aortic valve. You can’t see the valve on the screen, or any of the details, because x-ray images are only moving shadows, confluences of light and dark.
The cardiologist injects dye from the tip of the catheter. It looks like squid’s ink on the screen. And then, a beat or two later, the coronary arteries leap out of the gray background as if lightning has struck. The vessels, for an instant, are exquisitely clear.
The cardiologist freezes the image and studies it on the screen. The vessels look like root systems, like deep and secret things.
That idea—the notion that a piano wire, threaded in from the groin, could stop a heart attack as it occurs—is amazing. The idea itself is simple. But it seems so alien and unlikely nonetheless.
Later that night, I looked the man up on the computer again. I’d heard from the nurses already, but I wanted to see the note, in black and white. The cardiologist had gone home many hours before.
And there it was—a branch vessel, on the back of his heart, precisely where the EKG was least accurate. A vessel little more than a thread, supplying a tiny amount of muscle. But as the dime-sized piece of his heart died, it acted like a spark in dry tinder. It began to fibrillate. All of the normal muscle around it lit up in an instant, and began fibrillating as well. The shock had saved him, and had given the cardiologist time to work.
The cardiologist had placed a tiny metal straw known as a stent across the blockage. The blood flowed once more.
The procedure had taken 23 minutes from start to finish. But the dime-sized circle of dying muscle became pea-sized, and then hardly more than a pinprick. His heart had barely been damaged.
I hesitated at the end of my shift. It was late, after two in the morning, and I almost went out to my car and drove home in the dark, because that’s part of it also—leaving behind the good and the bad alike in their facelessness. But that night I indulged myself, as if I were young again, and walked into the main hospital, the halls lit and empty at that hour.
The ICU was on the fourth floor. There were only a couple of patients, and a couple of nurses on duty. A hospital ward in the middle of the night has a kind of softness to it. It feels like patience; the lights are down, the sick are sleeping around you, the nurses are calm and awake, the bustle of the morning is a few hours off.
The lights in his room were low, the flat monitor above the bed lit up, red and blue, digital and silent. The curtains were open, because he was being watched, and I could see him through the glass door in the twilight. His head was on the pillow, his goatee visible against the sheets, his chest rising and falling easily. All of the numbers above his head were normal.
I was there more for myself than for him. I didn’t know him and would never know him. I felt no sense of pride or ownership or power. But as he lay sleeping, he seemed miraculous to me. He was alive because of distance and science and curiosity, because of the rational mind and the cold eye that we’ve learned to cast. It wasn’t warmth or empathy or faith or tenderness that saved him. It was luck, and the idea of the body as a machine. That, and the folly of a hospital built in the scrub a five-minute drive from the roadside where, on the given day, he’d worked.
Glory, like failure, like so many of the black stories, is private and small in medicine. But there are moments of breathtaking greatness also, and they too pass unspoken like ordinary days, and that night I was very aware that I was looking at the product of greatness. I thought of him waking up in the morning, blinking at the view, and I knew from experience that he might easily fail to understand how close he’d come, that like a child he might shrug it off, and never grasp or wonder, or recognize, and that when his ordinary life continued, it would seem as ordinary as ever. But these are the moments we cling to, and as time passes, must remind ourselves to cling to. In a few hours, he would walk out of the hospital under the big western sky with his life before him again.
As I drove home, I turned up the radio to keep myself awake and rolled the window down. It was a warm night, the stars were out, the hospital was lit up behind me in the mirror until it receded, and then I pulled onto the secondary road, and passed the Denny’s and the Taco Bell, until finally I was on the interstate itself, another set of headlights streaming toward the city.
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