People - The Holders of the Hearts

This is a true story written by Christine K, telling of the first time she had to break the worst news to a patient’s loved ones.

His name was Marco: a 17-year-old soccer player in the ER with no pulse.

As our trauma team beepers went off simultaneously, I realized that this code must be the reason we heard helicopters from the OR earlier. It had to be. Surgeons are not usually on the Code Blue team but we were occasionally called in later for the complicated cardiac codes that need more: a cracked chest, extra lines, or bypass. And for children: anything less than heroic is unacceptable. 

After we broke scrub and grabbed our beepers, John (my chief cardiac fellow) and I quickly rinsed our arms at the scrub sink in the OR. My mind was racing with thoughts of what I would see, what I might have to do, what John would expect me to know, and, mostly, how we would perform the impossible, the improbable, the unlikely. That's what most people expect from surgeons, isn't it?

It seemed like it took 10 minutes, but we ran as hard and as fast as we could to the ER, getting there about 2 minutes after the call. It felt like slow motion as we burst through the back doors to the trauma bays. I could see all the bodies working on the boy, and the way all of their heads turned to us as we entered the room. I saw their faces change from expressions of numb exhaustion to expressions of relief, but also sadness and defeat. They’d clearly been working on him for quite awhile. 

As I got close enough to see past the bodies surrounding Marco, the first thing I noticed was the friendship bracelet on his right wrist. He’d had a choker, too, but it had been cut off by a pair of trauma scissors, as had his soccer uniform. He was handsome and muscular. I imagined he might be popular, one of the cool kids. 

I took all of that in as I looked for the usual evidence of how deep into the code they were. He had 2 peripheral IV lines and a central femoral line, all running fluids wide open. He was intubated and attached to a ventilator. I noticed a chest X-ray on the light box, with no abnormalities that I could see. The ER resident was doing chest compressions. 

John immediately asked the ER chief for code status. "Where are we with this kid, Rick?" He replied, exhausted and weary, with a quick summary: "He’s been through V-Tach, asystole, V-Fib, and then 3 short runs of normal sinus rhythm with a pulse. As long as 2 minutes. We've been through all of the ACLS protocol meds and I've started 3 different drips. We need to shock him again shortly. But that will make the 15th time I've shocked him. I just can’t get a sustainable, perfusable rhythm. Something isn’t right."

John took all this in with a deep sigh then quietly said to me and Rick, "Hold off on the juice and let’s get some internal paddles ready. We’ll open his chest. Keep the external compressions going for now along with the meds. Keep the vent settings the same. It doesn’t seem like we know how much time his brain was without oxygen. Let’s get some ice cold normal saline running through these large bore lines to decrease oxygen demand from other tissues."

Then with full command, he announced to the whole team: "This is the plan: everything keeps going as is for now, plus the cold saline, while Chris and I crack his chest. We all know that ER thoracotomies have a very low rate of success but that's our last option here today. Once we're in, we'll take over CPR with open cardiac massage and then cardiovert with internal paddles. If we get a rhythm...well, we all know what to do....our usual. And then he goes to the OR." 

So, I was thinking this: when is a good time to tell John that I've never cracked a chest on my own? I never got a chance to say it.

John stood before me, looking straight into my eyes across the patient, as I gloved up. "OK, Chris,” he said, “show me how it's done. Deep cut. 10 blade scalpel. Between the 4th and 5th ribs. Dissect the intercostal muscles with a Metzenbaum scissor. Slide your finger in between the ribs to see if you've entered the pleural cavity. Are you in? Yes? OK, run your finger the length of the incision to free up the tissues. Can you feel the heart if you turn your finger around?"

Yes. Yes, I feel his heart.

I knew what to do. I asked for rib spreaders and slid them into the incision I had created. I turned the handle and watched as the instrument spread the ribs apart, creating a wide open cavity that would allow us unfettered access to Marco's heart. I set the lock on the spreaders so that they would remain safely open.

Then John ordered, "Stop compressions." 

I knew that he wanted to see what the heart would do on its own. He and I stared at it. It quivered slightly. We looked at the monitor. There was no corresponding rhythm. John gently picked up Marco's heart and felt it. He closed his eyes and his face fell.

And I knew that look. 

When you work with someone 18 hours a day in a hospital, you become very close —a kind of close that marriage or friendship cannot describe or encompass. The hospital is an unnatural place where the best and worst moments of most people's lives are played out. We live there. We witness those moments. We participate in them, and we never discuss them. But we do draw each other closer in an unspoken intimacy that an outsider cannot penetrate.

So when John’s face fell, time stopped for me. I knew that he knew he had the answer. I stared at his eyes until he opened them. He stared right into mine and whispered, "Hypertrophy." My stomach dropped. I knew we would continue but there was little point in going on. John had diagnosed Marco with ventricular hypertrophy: a congenital disease of the heart that often causes athletes to die suddenly in the prime of their lives. The heart seems to be normal size but the muscle on the inside of the heart is too thick. As a person trains and becomes more and more athletic, their heart becomes thicker until very little blood can pump through the thickened ventricles.

John knew that the only chance this boy had would be if we got him onto bypass after we established a rhythm: a task that now fell to me. John came around to my side and placed Marco's heart in my hand and, with his hand over mine, showed me how to pump his heart with my hand to get effective, adequate compressions, but without puncturing the atrium with my thumb. I had only done internal cardiac massage once before and that was on a normal heart. Marco's heart was at least 3 times as thick as that.

As I started the cardiac massage, I kept an eye on the monitor to make sure that my compressions were providing a good sharp perfusable rhythm. John busied himself trying to get better central venous access so that we would be ready for bypass. Occasionally he took over for me when my arm started to cramp. 

It was amazing the number of people who had started to disappear from the room as we worked tirelessly into a second hour and Marco’s chances for survival plummeted. 

I had a singular purpose —to hold this boy's heart in my hand. Nothing else mattered. Everything else in my life had brought me to this. Marco would probably never know who I was but I was put there to hold his heart, to try to make it beat again. It stopped mattering that my arm hurt, or that I was hungry, or angry, or sad. I just kept pumping my hand. Open. Closed. Open. Closed. Open. Closed. 

But we knew we were losing. John couldn't get venous access. There just wasn't enough perfusion for him to get a line. In anger, he tossed the line tray across the room. I had never seen him so frustrated and defeated. "John," I said quietly, "we have to call this. He's only alive because of a vent and my hand. We haven’t had a sustainable rhythm in almost 3 hours.”

He had his head in his hands. Then he looked up at me...and with hard, sad eyes, said, "Time of death 6:07pm.”

The ER chief, Rick, came back into the trauma bay shortly after he heard the beeping of the heart monitor stop. He was surprised that we had tried for so long, especially after we discovered the hypertrophy. John asked if the boy’s parents were at the hospital yet. We learned that they’d arrived about 20 minutes ago and that they only knew what the soccer coach had told them: that their son had suddenly collapsed on the soccer field during a game and stopped breathing. But they didn’t know he coded. Rick told us that their English isn't that great and he was concerned about talking to them. That’s when I knew we would do it. John jumped in and said, "Let me. Please. I don't mean to step on your toes, but we had our hands on this kid's heart and I just feel..." Rick finished for him, "Like he was yours. I get it. No problem. Just let me know when you're done." John had one more thing to say, "You know, I have to let them see him. We'll clean him up, but they need to see him, so let your nurses know, please." Rick nodded, "Of course."

John and I worked silently and alone in that trauma bay for about 45 minutes. The only other person who came in was the janitor who mopped all the blood off the floor. We turned off the vent and removed his ET tube and the tape holding it around his mouth. We removed his IVs, his femoral line, his arterial line and all the tape holding those down. We removed the rib spreader and closed the thoracotomy site with large black nylon suture. We weren't worried about how this wound would heal. But we did place a fresh bandage over it.

At one point, John started to get impatient that it was taking too long and that Marco's parents would be anxious to talk to us. I made him look at me. I said, "Hey, this next 15 or 20 minutes is the last peace they will ever have in their lives. Meeting us will become their own personal hell, their "Before & After" moment. They will spend the rest of their lives wondering what Marco's last thoughts were, whether he was happy when he died, whether he was in pain at the end, whether he called out for them or not, whether it would have made a difference if they’d been there, if they could have done something differently, what his children would have looked like, and did they tell him they loved him today before school. Let's give them the next 20 minutes of peace. It's the last they will ever know."

"Yeah. Good point. Okay. Thanks,”John stuttered. The air was thick with the truth that I’d described, and a strange intimacy, as we stood next to each other, next to Marco, gently scrubbing dried blood from his skin with saline soaked gauze.

We took one last assessment. The blood was gone, the thoracotomy incision was closed and bandaged, all IVs were removed, the breathing tube was out, his bloodied clothes were off, the EKG leads and stickers were all removed. I thought that he looked strange with his socks on, so I took those off. John and I covered Marco with a fresh sheet, leaving just his head uncovered. Just as we were finishing up, I had a sudden and overwhelming need to cover him with a warmed blanket: no mother would want her child to be cold. I found one in the linen box and tucked it around him. 

We then closed the curtain and went towards the lobby where Marco's parents were waiting in a private family room.

There is no practice for this. There is no way to hide it. His mother saw me first and looked into my eyes. And, in that one glance, she knew. 

It's a sound that transcends all human cultures: the primal, visceral, keening wail of agony over the loss of a child. 

I still cannot understand how she was able to stop herself from tearing and ripping at her own flesh. I have learned over these years that some people do.

Whatever we had intended to explain seemed pointless now. Their son was dead. It didn’t matter how or why. They just needed to see him.

I led Marco's mother to the trauma bay. I held her hand. John walked behind us with Marco's father.

Before we entered the room, she fixed my eyes with hers and said, "How?" I touched my heart and then with the same hand opened in front of her, palm up, I made a squeezing motion, and said, "It stopped." I opened and closed my empty hand again, mimicking cardiac massage, and said, “I tried to make it start again. I couldn’t...his heart...couldn’t.” With wide, soft eyes, she asked, "You hold Marco's heart?" Tears slipped down my face as I nodded.

We waited for her husband and John to catch up to us. Marco’s parents joined hands nervously as John reached to open the curtain. And then the room filled with the piercing sound of despair and peace forever lost as she threw herself on Marco's body.

John and I walked slowly and silently out of the ER to collapse in a nearby call room. We knew the grief counselors and the ER staff would take over, handle the details, speak further to the parents, make arrangements, and take care of the scene. 

There are no counselors for the holders of the hearts.