"I really don't feel so good."

"Well, you don't look very good, either, Daddy." He was pale, sweaty, his voice strained. She turned off the interstate and headed toward the complex of hospitals located near the university. It was getting near rush hour and she was glad, as she accelerated through the turns, that the traffic was all headed the opposite way. She turned around to say something and saw her father slumped across the back seat. He wasn't breathing.

"Daddy!" There was no response. Should she stop the car, start doing CPR and hope someone would stop and help her or call an ambulance? Or should she drive, knowing that the hospital was close and her father could go without breathing for nearly six minutes before any brain damage would happen? In a second, she made her decision and floored the accelerator.

. . . . . .

When we hear a car drive toward the ambulance bay with its horn blaring, we know it can't be anything good: a drug overdose, a shooting or a heart attack, perhaps. The green van headed straight for the ambulance doors and slid to a stop. A young woman shouted for help, that her father was in cardiac arrest. I turned toward the secretary and told her to call a "code" for Trauma One then went to the car. Al, the medic, was right behind me with a bed and an ambu bag. We opened the van's side panel. Patrick lay on the seat, his skin a dusky color, eyes vacant. Al and I pulled him onto the stretcher. Others were here by now and we began pushing on his chest and giving him oxygen while heading toward the trauma bay.

What's the story?. . . Anybody hear what happened?. . . Respiratory's on the way. . . I got a line on the right, 18 guage. . .what's the monitor show?. . . what's the story on this guy? . . .he's fucking dead!, c'mon!. . . anything on the monitor?. . . what happened?

People are streaming into the room, wanting information, wanting to help. The physician grabs an endotracheal tube and intubates him, putting the plastic tube into his trachea. Someone then bags him (breathes for him), someone puts him on the monitor to see his heart rhythm, the senior resident assesses him and calls out orders, IV's are started. Someone has to do chest compressions to keep the blood circulating to his kidneys and his lungs. His clothes are cut off.

If you step back and watch, it's seems totally chaotic, but there is an order and a symmetry to the things that are done. Airway, breathing and circulation, the ABC's. It's always in that order. Give the patient a means to breath, deliver the oxygen, then see that blood is circulated so the oxygen can be used. Everything is done in support of the ABC's but it's done nearly simultaneously - nurses, physicians, techs, medics, all focused on this single patient.

"OK, let's shock him." says the doc.

I grab the paddles from the defibrillator. Someone else has put gel pads on his chest to help conduct the electricity. One paddle is pressed onto the right side of his chest, the other lower on the left. A long beep tells me the defibrillator is charged. I check to make sure that I'm not touching the patient or the bed and say "Clear!". Checking again that no one else is touching the bed, I then press the black buttons at the top of each paddle and the current surges into Patrick's heart muscle. His body tenses, the arms straighten, but it's not like the movies: he doesn't rise up off the bed. Nothing happens for a moment as we wait to see the results.

"Flat line. Once more at 300" The current is increased. Another shock and the results are the same. We settle in for the long haul. Most often we get patients who have been dead for many minutes or hours before they're even found. In those cases, the "code", the resuscitation efforts are basic and perfunctory. Patrick, in his earlier sixties, is fairly young, however, and we know he hasn't been down too long, What happens next is determined by how he responds. CPR continues, he gets IV medications, then another shock. And an amazing thing occurs -

"Monitor shows a rhythm!"

"Hold CPR! Got a pulse?"

"Yeah, I've got a good carotid." Patrick is back, though still unconscious. He has a blood pressure and we start to give him other medicines to stabilize him, but within moments, his heart stops again. It's a new round of electricity, CPR and drugs until he rallies again. This corporeal indecision continues off and on for nearly 45 minutes.His pulse returns yet again and we decide to bring in his family to give them a chance to say goodbye. It's taking him longer than most, but we know that his heart probably can't take much more of this.

His wife is there and, supported by Janice, she leans toward him, crying.

"Please come back, Pat'" she said. "Don't give up! Don't leave me."

She stroked his hair and held his hand. We stood to the side, watching him breathe and watching the monitor. Her grief shamed our sense of the inevitable, as though she could, by the force of her love and need, will what we could not with our medicines. When his heart stopped, we led her out and started CPR again.

"How long have we been going?" the doctor asks.

"About an hour, now."

"All right, let's give one more round of drugs and call it."

Another vial of epinephrine is cracked open and injected. A fresh tech moves in to do chest compressions. The click and whoosh of the ventilator keeps his lungs working. We're quietly waiting the order to "call it", to quit. I'm thinking about lunch. Al is wondering if has to tar the driveway tomorrow. Rosie is leaving for vacation in three days and remembers that she needs to pick up a few things from the store on the way home. The senior resident is thinking about his research project that's overdue. Outside the doors of Trauma One there is an entire ED full of living patients wondering what's taking so long.

"OK, check for a pulse."

CPR stops and hands reach for pulse points. The monitor, which previously showed the electrical signature of CPR, shows, not flatline, but a regular rhythm - a heart beat.

"I've got a good pulse."

"Any pressure?"

"Blood pressure is 108/50."

Patrick rallies again. But this time is different. He keeps a good pressure and his heart beat doesn't falter. We keep waiting for him to arrest again, but he doesn't - this time seems to be for real. We give the news to his family and transfer him upstairs to Intensive Care. We've all seen this before, though. He'll live for a few more hours, burn up a few thousand dollars worth of care before finally dying.

Except the next day Patrick is still alive. Not only alive, but breathing on his own, talking, smiling at his daughter and holding his wife's hand. Patrick is doing something none of us expected: he is sitting up in bed and looking not at all like a man who had been technically dead less than 24 hours earlier, After a week in Intensive Care and much medicine and evaluation later, his daughter drove him home.

Ninety-nine percent of all cardiac arrest victims brought into the ED never recover. Either their hearts are too far gone or they've been gone too long before anyone finds them. Even if CPR is begun instantly and done well, the old ED adage holds - dead is dead. Why were things different for Patrick? Our skills were just as good for the others who died as they were for him. Some people might say God didn't want him to die yet, but that does that mean God really wants all those others to die? Some fall back on the utterly meaningless "It just wasn't his time."

God's grace or dumb luck? Theories are attempts to rationalize the unexplainable. Maybe the real reason he lived is to amaze us with the unpredictability and tenacity of the human spirit; to remind us that, for all the things we know, there's that much more that we don't know.
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