Michael Crichton: Five Patients

"There's a worse one coming," one of the troopers said. Moments later, John Conamente arrived, groaning. As his stretcher came through the door, one of the residents asked him what hurt. He said it was his shoulder and his leg. Conamente was followed by Albert Sorono, also on a stretcher, complaining of severe pain in his chest and difficulty in breathing.

By now the waiting room was filled with troopers and policemen. The families of the injured men had not yet begun to arrive. Hospital personnel who had not been informed of the accident but had noticed the cluster of policemen stopped to inquire what was happening. At this time, no one really knew the nature of the accident and there was widespread confusion about it; most people thought a plane had crashed at Logan. An inquisitive crowd began to gather in the lobby. The EW administrators were busy trying to get identifying information on the patients and also attempting to keep the passageways from becoming clogged. "We got seven more coming," one of them said over and over.

A few minutes later, another ambulance pulled up and Ralph Orlando, a fifty-five-year-old father of four, was taken off. He had suffered a cardiac arrest on the way to the hospital and closed cardiac massage was being given by a nurse, the first person who happened to reach him as he was taken from the ambulance. Orlando was wheeled in at a dead run; the massage was taken over by a resident. The patient was taken to OR 1, where full re-suscitative procedures were begun.

The routine of cardiac resuscitation is now so standard that few people realize how recent it is. The basic principle of closed cardiac massage was first properly described in modern times in 1960. (It had been described in the nineteenth century but was not commonly practiced.) Prior to that time, a cardiac arrest was almost certainly fatal. The only treatment was thought to be open massage, in which the surgeon incised the chest and squeezed the heart directly with his fingers. Although frequently successful, open massage rarely produced long-term benefit; one study in 1951 indicated that of patients who underwent open massage, only 1 per cent survived to be discharged from the hospital. That figure still stands; open massage is now a last-ditch effort only.

Closed cardiac massage depends upon the anatomical fact that the heart is tightly packed in the chest between breastbone and backbone. Rhythmic pressure upon the breastbone will squeeze the heart enough to produce a pulse. Direct open massage is therefore not necessary, and the hazards of this surgery are avoided.

The purpose of cardiac massage is to maintain blood circulation which, in conjunction with artificial respiration, provides blood oxygenation for the brain. The brain is the organ most sensitive to lack of oxygen; under most circumstances brain damage will begin after three minutes of circulatory arrest. In contrast, the heart itself is much more durable and can resume beating after ten or more minutes. But by this time, unless resuscitation has already been begun, the brain will be irreversibly damaged.

In some situations, mere compression of the heart is enough to start it beating again, but the massage is generally accompanied by a variety of other maneuvers to correct metabolic changes from the arrest. This includes the injection of Adrenalin, calcium, and sodium bicarbonate. The experience of the last decade, utilizing these techniques, has demonstrated that cardiac arrest is reversible to an astonishing extent.

The procedure for Ralph Orlando was the standard one: closed massage and artificial ventilation, with simultaneous injection of substances to correct metabolic imbalance. This procedure failed to induce spontaneous contractions of the heart muscle. Electrical defibrillation was then begun.

No one had any idea how long it had been since Orlando had suffered his arrest; presumably whoever had ridden with him in the ambulance knew, but that person could not be found.

Initial electroshock therapy failed. Using a long needle, Adrenalin and calcium were now injected directly into the right heart ventricle, and further shocks were administered. It was now twelve minutes since his arrival.

While this was going on, the rest of the EW staff was organizing itself around the other patients. One resident was assigned to oversee the care of each injured man. In the operating room across from Orlando, John Conamente was also surrounded by people. He was simultaneously being examined by the orthopedic surgeons, having intravenous lines inserted in both arms, having blood samples drawn, being catheterized, and being questioned by the resident, who stood at his head and shouted in order to be heard over the noise of the people working around him. The resident conducted a typically stripped-down history and systems review, which under normal conditions might take ten or twenty minutes.

The resident asked, "What happened? Did it fall on you?" (At this time, most people still did not know the nature of the accident, except that something had fallen on a group of construction workers.)

"Yeah," John Conamente said.

"Where did it hit you?"

"My leg."

"Where else? Did it hit your shoulders?"

"Yeah."

"Did it hit your head?"

"No."

"Were you unconscious?"

"No."

"Does your left arm hurt?"

"Yes."

"Your other arm?"

"No."

"Your right leg hurt?"

"Yes."

"You have pain anywhere else?"

"No."

"Your chest hurt?"

"No."

"Breathe okay?"

"Yes."

"Pain in your belly?"

"No."

"Pain in your back?"

"No."

"You ever been in the hospital before?"

"No."

"You ever had an operation before?"

"No."

"Any heart trouble?"

"No."

"Any trouble with your kidneys?"

"No."

"You allergic to anything?"

"No."

"Can you see me all right?"

"Yes."

The resident held up his hand, fingers spread wide. "How many fingers?"

"Five. I'm thirsty. Can I have a drink?"

"Yes, but not now."

By now the orthopedists had concluded their examination. Conamente had fractures of his left arm and right leg.

Out in the hallway, another group was working on Thomas Savio, who complained of difficulty in breathing, pain in his chest, and pain in his lower abdomen. He had a large bruise over his right hip. There was a possibility of pelvic and rib fractures. A laceration on his forehead, while bleeding profusely, was superficial. He was wheeled off for X rays.

Meanwhile, in OR 1, attempts at resuscitation were discontinued on Ralph Orlando. Half an hour had passed since his arrival in the hospital. The resuscitation team filed out to help with the other patients, and the door to the room was closed, leaving behind two nurses to remove the intravenous lines and catheters and drape the body in a sheet.

Out in the lobby, John Lamonte, one of the workers, sat in a wheelchair and described what had happened. He was the least injured of all the men, though he had fallen from a height of thirty-five feet. "We were on a scaffolding," he said, "building an airplane hangar. There were three scaffoldings, all about thirty-five or forty feet up. One of them blew down in the wind. It came down real slow, like a dream. There were about twelve people on it, and some underneath." As he spoke, he gathered a crowd of listeners.

Across the room, one of the administrators was telephoning the City Hospital for a woman, to inquire about her brother-in-law. He had been taken there and not to the General. The woman bit her fingernails and watched the expression of the man telephoning. Finally he hung up and said, "He's fine. Just some lacerations on his hands and face. He's fine."

"Thank God," the woman said.

"If you want to get over there, there are cabs in front."