From our former colleague at Yale, cardiologist Barry Zaret MD, in the January 2009 edition of Psychosomatic Medicine, reads like a medical thriller:

In February 1997, I began a 4-month sabbatical leave from Yale School of Medicine where I had been a faculty member since 1973 and Chief of Cardiology since 1978. At the onset of this leave, my wife, Myrna, and I traveled to Spain where I spoke at a medical meeting. The meeting was held in El Escorial, about 30 miles from Madrid.

After the meeting, we traveled with some friends and colleagues to Madrid, to view El Greco, Velasquez, and Goya in the Prado and to visit the Reina Sofia, Madrid’s modern art museum, which now houses Picasso’s famous Guernica. Guernica had been in New York City at the Museum of Modern Art from the beginning of World War II until 1981. As dating college students in New York, Myrna and I spent hours sitting in the museum admiring and studying this large mural, done only in black, white, and shades of gray. Picasso had painted the mural for the Spanish pavilion in the 1937 World’s Fair. The subject was the bombing done by Hilter’s air force on behalf of General Franco against the civilian population of the small Basque village of Guernica in northern Spain. As only Picasso could, he depicted the horrors of war: its agony and isolation, the depth of human suffering, the depravity of man’s murder of man, and the search for light as it dramatically clashes with an all encompassing darkness.

Seeing Guernica again was like meeting an old friend after too many years of separation. The joy of reuniting triggered a Proustian cascade of memories: remembrances of courtship, early love, and also sitting on the low-lying bench in front of the mural that always led to back pain. Our friends and colleagues loved seeing Guernica—but for them, this was art appreciation and esthetics; for me, Guernica was recapturing and reuniting with events of almost 40 years ago.

From Spain, Myrna and I traveled to Israel where I gave several lectures. We also had the opportunity to spend a brief time with close friends and family. In addition, 3 days were set aside for painting together with my Israeli artist friend, Avner Moriah, in the Judean Hills. The trip ended all too quickly; but there had been enough time for emotional replenishment. It was now time for us to return to Connecticut. It was time to make ready for Purim 1997, the most eventful Purim of our lives.

I have long been fond of the holiday of Purim. Purim celebrates the saving of the Jews of ancient Persia as they faced the threat of genocide. The imminent slaughter was organized by the King’s evil Prime Minister, Haman. The heroes of the story are Mordechai and his niece, Queen Esther. Although Purim is not considered a major Jewish holiday, it is widely celebrated and its survival theme remains relevant today.

The celebration of Purim in the synagogue service is filled with merriment, boisterousness, and gaiety, the stamping of feet, and the whirling cacophony of noise makers when mention is made of Haman, the holiday’s villain. Costumes are an important part of the holiday and are worn by both adults and children. There is a wonderful admixture of frivolity and happiness combined with giving to others and charity to the poor. The overall giddiness of the celebration is embodied in the Talmudic instruction to drink alcohol, even to excess so that one cannot distinguish between the evil villain, Haman, who is cursed, and the righteous hero, Mordechai, who is blessed. But Purim also commemorates exile, isolation, bravery, and the miracle rescue of an entire people struggling to survive in the face of seemingly insurmountable odds favoring total annihilation.

Over the years, Myrna had brought me much closer to Purim, as she had to all aspects of Judaism. In her role as ritual coordinator of our large suburban synagogue, she played a critical role in organizing the Purim service, reading during the synagogue service the Purim story as it is written in the Scroll of Esther (Megillat Esther), organizing the party that followed, and coordinating the costumes that she, the rabbi, and cantor wore during the festive and rollicking evening service.

Purim of March 1997 would be different from all others. I would soon learn how important it would be to distinguish sharply between the cursed and the blessed and to act with a speed and focus that could not be lessened by drink or fatigue or defocused by celebration, jest, or unbridled merriment.

For the 2 weeks after our return from Israel, Myrna did not feel well. Her symptoms were nonspecific and generally vague. At the onset, it was more a sense of fatigue, attributable perhaps to time zone readjustment after a long trip out of the country and the undeniable psychological letdown experienced after high-quality international travel. She also complained frequently of headaches and earaches. These symptoms were often severe, but again quite nonspecific. She would often get ear infections or sinusitis, both of which could easily be responsible for the symptoms.

At the synagogue, plans for Purim were solidified. That year, Myrna and her colleagues agreed that the rabbi would dress as Moses and Myrna and the cantor would dress as Moses’ two siblings, Miriam and Aaron. It is written in the Torah that, while wandering in the desert, Miriam is punished by God for speaking against Moses and his wife. As a result, she develops what is generally translated from the Hebrew as leprosy, although it probably represents a different, more benign skin condition from which she ultimately recovers. For Myrna’s Miriam costume, she wore a white dress and red vest. She also applied white makeup designed to provide the look of the Biblical skin affliction. To complete the costume, she carried a tambourine because Miriam had led the Israelite women, timbrel in hand, in song and dance after the crossing of the Sea of Reeds and the escape from the pursuing Egyptian army. She looked eerie in white makeup, but in tune with the general Purim spirit. During the party that followed, one of our friends, Dan Oren, jokingly asked her if she was dressed as the angel of death. The irony of that comment would subsequently haunt him for years.

Our congregation proceeded with the holiday of Purim. This year, Purim began Saturday night, with a festive party scheduled to begin immediately after conclusion of the synagogue service. At the service, the Megillah was read by Myrna, the rabbi, and the cantor. The children stomped their feet and twirled their noise makers on cue at the sound of Haman’s name. They paraded in their costumes, and adult and child celebrated our people’s survival in Persian exile and isolation. At the party, we all had some drinks, although none of us as I recall obeyed the command to become ritually snuckered. (The command is actually for the celebration meal occurring the following day). We all ate well. Myrna had also prepared some special desserts for the party—fruit pizzas, an Israeli treat—which everyone enjoyed.

We are both quite tired, particularly Myrna, and we leave relatively early at about 12:30 AM. I drive home fully able to distinguish between the cursed Haman and the blessed Mordechai, although I am not sure that, if tested, my blood alcohol level would place me in a legally appropriate zone. We arrive at our house in Woodbridge, Connecticut after the short 10-minute drive. Houses in our little town are situated on relatively large pieces of land and are consequently quite distant from one another. On our little dead-end street, we are surrounded by protected woodlands, adding further to the sense of both privacy and isolation. Because there are no street lights, Cassway Road is totally dark. In view of the hour, our timed driveway lights have already ended their light cycle.

Myrna again complains of not feeling well: more severe headache, more fatigue than usual, exhaustion, and nausea. Throughout there is no feeling of chest pain or other symptoms. Is it the alcohol? Is it general fatigue? Is it a viral syndrome? The fatigue is so overwhelming that she is unwilling even to remove her white makeup, Miriam’s leprosy, before getting ready for bed. She remains in the bedroom in her nightgown, preparing for a well-needed sleep. I am still too involved in Purim to proceed immediately to sleep, still in need of decompression. I try reading a magazine in the living room located down the hall from our bedroom, but do not have much ability to concentrate on reading at that hour of night. I am a confirmed morning person; the time is well past my best hours. Moreover, Myrna’s symptoms are concerning; this seems more than fatigue. What about the headache? Could she be having cerebral bleeding? I check back in the bedroom several times, trying not to look nervous or ill at ease. She doesn’t notice my anxiety, she just indicates intense nausea and that she is likely to vomit. She just doesn’t feel well. I leave the bedroom but shortly return.

As I enter the bedroom, at about 2 AM, I see her in the adjacent bathroom starting to slump and then fall to the floor in front of the toilet. It seems as if she falls in slow motion, like in a movie scene, without a rapid descent and without a sound. As she falls, her body forms an unusual curved shape. Her arms do not extend to brace the fall. Her head rolls back. No sound comes from her. I rush in and call to her; she doesn’t respond. As I reach to pick her up, she is flaccid. She isn’t breathing. No pulse in her carotid artery.

The Purim spoof ends in that second. No noisemakers, no foot stamping, no costumes, no game. This is now the Purim of survival. There is no time to reflect, no refresher course. She’s dying. She’s dying. It can’t be. It is. And what do I do: physician for 31 years, cardiologist for 26 years, now alone in my bathroom in Woodbridge, Connecticut, on a dark Purim night? And my wife of 34 years is dying. No philosophy, no Socratic method. At this moment, I am not a Yale professor; I am a Bellevue intern holding my dying wife. Transcend time and place and return to 1966 and to New York. I need my intern’s energy and skills. I need that idealistic naiveté that propelled me through both the physical ordeal and the spiritual uplifting that characterized one year of the quintessential medical puberty rite.

I pull her away from the front of the toilet to a more open part of the bathroom between the shower and the sink. She is now lying flat on her back on the floor. CPR (cardiopulmonary resuscitation)—I must do CPR. With a burst of what neuroscientists describe as “implicit memory,” the cerebellum, striatum, and amygdala portions of my brain provide me with what I must now have—skills thought about and practiced many times during medical school and house staff training, but now long dormant and now only performed in a large academic medical center in association with a phalanx of interns and residents.

First, make a fist and deliver a blow to the chest wall: the “chest thump.” This sometimes can convert a fatal heart dysrhythmia and return the patient to a normal rhythm. I deliver a hard blow to her chest—no response—I’ve never hit Myrna—how strange it feels. Get on with CPR.

The ABCs of CPR are taught to every medical student. The three letters stand for airway, breathing, and compression. Clear the airway. Her mouth is clenched. I force her jaw open by pressing on both temporomandibular joints. My right index and middle fingers enter her mouth and move quickly as far as possible down her throat to clear away any possible obstruction to air flow. In response, she reflexively bites down hard on my fingers. Her incisors puncture my skin just below the second knuckle of my right hand. There is no pain, only numbness and free bleeding. The scar persists today, impressions of two incisors, each at slight angle, representing her signature bite. Her initials are carved in my hand. This reminds me of my early teen years when I first became interested in girls and my friends and I would carve our initials in trees together with those of our current girl friends and then surround the pairing with a primitively carved heart. MZ loves BZ, BZ loves MZ.

The airway is cleared as well as possible. I hold Myrna’s head back and place two fingers over her nostrils, closing her nose, and I begin artificially breathing. Our lips meet in mouth-to-mouth resuscitation. No, this is not the taste of passion. This is the taste of gastric acid refluxing back from her stomach to her airway. She’s aspirated gastric contents into her lungs. Never mind. We can deal with that later. Aspiration is common under the circumstances of cardiac arrest. How many hundreds of aspiration pneumonias have I treated in my life?

Start closed chest compression. Place your interlocked hands over her lower sternum. Don’t go too low or you’ll lacerate the liver. Keep your fingers off the ribs. Avoid fractures. Press down hard, hard enough to squeeze the limp heart between the sternum and vertebrae. Press in a staccato fashion: forceful, hard, abrupt. Release equally abruptly. Force blood out to the oxygen needy body. Keep the heels of your hands firmly on the lower sternum. Now press, press, with all your 2 AM energy. Press 15 times, then breathe twice for her, and then repeat, keep repeating.

There is a rhythm here, I can feel the rhythm. I feel once again like a teenager playing basketball on the Far Rockaway playground, racing down court, arms and legs moving smoothly, racing to the waiting hoop. My arms are pistons, my body an unfeeling machine, my muscles without pain or fatigue. Is this effective? How long can I last? As I compress, I look up to the bathroom ceiling and scream as loudly as I can, “You will not die!”—as if the loudness of my voice can serve to recruit more strength and more energy. “I will not let you die!” And in that moment, I believe it, I truly believe it.

In the weeks before starting my internship at Bellevue Hospital in New York City, I drilled myself on the performance of procedures needed for medical emergencies so that on July 1, 1966, day 1 of my career as a physician, I would be ready. I tested myself over and over again until perfect. I remember those mind drills, the studying of the Intern’s Handbook. Those drills helped during that intern year and beyond. Was my amygdala still ready to recall those drills?

As I proceed with this 2 AM dance of unilateral physical love on our bathroom floor, three leitmotifs move in and out of my consciousness. They provide an escape from the horror and force my focus away from the admission that the odds of Myrna surviving are exceedingly small.

First leitmotif: Myrna, your grandchildren will not be named for you. The Eastern European Jewish tradition is to name newborn children in memory of those who have died previously. No, Myrna, your future grandchildren will not be named after Malka Miriam (Myrna’s Hebrew name). They have great-grandparents and other relatives waiting to be memorialized. They will not be named after you. Compress 15 times, breathe twice, do this again.

Second leitmotif: thank you, Bellevue Hospital (Figure 1). Thank you for molding me into a physician who can still immediately respond to emergencies without thinking, functioning spinally. Thank you, Bellevue, for making me work harder and longer than I thought was possible, readying me to do this now, this moment. Thank you for working me every other night and every other weekend for 1 year. Thank you for 48 hours with small bits of sleep interspersed with emergencies, hospital admissions, CPRs, teaching rounds, work rounds, lab work, scut work, wheeling patients alone to the radiology department at 1 AM. Thank you. Thank you, Dr. Saul Farber, my mentor, my chief. Thank you, chief residents, senior residents, attendings, teachers, and all who taught what responsibility really means, who taught that responsibility doesn’t end when the shift ends. You’ve all made me ready for this Purim.

 

 

 

 

Bellevue Hospital Medical Housestaff, 1968–1969. The author is in the top row, fifth from the right. The two co-directors of the division, Dr. Saul Farber and Dr. H. Sherwood Lawrence, are seated in the first row, second and third from the right, respectively.

“In the weeks before starting my internship … I drilled myself on the performance of procedures needed for medical emergencies … Was my amygdala still ready to recall those drills?”

You’re not a college student working the night shift in the Far Rockaway Post Office! You’re always a doctor. Your responsibility is an appendage you carry with you awake or asleep, groggy or alert.

I think of Bellevue Hospital, the old red brick building where I learned my art, not the new modern, replacement glistening structure. I think of my old patients and I suddenly realize, Myrna, you are all the patients I have cared for in New York, Baltimore, California and New Haven. You are the Bowery derelict with pneumonia, meningitis, and delirium tremors. You are the terminal cancer patient, the young boy with blue fingers and congenital heart disease, the patient in septic shock, the patient with a heart attack. You are the taxi driver, the executive, the janitor, the pilot, the professor. You are all of these patients, and they have made me ready now for you and you are a patient with cardiac arrest. You are my wife and you will not die.

Compress, keep compressing. There still is no fatigue, no muscle pain, and there is no rational thinking. Just compressions. This is like the marathons I have run. You finished those three marathons; you will finish this. This isn’t 26.2 miles; this is your wife’s life. Just compress.

Third leitmotif: the image of Guernica studied just 1 month before in Madrid. It appears with crystal clarity. I see the screaming woman with arms outstretched, looking up to the sky, holding her dead baby. I see this woman of Guernica. I realize that my head is arched just like hers. I am also looking upward and I am also screaming. And I am as terrified and angry as she must have been. And the woman and I are instantly one, joined in a union that only those facing death can comprehend. I see the black, I see the gray. I see the horse’s head and the bull, the man also facing the sky with his hands pointing upward and his mouth also open wide. But mostly, I see the screaming woman with outstretched arms, looking upward.

The three leitmotifs circle and recur. My future grandchildren’s names, my thanks to Bellevue, and the woman of Guernica. And I keep screaming to Myrna, my white-faced Miriam, that she will not die. None of our neighbors can possibly hear these screams. The loudest sound is insulated by closed winter windows, long distances, and the thickness of the black Woodbridge night. Was this the isolation that Mordechai felt on the first Purim? Compress, compress, breathe.

What do I do next? CPR cannot go on indefinitely. How many minutes has this been going on? I don’t know. Keep compressing, keep compressing, keep breathing, keep the rhythm, keep screaming. Numb piston arms keep pumping. A wireless phone is a short distance away in the bedroom. I must get to the phone. This means stopping CPR. How can I stop? No choice, I can’t do this forever. I increase the tempo of chest compression and after a brief period, stop, and run to get the phone. I immediately bring it back to her on the bathroom floor. I breathe again and compress again and repeat the cycle several times. Then, I stop. Call 911. This is an emergency. My wife is dying. I’m a doctor and I’m doing CPR. Get here, 15 Cassway Road, Woodbridge. No more words. Compress again.

Beat, beat, beat, breathe. You will not die. Your grandchildren will not have your name. Thank you, Bellevue. The woman of Guernica. How long have I been doing this? Does it matter? Will she make it? The odds say no. Odds are for a bookmaker, not for a cardiologist doing CPR on his wife on his bathroom floor. Screw the odds. Malka Miriam must live.

The doorbell rings sometime around 2:30 AM. I must stop again. I beat hard and fast and breathe several times for her and then run to the door. Unlock and open the door. Disarm the alarm. Two policemen rush in. The sight of other people brings an immediate comfort. I rush back to the bathroom. The policemen follow. Beat, beat, beat. Breathe. You will not die! The policemen bring with them a portable defibrillator. I later learn that they had only just received the instrument and clearly hadn’t had sufficient training in its use. I tell them that we must immediately defibrillate. We rip off the nightgown top. My white-faced Malka Miriam lies flaccid on the bathroom floor, her breasts exposed. I step back and mistakenly put my faith in their skill. One of the policemen applies the paddles. Shock is delivered. No effect. I beat again. Breathe again. The policemen watch, almost paralyzed. They have a portable oxygen tank but no tubing or mask to deliver the oxygen. They have no suction apparatus. Shock again, now. The policeman places the paddles again for a second shock. No effect.

I look down at Myrna’s chest. No! No! No! The burn marks created by the paddles’ electric shocks on Myrna’s body indicate clearly that the paddles were not placed in the proper position on the chest. No wonder it didn’t work! You fools! Why did I trust you? I was drowning and you threw me a deflated life jacket. This is worse than isolation. A wave of anger rolls over me; it threatens momentarily to consume me. I must suppress this. Yelling at these men, chastising them, won’t help. I must retake control.

I grab the paddles. I’m a cardiologist. Listen to me. You recharge the defibrillator. Get ready to shock again. I place the two paddles, covered with gel to prevent skin burn, in the appropriate positions on the side and front of the chest and the shock is delivered. I feel her neck. I feel a weak pulse. She has a pulse. The well-meaning bunglers have wasted valuable minutes, but now she has a pulse. Don’t get angry, don’t stay angry. In seconds, a foggy Myrna opens her eyes and there is life. I try to tell her what has happened and she weakly nods her head, indicating at least some level of understanding. For the first time, I am beyond adrenalin and into real hope.

At this time, paramedics arrive in an ambulance. Thank God, someone who knows medical emergencies is here to help. We have tubing and a mask for the oxygen. It is applied. An intravenous line is started. We have suction. I cover her naked upper body. I kiss her forehead, still covered with white makeup, and hold back my tears. I’m visibly shaking. Stop it, not now, not now. Get composed, get organized. I stop shaking.

The first thing to do is call the hospital. I reach the answering service and get in touch with my on-call colleague, Joe Brennan. Immediate comfort. I’ve known and trained Joe from the time he was an intern. I’ve been his chief since he joined our cardiology fellowship program and later our faculty. He’s a first-class, highly respected clinician. I tell him what has happened and tell him that I don’t know whether this is a cardiac or neurologic event. Joe, this is Myrna’s life and you’re in charge. Joe gets our cardiology team ready and also has neurosurgeons available in case those headaches presaged a cerebral hemorrhage. I get out of my pajamas and put on street clothing. The paramedics place Myrna on a stretcher and move her to the ambulance and then head to Yale-New Haven Hospital, my hospital, the place where I grew to academic maturity. I follow right behind the sirens in the back seat of the police car.

Within 15 minutes, we are in the Emergency Room. She’s wheeled by stretcher into a cubicle. Joe is there waiting, lines of anxiety etched on his brow. He has also called in our two senior interventional cardiologists, Mike Cleman and Henry Cabin, also former trainees of mine, now key clinical members of my faculty, well recognized for their skill in performing cardiac catheterization and coronary angioplasty. They’re now in transit to the hospital.

An electrocardiogram is taken immediately. There are ST elevations in leads 2, 3, and AVF. No need for neurosurgery. She’s having an inferior wall myocardial infarction. She’s examined quickly by Joe. She has crackles in both lungs. She’s likely aspirated. I confirm to Joe and the emergency room physician that I had tasted her gastric acid during mouth-to-mouth resuscitation. She needs to go to the cardiac catheterization laboratory immediately. The laboratory team is activated and called in. By now, it’s 3:20 AM, Sunday morning. In view of the aspiration and possible heart failure, it’s important to have an endotracheal tube in place so that a mechanical respirator can assist her breathing. She is awake and understands. The emergency room physician gets ready to put in the endotracheal tube. I wait outside the cubicle with the curtain closed around patient and physicians.

From the murmurings behind the curtain, I immediately infer that they are having trouble placing the endotracheal tube. Over the top of the curtain, I can see the electrocardiogram (ECG) monitor. I watch as Myrna’s heart rate progressively slows. We can’t lose her now, not in the security of the hospital surrounded by colleagues. We’ve made it to the hospital. Here things should go well. We can’t lose her here in the security of the hospital! This can’t be happening. More noise. They call for an emergency tracheostomy tray. They can’t get the endotracheal tube down through her mouth and into her trachea. The manipulation and lack of breathing have caused a dangerous fall in oxygen levels and a marked slowing of her heart. She could soon be without a heart beat, asystole. This will kill her. Like many members of her family, Myrna has a short somewhat anteriorly placed trachea. This particular anatomy makes it difficult to intubate the trachea. They perform an emergency tracheostomy in the cubicle. No time to call an ear, nose, and throat (ENT) expert. This is done on site in the Emergency Room, crudely, but effectively. They cut open her trachea with a scalpel and insert a tube. Her airway is restored with the tracheostomy and she is now breathing on the respirator. Her heart rate, which had slowed to the 30s, returns to a normal level. Oxygen levels rise.

She is taken immediately to the Cardiac Catheterization Laboratory. My three colleagues, my former trainees, Joe, Henry and Mike, are in the laboratory. A coronary angiogram is performed quickly. The right coronary artery is totally blocked. The other major coronary arteries do not have high-grade blockage. This will require opening the right artery and then placing stents at the site of blockage.

I sit in the control room adjacent to the Cardiac Catheterization Laboratory, and watch as the procedure is being done. How many times had I been in this same chair, watching a procedure being performed in one of my patients? I’ve always tried, if schedule permitted, to be in the laboratory when my patients were being studied so that I could provide some level of physician continuity. It’s important for my patients, and important for me. I had stopped doing catheterization procedures after my third year as a faculty member. The demands of research and increasing administrative responsibilities made it impossible also to continue with catheter lab activity. I always secretly missed the excitement of the cath lab.

My three colleagues proceed with skill and efficiency. It’s rare to see three faculty members in the catheterization laboratory at the same time. For this case, this moment, each assumes his role, either as primary operator or assistant, without ego. Each performs with consummate ability as together they dance this ballet of opening the closed coronary artery with a balloon angioplasty and then follow by stenting that artery in an attempt to ensure long-term patency. It goes quickly, three stents are placed in the artery. It goes well.

It is only then, sitting in the control booth, that the events of the past few hours take hold. Myrna has had a cardiac arrest. She has had a myocardial infarction. The cardiologist side of my brain races. I replay the past several weeks over and over again. I still find no hint that her vague and nonspecific symptoms indicated a cardiac problem. She has always been healthy, the rock of our household. She has always taken care of the boys and me. She has kept all of us intact. She didn’t get sick. She didn’t like routine medical checkups and I couldn’t convince her to stop smoking. She was always a rock.

Miraculously she has survived. The chances of getting to this point are very small. How much permanent damage was done to her heart? Was there damage to the brain? Did she take a second hit to her heart or brain during the emergency tracheostomy? What about the aspiration? I call our rabbi and friend, Rick Eisenberg, even though it’s the middle of Purim night. I need catharsis; I need to talk, even briefly. A few words with a very shaken Rick ruins his sleep, but helps me enormously.

They finish the procedure and move her to the Coronary Care Unit (CCU). By now, it is about 5:30 AM. The CCU team, intern, resident, nurses, are briefed and take over. My colleagues leave for home and for some rest. I feel an overwhelming wave of fatigue. My piston arms are now heavy and my racing mind is now crawling. I feel confident she will make it through the night, but have no idea what her status will be in the morning. If I stay by the bedside now, I will only be in the way.

I walk across the enclosed bridge that connects the hospital to the medical school buildings and find my way to my office, the command center of Yale Cardiology. I stretch myself on the carpeted office floor and immediately fall asleep. Exhaustion triumphs, albeit briefly, over anxiety and fear. I sleep for perhaps 2 hours, just like the nights of my internship. I am awakened by one of my colleagues, who has come in to make rounds and sees a light in my office. He already has heard about the events of last night.

Back to the CCU. Myrna is groggy and not really responsive. Things are stable, but barely. There are lots of problems: bilateral aspiration pneumonia, low oxygen levels and acidosis, an unknown level of heart and brain function, low blood pressure, bleeding from several sites due to anticoagulants administered during the procedure, and a need to revise the emergency tracheostomy in the operating room. After I see her, Laura Cabin drives me home so that I can shower, change clothes, and then return to the hospital in my own car.

The next few days remain a timeless continuum. Early Sunday morning, I call our three sons who at that time are located in North Carolina, Rochester, New York, and Washington, DC. By the end of Sunday afternoon, Adam, Elliot, and Owen have either arrived in New Haven or are on their way. The boys remain for the next 3 days, seeing and comforting their patient mother, and tending to their shaken father. Their sensitivity, love, and support sustain me during these moments of my greatest darkness. I call Myrna’s father in New York and explain what has happened. Together, the boys and I spend most of each day in the waiting room outside of the CCU. I try my best to act primarily as the husband of a patient and not Yale’s Chief of Cardiology. It is particularly difficult to function this way on my own medical turf. This is the arena where I earned my academic bones. This is where my professional persona is housed. But now, I’m not the chief, I am a patient’s spouse. I am vulnerable beyond my medical degree, beyond my rank, beyond my credentials. I can sense how the staff initially tenses when I approach and enter the room. I try to reassure them. I try consciously to stay out of the way and provide only support, without offering curbside consultation or opinion. I speak to my colleagues as a family member, not as their chief. I don’t read Myrna’s hospital chart.

Myrna recovers and awakens. She is lucid and rational. Total retrograde amnesia removes any memory of the entire night and the subsequent 1 to 2 days. She receives 6 U of blood, antibiotics, dopamine to transiently assist her heart function, diuretics. She has the tracheotomy revised in the operating room. The bleeding stops. Heart function stabilizes. No further heart rhythm disturbances. The aspiration pneumonia improves and begins to resolve. The revised tracheostomy tube is removed and the wound begins to close. Remarkably, brain function seems totally intact. She begins the process of mobilization out of bed to a chair. Things move slowly but positively. Myrna is often cranky, impatient, unable to sleep, and periodically depressed. Seven days after Purim, for the first time, she walks 50 feet in the CCU hallway.

The boys each return home after 3 days and I now face alone each night in darkened Woodbridge. Because I am still on sabbatical leave, there are no professional activities that require cancellation. All of my day time is spent in the waiting room or at Myrna’s bedside. The moment I dread most occurs when I return home and have to deal with the answering machine and the multiple calls of inquiry concerning Myrna’s well-being. How many calls will I have to return each evening, repeating over and over again the same information? I need a daily press release, an e-mail giving an update and also telling people not to call. But how can I repel well meaning and caring friends and family? I will deal with this.

Seven days after being admitted to the hospital, she is ready to be transferred from the CCU to the adjacent stepdown unit. It is Sunday and again I am with Myrna all day. She has several visitors throughout the day. It is already early evening and still no transfer. We wait impatiently for the move. Transfer will be tangible evidence of improvement. The nurses tell us that they are waiting for a bed to be cleared. My impatience grows. I walk through the doors of the CCU into the stepdown unit. I hear that there is a problem with one patient. As I walk to the nurses’ station, I am told that the house staff is currently involved in a CPR. In the hospital room, there is frenzied activity. My recently refined reflexes immediately jump to the fore. My amygdala now needs no cues. I ask the senior resident if he needs help. He quickly responds, indicating that everything is “under control.” I nod and I smile broadly. Somehow this brief interchange puts me immediately in a different place. I feel the very extent of that smile deep in my cheek muscles. I can see my expression without a mirror. There is a level of glee, an irony; there is an ambivalent elation over not being needed. It is a strange, almost out of body feeling—close to the “high” long-distance runners sometime experience. I’ve only experienced this once before, on a long distance premarathon training run. I nod and leave. Much like in a scene in a Fellini movie, I turn and return to the CCU. The camera recedes and provides a panoramic view of a hospital floor, of a CPR in progress behind a closed door, and a smiling, somewhat stooped and fatigued middle-aged cardiologist against an antiseptic hospital background. One week and one lifetime. Two hours later, Myrna is moved to the stepdown unit. The sense of elation is palpable for both of us. She will make it.

Several days later is the time of hospital discharge. We follow the usual procedure of medication prescriptions, follow-up visits, need for a cardiac rehabilitation program, stress testing, etc. How many times have I gone over this litany with my patients before they are discharged? Patients can only leave from the hospital by wheelchair. With an accompanying nurse, I wheel Myrna, my Purim miracle, to the hospital entrance. I get my car from the hospital garage and we head back to Woodbridge. The image of Guernica recedes. I forget about Bellevue Hospital and coming of age as a physician. I still think about future grandchildren who will not be named for Malka Miriam.

The Jewish calendar has a wonderful rhythmicity. Several weeks after Purim, Passover, our holiday of liberation, occurs. We wait anxiously and happily for Passover. Since we moved to Connecticut, the celebrations of Passover, the Seders, have always been at our home. This obviates any intrafamily political issues. Once again, the Seders will be at our home. But this year, Myrna will not perform the obligatory weeks of preparation and cleaning and cooking that have always marked our Passovers. We celebrate the Seders with joy. We celebrate the liberation of our people from bondage in Egypt. I silently celebrate survival and our escape from the hovering angel of death.

Right after the two Seders, Myrna has a stress test. Remarkably, her ECG now has reverted to normal with no evidence of a heart attack and her echocardiogram shows totally normal heart function. She comes to our laboratory, the lab I developed, for her exercise nuclear imaging study. She exercises well. Her heart function on this study is again shown to be normal. The blood flow to the heart during exercise is also normal. This is beyond any expectation.

She comments that she has been feeling somewhat chilled recently and suggests that we should get a blood count to make sure she isn’t still anemic, despite the previous blood transfusions. Blood is drawn in the stress laboratory before the exercise test. Two hours later, as she is still in the lab, we learn that although she isn’t anemic, her white blood cell count has dropped to a dangerously low level. Although not symptomatic, she has a blood test that reveals that she has what is clearly an unusual but well-known complication of ticlopidine, the medication she receives to prevent blood clotting at the site of coronary stent placement. This medication was an effective therapy at the time, when used with aspirin to prevent platelets from sticking together and forming blood clots in the coronary artery where the stents were placed. Its beneficial effects in preventing clotting outweighed the small risk of turning off production of white blood cells in the bone marrow. It has since been replaced by a newer, more effective drug.

We now have a new and potentially very serious problem. Yale’s senior clinical hematologist, Tom Duffy, is consulted and agrees with the diagnosis. Myrna will have to be monitored very closely and she will need medication to stimulate her bone marrow to begin again producing white blood cells. She must make every attempt to avoid infection.

So we begin with a new problem, while still far from recovered psychologically from the events of Purim. This complication can be fatal. It can result in lethal infection at a time when body defenses are lowered. This complication involves a discipline that is far afield from my area of expertise. For me, this provokes greater anxiety than a cardiac issue I can fully understand. She is feeling fine, but because of the low white blood cell count, she stays at home avoiding contact with any possible sources of infection. She has frequent blood tests to check the white blood count. Her white blood cell count keeps getting lower, dangerously lower. I go to the hospital pharmacy to obtain the injectable bone marrow stimulating factor prescribed by Tom. It should stimulate the bone marrow to produce white blood cells once again. I take the medication home and give her the intramuscular injections.

On the last day of Passover, she suddenly develops an elevated temperature. We monitor this at home and the temperature keeps rising. I am overcome by fear and can’t control my anxiety. I indicate that she needs to call Tom Duffy and possibly be admitted to the hospital. She rejects this in the strongest of terms. We agree to watch. It is the end of Passover and I busy myself by putting away the special dishes and silverware used only for this holiday. I take her temperature every few hours. It is rising. You’ve got to go to the hospital, I say. She responds that, if she goes to the hospital, she will be exposed to more virulent hospital pathogens, she will get infected, and she will die. She feels better off being at home away from hospital pathogens. Is she right? My expertise doesn’t allow me to answer. Let’s at least consult Tom Duffy. We reach Tom and he too expresses concern to her. But Tom, the consummate sensitive clinician, is willing to compromise for a short time. If the temperature increases any further, she will have to be admitted. A small suitcase has already been packed. We wait, often in silence, our first major disagreement since Purim. We are afraid to speak, afraid to fight. We are both so frightened.

She sleeps through the night. No sweats, no shaking chills, no sign of infection. Miraculously, her temperature does not rise further. In fact, it falls over night and, wonderously, the next day she develops bone pain. This is one of the few medical instances where pain is a positive symptom. It is an indication not of damage, but of increasing bone marrow activity, indicating that the stimulating medication had done its job and her bone marrow will soon be producing lots of white blood cells. Hadn’t we already exhausted more than our share of miracles? She has aching in the shins, thighs, and hips. Her white count begins to rise and soon it returns to normal.

We now begin thinking about a future, about our oldest son’s upcoming wedding in a few weeks. Increased activity. Look for a dress. Look for a dress. Make travel plans. Try to resume life. The wedding is in Indianapolis. We stand together under the wedding canopy and cry freely. We dance at the party that follows and we live.

This coming Purim will mark 12 years since that 1997 evening. In March, Myrna will again make plans for the service and the celebration to follow. She will, as in all years previously, read the Megillat Esther at the service. She will be totally involved in the service. Retrograde amnesia has permanently confiscated her memory of Purim, 1997.

I also will take part in the service and the party to follow. I will wear a costume, and, as usual, photograph Myrna, the rabbi, and cantor in their coordinated costumes for our Purim archives. However, as in all the Purims since 1997, I will likely be a bit more reserved, some might say withdrawn. I’m sure at sometime during the evening, I’ll stare at Myrna’s tracheostomy scar and at the small scar below my second right knuckle, her initials. I’ll likely recall some new details of Purim, 1997. I will be thankfully and anxiously contemplative.

We now have a paramedic staffed ambulance based in the center of Woodbridge, available 24/7 to respond immediately to all medical emergencies with skill and efficiency. I’ve taken part in only a few CPRs since Purim, 1997. They’ve all occurred within the hospital and I’ve always been surrounded, almost enveloped, by the response team of well-trained and aggressive house officers and nurses. By now, none of the ever changing house staff know of my Purim experience, and that’s good. They feel that emergency care is their purview and not that of senior professors. I don’t offer my credentials.

 

We’ve not returned to Madrid, so I’ve not had the opportunity to stand in front of my favorite mural and tell my story to the lady of Guernica. Two years ago, Myrna and I returned to New York University Medical Center for my 40^th medical school class reunion. As part of the reunion, we toured the new Bellevue Hospital, a totally unrecognizable entity. The interns and residents looked fresh and remarkably rested. I remember feeling somewhat disoriented and disconnected during the entire tour, but nevertheless glad to return to the site of my formative medical years.

Our three children have all married. Currently we await the birth of our fifth and sixth grandchild. None of our grandchildren are named for Malka Miriam.

Barry L. Zaret, MD

Department of Internal Medicine

Section of Cardiovascular Medicine

Yale University School of Medicine

New Haven, Connecticut

copyright by Psychosomatic Medicine, use for educational purposes only.