I parked the ambulance in front of Hell's Kitchen walk-up number 414 and Larry and I pulled the equipment from the back. It was midnight in April, and the full moon lit the street like a saint's festival, and as I walked toward the blue-covered brownstone, the faces watching from its windows, I thought again of how much I'd needed this night to be quiet, of how I'd walked the seven blocks to work with my shaking hands actually clasped together in the act of praying for a quiet night, and of how, for all that, I'd been dispatched immediately, and without coffee, to this cardiac arrest.
The stoop stairs were littered with revelers drinking and shouting to a radio on the first floor, and when we reached the front gate the singers stopped shouting and then the music was only static. They cleared a lane up the steps, kicking empty cans out of our way, crowding at our sides for the bad news. What apartment? What apartment? Like they were holding lottery tickets no one wanted to win. Oh Jesus it's Mr. Burke, the oldest woman said, and the group gathered behind us to collect the stories of the man from 5A, of his drunken son, his spiteful daughter, his wife the saint, and his bad heart.
The front door opened, a young boy holding it. He was crying, and when we got inside the screams met us on the ground floor and I knew them well, like the patched rotting steps, the gray-yellow paint, and the red steel doors with three locks in every building I've climbed through to get to those screams at the top--they're always at the top. I knew Mr. Burke was dead and what an awful thing to know, and to have learned through time, and to have to climb.
Four flights. We were ushered into a small front room crowded with red velvet chairs and porcelain. Mrs. Burke stood in the center, surrounded by neighbors, and when we entered, their cries became choked voices, and the old woman's eyes had run dry, and she squeezed them tight. Over here, said a man standing in the hallway like a robbed and beaten sentry. He led us past the kitchen and a small bedroom, into a large back room with a king-size bed upon which lay the figure of Mr. Burke. A woman was kneeling over the old man. She looked up briefly as we came in and then turned and pressed her lips against the already colder, flaccid mouth of her father.
"We were just watching television," said the man who led us in, "and Dad yelled out and started punching his chest and before we could do nothing he locked himself in the bathroom. I said we oughta call you guys but he swore us not to. He was crying and I never once heard the old man cry and after a while we couldn't hear anything, so I broke the door in and he was barely breathing. I put him on the bed there and he just stopped."
Larry and I moved the body to the floor. "How long ago did he stop breathing?"
"Maybe ten minutes. The woman on the phone was telling us how to do CPR. Please, you gotta do something. This is gonna kill my mother."
"We'll do all we can," I said, wanting to sound confident, but ten minutes was too long, and CPR on a bed is useless. Even as I pulled out the Ambu-bag I wanted to put it back, to sit with the family and pour a few drinks, toast the life they remembered, for there was nothing to celebrate in the body whose heart I was supposed to start. Patrick Burke's time had come. He probably knew that when he locked the bathroom door.
I opened his mouth and felt a box of cool air pass through my fingers, like the morning breath of heavy snow, the last of his life leaving. I'm sure it was just gas built up in the stomach from CPR, but in the last year I had come to believe in such things as spirits leaving the body and not wanting to be put back, spirits angry at the awkward places death had left them, and though I understood how crazy I was to think this way, I was also convinced that if I looked up at that moment I would see the old man standing at the window, staring out over the tar-paper plots and gray ditches of his birthplace. I didn't have to look; I could feel him there, pressed against the glass, waiting for us to finish.
"Frank, what are you doing?" Larry was hooking up the wires to the electrode patches he'd just placed on Burke's chest. He plugged them into the EKG monitor and turned it on. I opened my eyes. "Come on, Frank, let's move along here."
I put the mask over Burke's face and squeezed the bag, though my heart wasn't in it, hadn't been in a long time, and neither was Mr. Burke's, whose EKG rhythm on the monitor was a flat green line. The spirit was gone. Standing by the window. If we did manage to jump-start his heart, there'd be only blood to fill it.
But my hands took over; they always do: trained on hundreds of cardiac arrests, they're automatic. I pulled out the long steel laryngoscope blade and inserted it into his mouth. Using it like a lever, I lifted the tongue up until I found the white vocal cords, like Roman columns, and I grabbed the thick plastic tube and carefully passed it through those gates, through the dark cartilage of the trachea, into the branched entrance of the lungs. I secured it, hooked the bag up to the tube, and pumped it hard.
I called for a backup. Dispatch said first available, which meant we would be on our own for at least twenty minutes. I didn't want to involve the man's daughter any further, but I needed her hands. She knelt by her father's head and I showed her how and when to squeeze the bag. She tried very hard but was lost looking into his eyes, her head falling back. "Squeeze," I had to keep saying.
Larry was crunching down violently on the man's chest and as I fit into the slim space between the bed and the man's right arm I heard one of the ribs crack, like deep ice in a winter lake. I turned the arm over, found a trace of blue vein, and plunged the needle in. I hooked up the IV and watched the bubbles ride the salt water into his arm.
Epinephrine first, one milligram pure adrenaline, a liquid scream in the vein to make the heart feel it's trapped in a burning shirt factory. Followed by one half milligram of atropine, a more subtle agent that rings an alarm and tells the heart it's not dead, only sleeping. This heart wasn't fooled. I waited a minute and gave him another epi, but the flat line only shivered a moment before flattening again. So I decided to hit him with everything at once, get it over with. I shot in an amp of calcium; gives the heart a Joe Louis punch. I drew up a vial of Isuprel and stuck it into the IV bag and let it run. Isuprel scorches everything in its path. It sets the heart on fire, and the heart can either come back to life to beat the flames out or lie there and burn like dead pine. I added in another epi and atropine and sat back to see what would happen.
The flat line on the monitor ran untouched, seemingly infinite and perfect like the axis of the universe, then suddenly it flexed, then bowed, a minute later exploding into one thousand shaking points. I could see the vibration in the chest under Larry's hands as every muscle in Burke's heart fired wildly in different directions. I charged up the paddles and placed them on his chest, twelve inches apart. "Clear," I yelled. "Clear." The daughter let go and then screamed when the man's frail body left the pinewood floor. The green line continued to dance, so I shocked him again. The man's face reared up to mine like a challenge. His daughter groaned and rubbed the head that had thumped heavily upon her knee.
The shock of defibrillation is like a slap in the face to the hysterical heart. Sometimes the slap alone gets the heart to pull itself together and start beating normally, but often the soft voice and soothing hand of lidocaine is needed. Just relax, the lidocaine says; everything will be all right. I gave him eighty milligrams and prepared to shock again, but the daughter would not let go. "No more," she said, and she was crying. "Please don't." Larry pulled her arms away from her father's face, and I hit him at full power. This time the body hardly moved. There was nothing left. The line on the monitor stopped dancing. It ran straight and smooth and showed no intention of rising. Larry returned to the man's chest, grunting with every compression. I heard another rib snap.
Larry was exhausted. Sweat dripped from his nose onto the man's blue shoulders, and he wheezed with every compression. Larry had trouble mowing his suburban quarter acre without a substantial nap, and a four-flight climb followed by ten minutes of CPR was more than his well-rested body could bear. There were a number of reasons why Larry should have become a plumber or a lawyer--anything except a medic--but chief among them was the way his body moved during CPR. He had a heavy gut, stretched by years of dozing off in his stain-guarded Naugahyde recliner, his head tilted forward just enough for him to swallow his beer without choking. When Larry knelt over the dead, his belly would swing like a bowling ball in a shopping bag. The force of this gyration met the force of gravity somewhere in his lower lumbar and inspired a number of unfortunate reflexes. With each compression, Larry's heels kicked up, his pelvis shot forward, and his head jerked back, giving all present the impression that Larry's work stimulated him far more than most would consider the limits of professional behavior.
"Why don't you let me take over," I said to him, "while you call Dr. Hazmat and ask for an eighty-three." After starting CPR and delivering a regulated set of treatments, medics have to call the on-call physician to receive orders for further treatment, or, as in the case of Mr. Burke, to call a dead man an eighty-three. He had been down over twenty minutes, and by the time Larry woke the doctor and explained the situation it would be thirty. All first-line drugs had been used, with little success. The man was dead. We were tired. It was time to pull out the tubes and catheters, unplug the monitor, put the man back on the bed, cover him, and leave this poor family to their grief. Time to get a cup of coffee and park the ambulance by the river for a few minutes of rest. I knelt in Larry's place and pressed my hands down on Burke's chest. Under the cracked ribs the heart felt like a flat tire. I apologized to him for both of us and gently built up to a soft, steady rhythm. For the first time I looked around the room, at the dust-covered artifacts of the man's life: unmatched socks under the bed, one gray suit in the closet, pictures scattered on the walls. I thought of all the hours I'd spent in rooms like this, kneeling on the floor, crunching the chests of dead strangers while putting stories together from the pieces they left behind.
Burke's wedding picture sat on the nightstand. He wore a black tuxedo and posed happily with his young bride on the church steps. From the top of the tall dresser in the corner Private Burke stared down, trying to look tough and ready to fight the Communists but succeeding only in looking young. On one side of him was a Purple Heart in a brown velvet case and on the other was a smaller photo, three GIs arm in arm, standing at a muddy crossroads. A signpost listed distances to different cities: NEW YORK, 7,862 MILES; SEOUL, 40 MILES. On the wall above that was a plaque from the New York Times to Patrick Burke, forty years of service, 1952-1992. Next to it, a photo of the man in work clothes, hands and feet dark with newsprint, looking small before the blue metal girth of the printer.
Across the bed, above Mrs. Burke's low, wide bureau, was a mirror as big as a bay window. In its glass a dark portrait of Christ stared at me from somewhere behind and above. He was pointing to his chest, to where the red robe opened, the heart wrapped in thorns, crowned by flames. At the foot of the bed, next to the window that opened on a wall of windows, the Burke family was born and raised. In its center were three collections of bald, smiling babies. Around them the two older sons became boys in baseball uniforms, then high school graduates. One of them, the son who had shown me in, was married near the window and had two smiling boys of his own. The other never made it that far, his life trailing off to the left, a photo of him bundled up and laughing in the snow, two dried-out palm leaves crossed behind the frame.
Both sons' lives appeared foreshortened in some way, shunted aside, as if the boys had been rushed toward adulthood to make room for their sister, the blond-haired freckled-faced favorite, whose life filled more of the wall than the window. I watched her climb out of diapers, start walking, and go to school. She prayed for all of us at her First Communion, loved to paint and play the violin. She won swimming medals and cheerleading awards, and she always smiled, a smile that grew brighter as her life grew higher, to the top of the wall, queen of the prom, the most beautiful daughter in the world, her place as sacred as the Christ looming behind me.
The girl's life on the wall ended there; no graduation or wedding or babies, nothing superseded that smile, and when I looked at the woman kneeling next to me I understood why. Her face was sharply lined, almost anorexic, still beautiful but harsh and pale as raw quartz. Her blond hair was dyed black and chopped into short, straight bangs. Black makeup ran down her cheeks, and the loose-fitting black tank dress she wore showed the bleached points of her shoulders. It seemed as if she hadn't smiled since that night at the prom, as if she had spent the last ten years fighting her way off that wall, and there, on the floor, as she held her dead father's head between her knees, it seemed she had succeeded miserably.
"Squeeze," I said. I wanted to give some lasting consolation. There was none. "Maybe you should take a break. Your brother could come in for a few minutes and then my partner will be back." "No." She shook her head. "He couldn't handle it." I felt bad for bringing her into this, but she was right: it was a job best done by the already fallen and, in my case, the still falling. I tried to imagine our sitting like that on the Great Lawn in Central Park, a picnic lunch between us on a bright blue and green spring afternoon. I opened the wine and she smiled and stretched her back on a cool breeze. Two young people.
"Do you have any music?" I said.
"Music. I think it helps if you play something he liked." I was already using the past tense.
"John," she yelled, "put on the Sinatra."
John came in. He was crying.
"Play the Sinatra," she whispered.
The opening strings of "September of My Years" drifted through the room. Not salsa, I thought, not a good rhythm for CPR, but what music to leave with. Unconsciously I picked up my pace and concentrated on my hands. There was a time when I believed music could make a dead heart beat again, and I once believed my hands were electric and bringing someone back to life was the greatest thing one could do.
I have done CPR in grand ballrooms on Park Avenue and in third-floor dance halls uptown. On Park they stand tall black panels around you to shield the dancers from an unpleasant view, while the band keeps up their spirits with songs like "Put on a Happy Face." Uptown the music never breaks and the dancers' legs whirl around you like a carnival ride. I've worked on the floors of some of the finest East Side restaurants, serenaded by violins while the man at the table next to me cut into his prime rib, and I have worked under the gory fluorescence of basement diners where taxi drivers can order, eat, and be back on the road in ten minutes. I've watched Broadway shows from the front row, kung fu pornography from Times Square balconies. I once brought a bartender back to life on the top of his bar while Irish dance music played. The patrons moved over for us, but no one stopped drinking.
One of my first cardiac arrests was in the Graceland Ballroom. I'd been there the Friday night before, to pick up a young man shot in the head, but this was Sunday afternoon, when families come from all over the city to talk and dance. A salsa band was playing, and the crowd of dancers made a path for us without losing a beat. The man lay dead in the middle of the floor, dead but not lifeless, because nothing could be lifeless in a room so full of laughter and dancing and music that sounded off your heart. We had a backup unit behind us and my partner and I moved perfectly--intubated with an epinephrine on board in twenty seconds. I took over CPR, my hands rising and falling into the rhythm of the music and the dancers' feet stepping nimbly around us to the salsa beat, a pulse of life. On the monitor I watched my compressions become perfect beats, and when I took my hands away the beats continued. "He has a pulse," I shouted, and stuck my thumb up in the air. The man started breathing on his own, and as we pulled the stretcher out the crowd cheered and slapped us on the back and the dancers filled in behind.
Walking from that room I was blessed by life. I had purpose for the first time and it carried me through those early wild years. Only much later did that beat begin to fade, and only recently did it disappear, leaving a cold stone in its place.
Larry had been on the phone ten minutes, and my knees felt as if I'd just spent an hour in a confessional. I had to admit that Burke looked better. The blue was gone from his cheeks, and the broken vessels in his nose had turned a familiar red. He wasn't that old really, barely sixty. I noticed beats on the monitor, too wide to carry a pulse, but they were gathering speed. I pumped on and listened to Sinatra sing of the brown leaves falling down. When I looked up again the beats had tightened. I stopped and found a weak pulse in his neck, which soon became a strong pulse at the wrist. I sat on the bed. His brain was dead; I was pretty sure of that. I checked his pupils; they were fixed in place, but his heart was beating like a young man's. Larry came in.
"It's okay, Frank. We can call it. Eighty-three."
"No we can't," I said. "He's got a pulse."
The daughter looked up. "Is he going to be all right?"
"His heart's beating." I didn't say that he would never wake up and that his heart would beat on as long as machines pumped in food and oxygen--that I was just acting on orders.
The news of Mr. Burke's recovery spread quickly, and soon the living room was full of crying, smiling faces. The backup unit arrived with a longboard and the two EMTs helped us strap the old man in. Larry and I packed up the equipment.
The stairway was tight and it took some time to get down; at each turn we had to tilt the board and pass it hand to hand over the railings, all the time fighting to keep the airway tube in place. The daughter led our procession, glaring at the faces that peered out from every door. When we reached the bottom she waved her arms at the people still sitting on the stoop--"Get out, get out"--pushing the ones on the top until the crowd moved and split, gathering on each side of the front gate to watch us bear Mr. Burke down the last six steps.
At the back doors to the ambulance I felt the rain start. I looked up to where the clouds had moved under the moon, and in the fifth-floor window I saw Mr. Burke standing, watching the proceedings. The light seemed to go through him, his body too thin to stop it, but he felt more real to me than the man strapped to the board, the eyes unblinking in the rain. I held my breath and bent over, waiting for the feeling to pass. When I looked up again, Mrs. Burke had taken his place. She was holding a suit and a pair of shoes; she reached up her arm and the light went off. "Let's go, Frank," Larry said, and together we loaded Burke's body into the back.
There is an old woman named Doris who for years has been wandering the streets of Times Square. She carries all her belongings with her in two tattered canvas bags, and she sleeps in a box next to the playground in Clinton Park. She walks most of the day and night, her bags held just inches above the street, her head down, speaking to the passing ground in bitter tones. She seems to hate everything, but most of all she hates ambulances, for every ambulance she sees is the one that took her daughter away. If I park long enough in the area of Forty-fifth Street and Seventh Avenue, inevitably I'll hear a pounding on the back doors and Doris calling, "Marie, Marie, it's Mama. I'm going to get you out." Then she walks around to the front. "You've got my daughter; she's in there," she'll say. "You give her back." The first few times I saw her, I tried talking to her, but her hatred was uncompromising, exhaustive, a mother facing her child's killers for the first time. "You give her back," she yells, picking up her bags to follow as I drive away.