Alton Miller was with Mayor Washington on the morning of Nov. 25, 1987, at a ground-breaking ceremony for the Kenwood-Oakland Community Organization on East 46th Street, not too far from the neighborhood where the mayor grew up and where he was then living, at 5300 South Shore Dr. Afterward, at 10:30 or so, while in the limousine on the way to City Hall, Washington told his press secretary: ”I still feel stuffy. I can`t shake this virus.”
About 30 minutes later Washington collapsed onto his desk in the mayoral office, the victim of this nation`s No. 1 killer-sudden cardiac death. Sudden cardiac death, defined as death within 24 hours of an acute heart attack, happens about 1,200 times a day, roughly 438,000 times a year. It works out to almost one American death every 72 seconds of every day. This epidemic is occurring because, ironically, in one of every three cases the first sign of a patient`s underlying heart disease is the sudden heart attack itself-and death.
Mayor Washington was one of these cases. He was given state-of-the-art resuscitative care, both by paramedics who rushed to the scene and later by the staff at the Northwestern Memorial Hospital emergency room, but he was essentially dead when he collapsed at his desk. Everything possible that could have been done for the mayor after the fact was done, but it proved to be of no practical consequence. Unfortunately, all of the things that the mayor might have done for himself before the fact had not been done. What the mayor called ”stuffiness” might very well have been the first sign of congestive heart failure, caused by fluid backing up into his lungs.
Harold Washington, who leaves a rich political legacy, also provides a textbook example of how not to take care of your physical health. The mayor, a lifelong heavy smoker who was 100 pounds overweight and suffering from long-standing high blood pressure and high cholesterol levels, unknowingly was walking around with a heart grotesquely swollen to about 2 1/2 times its normal size and coronary arteries that were severely clogged. It was as if a rusty pump were trying to force water through a clamped hose. The mayor`s heart, weakened after years of pumping against increased resistance, simply gave out.
His silent heart problem was of such severity that Dr. Robert S. Eliot, the director of the Cardiovascular Institute at Swedish Memorial Center in Englewood, Colo., and a leading expert in sudden cardiac death, observes, ”If the American Heart Association made house calls to patients in trouble, Harold Washington would have been near the top of the list.” But that`s hindsight. No one knew the severity of the mayor`s problems until it was too late.
The warning signs were subtle and easily missed, recalls Miller. ”The mayor did appear to be slowing down, even to the point where he would occasionally take the day off,” he says, ”but we all missed it at the time. Besides, you simply do not tell your boss, `You`re not looking well.` When you only have a 15-minute appointment with the mayor-which will probably be cut back to 8 or 10 minutes-talking about his health is about No. 70 on the list of 50 most important things to talk about.”
On Nov, 25, 1987, Miller was in the mayor`s office, checking off some of the 50 most important items on the agenda, when he looked up and saw Washington slumped across his desk. ”It looked weird, but at first I thought that there was a logical explanation,” Miller recalls, ”like he might have been reaching for something, but within an instant I knew better. I said,
`Mayor, Mayor?` Then I bolted to the door and told the guard (Frank Lee, the mayor`s personal bodyguard), `Frank, the mayor needs you.` Then I told Delores Woods (the mayor`s secretary of 20 years) to start calling people.”
The police got the call at 11 a.m., and the Chicago Fire Department one minute later. Miller returned to Washington`s office and moved aside the huge mayoral desk so that the three bodyguards could perform manual cardiopulmonary resuscitation (CPR). Next came the CPR efforts of the fire-department paramedics, who within minutes arrived for an all-out attempt to save the mayor`s life.
It had been a slow morning at the Northwestern Memorial Hospital emergency room (ER)-until 11:10. The hospital`s first patient that day had checked in shortly after midnight, a 49-year-old man with asthma who came in at 12:20 a.m., complaining that he was having trouble breathing. Ten minutes later the first cardiac patient appeared, a 72-year-old woman complaining of chest pain. The ER register indicates that ”Washington, Harold,” no address or occupation listed, was patient No. 29 on a day the ER would treat 92 people.
At the control desk in the center of the ER is a black phone directly linked to Chicago Fire Department paramedics. When it rang at 11:10, the caller told the nurse who answered, ”I need to talk to a doctor.” The attending ER physician that morning was Dr. David Kramer, 32, who recalls,
”When I was asked to come to the phone, I knew that something was off-base and we were in for an unusual case.”
The caller was Ron Smith, chief of the City Hall paramedics, and he came quickly to the point, ”The victim is the mayor.” Kramer adds: ”Well, my adrenaline rose a bit, but we follow a routine that is very ingrained. These paramedics are under the direct medical control of Northwestern, and they work under standing medical orders that follow the American Heart Association`s protocol for advanced cardiac life support. Our goal was to try to convert the mayor`s heart rhythm from ventricular fibrillation-it was beating more like a quivering bag of worms than like a powerful pump-into a `perfusable rhythm,` a rhythm that would circulate enough blood to keep the brain and the body alive.”
The paramedics continued their work for 12 minutes until, at 11:23, Kramer ordered that the mayor be transported to the ER. While Washington lay on his office floor, the paramedics pursued the ”ABC`s” of CPR and advanced life support: secure an airway, assure breathing, assure circulation. One paramedic can provide basic CPR, doing mouth-to-mouth breathing and manually compressing the chest. In the mayor`s case, several fully equipped paramedics were on the scene performing advanced life support.
An endotracheal tube was placed into the mayor`s mouth, and with the aid of a laryngoscope, it was directed into his trachea, or windpipe. After the tube was taped down, a black Ambu-bag was connected to the tube and squeezed by a paramedic to take over the mayor`s breathing in the process known, inelegantly, as ”bagging the patient.” Meanwhile, with the patient`s airway and breathing assured, the efforts to restore circulation continued. Under the best of conditions, manual compression of the chest can provide only 25 to 30 percent of the blood flow circulated by the normal heart. In the mayor`s case, there was an added and significant complication: He had a massive barrel chest.
Kramer explains: ”We had to convert his heart rhythm from ventricular fibrillation-beating chaotically-into a life-sustaining rhythm. We had initially given epinephrine (adrenaline, to jolt the heart through the endotracheal tube. Within seconds an intravenous line was placed into each arm under the elbows. After priming the lines with a mixture of dextrose and water, we (introduced) four drugs: additional epinephrine; atrophine and lidocaine, to try to change the chemical environment of the heart muscle so that it would respond to an electrical jolt; and sodium bicarbonate, to counteract the acidosis caused by lack of circulation. As they infused the drugs, the paramedics placed spoonlike paddles from their `Life-Pak` onto the mayor`s bared chest, selected the maximum amplitude and tried to shock the heart back into rhythm.”
As the paramedics struggled over the stricken mayor at City Hall, the telemetry hookup at Northwestern enabled Kramer to monitor a video readout of the mayor`s heartbeat. The lines remained fuzzy and squiggly, evidence of a continued, chaotic rhythm, as opposed to the normal peaks and valleys that indicate the rhythm of life. There was nothing more to be done at the scene, and at 11:23 the ambulance left City Hall and proceeded north on LaSalle Street toward the Northwestern Memorial Hospital ER on East Superior Street. Kramer and his boss, ER director Dr. James Mathews, 44, sounded the alarm for a full-blown hospital resuscitation, a procedure that Kramer describes as
”organized chaos.”
The ambulance and the sizable contingent accompanying the mayor arrived at the ER at 11:33, and the paramedics immediately carried their patient on a stretcher into the ER`s ”hyperacute” room, a spacious, fully equipped facility located right inside the emergency entrance off the corridor leading to the main ER. The mayor would be met by a sea of blue, a medical team that rapidly grew to include 12 physicians, 6 nurses, 2 heart-lung-machine perfusionists and 2 respiratory-care specialists, all in operating-room scrub blues and standing by to provide hands-on care.
As the mayor was wheeled in, the doctor in immediate charge was Mathews, the ER director. He recalls, ”Truthfully, I was not that optimistic because in my 15 years of clinical experience I have found that if a heart-attack victim shows no response at the scene, then his chances for recovery are slim.”
If the mayor were to have a chance at recovery, his only realistic hope was a state-of-the-art machine being wheeled off an elevator at the same time that he was being taken off the ambulance. The medical device is an innovative version of the cardiopulmonary support (CPS) machine that is used to carry out a procedure called ECMO (for extracorporeal membrane oxygenation). It is, in effect, a portable version of the heart-lung machine used in open-heart surgery that can be set up more quickly and operated more easily than its bulky operating-room counterpart.
Jackie Smith, the clinical nursing manager of the cardiac surgical intensive-care and step-down units, brought the $15,000 CPS machine on a cart from its home in the cardiac-surgery suite on the fourth floor down to the hyperacute room on the ground level at about the same time that heart surgeons John Sanders and Renee Hartz arrived on the scene. On Nov. 25, 1987, this was the only portable CPS machine in Chicago. Mayor Washington was about to become only the seventh patient in Chicago to have the benefit of this portable heart-lung pump for an attempted resuscitation from cardiac arrest.
With the arrival of the portable CPS, Sanders took command of the ER effort. The 45-year-old surgeon, who had told his wife that morning that he was ”in for an easy day” and was looking forward to an early getaway with his family for Thanksgiving at their cottage in southern Wisconsin, recalls:
”Surgeons have no trouble taking charge. It`s part of our personality.”
Sanders is the chief of the medical staff at Northwestern, and at his command was a staff of 21.
Observing the team effort and kept fully informed were the mayor`s personal physician, Dr. Antonio Senat, who had been called on his car phone and who beat the ambulance to the hospital and provided vital medical information about the mayor to the ER staff, and Dr. Lonnie Edwards, Chicago`s health commissioner.
First, Dr. Richard Davison, a cardiologist and chief of the hospital`s intensive-care facilities, intravenously infused some new mixtures of heart drugs, including the potent Bertyllium, to try to alter the chemical environment of the heart and restore a functional rhythm. Kramer, meanwhile, was continuing manual compression of the chest. There was no response, and within minutes Sanders decided to connect the CPS machine.
He observes, ”Without this machine, our only option would have been open-chest massage of the heart, and this procedure is at best only 20 percent more efficient than the manual CPR and shocks he had been receiving.”
The surgeons-Sanders and Hartz-required only six or seven minutes to connect the CPS machine to the mayor`s femoral artery and vein and to get the machine to full circulatory flow. ”Actually, the light was very good in that room,” Sanders recalls, ”the incision and connections went very smoothly and the patient was on the machine within 15 minutes from the time we were notified by the ER.”
