CPR

Night Shift

Chapter 19: CPR

The eighteenth time.

Delia would count this call afterward, would add it to the ledger, the private ledger that she kept in her mind, the ledger that tracked the CPR calls, the calls where the protocol connected her voice to a patient's body through a caller's hands, the calls where the counting was the thing, where the dispatcher's voice became a medical instrument and the instrument was played for minutes that felt like hours and the hours were measured in compressions, in the rhythm of the counting, in the numbers that Delia spoke into the headset and that traveled through the phone line to the caller's ear and from the ear to the hands and from the hands to the chest.

The call came at 12:52 AM. A Saturday. The third week of October.

"Memphis 911, what is the location of your emergency?"

"My husband — he collapsed — he's on the floor, he's not moving, he's not —"

The voice was a woman's. The voice was the voice of a wife watching her husband die on the kitchen floor — Delia would learn later that it was the kitchen, that the man had been standing at the counter, that he had been getting a glass of water, that the glass was on the counter and the water was in the glass and the man was on the floor and the glass was not broken because the glass had been set down before the man fell, the glass the last thing the man had held, the last object the man's hands had touched before the hands stopped working, before the arms stopped working, before the body stopped working, before the heart that had been beating for however many years the man had been alive stopped beating in the kitchen at 12:52 AM on a Saturday in October.

"Ma'am, I need your address."

"1847 Ketchum — 1847 Ketchum Road."

"Is the person conscious? Is he awake?"

"No — he's not — his eyes are closed, he's not responding, I'm shaking him and he's not —"

"Is he breathing? Put your face near his mouth. Can you feel or hear any breathing?"

A pause. The pause of a woman bending to her husband's face, putting her face near his mouth, the intimacy of the gesture — the wife's face near the husband's mouth, the closeness that in another context would be a kiss, would be the nearness of love, but that in this context was the assessment, the protocol's first assessment, the question that determined everything that followed: is the patient breathing?

"No. No, he's not breathing. Oh God. Oh God, he's not breathing."

The tree opened. The branch: unconscious, not breathing. The determinant: Echo. The protocol: CPR. The instruction: begin.

Delia dispatched. EMS, Code 3, lights and sirens, cardiac arrest. She dispatched while she spoke, the dual operation, the hands on the keyboard and the voice in the headset, the two channels working simultaneously because the time was the thing and the time could not wait for the dispatch to precede the instruction, the dispatch and the instruction had to be simultaneous because every second without CPR was a second of oxygen depletion, a second of brain death, a second subtracted from the window, the window that the research said was approximately ten minutes, ten minutes during which CPR could maintain sufficient blood flow to preserve brain function, ten minutes that were the gap between the cardiac arrest and the arrival of the paramedics, ten minutes that the dispatcher filled with the counting.

"Ma'am, listen to me carefully. I'm going to help you. I need you to do exactly what I tell you. Can you hear me?"

"Yes — yes, please —"

"What is your name?"

"Denise. Denise Palmer."

"Denise, is your husband on a hard surface? Is he on the floor?"

"Yes, he's on the kitchen floor."

"Good. That's good. I need you to kneel beside him. Are you beside him?"

"Yes."

"I need you to place the heel of your hand — the bottom part of your palm — on the center of his chest. Right between the nipples. Find that spot and place your hand there."

"Okay — okay, I have it."

"Put your other hand on top. Lace your fingers together. Keep your arms straight — do not bend your elbows. You're going to push down on his chest, hard, at least two inches deep. I'm going to count with you. Every time I say a number, you push. Push hard. Push fast. Ready?"

"I can't — I don't know if I can do this —"

"You can do this, Denise. You are the only person who can do this right now. Your hands are his heartbeat. Ready?"

"Yes."

"Push. One and two and three and four and five and six and seven and eight and nine and ten and eleven and twelve and thirteen and fourteen and fifteen and sixteen and seventeen and eighteen and nineteen and twenty and twenty-one and twenty-two and twenty-three and twenty-four and twenty-five and twenty-six and twenty-seven and twenty-eight and twenty-nine and thirty. Stop."

Delia heard the compressions through the headset. She heard the sound of Denise's hands on her husband's chest, the sound that was rhythmic and that was wet, subtly, the wet sound of flesh pressing against flesh, the sound that was the CPR's acoustic signature, the sound that dispatchers recognized, the sound that confirmed that the caller was following the instructions, that the hands were on the chest, that the pushing was happening, that the chain was active.

"Tilt his head back. Put one hand on his forehead, push it back. Lift his chin with your other hand. Pinch his nose. Put your mouth over his mouth — seal it completely — and blow until you see his chest rise. Two breaths."

She heard the breath. She heard Denise blow air into her husband's lungs, the forced exhalation, the sound of a wife breathing for a husband who could not breathe, the intimacy of the act — mouth to mouth, the wife's air entering the husband's lungs, the air that was not the husband's air but that would serve as the husband's air, the air that would carry the oxygen that the blood needed and that the compressions would push through the body.

"Good. Did his chest rise?"

"I think so — yes, I saw it move."

"Good. Give one more breath."

The breath.

"Good. Back to compressions. Same spot, hands on the center of his chest, push hard, push fast. One and two and three and four and five..."

Delia counted. She counted the way she had counted seventeen times before, the way the protocol required, the rhythm steady, the numbers even, the "and" between each number the metronome's click, the rhythm set at 100 to 120 compressions per minute, the rate that the research said was optimal, the rate that Delia maintained with the precision that practice had given her, the precision of a person who had counted this count seventeen times and whose body knew the rhythm the way a drummer's body knew a beat, the rhythm lived in the muscles and the breath and the voice, the rhythm the thing that Delia gave to Denise and that Denise transmitted to her husband through her hands, the rhythm the substitute heartbeat, the external heartbeat provided by a wife's hands directed by a dispatcher's voice.

"...fifteen and sixteen and seventeen and eighteen and nineteen and twenty..."

"Is he going to be okay?" Denise said, the words coming between compressions, the words squeezed out of the space between the pushes, the question that was the CPR caller's question, the question that all of them asked, the question that Delia could not answer.

"You're doing great, Denise. Keep pushing. The ambulance is on the way. Twenty-one and twenty-two and twenty-three..."

The redirection. The answer that was not an answer. The answer that redirected from the outcome (unknown) to the action (known), from the future (uncertain) to the present (certain), the present being: push. Keep pushing. The pushing is the thing. The pushing is the answer. The pushing is all there is right now, the pushing and the counting and the breathing and the chain, the chain that connects your hands to his heart through the chest that you are compressing, the chain that is the system's most extraordinary mechanism, the mechanism that turns a phone call into a cardiac intervention.

"...twenty-eight and twenty-nine and thirty. Stop. Two breaths."

Denise breathed. Delia listened. The breaths were there — the forced exhalations, the sound of the rescue breathing, the sound confirmed.

"Back to compressions. One and two and three..."

The minutes passed. The counting continued. The compressions accumulated — thirty compressions, two breaths, thirty compressions, two breaths, the cycle repeating, the cycle the protocol, the protocol the pattern, the pattern the rhythm, the rhythm the thing that Delia maintained while the minutes passed and the EMS units approached and the gap between the call and the arrival slowly closed.

Two minutes. Three minutes. Delia checked the map. The EMS unit was responding from the Whitehaven station, six minutes from the address. Six minutes was the gap. Six minutes was the time that Denise's hands had to fill, the time that the counting had to bridge, the time that stood between the cardiac arrest and the professional help that the paramedics would provide — the defibrillator, the medications, the IV, the equipment that could restart the heart that the compressions were maintaining but could not restart, the compressions the holding action, the bridge, the thing that kept the blood moving while the real help drove through the streets of Memphis at 12:52 AM with lights and sirens.

"...twelve and thirteen and fourteen..."

"How long until they get here?" Denise said.

"A few more minutes, Denise. They're close. Keep pushing. You're doing amazing. Fifteen and sixteen..."

"My arms are getting tired."

"I know they're tired. I know this is hard. But your arms are the most important thing in the world right now. Push through the tired. Push through it. Seventeen and eighteen..."

Delia's voice was steady. Her voice was the instrument, the instrument played at the pitch and the volume and the tempo that the moment required, the instrument that did not waver even as the call passed the five-minute mark and the counting passed the three hundredth compression and the wife's arms were tired and the wife's voice was breaking and the situation was the situation, was the kitchen floor and the husband not breathing and the wife's hands on his chest and the dispatcher's voice in the wife's ear, and the voice did not waver because the voice was the training and the training held and the training said: steady, steady, steady, the voice steady the way the compressions must be steady, the voice the model for the hands, the voice showing the hands what steady looked like, what steady sounded like, what steady was.

"...twenty-eight and twenty-nine and thirty. Stop. Two breaths."

The breaths.

"Back to compressions. You are incredible, Denise. One and two and three..."

Six minutes. Seven minutes. The EMS was close — Delia could see the unit on the map, two blocks from the address, the icon moving through the streets, the icon the representation of the ambulance, the ambulance that contained the paramedics and the equipment and the drugs and the defibrillator, the ambulance that was two blocks away and would be there in less than a minute and the minute was the last minute, the last sixty seconds of the gap, the last sixty seconds that Denise's hands had to fill.

"...fifteen and sixteen and seventeen..."

"I hear the sirens," Denise said. "I can hear them."

"Good. Keep pushing. Don't stop until the paramedics are right there, right next to you. Keep pushing until they tell you to stop."

"...twenty-two and twenty-three..."

The sirens grew louder through the phone. The sirens the signal. The sirens the sound of the arrival. The gap closing.

"...twenty-seven and twenty-eight and twenty-nine and thirty."

The door opened. Delia heard it through the phone — the sound of the front door opening, the sound of the paramedics entering, the professional voices joining the wife's voice, the voices of the EMS crew arriving at the scene, the scene that was a kitchen and a man on the floor and a woman on her knees with her hands on his chest.

"Ma'am, we've got it from here."

Denise stopped. Delia heard the stopping — heard the absence of the compressions, heard the change in the phone's ambient sound, heard Denise stand up or move back, heard the space open between the wife and the husband as the paramedics moved in, the transition happening, the amateur yielding to the professional, the wife's hands replaced by the paramedics' hands, the dispatcher's counting replaced by the paramedics' equipment.

Delia heard the paramedics work. She heard fragments — the staccato of their communication, the sounds of the equipment, the monitor's electronic tones, the defibrillator charging. She heard the sound that the defibrillator made when it discharged — the thump, the electronic thump that was the sound of electricity entering the body, the sound of the machine attempting to restart the heart that the compressions had maintained.

She heard Denise crying. The crying was the sound that came after the compressions stopped, the sound that the wife had been holding during the counting, the sound that the counting had contained, the counting's rhythm a container for the wife's terror, the rhythm giving the wife something to do with the terror — push, push, push — and now the pushing was over and the terror had no container and the terror became the crying.

"Denise," Delia said. "The paramedics have him. You did everything you could. You did eleven minutes of CPR. You kept his blood flowing. You gave him the best chance."

Eleven minutes. 660 compressions. 44 rescue breaths. Delia knew the numbers because the counting was the calculating, the counting a form of arithmetic that the dispatcher performed unconsciously — 22 cycles of 30 compressions and 2 breaths, the cycles counted by the sets, the sets counted by the pauses, the pauses the markers in the stream of numbers, and the stream had lasted eleven minutes, eleven minutes during which Denise Palmer's hands had pushed on her husband's chest while Delia Robinson's voice had counted in her ear.

"Is he — will he —" Denise said.

"The paramedics are working on him. They have the equipment to help. You did your part, Denise. You did your part."

"I don't even know if I was doing it right. Was I doing it right?"

"You were doing it right. I could hear it. Your compressions were strong. You did it right."

The reassurance was true. The reassurance was the thing that Delia could provide — the validation that the wife's effort had been correct, that the wife's hands had done what the voice had instructed, that the protocol had been followed and the following had been good. The reassurance was the thing that Delia could say with certainty. Everything else — the outcome, the survival, the husband's fate — everything else was uncertain, was unknown, was in the paramedics' hands now, was in the ambulance, was in the hospital, was in the future that Delia could not see from Console 7.

"Denise, is there someone I can call for you? Family, a friend?"

"My sister. Can you — can she meet me at the hospital?"

"Of course. What's her number?"

Denise gave the number. Delia noted it. She would relay it — the small thing, the logistical thing, the thing that was outside the protocol but inside the human, the thing that a woman at 12:52 AM on a kitchen floor needed, which was not just the paramedics and the equipment but the sister, the family, the person who would be at the hospital when the ambulance arrived.

"Denise, you did an extraordinary thing tonight. Take care of yourself."

"Thank you. Thank you for — for counting. I couldn't have done it without the counting."

"You did it, Denise. The counting was just numbers. Your hands did the work."

Delia disconnected. She logged the call. She typed the narrative: cardiac arrest, 1847 Ketchum Road, male patient, unresponsive, not breathing, wife initiated CPR with dispatch assistance, 11 minutes of CPR prior to EMS arrival. She typed the disposition. She typed the times: call received 12:52, CPR initiated 12:54, EMS on scene 1:03. She typed the data, the data the record, the record the system's version of the eleven minutes, the version that was numbers and codes and timestamps, the version that did not include the sound of the compressions or the sound of the breathing or the sound of the wife's crying or the sound of the defibrillator or the sound of Delia's voice counting to thirty twenty-two times.

She sat at Console 7. Her hands were on the desk. Her hands were not shaking — the shaking was for the calls involving children, the shaking the mother's response, and this call did not involve a child, this call involved a husband and a wife and a kitchen floor, and the response that this call produced was not the shaking but the stillness, the particular stillness that followed the CPR calls, the stillness that was the body's response to the eleven minutes of counting, the eleven minutes during which the voice had been the instrument and the instrument had been played and the playing had required a concentration that left the body emptied, the concentration consuming the body's reserves the way the compressions consumed the caller's arm strength, the dispatcher's voice working as hard as the caller's hands, the voice the muscles and the counting the effort and the effort sustained for eleven minutes leaving the voice depleted and the body still.

She did not know if the man lived. She would not know. This was the probability, the near-certainty, the condition of the job. She would not receive the follow-up. She would not learn whether the eleven minutes of counting and compressing were the eleven minutes that saved the man's life or the eleven minutes that preceded the man's death. She would not learn whether the defibrillator restarted the heart or did not restart the heart. She would not learn whether the ambulance arrived at the hospital in time or not in time. She would not learn whether Denise's sister was at the hospital when Denise arrived or whether Denise arrived alone.

She would not learn the ending.

The not-learning was the condition. The not-learning was the thing that Patricia had warned about in the schoolroom, the thing that Marcus had confirmed at Console 6, the thing that the job imposed on the dispatchers who performed it — the not-learning of the endings, the not-knowing of the outcomes, the perpetual state of the beginning without the conclusion, the story started and not finished, the call taken and the dispatch made and the counting counted and the chain forged and the chain held and the chain terminated at the moment of the paramedics' arrival, the chain's last link the dispatcher's voice and the chain's continuation beyond the dispatcher's voice the part of the story that the dispatcher did not get to read.

Four out of seventeen. Before tonight, Delia had known the outcomes of four of her seventeen CPR calls. Four had survived — she had learned this through the informal channels, the channels that the system did not maintain but that the people in the system created, the channels that were a supervisor's mention or a paramedic's report or a news story or the rare, the very rare, the almost-never callback from a caller who called to say: he lived. She lived. They made it. Thank you.

Four out of seventeen. Twenty-four percent. The number was a statistic and the statistic was a comfort and the comfort was thin, was insufficient, was the comfort of a number that said: some of them lived. The number did not say which ones. The number did not say whether the ones who lived were the ones where the counting was perfect or the ones where the counting was imperfect, the ones where the compressions were strong or the ones where the compressions were weak, the ones where the EMS arrived in six minutes or the ones where the EMS arrived in twelve. The number did not connect the effort to the outcome. The number was aggregate, was statistical, was the population-level answer to the individual-level question. The individual-level question — did this man, tonight, on Ketchum Road, in the kitchen, with the glass of water on the counter, did this man live? — the individual-level question had no answer. The answer was somewhere — in the ambulance, in the hospital, in the family, in the future — but the answer was not at Console 7, and Console 7 was where Delia was, and Console 7 was where the question lived without its answer, in the space where the unanswered questions lived, in the archive, in the body.

She added the call to the ledger. Eighteen. Eighteen CPR calls in six years. Eighteen times the counting. Eighteen times the chain. Eighteen times the voice becoming the instrument becoming the rhythm becoming the heartbeat of a person whose heart had stopped. Eighteen.

The ledger did not have outcomes. The ledger had calls. The calls were the entries. The entries were the counting — the minutes of counting that Delia's voice had provided, the minutes that she carried in the ledger the way she carried the calls in the archive, the carrying the thing, the carrying the weight, the weight the job, the job the night, the night the shift, the shift the life.

Marcus looked at her. He had heard the counting — eleven minutes of counting, the numbers audible across the ten feet between Console 6 and Console 7, the counting the sound that every dispatcher on the floor recognized, the sound that meant a person was dying and a dispatcher was counting and a caller was pushing and the chain was active.

Marcus's look said: eighteen.

Marcus knew the ledger. Marcus had his own ledger. Marcus's ledger was longer — ten years of CPR calls, ten years of counting, the numbers higher, the archive deeper, the body's storage fuller. Marcus's ledger was the senior version of Delia's ledger, the version that said: the ledger grows, the ledger does not shrink, the ledger is the accumulation, and the accumulation is the carrying, and the carrying is the job.

Marcus extended the thermos. Delia took it. She poured coffee into the lid. She drank. The coffee was cold now — past cold, room temperature, the French press coffee that Sandra had made hours ago reduced by time to a liquid that served not as coffee but as ritual, the drinking the ritual, the sharing the ritual, the thermos between Console 6 and Console 7 the ritual object, the object that said: the call is over, the counting is over, the eleven minutes are over, the voice can rest, the instrument can be set down, the drummer can stop, the rhythm can cease.

The phone beeped. The double tone.

Delia returned the thermos. She pressed the key.

"Memphis 911, what is the location of your emergency?"

The next call. The next voice. The next emergency.

And at 1847 Ketchum Road, the ambulance was gone, the kitchen was empty, the glass of water was on the counter, and the man who had been on the floor was in the ambulance or at the hospital or alive or not alive, and Delia did not know which, and the not-knowing was the condition, and the condition was the job, and the job was the next call, and the next call was now.

She answered.