Getting It Right: The Heart of the Matter

Sixty-one year old Paul Chastain is shoveling snow out on his front walk. The wind is biting cold. The snow is heavy and damp.

As he works, he becomes short of breath. He feels a burning sensation in his chest with each lift of the shovel. Paul thinks he must have pulled a muscle in his chest. He stops for a moment and realizes he is positively drenched with sweat. A sensation of lightheadedness overtakes him. A bit of dizziness comes on. Paul decides the rest of the job will have to wait. He heads into the house for another cup of coffee.

Marta Bingaman is a fit and trim fifty-year-old woman. As she is jogging one day, she pauses at a traffic light and bends to rest her hands on her knees. She feels a pressure in her chest, as if a band were tightening around her rib cage. Her fingertips are tingling. Her heart is pounding, but it usually is after she’s run this far. As the light changes, she is hit by a powerful wave of nausea. She holds onto the light post and weaves a bit, then drops to her knees and vomits violently. Marta feels a little better after a few minutes and she finishes her run.

Thirty-eight-year-old Jeff Wheeling isn’t feeling well this morning. He thinks maybe he has a touch of the flu, or maybe a light case of food poisoning. His stomach feels upset. He has a bloated feeling. He’s belching a lot. He feels weak and tired. There is an ache in his jaw. He thinks maybe he was grinding his teeth in his sleep. Suddenly, he feels the need to evacuate his bowels. He heads into the bathroom. That is where he dies.

If you guessed that each of these people is likely experiencing a heart attack, you guessed right. Heart attack (myocardial infarction) occurs when one of the coronary arteries becomes occluded (usually by a free-floating plaque) killing the heart tissue served by that arterial branch. If the occlusion kills so much tissue the heart can no longer effectively pump blood to the rest of the body, the patient will die. Sometimes, the occlusion does not have to kill off a large part of the heart muscle for the patient to die. The oxygen-starved tissue may have a sort of tantrum, sending the heart into a lethal arrhythmia (a series of dangerous waveforms that interfere with the heart’s normal rhythm). When this happens, the heart is still beating, but not in a manner efficient enough to pump blood to the rest of the body’s vital organs.

The common signs and symptoms with which most people are familiar include a crushing substernal (below the breastbone) chest pain, shortness of breath, and pain or tingling that radiates down one or both arms. A heart attack does not always, nor even usually, manifest in just this way. It can look like flu, a backache, a toothache, dizziness, sudden fatigue, diaphoresis (a drenching sweat in the absence of exertion), and, most ominously, skin color changes to ashen or cyanotic (bluish) hues.

Not all heart attacks are lethal, and may resolve even without medical treatment (though it is always best to seek medical care for such a serious condition). A significant number of people are diagnosed as having the type of damage caused by a heart attack without ever having been aware of any such cardiac event. They just didn’t know they had a heart attack. This is often the case with men who have high pain tolerance levels and who do a lot of hard physical labor.

When a heart attack is so severe as to cause the heart to stop beating, it is called a cardiac arrest. Clearly, not all heart attacks result in cardiac arrest. Nor are all cardiac arrests the result of cardiac episodes. You can experience a cardiac arrest from huffing paint, getting shot, having a toaster fall in your hot tub, the coyote dropping an anvil on you, if you freeze while chasing your kid through a hedge-maze with an axe, or if you experience any trauma wherein you lose the majority of your blood. Anything that kills you will result in cardiac arrest.

The point of a “Getting It Right” article is to show you how to add some realism to your writing. Part of that entails showing you what it looks like when people get it wrong. I am sure you have read or seen medical dramas wherein someone who experiences a cardiac arrest undergoes a brief bout of CPR by the protagonist and then sits up and says, “Wow. That was close. Thanks.” Or, a patient who receives one or two shocks with the paddles (this device is called a defibrillator) who then regains consciousness and feels just great.

That stuff just does not happen. The object of CPR is not actually to restart the heart, though that sometimes happens. The purpose is to prevent death of brain tissue by forcing blood through the system, operating the heart manually, since it is not beating on its own. If a patient requires CPR, even if their heart rhythm is restored, they will likely not regain consciousness for some time. They are also at severe risk for relapse into cardiac arrest since the underlying cause of the arrest has not yet been treated.

The same is true of defibrillation. A patient who has been defibrillated may have their heartbeat restored. Even so, they will usually remain unconscious. Often, multiple shocks are required, and in the vast majority of cases, defibrillation fails to restore a perfusing (adequate to oxygenate tissue) rhythm to the heart. In those few instances when it does work, the patient will be at extreme risk until the underlying causes of the arrest are attended to.

A successful resuscitation requires an awful lot of things to go right. They usually don’t. When it happens, it incorporates not only early chest compression and defibrillation, but endotracheal intubation (a tube inserted down the trachea for the delivery of oxygen by a ventilator or handheld resuscitation device), vigorous oxygenation, an intravenous line and a lot of pharmaceuticals.

It’s not the sort of thing you can MacGuyver. If your character hooks somebody up to a pair of jumper cables in an attempt to improvise defibrillation, the victim will most likely end up on the crispy end of done.

If you have a character experiencing a heart attack, take some time to make the details convincing. Remember, a lot of people in medicine read. They need something to do while they are waiting to hear back from your insurance carrier.

Author: Stephen Hise

Stephen Hise is the Evil Mastermind and founder of Indies Unlimited. Hise is an independent author and an avid supporter of the indie author movement. Learn more about Stephen at his website or his Amazon author page.

19 thoughts on “Getting It Right: The Heart of the Matter”

  1. Good summary. There’s a reason why hospitals are scored on the time it takes them to diagnose and treat heart attacks, and why communities with ambulances that can respond to a crisis and get patients to the ER within 10 minutes have a much higher survival rate for heart attack. Those first few minutes are key. Emergency treatment in a hospital is the best, most reliable way to ensure someone survives.

    If someone has passed out from sucking down a little water, CPR can actually bring them back rapidly (although they’re still going to feel like crud, and the risk for pneumonia is still an issue) to consciousness. But that’s a very different issue from a heart attack.

    1. Early intervention is usually the thing that makes a difference in those instances where any difference can be made. Good comment, Kevin. 🙂

  2. Excellent advice! My son’s gf is a nurse AND a paramedic and absolutely refuses to watch any medical show as they so often get the details wrong.

    1. I’m right with her. Even when they get it right, it doesn’t do much for me. Been there, done that. I’m not interested in a busman’s holiday.

    1. One of the more frequent things I see in movies and television shows is the use of defibrillators on patients who are in arrest because of motor-vehicle trauma.

      Under the very best conditions, defibrillation will work when the problem is just that the heart went into arrest because of an idiopathic arrhythmia. It will not work if the reason for the arrest was poisoning, freezing, or that the patient bled out.

  3. Wow, Stephen. Got my CME (continuing medical education) from IU this year. 🙂
    Did you forget to tell IU readers and writers, not only should each civilian be trained (the Red Cross and others do it) in CPR (so when you’re at a critique and someone clutches their chest and faints you can help with more than story arc), but if a character in your story is going to perform civilian CPR, make sure they have been trained and do it right.
    Save lives, real ones and fictional ones, properly. 🙂

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