In the year his heart stopped, Dr. Zack Winston checked his watch as he headed to the ER suture room for his next patient. Four p.m. Two hours left. Strident blare from the EMS radio stopped him in mid-stride. His experienced ear caught the gist of the paramedics’ report. “Three minutes out . . . Full code . . . Fifty-two-year-old male . . . Seen in your ER yesterday.” Zack’s heart plunged. Who? He turned from the suture area and hustled to the resuscitation room. Paramedics burst through the doors, wheeling their patient on a narrow gurney. Zack recognized Carl Barnett, even with a plastic LMA tube protruding from his mouth. A medic squeezed air into the tube from a green football-shaped neoprene bag. Another medic straddled the gurney, performing vigorous chest compressions. Another held an IV bag aloft, its tubing plugged into a catheter in the patient’s arm. Carl’s skin looked waxy, pale gray-blue, and mottled. He’d had a healthy pink complexion when Zack saw him in the ER the previous day. A medic spoke into Zack’s ear. “Wife found him in full arrest on the floor in their home. She’s a nurse, doing good CPR when we arrived. No pulse or rhythm on scene or during transport. Down time at least twenty minutes. Unknown how long he went without CPR.” I MIKE KRENTZ 2 A strong grip on Zack’s arm swung him into the florid face of Janice Barnett, Carl’s wife, ICU head nurse. “Do not lose him.” Stern. A swallow. Softer voice. “Please.” “We’ll, uh, do our best, Jan.” Zack followed the paramedics into the resuscitation room. The cardiac monitor showed a wavy horizontal line with an occasional bump that resembled an inverted U. Agonal rhythm. Dying heart. Odds of save, zero to zilch. Zack recalled a favorite saying: A thin line separates cardiopulmonary resuscitation from assault on the already dead. His gaze swept from the monitor to the patient. Carl Barnett, already dead. From behind, Janice bumped into Zack, scowled, and moved to pass. He blocked her path. “You shouldn’t be in here.” She flipped a frizz of frosted platinum hair off a sweat-dotted forehead. Hazel eyes pierced him. Her tone pleaded. “I must be with Carl.” Zack nodded to Monica Harris, ER head nurse. She steered Janice to a corner from where she could watch without interfering. Zack turned to his patient, his back to the man’s wife. Carl’s skin color had not improved from arrival. The monitor displayed the same wide bumps, at a more ominous rate of thirty. Zack had never seen anyone recover from prolonged agonal rhythm—not to useful life. He started the protocol for managing pulseless electrical activity. The algorithm for the already dead. Protocol. Routine. They needed an outlier, something to reverse the man’s status from already dead to almost died. When you hear hoofbeats, think horses not zebras. Zack needed a zebra. “Continue CPR,” he said. “Get the ultrasound machine.” Zack performed a quick cardiac ultrasound, looking for heart-wall motion, contractions—maybe a dilated right ventricle to suggest massive pulmonary embolism. Maybe cardiac tamponade. Zebra hunting. The test showed ineffective heart contractions, nothing more. He recalled his interactions with the Barnetts the previous day. Fit and healthy, with no cardiac risk factors, Carl had come in with chest pain that DEAD ALREADY 3 began at rest. The pain had resolved in the ER without treatment. Zack had run a gamut of standard tests and calculated a low probability for acute heart disease. He had explained everything to Janice, whose subtle mistrust had never waned, even when she agreed to take her husband home. What happened in the interim? Zack could not accept defeat. He went off protocol and tried other medications. Atropine. High dose epinephrine. The entire arsenal. “Asystole,” a nurse said. An undulating line snaked across the EKG screen. No bumps. “Respirations?” The tech paused the ventilator. A minute passed. No breaths. Zack felt over the carotid arteries in the neck. No pulse. He listened over the chest. No heartbeat. He turned to look at Janice Barnett weeping in the corner. “I’m sorry,” he said. Tears ran down her face. “I know.” He looked at the clock. “Time of death, 1536.” Already dead, around 1425. Monica Harris seized Janice’s arm and led her toward the door. “Let’s go to the quiet room while the staff cleans up, then you can come back and say good-bye.” Her grip tightened until Janice winced. As the two women left the resus room, Zack froze. His feet refused to move. His mind lurched far away from the familiar milieu of Bethesda Metro Hospital ER. A young woman’s body lay lifeless on an operating table in front of him. Blood ran down the sterile sheet and dripped onto his shoes. He took a few seconds to return to the present, then headed to the suture room. twenty-something disheveled man with a scruffy beard-shadow, unraveled brown ponytail, and hostile features sat on the edge of the gurney. He held his arms tripod-like beside him, hands pressing on the thin mattress, body leaning forward—a gorilla poised to lunge. As Zack moved A MIKE KRENTZ 4 closer, the distinct odor of recycled booze assaulted his nostrils. The man sported a purple-and-maroon swollen and busted lip. The dirty, yellowencrusted edges of the laceration suggested it was a day old, if not more. Dark blue and light purple bruises around the man’s face and upper torso completed the picture. The patient told Zack that he had started drinking the previous night, got into a fight that he somewhat remembered, continued drinking, passed out, slept most of the day, and awakened an hour before coming to the ER. “I need this fixed good, Doc. Got a job interview tomorrow.” In a calm voice, Zack explained that if the man had sought treatment soon after the injury happened, they could have cleaned and repaired the laceration with good results. “Too late for that,” he said. “One-hundred-percent probability it’s infected. If I suture it now, germs will get trapped inside and create an abscess that will get ugly. Best we can do is clean it up, put a dressing on it, and let it heal on its own. It’s going to leave a scar. If that’s a problem for you after it heals, you can get a plastic surgeon to fix it.” At a hefty price. Irate, the young man leaped off the gurney, pushed Zack aside, and stormed out of the suture area. “Just another fucking ER doc. I’ll go where I can get some real help.” Straight to the nearest bar, Zack thought. Too bad about that job interview. He shrugged. Not the first time he’d been called a “JAFERD.” Many emergency physicians had withstood similar, or worse, cheap shots. On a popular ER docs’ social media site, a colleague had devised a counter-acronym: BAFERD (“Bad Ass Fucking ER Doc”), a badge-ofhonor adopted by emergency physicians with multiple years on the front lines taking on the worst life-and-death battles, the most serious and unusual illnesses and injuries, suffered by a diverse cast of humanity; yet handling it all with aplomb and unimaginable self-esteem. Back in the day, Zack Winston had considered himself a total BAFERD. Now . . .?