This section is on heart attacks, but before we begin we should talk a little about what a heart attack is.

Cardiac muscle is unlike any other type of cell in your body. If you run well-oxygenated blood through, say, your leg, you’ll find that the leg consumes only about 20 to 30 percent of the available oxygen and sends the rest on down the river. A leg muscle can continue to live for up to eight hours after its oxygen has been cut off. Send oxygenated blood through the arteries that supply the heart muscle and it will suck every last molecule it can get from the blood cells. Deprive the heart muscle of oxygen for a few minutes and it’s dead…forever. The only other organ with a similarly ravenous lust for oxygen is the brain.

Knowing the heart’s voracious appetite for oxygen, you can see, I’m sure, why blocking the arteries that supply blood to the heart is a very bad thing. Over the course of many, many hamburgers and fried fish sandwiches "plaque" or fatty goop collects in the walls of your arteries. It does not, as is commonly believed form on the inside wall of your arteries. It collects between the layers that make up the walls of your arteries, sort of like a pimple grows between layers of skin. At some point late in the cycle one of these "pimples" pops. This causes several problems.

First, all the goop that was formerly trapped in the "pimple" gets out and starts traveling downstream. As the goop moves along it eventually causes teensy logjams as it reaches small blood vessels, causing them to be blocked. This usually doesn’t cause serious problems, but it certainly can if the logjam blocks a large enough or an especially critical artery.

To understand the second problem you have to know a little about the way clotting works. The stuff that makes blood clots is a collection of several separate components, collectively called platelets, that run around loose in the bloodstream looking for trouble. When they find trouble, they very quickly combine together to build a sort of microscopic dam to plug the leak. What they look for is something that does not belong inside a blood vessel, like a piece of a stick or some of the outside world. A damaged blood vessel wall also gives off some chemicals that clue the clotting mechanism in. When they find these things, they start the process of building a dam that’s normally vitally important in that it stems the leaking tide of vital blood.

When the aforementioned "pimple" in the vessel wall breaks it exposes the inside of the fatty pocket to the flow of blood. This surface looks to the ever-suspicious platelet like something that needs to be fixed. Eager to do a good job these tiny clot makers begin building their dam of life. Unfortunately in this instance it’s a dam of death. (They meant well, really)

As the clot forms it slowly begins to block the artery and obstruct the flow of oxygenated blood to the heart muscle. At this point the cardiac muscle down stream from the blockage begins to die. This usually causes the owner of the heart in question to suddenly feel very poorly and begin to have some chest pain.

Circulation from neighboring vessels can sometimes relieve some of the strain (called collateral circulation) and a person can live without as much as 30 percent of his or her heart muscle; though not terribly well. The most immediately pressing problem is that heart muscle has an attitude to start with and being oxygen starved puts it in a very bad mood. This is very bad.

Cardiac muscle is the only type of muscle that has "automaticity", the previously mentioned "attitude". This means that left to its own devices heart muscle cells will contract on their own, without asking anybody. This is sort of like your legs deciding on their own to go out for a stroll. Automaticity is a protective measure that insures that even if the normal electrical system that controls the heart gets damaged or destroyed the heart will continue to beat.

This system works very well as long as all the heart muscle cells can agree on when to fire and fire together, causing a coordinated contraction that actually pumps some blood. The problem that arises during a heart attack is that the oxygen starved heart muscles become less and less attentive listeners and if all goes horribly wrong, they begin contracting on their own without regard for the opinions of their neighbors. This results in an uncoordinated quivering of the heart rather than any meaningful contraction.

At this point blood flow that was leaving the heart to supply the rest of the body, and not insignificantly, the heart itself, stops. This results in a total loss of blood flow to an already beleaguered heart and if something doesn’t change very rapidly, a funeral.

The "everybody does their own thing" phase where cardiac muscle cells begin to contract independent of one another is called "fibrillation". If at the onset of fibrillation there happens to be a paramedic or other like minded individual near by who happens to have a defibrillator (that fancy machine you always see people getting shocked with on TV) and that person happens to be paying attention to what’s going on, than this otherwise very serious turn of events can be favorably altered. This is one of the paramedic’s best opportunities to look really cool.

What a defibrillator does is to pass a large quantity of electricity, say enough to run a large refrigerator, through the unsuspecting victim’s body. This does two things. First, it hurts like hell. Second, it makes all the muscle cells in the victim’s heart contract at the same time. That it also makes every other muscle in the victim’s body contract at the same time is a happy coincidence that makes for dramatic filmmaking. Once this contraction has passed there is a possibility, maybe even a likelihood that the heart muscle cells will begin behaving themselves and the heart will begin to beat normally again. This, when combined with some cool drugs and a bit of good luck will result in the return of a living, breathing, talking person from a corpse.

I wouldn’t say in the presence of an attorney that paramedics sometimes approach chest pain with a bit of nonchalance, but sometimes paramedics approach chest pain with a bit of nonchalance. (You’re not an attorney, are you?) Once you’ve decided that the patient has cardiac or possibly cardiac chest pain you break out your favorite chest pain recipe and start down the list. First a little of this, then one of those… Assuming the patient begins getting some relief from the pain, which they nearly always do, the recipe remains the same. This you do two or three times a day, every day you work for years and years. It’s hard not to get a little nonchalant. This is the story nonchalance derailed.

On a not very remarkable late summer morning my partner of the day Chuck and I were cruising the streets when we got a call for a 43-year-old with chest pain. We arrived at an upper-middle class house and made our way to the back bedroom to find said 43 year-old sitting on the bed with his wife and two daughters huddled around him. He said he’d been outside mowing the yard when he started having chest pain. This was not an at all unusual presentation of chest pain, as yard work is a leading cause of chest pain. The gentleman in question looked pretty good so we put our new friend on the stretcher, wheeled him to the ambulance and started down the recipe list. A few steps down in the recipe, which we cleverly call an algorithm to confuse people, I was required to move a switch on the cardiac monitor so as to have a look at the heart in question from another angle. This allowed us to see if the heart muscle was getting mad or not. The moment I switched it, the display became jumbled. This often happens when you take a piece of delicate instrumentation designed to pick up a thousandth of a volt through two feet of flesh and bounce it down some pot-hole filled road. The jumbling is called artifact. Not to be undone by a machine, I brilliantly turned the switched back to its original position. Much to my surprise and dismay the artifact was still there. In was perplexed for a moment and then the answer hit me. V-fib…the monitor was thoughtfully displaying ventricular fibrillation. V-fib looks very much like a squiggly line, which coincidentally is what most artifact looks like.

This new discovery had a detrimental effect on my being able to continue semi-mindlessly follow the recipe. The guy had had the nerve to up and die without so much as a decent goodbye. This annoyed me some, and I decided that I could have none of it. Also I had thoughtfully reassured his family that everything would be fine and it would be poor form, I thought, to show up at the hospital with dead patient. It was time, I thought, to do something cool.

I grabbed the paddles, selected 200 watt/seconds on the dial and zapped him. This could be really bad, I thought as I pushed the "fire" buttons. I’d be really bummed if this guy died in the back of my ambulance. Possibly very uncool, I thought.

Just then, to my amazement, the gentleman took a very deep breath, opened his eyes and said, in a calm voice that his chest felt a bit better. My previous reality shift had only started about five seconds before and this new shift left me reeling. He didn’t even know anything had happened. We talked a bit (as I "nonchalantly" loaded him up with miracle drugs and did everything else I could think of to keep him from repeating his performance) and finished our trip to the hospital without further adventure. As far as I know he never did find out that he’d died in my ambulance. He just stopped being dead. I spent the rest of the day shaking my head in disbelief. I finally concluded that this defibrillation thing was very cool indeed. He stayed at the hospital a few nights, had his coronary arteries cleaned out and went home to his yard work where I imagine he still is.