The Year of Magical Thinking

18

At the time I began writing these pages, in October 2004, I still did not understand how or why or when John died. I had been there. I had watched while the EMS team tried to bring him back. I still did not know how or why or when. In early December 2004, almost a year after he died, I finally received the autopsy report and emergency room records I had first requested from New York Hospital on the fourteenth of January, two weeks after it happened and one day before I told Quintana that it had happened. One reason it took eleven months to receive these records, I realized when I looked at them, was that I myself had written the wrong address on the hospital’s request form. I had at that time lived at the same address on the same street on the Upper East Side of Manhattan for sixteen years. Yet the address I had given the hospital was on another street altogether, where John and I had lived for the five months immediately following our wedding in 1964.

A doctor to whom I mentioned this shrugged, as if I had told him a familiar story.

Either he said that such “cognitive deficits” could be associated with stress or he said that such cognitive deficits could be associated with grief.

It was a mark of those cognitive deficits that within seconds after he said it I had no idea which he had said.

According to the hospital’s Emergency Department Nursing Documentation Sheet, the Emergency Medical Services call was received at 9:15 p.m. on the evening of December 30, 2003.

According to the log kept by the doormen the ambulance arrived five minutes later, at 9:20 p.m. During the next forty-five minutes, according to the Nursing Documentation Sheet, the following medications were given, by either direct injection or IV infusion: atropine (times three), epinephrine (times three), vasopressin (40 units), amiodarone (300 mg), high-dose epinephrine (3 mg), and high-dose epinephrine again (5 mg). According to the same documentation the patient was intubated at the scene. I have no memory of an intubation. This may be an error on the part of whoever did the documentation, or it may be another cognitive deficit.

According to the log kept by the doormen the ambulance left for the hospital at 10:05 p.m.

According to the Emergency Department Nursing Documentation Sheet the patient was received for triage at 10:10 p.m. He was described as asystolic and apneic. There was no palpable pulse. There was no pulse via sonography. The mental status was unresponsive. The skin color was pale. The Glasgow Coma Scale rating was 3, the lowest rating possible, indicating that eye, verbal, and motor responses were all absent. Lacerations were seen on the right forehead and the bridge of the nose. Both pupils were fixed and dilated. “Lividity” was noted.

According to the Emergency Department Physician’s Record the patient was seen at 10:15 p.m. The physician’s notation ended: “Cardiac arrest. DOA — likely massive M.I. Pronounced 10:18 p.m.”

According to the Nursing Flow Chart the IV was removed and the patient extubated at 10:20 p.m. At 10:30 p.m. the notation was “wife at bedside — George, soc. worker, at bedside with wife.”

According to the autopsy report, examination showed a greater than 95 percent stenosis of both the left main and the left anterior descending arteries. Examination also showed “slight myocardial pallor on TCC staining, indicative of acute infarct in distribution of left anterior descending artery.”

I read this paperwork several times. The elapsed time indicated that the time spent at New York Hospital had been, as I had thought, just bookkeeping, hospital procedure, the regularization of a death. Yet each time I read the official sheets I noticed a new detail. On my first reading of the Emergency Department Physician’s Record I had not for example registered the letters “DOA.” On my first reading of the Emergency Department Physician’s Record I was presumably still assimilating the Emergency Department Nursing Documentation Sheet.

“Fixed and dilated” pupils. FDPs.

Sherwin Nuland: “The tenacious young men and women see their patient’s pupils become unresponsive to light and then widen until they are large fixed circles of impenetrable blackness. Reluctantly the team stops its efforts…. The room is strewn with the debris of the lost campaign…”

Fixed circles of impenetrable blackness.

Yes. That was what the ambulance crew saw in John’s eyes on our living room floor.

“Lividity.” Post-mortem lividity.

I knew what “lividity” meant because it is an issue in morgues. Detectives point it out. It can be a way of determining time of death. After circulation stops, blood follows the course of gravity, pooling wherever the body is resting. There is a certain amount of time before this pooled blood becomes visible to the eye. What I could not remember was what that amount of time was. I looked up “lividity” in the handbook on forensic pathology that John kept on the shelf above his desk. “Although lividity is variable, it normally begins to form immediately after death and is usually clearly perceptible within an hour or two.” If lividity was clearly perceptible to the triage nurses by 10:10 p.m., then, it would have started forming an hour before.

An hour before was when I was calling the ambulance.

Which meant he was dead then.

After that instant at the dinner table he was never not dead.

I now know how I’m going to die, he had said in 1987 after the left anterior descending artery had been opened by angioplasty.

You no more know how you’re going to die than I do or anyone else does, I had said in 1987.

We call it the widowmaker, pal, his cardiologist in New York had said about the left anterior descending artery.

Through the summer and fall I had been increasingly fixed on locating the anomaly that could have allowed this to happen.

In my rational mind I knew how it happened. In my rational mind I had spoken to many doctors who told me how it happened. In my rational mind I had read David J. Callans in The New England Journal of Medicine: “Although the majority of cases of sudden death from cardiac causes involve patients with preexisting coronary artery disease, cardiac arrest is the first manifestation of this underlying problem in 50 percent of patients…. Suddencardiac arrest is primarily a problem in patients outside of the hospital; in fact, approximately 80 percent of cases of sudden death from cardiac causes occur at home. The rate of success of resuscitation in patients with out-of-hospital cardiac arrest has been poor, averaging 2 to 5 percent in major urban centers…. Resuscitation efforts initiated after eight minutes are almost always doomed to fail.” In my rational mind I had read Sherwin Nuland in How We Die: “When an arrest occurs elsewhere than the hospital, only 20 to 30 percent survive, and these are almost always those who respond quickly to the CPR. If there has been no response by the time of arrival in the emergency room, the likelihood of survival is virtually zero.”

In my rational mind I knew that.

I was not however operating from my rational mind.

Had I been operating from my rational mind I would not have been entertaining fantasies that would not have been out of place at an Irish wake. I would not for example have experienced, when I heard that Julia Child had died, so distinct a relief, so marked a sense that this was finally working out: John and Julia Child could have dinner together (this had been my immediate thought), she could cook, he could ask her about the OSS, they would amuse each other, like each other. They had once done a breakfast together, in a season when each was promoting a book. She had inscribed a copy of The Way to Cook and given it to him.

I found the copy of The Way to Cook in the kitchen and looked at the inscription.

“Bon appetit to John Gregory Dunne,” it read.

Bon appetit to John Gregory Dunne and Julia Child and the OSS.

Nor, had I been operating from my rational mind, would I have given such close attention to “health” stories on the Internet and pharmaceutical advertising on television. I fretted for example over a Bayer commercial for a low-dose aspirin that was said to “significantly reduce” the risk of a heart attack. I knew perfectly well how aspirin reduces the risk of heart attack: it keeps the blood from clotting. I also knew that John was taking Coumadin, a far more powerful anticoagulant. Yet I was seized nonetheless by the possible folly of having overlooked low-dose aspirin. I fretted similarly over a study done by UC — San Diego and Tufts showing a 4.65 percent increase in cardiac death over the fourteen-day period of Christmas and New Year’s. I fretted over a study from Vanderbilt demonstrating that erythromycin quintupled the risk of cardiac arrest if taken in conjunction with common heart medications. I fretted over a study on statins, and the 30 to 40 percent jump in the risk of heart attack for patients who stopped taking them.

As I recall this I realize how open we are to the persistent message that we can avert death.

And to its punitive correlative, the message that if death catches us we have only ourselves to blame.

Only after I read the autopsy report did I begin to believe what I had been repeatedly told: nothing he or I had done or not done had either caused or could have prevented his death. He had inherited a bad heart. It would eventually kill him. The date on which it would kill him had already been, by many medical interventions, postponed. When that date did come, no action I could have taken in our living room — no home defibrillator, no CPR, nothing short of a fully equipped crash cart and the technical facility to follow cardioversion within seconds with IV medication — could have given him even one more day.

The one more day I love you more than.

As you used to say to me.

Only after I read the autopsy report did I stop trying to reconstruct the collision, the collapse of the dead star. The collapse had been there all along, invisible, unsuspected.

Greater than 95 percent stenosis of both the left main and the left anterior descending arteries.

Acute infarct in distribution of left anterior descending artery, the LAD.

That was the scenario. The LAD got fixed in 1987 and it stayed fixed until everybody forgot about it and then it got unfixed. We call it the widowmaker, pal, the cardiologist had said in 1987.

I tell you that I shall not live two days, Gawain said.

When something happens to me, John had said.