The voice is as thin as the tissue difference between life and death, between health and debility. And San Jose could have landed on either side of that delicate line after suffering a sudden cardiac arrest in August at his thrice weekly racquetball game.
But thanks to bystanders who provided immediate CPR, paramedics who responded promptly and a relatively new and brain-saving cooling therapy, the prospects are excellent that San Jose will recover completely.
"The whole system worked perfectly," said the grateful and effervescent San Jose.
As a result the popular community activist and gadfly, known throughout Long Beach and particularly in his Northtown neighborhood, will be able to continue to deliver his particular brand of wit and wisdom.
He will also be able to continue his volunteer work with at-risk and impoverished youth through his nonprofit Bikes 90800.
Although San Jose still faces open heart bypass surgery Monday, the procedure is relatively low-risk and should return him to full health.
Bystanders save lives
That everything worked just right for San Jose is an object lesson in the importance of CPR training for regular folk, rapid paramedic response and hospitals being properly outfitted with needed technology.
"Mostly what I want to focus on was the ability of the hospital to do the right things and the importance of bystander CPR," said San Jose and his wife, Pat Long-San Jose, as they dined at Nino's Restaurant on a recent afternoon.
San Jose said he and his wife had talked about what they would to do should he have a major health setback, such as a cardiac arrest. San Jose's biggest fear was being debilitated and unable to care for himself.
"I didn't want to be a burden on my wife," San Jose says.
But that's the predicament San Jose faced when his heart stopped and he collapsed Wednesday, Aug. 4(it's OK in this context to have day, date-jd) at the L.A. Fitness Club in Long Beach between games of racquetball.
The last thing San Jose remembers from that morning was chatting with a neighbor before heading off for his workout.
Right place, time
Luckily for San Jose, he hangs out with the right kind of people. On hand when San Jose collapsed were two doctors and a nurse, who immediately jumped in and began administering cardiopulmonary resuscitation.
Showing his trademark wit, San Jose jokes about his cardiac arrest.
"I don't recommend doing this at home, but if you do it, plan it well," San Jose says. "I had two doctors and a nurse."
Although he can joke about it now, those first moments after the cardiac arrest may have made all the difference.
"If I had collapsed anywhere else, the outcome wouldn't have been the same," San Jose says.
Dr. Stuart Finkelstein, who often plays with San Jose, was the first on the scene. He was at the juice bar when San Jose staggered off the court.
"I could see he looked poorly," Finkelstein said. "As he (passed) out, I caught him."
Finkelstein said he thought San Jose, who suffers from diabetes, was suffering from hypoglycemia. San Jose briefly regained consciousness but went out again and turned blue.
He had crossed the line between life and death just that quickly and now time was everything.
Finkelstein began CPR and was immediately joined by Ashley Maselli, a pediatrics nurse at Long Beach Memorial Medical Center, and Dr. Andrew Wittenberg, an emergency room doctor there.
Maselli had been on an exercise machine when she heard a commotion and saw San Jose go down.
"He went into full cardiac arrest," Maselli said. "So I opened an airway, because it looked like he was trying to swallow his tongue and checked for a pulse, -- there was none."
Wittenberg had been leaving the gym when he was called back to help. He took over chest compressions and San Jose "pinked up," according to Maselli, meaning he was getting oxygen.
"It felt like slow motion," Maselli said. "He was really gone."
Finkelstein said he went to get an automated external defibrillator to restart San Jose's heart, but by that time paramedics had arrived and took over.
As San Jose was rushed out to the ambulance, Finkelstein noticed San Jose's heart had gone asystolic, or flatline, and he wept.
"I thought he was dead," he said. "I remembered that my dad had died in a health club. I was just a mess. It took me back to when my dad died."
Maselli said she quickly cleared out with her two boys, 2 and 4 years old, so they wouldn't have to watch.
Like Finkelstein she held out little hope.
"I was really not sure," she said about whether San Jose would survive. "I know the statistics are pretty low when you get to the point where the heart is not functioning at all."
What is a cardiac arrest?
When a person suffers a cardiac arrest, the flow of blood to the body immediately stops.
Successful CPR maintains a flow of oxygenated blood to the brain and the heart, which are most vulnerable to damage from lack of oxygen (hypoxia).
Effective CPR extends the brief window for a successful resuscitation without permanent brain damage.
The National Heart, Lung, and Blood Institute, says between 250,000 and 450,000 Americans have sudden cardiac arrests each year. Almost 95 percent of these people die within minutes.
According to the American Heart Institute, although no national statistics are kept on the benefits of immediate CPR plus defibrillation (electrical shock to the heart) they are vital.
"In cities such as Seattle, Wash., where CPR training is widespread and EMS (Emergency Medical Services) response and time to defibrillation is short, the survival rate for witnessed (ventricular fibrillation) cardiac arrest is about 30 percent.
"In cities such as New York City, where few victims receive bystander CPR and time to (EMS Emergency Medical Services) response and defibrillation is longer, survival from sudden VF (ventricular fibrillation) cardiac arrest averages 1 to --2 percent," according to the Heart Institute's website.
Quick paramedic responseThe ambulance ride
A unit from Fire Station 9 arrived just 32 minutes after receiving the call.
Capt. Wes Ward said San Jose was pulseless. Firefighters defibrillated San Jose and within a half-minute firefighter paramedics Dave Rosa and Josh Hogan arrived.
"They went through their pack of tricks," Ward joked.
The captain, a former paramedic, said San Jose had to receive multiple shocks before he arrived at the hospital. But when paramedics hit the doors at Memorial, just 22 minutes after the call was received, San Jose had a pulse and his blood pressure was up.
"I don't think there's another department around that could do that," Ward said of the quick response and turnaround.
"In this case, quick response and rapid transit saved his life," Ward said.
San Jose was still on the delicate edge between life and death, but now he had a fighting chance.
Arriving at Memorial
Pat, a nurse at Long Beach Memorial Medical Center, was in a meeting when she heard the chilling news that her husband was being transported to the hospital.
Pat rushed to the emergency room, arriving shortly after her husband.
She remembers sending a message for her colleague, Vickie Barbara.
"I always told her I want you there advocating for me," Pat said. "She's like a dog with a bone;, you need her there advocating for you."
Barbara is a big proponent of the hypothermia treatments and says in the six months since Memorial has been using it she has regaled Pat with success stories of the patients.
"I get very emotionally attached to these patients," Barbara says.
But when the call came in for San Jose, the last thing she expected was it to be for someone she knew. "the last thing I would expect was to someone I knew."
As a nurse, Pat said she had to maintain her composure and professionalism, as hard as that might have been.
"I felt I had to trust my system and my hospital," Pat said as she tried to process and track the medical information and science. Maintain her discipline.
Pat and David had talked about what they would do if seriously stricken. Dave did not want to be kept alive by machinery. He feared becoming a vegetable or severely debilitated.
"All that went through my mind," Pat said.
"I knew what it was all about, the procedures and the process," Pat said. "You just have to leave it to them."
But she was helpless to do anything but trust and believe in her hospital.
San Jose was immediately rushed to the heart catheterization lab, was given and angiogram and determined to fit the protocol for hypothermia treatment.
Pat could only wait.
"I'm a calm person so I'm just waiting," she says. "I had a great deal of concern of course, but my mind was thinking, going through all the possibilities. I guess I was hoping and praying all the outcomes were good."
Because of the early care San Jose received, he was a good candidate for a technique that lowers the body temperature and brain temperature.
"The reason we do this is because we're trying to save the brain," said Angie West, a nurse and the director of neuroscience at Memorial.
Had San Jose gone even minutes without CPR, required prolonged resuscitation or other complications, the damage could have been irreversible.
When oxygen delivery ceases, the brain releases chemicals in what's called an ischemic cascade, which damages cells in the central nervous system.
While the early CPR was vital, and the rapid response and delivery improved his chances, the chemicals released at the onset of the attack continued a destructive path through San Jose's body.
In recent years, doctors have begun using hypothermia to reduce the brain's need for oxygen, delaying or diminishing cell damage and lowering the brain's release of the damaging chemicals.
Although scientists have studied the effects of lower body temperatures and healing for decades and the procedure has been recommended since 2005, the use of hypothermia in local hospitals is relatively new.
In some areas, ice cold saline injections and putting ice on victims of cardiac arrest is a part of paramedic treatment, although that is not yet part of the treatment protocol in the Los Angeles area, according to Ward.
At Memorial, although it has long been lobbied for, hypothermia has only been used for the past six months on 10 patients. Eight have had full neurological recovery, according to West.
The hospital uses the Arctic Sun device, which consists of gel-filled pads that are wrapped around the patients' torsos and legs and contains temperature controls for cooling and heating.
When San Jose arrived, there was a problem. The hospital's only cooling device was being used, as was a back-up device.
West said efforts are under way to get more, which have been used more extensively than expected and with great results.
"The ability to give (patients) back their lives is really amazing," Barbara says. "This team we have put together has made a difference in eight people's lives, and it it tremendously rewarding."
The hospital was able to procure one from Saddleback Memorial Medical Center Hospital, but it delayed therapy several hours. San Jose was lucky the damage remained limited.
While awaiting arrival of the machine, San Jose was treated with a cold IV to keep his temperature in check.
During hypothermia therapy, the body's core temperature is lowered to about 91.4 degrees Fahrenheit for 24 hours and then slowly brought back to normal.
Researchers have found the therapy preserves neurological function, with one report finding "neurological outcomes after cardiac arrest improved from 15 percent before the use of (therapy) to 35 percent after the initiation of therapy."
After undergoing the therapy only time would tell how San Jose would react.
Although it was clear San Jose had crossed the threshold between death and life, huge questions lingered about the quality of that life.
It would be days before Pat and doctors would know the extent of San Jose's recovery and whether he'd emerge healthy or with some impairment, minor or severe.
"I'm thinking we had this discussion. If he had a severe impairment he didn't want to be kept alive on a machine," Pat said.
All Pat could do was wait as her husband slowly, oh, so slowly, began to return.
San Jose's 70th birthday came and went in the hospital.
Three days after arriving, San Jose remained sedated on a breathing machine. Occasionally he could respond to commands by squeezing a hand.
With a breathing tube down his throat, San Jose couldn't talk. Gradually he began responding to questions, blinking answers. But it was painstaking as meds were reduced and Pat worried.
"It's hard to know," Pat said of reading the signs, interpreting the myriad synapses and electric currents that flow through the body and must be perfectly tuned to avoid possibly disastrous outcomes.
On Tuesday, six days after the attack, the breathing tube was removed and San Jose regained consciousness.
Pat remembers the first real sign that Dave, the old Dave, was back came a day or so after he regained consciousness.
"He asked a nurse if she was Japanese," Pat recalls. "Then he said 'I'm Filipino.' I knew once he could make that recognition, bring those connections and ask those questions that he'd be all right."
San Jose spent 11 days in critical care unit and 17 days overall in the hospital.
San Jose remembers his first conscious thought was that he had suffered a seizure.
Regaining consciousness was only the first step. Next he had to relearn basic functions and skills.
"It's like being a baby. You have to learn to feed yourself again," San Jose said.
It was difficult for San Jose, particularly with his fear of "being a burden."
Recovery came in fits and starts.
"I couldn't walk," San Jose recalls. "Then I'm thinking, am I going to be this way the rest of my life?"
But 17 days after suffering the attack, San Jose and Pat emerged from the hospital together.
Flood of support
Through his recovery and since leaving the hospital, San Jose says he has been overwhelmed by the well wishes and shows of support
"I never knew I was so loved," San Jose says. "I think that's what probably brought me back, I don't know."
In some ways the entire ordeal still seems surreal, especially for someone who has always been fit and healthy.
"I still can't quite grasp it," San Jose says of his near death experience.
For the record he adds that he doesn't remembers seeing any lights or God or anything between when he left to play racquetball and woke up asking "What the hell happened?"
Since leaving the hospital, San Jose has been making the rounds, with Pat pressed into duty as his chauffeur. He has been back to the health club, and he visited the fire station. He has tried to thank those who saved him, though he doesn't quite know how you do that.
Maselli said she stopped by to visit San Jose in the hospital and was amazed to hear his life story and the things he has done for underprivileged kids.
"He asked me what he could do to thank me," Maselli said. "I said, 'Just keep doing what you're doing. That's the best thanks.'"
Finkelstein said he was thrilled to learn San Jose had survived and had little lingering damage.
"Boy, when he came back to the gym with his wife and daughter, in 30 years in medicine I've never felt so warm and fuzzy. It was a spiritual moment."
The two racquetball foes shared a light-hearted moment when Finkelstein made San Jose promise not to keep bedeviling him with soft shots.
"I told him to hit the ball like a man," Finkelstein joked.
Beneath the mirth, Finkelstein said he was amazed to learn San Jose's narrative outside of the gym andsome of the deeper connections he and San Jose share outside of the gym they share.(fix OK per JF)
Both have a passion for helping at-risk kids. Finkelstein, an addictions specialist, works with the 10-20 Club, a nonprofit in Downey that, among its services, offers classes on drug and alcohol abuse.
Finkelstein also learned that a former medical school classmate of his works with San Jose doing tattoo removals for former gang members.
Leave it to San Jose to come back and immediately begin forming associations and connections.
As for the future, San Jose doesn't know where it will lead. He is wondering what to do with this second chance.
"The first life was quite a life," San Jose says. "I wonder what the second one will be like."