As a nurse, Heather Miller had talked to patients who had seen themselves approaching a light as they went through near-death experiences.
The Iron River woman had no reason to suspect it would happen to her.
And then it did.
Three times on May 26 of last year, as her colleagues at St. Luke's hospital in Duluth labored furiously to save her life, the unconscious Miller saw herself in darkness, being drawn toward a warm, comforting light.
It has changed her perspective, Miller said, on her work, on her family, on life and on life after death.
"I feel like I'm here to tell people that when you die it's going to be OK, and people who died before them, they're OK," said Miller, 39, during an interview in the day surgery area at St. Luke's, where she works. "That transition was so awesome."
Miller's journey to the edge of death began innocuously.
Last May 12, she underwent a hysterectomy. It went well, she said; she was coaching a T-ball team four days later. But she started feeling short of breath with exertion. Her mother, a retired nurse, suggested she get it checked out.
Miller didn't. With three young children to care for, she had responsibilities, she explained. Besides, she's like other people in medicine, she said, who downplay their own symptoms.
"We tend to pooh-pooh things," Miller said. "So unless you're dying, you're not going in."
She told her mother she was fine. It was probably just low hemoglobin following the surgery, and she just needed to take more iron.
On the night of May 25, she suddenly knew it was much more serious than that.
"I'd bathed my kids and got them into bed and went down and sat down in a chair in the living room, and I got this sudden chest pressure, chest pain, like: 'Gonna die'," she recalled. "Like impending doom that people talk about."
She had no doubt about what it was. After 16 years in nursing, including work in the emergency room, she knew that gynecological surgery puts people at higher risk for blood clots, she said.
That can lead to a blockage in the pulmonary arteries to the lungs, with symptoms including shortage of breath, coughing, chest pains - and, in cases Miller had witnessed, a feeling of impending doom.
She knew, Miller said, that she had a pulmonary embolism, which she often abbreviates as PE, and that she was in grave danger.
Although there is a higher risk of PE following gynecological surgery, it's "very rare" for it to actually happen, said Dr. Melissa Miller, an OB-GYN specialist at St. Luke's who is not related to Heather Miller and did not perform the hysterectomy on her.
Nonetheless, precautions are always taken to reduce the risk still further, Melissa Miller said. In the case of a low-risk patient such as Heather, that would mean applying compression stockings to massage the calves and help prevent blood clots from forming in the veins of the patient's legs.
For whatever reason, the very rare had happened in Heather's case.
'I know I'm dying'
The Millers live near the Delta Diner, five miles outside of Iron River. It takes her an hour to drive to work, she said. Volunteer emergency responders would have to get to their base in town before speeding to the Millers' home.
She opened a door, craving oxygen, but the air was humid, and it didn't help. She sat again and then, feeling she was going to pass out, lay on the couch.
It helped, a little.
"I'm sure my blood pressure stabilized, but I was still going to die," she recalled. "I knew I needed oxygen. I knew I lived in Iron River, Wisconsin, and I knew at this point it was a PE."
She hadn't yet said anything to her husband, Glen. Now, she did.
"At this point I know I'm dying, and I was yelling at him to call 911 and trying not to freak out and trying to keep my composure," she said. "I was just trying to stay alive, which was very difficult."
Glen Miller, an insurance agent with a dry sense of humor, tried to keep the mood light even as he seemed to be losing his wife, he said. Having recently completed a CPR class, he said, "Let me get my manual."
The children came from their rooms, alarmed. One of the boys was crying. Heather was careful not to mention "dying" in front of them, she said, but she thinks they heard her say that when they were still in their rooms.
Iron River Ambulance arrived in 12 minutes, an "awesome" response time given the circumstances, Heather said. An oxygen mask was applied, but she still felt like she couldn't breathe. Along the way to Duluth, she was transferred to Gold Cross Ambulance.
Glen dropped off the kids at his parents' and drove on to St. Luke's.
In the ER
The attending physician in the emergency room was Dr. Jonathan Shultz.
"It was immediately evident she was very ill," Shultz recalled in a phone interview.
Like Heather, he knew the symptoms and her recent surgery pointed toward a pulmonary embolism, Shultz said. He ordered a CT angiogram of her chest, in which a dye is injected that will show blood clots. But even before that took place, he put her on heparin, a drug designed to prevent blood from clotting.
The image showed Heather had a sub-massive pulmonary embolism, the second most critical kind, he said. Immediately, he called the hospital's interventional radiology department. In existence at St. Luke's for only about six years, the technology involves a quarter-inch incision in the patient's leg, said Dr. Morgan Althoen, the interventional radiologist who treated Heather. Catheters are inserted and snaked to the heart and then to the pulmonary arteries. They're used to deliver "clot buster" medicines, and a vacuum device is attached "to suck out clot as we fragment it," he said.
Before that was tried, Heather was placed in intensive care overnight, her condition being monitored. Interventional radiology is a high-risk, aggressive procedure, Shultz said, new enough that not everything is known about its effects. Although it wasn't his call, Shultz said placing Heather in ICU to see if her body would start absorbing the clots was a wise decision.
In retrospect, Shultz said, it's clear Heather wouldn't have survived just with medicine. She also wouldn't have survived transfer to another facility. That wasn't necessary anyway, he said, because St. Luke's had interventional radiology available.
A 'last-ditch' effort
By morning, Heather's condition was deteriorating. She was wheeled into the operating theater, met by a team that included Althoen and Dr. Norman Boucher, an anesthesiologist. Both had worked alongside Heather.
In separate interviews, both Althoen and Boucher said they had to put the thought that they were operating on a colleague out of their minds.
"Oh, it hits you later," Althoen said. "I mean, we worked together for a number of years here. Trying to go to sleep that night after the procedure you think, 'Wow, I knew that person.' Thankfully, I'll still get to work with her."
The fact that interventional radiology was called upon indicated how critical Heather's condition was, Althoen said.
"When I get involved in these cases, at that point it's either my specialty or nothing," he said. "It's kind of the last-ditch effort to try to save the patient's life."
His job was to remove enough blood clot to allow Heather's heart to function, Althoen explained. The vacuum device on a catheter has been available only about a year and a half, he said. Without it, in Heather's case, the job likely would have been impossible. Just a decade ago, he said, there would have been no hope of saving Heather's life, regardless of where she was treated. The technology simply didn't exist.
As it was, Heather was "very unstable" in the early going, Althoen said. Three times, his patient "coded," meaning that "her blood pressure falls acutely to the point that it's not compatible with surviving."
When that happens, "I have to stop working and let the anesthesiologist pound on her chest," he said.
Boucher was applying all his skill to keep Heather alive.
"At the moment that Heather comes in you think there doesn't seem to be a lot of hope here," Boucher recalled. "But the initial response for me is ... you're going to try your damndest to do it, but there's a part of me that says, 'I don't want to go through a failure. I don't want to go through another loss.' "
Those failures haven't happened often, Boucher said, but when they happen "they stick with you throughout your career."
The short-term prognosis was grim.
"I have dealt with pulmonary emboli in patients before, all of whom have died," Boucher said. "This is the first time that I've seen a massive PE like this survive."
'The best thing ever'
Heather has no way of knowing, she said, but it makes sense to her that those three encounters with light corresponded with the three times she coded.
The experience, she said, was exactly as many others have described but still hard to put into words.
She was in blackness, moving toward light at the end of a tunnel. "But the thing about it was I knew it meant death, and I really didn't want to go into the light," Heather said. "Even though it was awesome. It was, like, the best thing ever. ... There was no pain, there was no worry. There was nothing. It was so comforting. But for some reason I didn't want to go in."
She felt she was given a choice, Heather said, and each time she pushed herself away from the light.
"Well, the third time I got very close to going in because I wanted to," she said. "Because it was super awesome. And I was, like, 'You know what? Let's go in.' But then right before I got in I was like, 'No, I cannot. And then nothing.' "
'My poor kids'
The surgery took hours, Althoen said. It didn't remove all of the clots, nor was it intended to. It stabilized her to the point where her body, helped by medication, could do the rest of the work.
She was unconscious, in a ventilator and intubated - a tube into her trachea - for the next five days.
Heather described the entire experience with calm enthusiasm, becoming emotional only when it came to her children, now ages 9, 7 and 3. She teared up when talking about the days she was in the hospital, away from them.
"My poor kids," she said. "It was the end of school for them. It was their last day of school. I missed their field trip. ... And that was very hard for me as a mom."
Glen Miller stayed by his wife the entire time, the couple's parents caring for their children and his parents filling in at his insurance office. When Heather awoke, he spent hours giving her drops of water through a tiny sponge. She told him she had seen light at the end of a tunnel three times, Glen recalled; he told her she had coded three times.
"I've never been skeptical about my wife, what happened to her," Glen said. "When she told me the story and I told her, 'You coded three times' - it was kind of a weird coincidence."
'It's so real'
The doctors interviewed for this story all have known of other instances of patients near death later reporting they had seen light at the end of a tunnel, they said. What it means is another question.
"Some people ascribe a religious significance," Althoen said. "Less-religious people describe it as what it looks like when your brain is shutting down."
Shultz has heard people's near-death stories a number of times, he said, now as an ER doctor and earlier as a paramedic. He is struck by how similar the stories are.
"Given the wide variability of human physiology, or the way in which people die, I find it hard to believe that there is a physical explanation for everybody having a similar experience," he said.
There's no doubt in Heather Miller's mind.
"I'm a Christian, so I never once thought that it didn't happen when people would tell me," she said. "But now that I've been there it's like, omigosh, it's so real."
Heather's road since her near-death experience hasn't been smooth. She has been hospitalized several times, racked with coughing so extensive that at one point she cracked a rib. She has been to the Mayo Clinic and the University of Minnesota, and the latter diagnosed her with vagus nerve damage, for which she is being treated.
How that might have stemmed from Heather's pulmonary embolism and her treatment for it is "anybody's guess," Althoen said. According to the literature on the subject, "people come out of this with a variety of symptoms that we hadn't really known before because most of these patients died before," he said.
To Heather, the complications barely matter.
"Cool. I'm alive," she said. "If this is what I have to deal with, OK, it's something I have to deal with."
The experience has changed her attitude about work, Heather said, even though it already was a job she loved.
"I just have a different side of it now," she said. "I feel like I'm more understanding."
She also has found herself telling her story to people who needed to hear it: a nurse who started crying, and then explained that her husband had died two weeks earlier; a patient whose grandmother had just died.
Getting the story out is so important to her, that in addition to her full-time job, her two-hour daily round-trip and her family responsibilities, Heather is working on a book about her experience, she said.
The experience also has led her to an even greater appreciation of her family.
"Your job is important, but your family is more," Heather said. "My kids were almost without a mother. We all know that happens. And how sad. I just can't stress enough how important life is."
Seeing their mother being taken away during the night in an ambulance and next seeing her in the hospital was, understandably, traumatic for the children. Maddie, the youngest, often asks her mother if her belly hurts, Heather said, and doesn't want her to go to work, fearing she won't come back from the hospital.
The oldest child, 9-year-old Caden, asked his mother if she had died, because he heard that she had, Heather said.
"And I did say, 'You know, I did see heaven,' " she related. "And it was awesome. But I'm back."