What happened to Sam Blackman was inconceivable.
The 41-year-old was an avid runner and ultimate Frisbee enthusiast. He was vibrant and cheerful. He was Portland's most successful tech entrepreneur, a vocal advocate for education and civic philanthropy. His future seemed boundless.
On a warm Saturday evening last August, Blackman collapsed while delivering a toast at his brother's wedding on Sauvie Island. Guests rushed to perform CPR and summon paramedics but he never recovered. Blackman died in a Portland hospital the next day, mourned by his young family, a fast-growing company and a city he loved.
It's the kind of tragedy that defies understanding. But there is an explanation.
"Obviously this is disheartening and shocking. That is unfortunately the nature of this disease," said Eric Stecker, an Oregon Health & Science University cardiologist who has spent his career studying sudden cardiac arrest, the broad term for the disturbance in the heart's rhythm that triggered Blackman's death.
Sudden cardiac arrest is actually a leading cause of death for men in their 40s but it's agonizingly difficult to predict. And once it starts, any chance of survival is measured in minutes and proximity to a defibrillator.
Sauvie Island sits right in Portland's backyard, a refuge of beaches, rivers and farms less than 20 miles from downtown. Though it attracts hundreds of thousands of visitors every year, it's remote from an emergency services standpoint.
Blackman suffered his attack at a wedding on a farm, which didn't have one of the automated external defibrillators required in large offices and big public venues. Friends and family waited an excruciating 16 minutes for volunteer firefighters, and it took several more minutes for an ambulance to arrive from a prior call near Portland International Airport.
Multnomah County is considering changes to its ambulance contract that could provide faster service to Sauvie Island, but Stecker - who was not involved in Blackman's treatment - said even a much quicker response probably wouldn't have made a difference in this case.
Yet there is still an opportunity to learn from the tragedy, Stecker said, for people who might be at greater risk and those who might be in a position to respond to future crises.
"At least we can increase awareness of where it could have made a difference," he said.
Sudden cardiac arrest
Causes
: Heart disease related to smoking, diet, lifestyle or high blood pressure. It can also be caused by genetic or other, unrecognized factors.
Prevention
: Healthy lifestyle, cardiovascular preventive care, evaluation of concerning symptoms. While many cases can't be anticipated, attention to overall cardiovascular heart and preventive care can significantly reduce risk.
Treatment
: Ninety percent of people who suffer it die. But immediate cardiopulmonary resuscitation (CPR) will help sustain a patient for a very brief period, and treatment within few minutes from a defibrillator can sometimes revive patients.
Source: American Heart Association, Eric Stecker, OHSU
Blackman was co-founder and chief executive of Elemental Technologies, which uses standard computer hardware to adapt video for online streaming. Clients include HBO, ESPN, the BBC and many others that use its technology to stream video onto TVs, PCs, smartphones and tablets.
Amazon bought Elemental in 2015 for $296 million and changed its name to AWS Elemental. Blackman remained CEO, though, and Amazon's new Portland outpost expanded rapidly. It now employs more than 400 at its new downtown offices.
As Elemental grew, Blackman became increasingly vocal about boosting public education in Portland, protecting the environment and increasing diversity within the tech industry. Friends and family members quietly speculated about a forthcoming political career, and his death brought tributes from Portland's mayor, Oregon's governor and one of its senators. U.S. Rep. Earl Blumenauer hosted his memorial service.
Elemental sponsored a number of philanthropic initiatives, including a regular 4K4Charity run at industry events and in Portland. The next is Oct. 12, at Tom McCall Waterfront Park. Blackman was typically among the first finishers in those races. At his memorial service, his family put the bike he rode to work up on stage alongside his ultimate Frisbee disc. He coached his sons' grade-school basketball team.
Remembrances
Sam Blackman's family asks that remembrances be made to the
,
, or
.
Fundraiser
AWS Elemental is hosting its annual Portland
this Thursday at Tom McCall Waterfront Park in downtown Portland. It supports Rosemary Anderson, an alternative high school for students who are not succeeding in public schools.
Blackman's family said he died from ventricular fibrillation, a form of disturbance to the heart's electrical rhythm that can lead to cardiac arrest.
A death like his feels especially horrific because it seems to come out of the blue. But Stecker said it's a surprisingly common cause of death, especially for men in their early 40s.
Of men that age in Multnomah County, about 30 per 100,000 die every year from sudden cardiac arrest, according to Stecker. He said that's nearly as high as the rate of death for all cancers combined, and higher than any other single cause of death besides accidents.
"We don't think about it because people don't talk about it, and they may mischaracterize it," Stecker said.
Often, sudden cardiac arrest results from underlying coronary disease. That can be genetic, or can be triggered by smoking, a fatty diet, lack of exercise or other lifestyle issues.
People can significantly reduce their risk of sudden cardiac arrest by living healthy, but Stecker said it also strikes people like Blackman who don't exhibit those risk factors.
Blackman's family said he blacked out once while exercising in the months before his death. When that happens to a fit person it can suggest serious heart problems, and the records show that he sought a medical explanation. But an electrocardiogram came back "normal."
Nearly everyone experiences heart palpitations from time to time and many people have occasional heart arrhythmia. Rarely, Stecker said, does that indicate a more serious condition.
While researchers are working to find ways to differentiate routine episodes from symptoms of a more serious condition, he said today's doctors often have no reliable way to distinguish a benign arrhythmia from one that signals a potentially fatal problem.
"This is every family's worst nightmare, and it's also every cardiologist's worst nightmare," Stecker said.
Records show at least three medical professionals were present at the wedding when Blackman collapsed, and they immediately began CPR. Several other guests called 911. Friends and family became increasingly frantic as the minutes ticked away, and 911 callers asked again and again whether the ambulance was close.
Did the operator understand how urgent the situation was? Yes, yes, help is coming with lights and sirens.
Eleven minutes in, a caller asked once more when they could expect the ambulance.
"It's still a ways off," a 911 operator replied, forlornly. "I'm really sorry for you guys. When you get out on Sauvie Island everybody is so far off, and it's a volunteer fire department."
In Portland, residents can typically expect an ambulance or fire truck within four or five minutes of making a top-priority medical call. On Sauvie Island it takes almost 19 minutes for an ambulance to arrive, on average.
The Sauvie Island Fire Department is less than a mile from where Blackman collapsed, but volunteer firefighters had to assemble at the station and collect a portable defibrillator before proceeding to the scene. Emergency call records indicate they didn't reach Blackman for 16 minutes.
Longer response times come with the territory in rural places, said Sauvie Island resident Chet Orloff, who volunteers to work on emergency planning in the community. Volunteer firefighters give up time each week to train, and spend weekends on call to respond quickly to emergencies.
For the island's roughly 1,600 residents, Orloff said, that seems to be enough.
"Most people who live out here, whether they are long-term agricultural people or people who've sort of chosen a rural setting, as is the case with us, the balance is on the side of, we've accepted the fact that there's a little bit of a distance there," said Orloff, a Portland museum director and adjunct professor at Portland State University. "But that's the tradeoff most people are willing to have."
Still, few other rural communities in the state attract the volume of people Sauvie Island does by virtue of its proximity to Portland.
The Oregon Department of Fish and Wildlife reports that nearly 800,000 vehicles a year, on average, visit the island's beaches and other wildlife areas. Allowing for multiple passengers in each vehicle, that suggests 1 million or more visit Sauvie Island annually.
Generally speaking, that doesn't translate into a huge volume of emergencies. American Medical Response, which contracts with Multnomah County for ambulance services, said it has received 93 calls to Sauvie Island through September.
AMR's contract with the county requires it to arrive on scene within 20 minutes for 90 percent of the top-priority calls to rural areas, and county records show the company met that standard. (For urban calls, it must be on-scene within 8 minutes, 90 percent of the time.)
The ambulance response time to Blackman's emergency on Aug. 26 was between 23 and 25 minutes, according to AMR and incident reports. That's at least five minutes longer than AMR's average response to Sauvie Island.
AMR deploys 27 ambulances at peak times, according to Rob McDonald, the company's operations manager for Multnomah County; it had 18 ambulances deployed that Saturday evening.
It was an especially busy night, McDonald said, and just two ambulances were available when the call came in on Blackman's cardiac arrest. The closest was by the Portland airport, near the opposite side of the city from Sauvie Island.
Since cardiac arrest typically requires a defibrillation within a few minutes, that night's unusually long response time likely did not change the outcome in this case. But Multnomah County and AMR were already considering ways to improve response times to remote parts of the county.
Multnomah County's contract for ambulance services is up for bid next year, and the county's proposal for a new contract would allow for subcontractors in areas with a "difficult geography" - potentially including Sauvie Island.
Sauvie Island is closer to Beaverton and Scappoose than to much of Portland, but McDonald said the current contract doesn't allow for an exchange of ambulance services with those areas.
A new contract could make allowances for "mutual aid" across those borders, he said: "It's something that, as far as we're concerned, we're pretty excited about."
Automated defibrillators (AEDs) can sustain a victim of sudden cardiac arrest by analyzing a patient's heartbeat and, when necessary, shocking the heart to restore a natural rhythm. Oregon law requires AEDs in office buildings and large public venues. They typically run between $1,500 and $2,000.
"I recognize you can't put AEDs absolutely everywhere," said Stecker, the OHSU cardiologist. But they're already more common than many people realize.
If more people knew to look for them in schools, offices and gyms, and took the time to learn how to use them, Stecker said AEDs would save more lives.
Blackman's grieving family declined to revisit his death. At his memorial service last month, though, his mother said it could not have been foreseen or prevented: "No what-ifs apply here."
And his brother Eli told close to 1,000 mourners that he, and they, would have to make peace with a death that defied reason.
"We want things to make sense, but they don't always," Eli Blackman said. "And that's OK."
Correction: This article has been corrected, based on additional information, to indicate that Blackman blacked out only once while exercising in the months before his death.
-- Mike Rogoway; twitter: @rogoway; 503-294-7699