My day at work

[ERCougar]

I posted this to a medical blog I occasionally contribute to...

Man in his late 70's is rushed back to the trauma room complaining of chest pain. History of MI and CABG (open heart surgery). He's diaphoretic, pale, and does not look good. Blood pressure's in the 70's with a HR in the 30's. Complete A-V block on the monitor. EKG shows inferior wall MI. We start pacing him, get him aspirin, and await the chest x-ray. With the pacer, BP's improved to 130/80 range. His chest x-ray looks good, we don't have a cath lab at this hospital, so we call the transferring facility and helicopter, start lytics and heparin. He's in a paced rhythm, stable blood pressure, tolerating the pacer well at about 20 mA with good capture.

Gradually, his pressure starts to drop. 110's....90's...80's...70's....nothing. Electrical activity on the monitor, no pulse. We start CPR, open up the fluids. I turn around to talk to the wife, as the patient had requested "no life support" (whatever that means). I get the sense that what he had really wanted was to not be on a ventilator for the rest of his life, so I explain to her that this may reversible if we can get him to the cath lab, and that this is probably worth a round of CPR. She agrees, so we continue. After a couple of minutes, recheck the pulse...still nothing. Push epi and continue CPR. We intubate him. Couple of more minutes and we get a pressure. A good pressure. Funky wide-complex rhythm bordering on V-tach, which is either epi effect (for non-medical folks still reading--you can pump epinephrine into a dead heart and make it beat for a few minutes until the drug wears off...bad) or reperfusion rhythm (a rhythm frequently induced by lytics that resolves on its own...good). But still...it's a good blood pressure. A few more minutes and more narrow complexes...things are looking good.

In the meantime, the helicopter has arrived. They're getting him ready for transport when his pressure starts to drop again. He arrests again. We start CPR and I again turn to the wife. At this point, she's not as enthusiastic about things and we decide to stop efforts. The code is called. Nurse pushes epinephrine. There is some dispute (in her mind) about whether she heard the code being called and pushed epinephrine anyway. In any case, I glare at her and ask her to turn off the monitor so the wife doesn't have to sit and watch her dead husband's heart beat for the next 5 minutes. Our nursing coordinator takes the wife into another room so that we can "clean up things in the room".

For the next few minutes, we watch the heart predictably start to beat, with palpable pulses. He occasionally takes a breath here and there, but nothing that you wouldn't expect from the epinephrine. I leave the room to discuss things with the family and contact the receiving facility. Soon, the nurse interrupts me, "Doctor, can I borrow you for a minute?". As I come into the room, she says "this patient's not dying". We turn back on the monitor to see that he still has a funky rhythm but a pretty good pressure. He's also breathing on his own. Problem is, the coroner's been called, the transfer's been cancelled, the helicopter's gone, and the code has been called. This guy's been dead, not once, but twice. This HAS to be the epi. It WILL wear off. And anyway, the wife asked us to stop resuscitative efforts. We all agree to turn off the monitor and try to delay the family from seeing the body for a little longer.

To make a long story short, over the next 30 minutes, this guy continues to "stabilize". Now he's breathing regularly, albeit with a tube in his throat. He's making purposeful movements. "Sir, can you hold up two fingers?" He holds up two fingers. "Do you want this tube out of your throat?" He nods. This guy is alive and functioning. He has a good BP. He's in sinus rhythm off of the pacer--best rhythm he's been in yet. I haven't seen the cath report yet, but I do know he made it to the facility without any problems.

A true resuscitation.

Being a believer most of the time, with occasional forays into agnosticism, I have to wax metaphysical here and wonder what God's role is in all of this. Before I was in medicine, I used to think of death as being this black-or-white thing, and when it's time to go, God takes you. There are plenty of medical folks who think this way--the flight nurse was helping to comfort the wife and said to her, "He's just got somewhere else to be now"--a very sensitive way of putting it that she seemed to really appreciate.

So what happened here? Did God just come down and say, "it's time" only to come a few minutes later with "well, maybe not"? And then only to change His mind two more times?

Or did Billy Crystal have it right all along?

[Tex]

Originally Posted by ERCougar

So what happened here? Did God just come down and say, "it's time" only to come a few minutes later with "well, maybe not"? And then only to change His mind two more times?

Just curious ... why must the assumption be that God was changing his mind?

[Runner Coug]

So basically, everyone gave up on the poor guy except the nurse. If I'm ever in your ER, will you please make sure I get her?

[Rickomatic]

Originally Posted by Runner Coug

So basically, everyone gave up on the poor guy except the nurse. If I'm ever in your ER, will you please make sure I get her?

Now that made me laugh.

[ERCougar]

Originally Posted by Tex

Just curious ... why must the assumption be that God was changing his mind?

I'm not assuming anything...I'm just asking. I take it from your question that you belong to the Miracle Max school of thought?

[ERCougar]

Originally Posted by Runner Coug

So basically, everyone gave up on the poor guy except the nurse. If I'm ever in your ER, will you please make sure I get her?

Pretty much, yeah...

Actually, the potential issue here is over-resuscitation not under. Remember, this guy had an advanced directive that said he didn't want any resuscitative measures done. Now, in discussing this with his wife, I felt that given the situation, it warranted at least one round of CPR, but there are doctors who wouldn't have done anything based on that directive. There are many who think we shouldn't be resuscitating an 80-yo anyway, the reason being that they rarely resuscitate to any sort of functional status. The odds of him returning to any normal state after two arrest episodes are dramatically lower. His ability to follow basic commands is really remarkable, but we'll see what sort of functional status he ends up with.

If the shit hits the fan on this because he comes back as a vegetable, the nurse who pushed the epi will be in a whole lot of trouble. I can answer for my end; she can't answer for pushing a drug without an order after the code has been called.

So, I realize you're joking but no--you probably don't want that nurse.

[Colly Wolly]

Interesting story, thanks for posting.

I had my first ever medical emergency experience this past January when we were visiting my wife's grandparents in San Diego (El Cajon-Blossom Valley area). It was the evening and we were watching tv with her grandmother and great aunt. All of a sudden, the great aunt starts making these weird snoring, horse-like noises with her eyes closed. Very loud and animated. Then she just stops. We call ner name and no response. I walk over to her chair and see that she had wet herself. No breathing, and no pules. Time to call 911. My wife's grandmother calls 911 while a cousin performs CPR and I administer a blessing. I got my first exposure to "agonal" breaths. Freaky.

The ambulance gets to the house and they giver her some shots and put her on this boogie board thing that had a belt on it that did the CPR compressions. By some miracle they get her heart beating again. We go to the hospital and the ER doctors are saying it's not good, she's in a coma, and it's time to call relatives to get the affairs in order. She was intubated and breathing on her own, but she was twitching like crazy and not responding to physical stimulation or sound. We left the hospital that night thinking we wouldn't see her alive again.

The next morning she was awake and talking. Doctors couldn't believe it. Sorry for rambling. I just think it would be crazy to be an ER doctor and see people go through stuff like this on a regular basis.

[Zulu451]

Here is another one for you:

I have a young woman with end stage breast cancer, mets to the brain, lymphangitic spread to the lungs with malignant pleural effusions (long doctor words for mets to the lungs creating fluid to accumulate in the lungs that won't go away). She had bilateral mastectomies done about a month ago for the large fungating tumor that was erroding through her chest and skin. She has been in complete denial for the past 4 years. Her right side was invading the chest wall and we had to leave a large open wound. Wound vac'd it and skin grafted the site, essentially skin grafting over tumor. Post op, she won't come off the ventillator, her lungs are so stiff from tumor that she can't breath on her own. With her on the vent, her dad becomes the surrogate, of course she had no living will, in fact she hadn't even told her family about her cancer. That was left up to me. Now on the vent for 3 weeks, not getting any better, she has been given every possible chemotherapy to get the tumor to regress but it won't. Her father has finally agreed to make her DNR (Do Not Resuscitate) and no escalation of care (leave her alone where she is at care wise). A month ago the poor guy though he was going to go camping and fishing with her. No father should have to bury his child, let alone in this fashion. Every day I get to walk by and watch her suffer. She has been anuric (no urine) for 3 days now, up about 11 liters of fluid and dying a slow, slow death, with lots of narcotics on board. It rips my heart out to be a spectator of this.

[ERCougar]

Originally Posted by Colly Wolly

Interesting story, thanks for posting.

I had my first ever medical emergency experience this past January when we were visiting my wife's grandparents in San Diego (El Cajon-Blossom Valley area). It was the evening and we were watching tv with her grandmother and great aunt. All of a sudden, the great aunt starts making these weird snoring, horse-like noises with her eyes closed. Very loud and animated. Then she just stops. We call ner name and no response. I walk over to her chair and see that she had wet herself. No breathing, and no pules. Time to call 911. My wife's grandmother calls 911 while a cousin performs CPR and I administer a blessing. I got my first exposure to "agonal" breaths. Freaky.

The ambulance gets to the house and they giver her some shots and put her on this boogie board thing that had a belt on it that did the CPR compressions. By some miracle they get her heart beating again. We go to the hospital and the ER doctors are saying it's not good, she's in a coma, and it's time to call relatives to get the affairs in order. She was intubated and breathing on her own, but she was twitching like crazy and not responding to physical stimulation or sound. We left the hospital that night thinking we wouldn't see her alive again.

The next morning she was awake and talking. Doctors couldn't believe it. Sorry for rambling. I just think it would be crazy to be an ER doctor and see people go through stuff like this on a regular basis.

"boogie board think with a belt"--that one made me laugh.

That is pretty miraculous. She's pretty lucky you started CPR that quickly (well, the blessing helped too...). Unwitnessed arrests are particularly bad if no bystander starts CPR.

[ERCougar]

Originally Posted by Zulu451

Here is another one for you:

I have a young woman with end stage breast cancer, mets to the brain, lymphangitic spread to the lungs with malignant pleural effusions (long doctor words for mets to the lungs creating fluid to accumulate in the lungs that won't go away). She had bilateral mastectomies done about a month ago for the large fungating tumor that was erroding through her chest and skin. She has been in complete denial for the past 4 years. Her right side was invading the chest wall and we had to leave a large open wound. Wound vac'd it and skin grafted the site, essentially skin grafting over tumor. Post op, she won't come off the ventillator, her lungs are so stiff from tumor that she can't breath on her own. With her on the vent, her dad becomes the surrogate, of course she had no living will, in fact she hadn't even told her family about her cancer. That was left up to me. Now on the vent for 3 weeks, not getting any better, she has been given every possible chemotherapy to get the tumor to regress but it won't. Her father has finally agreed to make her DNR (Do Not Resuscitate) and no escalation of care (leave her alone where she is at care wise). A month ago the poor guy though he was going to go camping and fishing with her. No father should have to bury his child, let alone in this fashion. Every day I get to walk by and watch her suffer. She has been anuric (no urine) for 3 days now, up about 11 liters of fluid and dying a slow, slow death, with lots of narcotics on board. It rips my heart out to be a spectator of this.

Wow...fortunately, our painful situations are short-lived. I see plenty of tragedy, but I don't have to watch it draw out over weeks. I can't imagine having to bury one of my children, even if they were an adult--I can understand the denial.

Can you get her into hospice?