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Saturday, April 24, 2010

Lisa

I walked back into the nursing area carrying a hospital dinner tray with the barely touched remnants of stuffed shells and a salad. The nursing stations were empty. Everyone was huddled outside of room 4.

Lisa was our youngest patient in the ICU that night: she was only in her early thirties. She had been transferred from the surgical recovery unit to the ICU after her unit had called the Rapid Response Team due to post-operative tachycardia, hypotension and most likely some other stuff that I didn't know about. After she returned from her CT earlier that day, we learned that she had a big pulmonary embolism (I even got the intensivist to show me her CT!). She had been mostly bedridden for the the past couple weeks due an exacerbation of her Crohn's disease, which likely made her a pretty decent candidate for thrombus formation.

"E., get a crash cart."

I immediately put down the tray, unplugged the crash cart and rolled it into the room. It was all sort of a blur after that. I uncoiled the EKG leads and attached them to Lisa's chest. I put on the defibrillator pads. Someone was doing chest compressions. One of the respiratory therapists was bagging her. We stopped compressions for a minute. She was in coarse v-fib.

The physician gave the indication to defibrillate.
"Charging."
"Clear."

Lisa's body jumped a little. I looked at the monitor. She was still in v-fib. Her brother was now in the hallway, getting freaked out, madly trying to call his father on the cell phone. Everything had been happening so quickly that the doors to her room had never been closed, a curtain never pulled, and he stood outside the door watching as we started IVs, shocked her, and put in a central line. I pulled the curtain closed as one of my coworkers shut the door.

They shocked her again. She was now in fine v-fib. It was crazy. The whole scenario was surprisingly similar to the ACLS simulations I had attended earlier in the year. We were pushing what seemed like tons epinephrine and atropine, and later amiodarone. We had used up some of the drugs from the first med tray, so I opened another crash cart to get a second med tray. Dr. FavoriteCardiologist arrived to do a stat echocardiogram. Lisa's left ventricle wasn't pumping effectively at all and her right ventricle was huge.

Dr. FavCardiologist visualized the clot. They ended up giving her a thrombolytic agent even though she had recently had surgery. The tpA seemed to briefly help. Meanwhile, the intensivist was intubating her with the assistance of one of the respiratory therapists. It seemed like there was nothing we could do to stabilize her. Her blood pressure was tanking. Dr. FavoriteCardiologist asked Dr.GeneralSurgeon if he could do an emergency thrombectomy (surgically removing the clot). Somehow I missed the rest of the conversation, but I have the feeling it went something along the lines of:

Dr.FavCardiologist: She's going to die unless we get this clot out."
Dr.GenSurgeon: "I don't feel comfortable doing a thrombectomy."

*This is a small, rural hospital that has limited surgical staff and breadth of procedures.

It was strange to now see this patient - who had been talking and hanging out with her family not so long ago, now intubated and with a mottled complexion, her blue eyes half-open and fixed unnaturally upon the ceiling, her breasts exposed and her hospital gown pulled down around her waist in a bed littered with empty syringes, medication boxes, and cellophane wrap.

We continued to defibrillate her and administer more medications. I took turns doing chest compressions. This was the first time I had ever done chest compressions on a real person. After more drugs and more defibrillating, she was in sinus rhythm, then a slow wide-complex rhythm, then a junctional rhythm. One doctor felt a pulse and another did not. It seemed like these ACLS algorithms continued forever like some kind of medical choose your own adventure book..and eventually, no one could feel a pulse. I don't remember when we decided to stop, but she had been having PEA for quite a while, then asystole. We had gone through four med trays, and the code had been going on over an hour. One of physicians called time of death. It was 7:41 p.m.

The doctors who had participated in the code came out one by one. They quietly explained what happened to the family. The entire time I kept expecting some kind of dramatic lament from the family, but they were silent.

This was not my first death in the healthcare setting. I was surprised that this time I was less upset than usual. It's not that I wasn't deeply sorry for the family, but I also didn't feel like I had to go running out of the hospital as soon as possible to secretly cry in my car for twenty minutes. She was young and her death was unexpected, but for whatever reason, I just felt more fascinated with the twists and turns that her code seemed to take -- it was such an adrenaline rush. It was something new have a role and to be useful, and to have a basic understanding of what was going on.

All I remember thinking as I walked out of the doors of the hospital and looked at the flowering spring foliage was: this is definitely what I want to do.

1 comment:

  1. Very well written post. It's nice that you get to see how you react to being in the middle of code-storm before you sign up for the long haul of medicine. I really wonder sometimes how some of my classmate colleagues will handle it because it is something you can't predict.

    And it is a great affirmation to have that feeling of certainty when it is all over.

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