The last week in the ER has been a little rough for everyone. We had back to back days with a number of very sick patients. More than a couple ended up intubated and admitted to the MICU (Medical Intensive Care Unit where we take care of critically ill patients). Some didn’t make it all the way upstairs.
One woman was brought to us by Chicago EMS. She had been at a nearby clinic waiting for a long scheduled follow-up appointment when she collapsed in the waiting room. She was a cancer patient, likely terminally ill. As she arrived one of the paramedics was straddling her on the gurney given chest compressions for CPR. She had been intubated in the clinic office and they were breathing for her through the tube. We took over chest compressions and breathing and hooked her up to our monitors. She had no electrical cardiac activity, which was confirmed when I ultrasounded her heart. We started giving medications that would hopefully make her heart more receptible to our CPR efforts.
After a few minutes we stopped and checked the monitor. She now had electrical activity, but the heart wasn’t beating as she had no pulses. We continued CPR while placing a central venous line in her thigh so we could run high volume fluids into vascular system. After a few more minutes we again stopped to check the monitor. She was in ventricular fibrillation. Normally this is a very dangerous rhythm but for someone who a few minutes earlier had no cardiac activity whatsoever it was actually a good sign.
We shocked her twice and he regained her pulses. I checked her heart on ultrasound and it was beating normally with no fluid around the heart (a good sign). We called the MICU service to come and see the patient and we started IV medications to keep her blood pressure up and prevent her heart from going into a dangerous arrhythmia. As they were reviewing the patient’s course with us in the ED, she again lost her pulses and cardiac activity. We started CPR again and again pushed IV medications to try and restart her heart. The MICU service went back upstairs and asked us to call them in the unlikely event that we got her back.
They weren’t being callous when they said this. First of all, it’s an extremely rare event that we are able to resuscitate someone back to life when they come to us in asystole (no electrical activity in the heart). To get them back and then lose it again, makes it very very unlikely especially in someone with terminal cancer. However, after another 5 minutes of CPR we got her heart to restart. We started giving her blood transfusions as we found out her blood count was very, very low. She eventually made it upstairs to the MICU.
The other patient was an elderly gentlemen with a known aortic aneurysm. This is a condition where the aorta (the large artery that feeds blood to your entire body through various branches) develops a ballooning of its wall. It can continue to grow and eventually rupture which will lead very quickly to death. People with aneurysms of the aorta are evaluated every 6-12 months to see if their aneurysms are growing at all. If they grow past a certain size or over a certain rate, then surgery is done to replace the aneurysm with a graft.
The patient came in with abdominal pain, which is quite common in people with aneurysms. However, when he was evaluated by one of the senior residents he wasn’t doing well: he was mentally altered and was having difficulty breathing. We moved him into the resuscitation room and began taking measures to hopefully protect him. As we placed a central line and evaluated to see if he’d need to be intubated, we noticed his belly start to distend. We grabbed ultrasound and tried to look for blood leaking into his belly. We couldn’t see any but still had high suspicion that his aneurysm had ruptured. We called surgery to come and see him. In the meantime we decided to intubate. He eventually lost the pulse in his L thigh although his R was still strong. This was more evidence that his aneurysm was either quickly growing and about to rupture or had already ruptured. During surgery’s evaluation, we noticed some strange activity on the heart monitor. We did another EKG… he was having an acute heart attack. We called cardiology and he was taken to the cath lab so that they could attempt to relieve any blockage in his heart vessels.
In woman who went to the ICU eventually was taken off life support by her family. Even though we had her heart working, her brain and likely been deprived of oxygen too long and serial neuro exams demonstrated that she had almost no chance of meaningful recovery. The family elected after 2 or 3 days to allow her to die in peace.
The man who went to the cath lab, also died. He was on the table in the cath lab when he coded. I don’t know the specifics of what happened so I won’t guess too much other than to say, he was probably bleeding from his aneurysm into his belly. The heart attack likely wasn’t from any blockage, but from the fact that there was no blood to feed the heart as it was pouring into the belly. His family was extremely anxious (as any family would be) and we kept them as informed as we could during our resuscitation efforts in the ER and as we waited for surgery and cardiology to evaluate the patient and eventually bring him to the cath lab.
In both instances, the staff felt that we had done just about everything we could have in our power to prevent death. If we had both cases again, we’d likely do everything the same. There was nothing we could have done to prevent an aneurysm from rupturing and no medication could have prevented a sick heart from going into and out of dangerous arrhythmias other than what we were already giving. It’s hard for physicians to realize that sometimes when you do everything you can, people still die in front of you. As hard as it is for us, we realize it’s even harder for the families.
I’ve been in resuscitations where we worked for almost an hour… well beyond the amount of time we should have. When you explain to families that you did everything you could, they demand that we keep trying. At some point though the chance of a meaningful recovery is too slim and we have many other sick patients that demand our care. I don’t know that it’s fair or accurate to draw an analogy between the Coast Guard and the NFL players lost at sea, but it makes sense to me in what I do. I’m by no means a search and rescue expert. I do have a pretty good idea of how long someone could reasonably survive at sea as both a physician and a brother to a Navy Lt and Naval diver. If they say they did every reasonable thing they could then at some point you have to accept that.
I’m not arguing it should be easy and that if it was my family I’d take it well. But having been on that same side as the Coast Guard, I know how difficult it is to accept defeat and failure. It may look as if they’re giving up because of race or another factor. But I can almost guarantee you that they would much rather keep looking and be able to give the families the bodies of their loved ones. None of us are looking to fail at the basic responsibilities of our jobs. I obviously can’t speak for all of them, but I’ve known a few people in military search and rescue. They’re likely taking this hard. Clearly, not as hard as the families, but this isn’t the outcome that any of them would have desired.
Hopefully all of the deceased and their loved ones can find peace through time and understanding.
Hospital Stories: My Intern Year... and Hopefully Beyond 