Sunday, March 22, 2009

This Is Why We Do It

She was a beautiful woman in her late 40's. I was a disheveled and sweaty triage nurse. Our waiting room was overrun with people holding their bellies, foreheads, children's hands, and cell phones. There were no beds in the department. There was a large stack of charts waiting to be brought in, and still another chart buzzed through the printer.

I looked at the chief complaint: "food poisoning".

I called her to the triage station from the waiting room but she simply lifted her head, brown hair covering most of her face.

"Do you need a wheelchair?"


I wheeled her in and looked at her flushed cheeks. She didn't look well, but then again, if she had food poisoning she probably had high velocity liquids coming out of her from all angles. I asked her what she had eaten, a hamburger and caesar salad. Ooooh. Hamburger. Not good. She had vomited once in the parking lot. No diarrhea. Her heart rate and oxygen were normal. Afebrile.

No meds, no allergies. She told me she had a history of hypertension but her doctor had recently taken her off her meds because she "needed to lose 10 lbs and then be reassessed". She only looked about 10 lbs overweight, if that. Her BP was 208/110. Umm...

"Do you have a headache?"

"Yeah a little bit."

"Visual disturbances? Double vision? Spots? Stars?"


"Chest pain?"


"Do you feel lightheaded? Dizzy?"


Ok. Symptomatic HTN. No beds. Except for trauma bay. I asked the acute side nurse if she'd mind me popping this food poisoned lady into the trauma bay, just for a few minutes so I could get her on a monitor, get an EKG, and do a more thorough assessment. Her pressure was high and I was just not sure what was going on with her. "Do what you have to do" was the reply from the harried nurse who already had her hands full with a query stroke and 2 cardiac patients.

I wheeled the patient into the trauma bay, her repeat pressure was 168/78, HR 97, O2 98%. Now I was feeling sheepish for using our hallowed trauma bay for yet another puker and pooper. I asked her to turn from her side onto her back so I could hook the oxygen tubing behind her ears. I pulled the dark hair from her face. Her head turned in my direction, clear blue eyes stared up at me as she murmured, "I need to lay on my side for a minute". Her eyes rolled back in her head and she began to seize. Her face began to turned blue, first just around the mouth, then spreading up her cheeks, an unnatural mauve. Her husband used his body to keep her from rolling off the other side of the bed.

"I need some help in here!" as I pulled up the side rails and grabbed the bag valve mask for oxygen.

Within minutes two other nurses were at the bedside with a doctor in tow. Instantly we set about our duties.

An I.V is placed in her arm, valium goes in. No pulse. The OPA is inserted and we are bagging her. Her rhythm shows v.fib. The skin of her arms begins to mottle, and as I cut off her shirt I see that her chest is also mottled, no demarcation line though. I stick the quick look pads to her chest and charge the defibrillator.

When was the last time I hit the shock button? Why is this lady dying on us?

I see her husband standing with his eyes fixed on the head of the bed, mouth slack but eyes attentive, seeking. Just then another nurse offers to walk him outside, he agrees.

"I'm clear, everyone is clear. Shocking!"

And thus began the long hour of CPR. 13 shock deliveries, 8 doses of epi, a dose of magnesium sulphate (during a brief Toursades episode) and one dose of atropine.

We would get a rhythm, then a pulse, then back into v.fib. It was a roller coaster. We had no idea why this was happening--she could be a bleed--but was it hemorrhagic or ischemic? Was she an acute M.I? We had no labs so couldn't determine if it was her electrolytes. Pulmonary embolus?

We had intubated her successfully on 2nd attempt with a 6.5 after the 7.0 was a no go. With the intubation and bagging her sats remained 100% and we kept CPR going throughout. The numbers were running through my head...she'd been down now for over 60 minutes, she was getting 25% circulation of oxygenated blood thanks to the CPR, we'd given her enough joules of energy and epinephrine to power a leg of the Boston marathon and we still didn't know what was happening to her. What were we saving now? Would she be on a vent with severe brain damage the rest of her life? Would she even take to a vent? When do we call it? With enough epi on board I've seen PEA last for ages. After such a long time the heart is just twitching, it has no intention of ever beating again.

The lab attempted to do an EKG but due to mechanical interferance from the monitors and defib pads (which I was not about to remove any time soon) the print out was basically unreadable.

Her pupils were fixed and dilated. She is frighteningly cyanotic despite what our monitors were telling us.

She went into sinus rhythm. Tachycardic but sinus. We prayed that this time it would continue for longer than a few seconds.

It did.

The paramedics had arrived to take her to the Big Hospital. Her color began to improve, her cheeks no longer dusky. The mottling on her arms faded as they returned to a pale pink color. She was taking the odd breath against the tube.

We packed her into the ambulance, the doc and I at her side. We pulled out of the parking lot just as the respiratory tech pulled into the lot. Gotta love rural emerg. I attempted to fill in the gaping holes in the charting as the ambulance careened along the rainy streets. The paramedic student bagging her.

We arrived at Big Hospital and went through the usual song and dance with the dragon-lady triage nurse:

"Who is this patient? Where are you guys coming from?"

"We're from Small Hospital down the road, we talked to your ED doc who accepted her, this is the cardiac arrest we're bringing in..."

"I have never heard anything about this woman."

"Well, as you can see, she is intubated and unconscious. We've been working on her for over an hour. She needs a STAT CT among other things and time is of the essence, she could crash again at any moment before we know what is going on with her..."

*Large audible sigh from Dragon Lady.*

"Fine, roll her into trauma bay 1".


We get her into the trauma bay, give report to the nice accepting ER doc in shorts and the cranky ER nurse with green streaks in her hair. The RT saunters in in his scrubs and PUMA's, looks at the tube and remarks, "the tube is too small". I stifle a remark about his genitals and point out that it has provided her with adequate oxygenation thankyouverymuch pointing out her color and sats. Asshole. I am so not in the mood.

Doc and I walk down the hall where our paramedics are anxious to get us back to our hospital before they go on another call. We see her husband and young son walk into the waiting room. Both Doc and I say goodbye to him. I shake his hand and say something about hoping for the best outcome for his wife. He walks in a daze to the quiet room with the teary eyed boy trailing behind.

We return to the department.

I call the CV-ICU everyday.

Day 1: She had been to the cath lab, showed a 30% occlusion in her LAD artery. She had had two stents put in, and was still in an induced hypothermic coma so neurological status was unknown. Outcome did not look good.

Day 2: Still intubated and in coma. Body temp not rising despite cooling protocol cessation.

Day 3: Still intubated but some periods of wakefulness, responding to voice.

Day 4: The nurse comes on the phone and I ask again how Mrs. D is doing. I explain that I was one of the nurses involved with her code at Small Hospital.

"Oh I am looking at her right now, sitting up and having coffee with her husband."

A sputter from my end of the phone comes as the reply.

"Yeah, none of her doctors can believe her recovery. She has no neurological deficits at all. Well, she has some amnesia from the night of the arrest. She remembers going to the movie but nothing about the dinner or afterward. But that is probably a blessing, who would want to remember any of that? You guys did great work on her out there at Small Hospital!"

I tell her she has no idea how much I needed that news this week, thank her and hang up. My eyes are filling with tears of joy and relief.

I am still stunned and thrilled at this outcome. I cannot remember the last time I was part of a successful resuscitation. Scenes from that night keep replaying in my head and all I can do is shake my head with gratitude that she is alive today.

This is why I love my job.


Keet said...

LIke wow.

Good work team! That rocks, and that is why we do what we do, in whatever way we do it... Says the policy & safety nurse. :P

You are really an inspiration.
<3 K.

Anonymous said...

Fantastic job from all involved!
That one should be enough to lift the spirits for at least a couple of months!!

It's amazing what some patients can tolerate, then still make a full recovery.

Well done

Albinoblackbear said...

Thanks Keet. I wrote this post mostly to convince you to come to the darkside with me (i.e. working in the trenches instead of cashmere :P). Kidding. It was an amazing team effort really, everyone was calm and very focused. Cool to see and be a part of.

Medic-Yes, it has been a big boost for the staff and doc involved. In our smaller hospital we don't get the volume of codes that the tertiary sites get--so it is very rare to have such a good outcome (just based on the law of averages).

It is amazing. I am still in awe.

Thank you.

Dragonfly said...

Thats amazing. Good team work (not so much dragon lady but you cna't have everything - good name for her, some people like to huff and puff and everything is too much trouble for them, including sometimes patient care).

Bostonian in NY said...

Nice catch ABB...the Force is strong with you. Talk about atypical presentation of MI in a female! Well written post as well.

Albinoblackbear said...

DF--Yes, it was great team work. Sometimes hard to find in the medical setting eh?
I had a small chuckle to myself that Dragon Lady (who I have dealt with on numerous occasions) was still rolling her eyes despite the obvious emergency nature of the case. It proved my suspicions that no matter what I transfer to her it'll always be some insignificant 'overreaction case' from the Small Hospital! :)

BINY-Much appreciated. Yes, my housemate said the exact same thing you did, "talk about an atypical female M.I presentation!" It's true.

This week at work I had to fight the urge not to do a waiting room EKG and cardiac labs on every woman who walked through the door with n/v/d! :)

Rogue Medic said...

an unnatural mauve?

Do you get many with a natural mauve coloring?

Dragon Lady is sadly typical in health care. For some reason the first response on transporting unstable/potentially unstable patients to many hospitals is Nobody told me anything about this, and whining about this ignorance, rather than trying to find out if someone else does know something about the patient.

It seems that the more critical the patient, the more critical the gatekeeper is of my foolish attempt to bring a patient to his/her hospital.

I have found that getting the name and number of the accepting physician and writing them on a demographic page, with a couple of copies, helps. I hand these to the obstructionists and it occasionally seems to satisfy their need for data terminal input.

These low level functionaries are just trying to point out that I am kinda a big deal. The patient is but a means of providing them with their time in the spotlight. The sad thing is that those in charge have no realization that this is a bad thing. Yet they are in charge.

Rogue Medic said...

Oh, yeah. Nice catch and resuscitation.

Albinoblackbear said...

Rogue--Interesting thoughts. Whenever I hear the "nobody told me comment" I just want to say, "did the chest pain who just walked in off the street send you a memo giving you a heads up regarding his arrival?" but then I think that might get us off on an even MORE wrong foot.

Yes I am classic for forgetting who the accepting doc is when I arrive and I know I ought to make more of a note of it so save at least some angst.

And it is certainly true, it is about the power struggle and asserting yourself, muscling into the spotlight when you can--especially when you are a bitter and jaded Triage nurse who gets off on trying to make other nurses look like idiots. I just smile and grind my teeth. Show them they can't break me! :)

I wish you worked in our jurisdiction. I am sure we'd have some mutual eye-rolling events.

Rogue Medic said...

In the US it is not permissible to transfer a patient without a receiving physician. I think this is part of EMTALA.

Some hospitals have concerns about patient dumping. The receiving hospitals tend to be in places with a payer mix heavily weighted toward draining hospital resources.

In spite of all of that, when presented with an unstable/critical patient, it is not acceptable to do anything other than attend to the patient. Unfortunately, pointing that out to the offending party does not seem to speed things along.

Having a punching bag at work is helpful in providing a means of endorphin dosing that helps the body to deal with these frustrations. Unfortunately, the punching bag is not available until well after the incident.

I even occasionally manage to hold my sarcasm until out of earshot of the gatekeeper.

Sometimes others will go out of their way to make up for the behavior of the gatekeeper.