Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (6 page)

His heart had reperfused. The blocked coronary artery had reopened.

There were four of us at the bedside now. The other nurses had abandoned their patients and rushed over to help. Someone pulled over the crash cart; someone else ran for the morphine and the heparin.

Now we spoke staccato—trade lingo.

“Bolus heparin?”

“Five thousand.”

“How much an hour?”

“Thousand. Can we hang dopamine?”

“We can if you ask for it. Give me a twenty-gauge.”

“Hey, call for a portable chest.”

“Do you want a blood gas?”

“Not if we're giving TPA.”

“You need more tubes?”

“I need a heparin flush and some tape here. Someone get me another I-VAC. This one is a dead marine.”

“Yes on the dopamine.”

“How fast?”

“Renal dose, two mics only, okay?” I turned and shouted across the room to the desk clerk. “Who's on call for cardiology?”

The unit clerk called back, “I'm checking, I'm checking.”

I turned back to the patient. “Honey, how do you feel?” I didn't even listen to the answer. She looked terrible.

The unit clerk called back. “It's Gupta.”

“Which one?”

“The short one. Rajiv.”

“Well, call him. Tell him we have an acute anterior wall infarct here.”

Carolyn waved a hand at me. “You want a gas?”

“I already said no.”

“Are you sure?”

“Where's Bill and where's our drug?”

“It's coming, for Christ's sake.”

PVCs appeared on the monitor. Premature ventricular beats—hiccups of the heart. Almost everyone has the occasional PVC, usually not dangerous in themselves, but not totally innocent either. I studied the monitor, watching as the green point of light swam across it, each heartbeat etched out on the gray screen; the regular atrial blip and ventricular ricochet, the chaotic extra beat here, there. Carolyn stood beside me, studying the monitor as well, scowling. I recycled the blood pressure cuff and glanced down at the patient.

The woman's face was still ashen gray. I realized I'd never paid much attention to that phrase, ashen gray; the color of no color.

Again I gazed up at the monitor, assuming the usual posture (hips slung forward, shoulders drooping, mouth dangling open) that physicians instinctively assume when they are befuddled by what's on the monitor screen.

Blood pressure: 78/40.

Pump failure. As simple as that. The heart muscle is a pump, and the blood pressure gives a glimpse of its pumping power. Right now though, so much heart muscle was without oxygen that the heart really couldn't pump enough to generate the kind of blood circulation one needed in order to sustain life. We needed to open up that blood vessel, lyse that clot, right now.

Bill, the technician, came in at a dead run from the pharmacy, plastic bag of TPA held aloft. He tossed it to Carolyn.

“Did you get Gupta?” I shouted at the desk clerk.

“Just now; I'm on the phone with his nurse. He's got a patient in the cath lab. He'll come when he's finished.”

The luck of the draw. Gupta could have taken this woman to the cath lab if he was free. If the TPA didn't work, that was the next thing to try.

I stared up at the monitor, thinking. Maybe I should try to get someone other than Gupta here. But where else could I find a cardiologist on a Sunday afternoon?

“Is there anyone else we can call?”

“I'll try.”

Carolyn hung the TPA. Average time to reperfusion, I had read, was twenty-seven minutes—when it worked. Did we have twenty-seven minutes?

I leaned back over the patient, clasping her hand in mine. “On a scale of one to ten, where ten is the worst pain you ever had and one is just a tiny pain, what do you say your pain is?”

“Ten,” she breathed. She looked too frightened to move.

“Honey, we've given you some medicine that will help you get better. You just have to hold on until it works.”

She nodded, clutching at my hands, and closed her eyes. “Okay, okay,” she whispered. I could barely hear her.

The radiology technician showed up with her portable x-ray machine. I stood next to the machine as she adjusted the giraffe-necked cone.

“Yikes,” she whispered to me. “That woman looks like shit. What's her problem?”

“She's dying,” I whispered back.

We sat the patient up in the bed for her x-ray. She looked like a broken puppet, head rolling, eyes staring off into nothing. I helped the technician tuck the cold, flat x-ray plate behind her and steadied her for a moment so she wouldn't pitch off to one side.

The technician stood back, the trigger in her hand. “X-ray!” she called out. “Shield 'em if you got 'em.”

Buzz. Safety.

We pulled out the cassette and I recycled the blood pressure cuff: 80/50. We were losing ground. “We need to hang some saline,” I told Carolyn. I probably should have ordered this before.

“How much?”

“Give her two hundred and we'll see.”

“Shall we try some morphine?”

I looked at the monitor, checking the pressure. “We can touch her with a milligram, maybe.” I was mentally reviewing everything I knew about the patient and everything we were doing. Was there something I missed? Was I wrong? Was this actually an aortic dissection, a rip in the wall of the body's main artery? Or maybe a pulmonary embolus, a massive clot in the lungs?

I ran my hands from her feet up to her groin, reexamining her pulses. She had good femoral pulses. Belly was soft. I listened to her lungs. Crackles there, water on the lung. Heart failure, failure, failure.

The x-ray technician tapped my shoulder and thrust the chest x-ray up on the view box next to the bed. I peered at it, looking for answers. No heart enlargement, normal-looking aorta, no evidence of a dissection. This was a normal x-ray.

I leaned over her. “Pain any better?” I whispered.

She turned her face in my direction, but she seemed to be somewhere else. She looked as if the pain had consumed her.

“Gupta's on the phone,” the clerk sang out.

I took one last glance at the monitor before I turned away. One PVC, two PVCs. No, God, she was in V-tach.

V-tach, ventricular tachycardia—a heartbeat triggered from deep within the ventricle. Sometimes there is a pulse with it—the rhythm can be life-sustaining, though usually not for long. Other times the heart just gives up, pumping no blood. When this occurs, the rhythm is the last brief burst of electrical activity the heart assumes before it dies.

I groped at the woman's neck, trying to find a pulse.

“Oh, shit,” Carolyn said. She had just looked up at the monitor. “Christ.”

“She's got a pulse. Honey, can you talk to me? Honey, honey?” To Carolyn: “Get the lidocaine.” Lidocaine is a drug used to banish bad heart rhythms. “I think this may be from reperfusion.”

The reperfusion arrhythmias, the jolt and shutter of an engine restarting. If we were lucky, this was a signal that her artery had opened back up with the TPA.

“Honey, can you talk to me?”

She barely moved her lips. “I feel so weak,” she said.

“The pain, dear. On a scale of one to ten…”

“It's still a ten.”

I again recycled the blood pressure cuff: 85/50. Holding, anyway. I checked the IV bag. She had gotten 120 cc.

Carolyn injected the lidocaine. “Do you want to shock her?” she said.

“Wait, give her a second.”

A minute, two minutes. Still a good pulse but still V-tach—reperfusion arrhythmias usually don't last this long. And the patient usually stops having chest pain…

The V-tach rhythm stopped suddenly. Straight-line; no heartbeat. I had gotten no further than to put my hand to my mouth when the flat track of light wobbled, bucked once, twice, and settled into a sinus rhythm. Rate 110. The lidocaine had worked.

Blood pressure 92/50.

The chest pain was a little better, the patient told us. Eight on a scale of one to ten.

“Come on, God,” I prayed. “Let the TPA do its stuff. Please, God, just this once.”

“Let's touch her with a little more morphine,” I said. “What about Gupta?” I shouted out to the desk clerk.

“He said he'd be here when he finished.”

I stood watching the monitor—which stayed in a blessed sinus rhythm—no PVCs. The blood pressure cuff recycled: 74/32. Not good. And then I thought, hell, why lie? This was very bad. I was sure she had not reperfused.

I wheeled around to Carolyn. “Where the hell are the blood gas results?”

“You said you didn't
want
a blood gas.”

“Oh, well…let's go up on the dopamine.”

Dopamine is a drug that, in part, causes the heart to work harder, beat stronger. “Flogging the heart,” it's called.

“What are you at?”

“Twenty mics.”

“Higher,” I said. “What about a Foley?”

Carolyn looked at me askance and said, not unkindly, “Yes, Doctor.” She already had the kit out.

A Foley is a tube placed in the bladder to drain urine. (Who was Foley? I have always wondered, and what's it like to be immortalized as an aid to urination?) The urine draining from the Foley would give us a rough idea of how well the kidneys and, indirectly, other organs like the liver, the gut and the lungs were being fed oxygen. Good urine output meant good perfusion.

We struggled to get the Foley in. I stood holding the patient's right leg on my shoulder. This is the other part that never shows up on TV, the part of emergency medicine that involves groping around in various genitalia sticking rubber tubes into available orifices. The least glamorous job in the world.

There was a trickle of urine.

“Dust,” Caroline said. “Nothing but dust.”

Pump failure, pump failure: 76/40 and holding. What should I do? Kidney function gone to ground. Blood pressure terrible. If only she would reperfuse. If only Gupta would get here. If only we could find another cardiologist.

“Have you tried calling the other Gupta?” I shouted to the clerk.

“Yes, his office said he's in Duluth for a conference.”

“Duluth,” I repeated stupidly. “Well, then how about Rawlings?”

“He's not on call either, and his answering service said they were not allowed to call his house if he wasn't on call.”

“Dear Jesus,” I whispered, then leaned over the bed. “Honey, how are you doing?”

She spoke up in a little voice. “Chest still hurts.” She seemed to get littler and littler with each passing moment, with each notch down in her blood pressure.

“On a scale of one to ten…” I didn't really want to know the answer.

“A little bit better.”

Blood pressure 70/40. We were losing ground, really; with the dopamine and fluids it should come up at least a little. Why didn't the TPA work?

I looked down at the patient. On her right arm, where we had drawn some blood, there was a trickle of blood that wound down to her hand and dripped onto the floor. She was bleeding from her IV site, blood oozing onto the sheet. Couldn't get more anticoagulated than that, I thought.

The woman put out her hand to me. “No,” she said. Her hand dropped.

“Christ.” This was Carolyn. “She's in V-fib.”

I looked up at the monitor. So she was. V-fib is a terminal rhythm; a heart that is not beating at all, but is quivering. The monitor displays this quivering as random noise, a squiggle. That's what we saw now.

Her reperfusion rhythm! I thought. I stood for a moment, rooted, hoping, praying. But the woman stayed in V-fib. This was not a reperfusion arrhythmia.

“Paddles,” I said. “We need to defibrillate her.”

Defibrillation; electrical medicine. The best way to understand it is to think of the heart as a collection of millions of electrical cells, usually well coordinated. Under circumstances of hypoxia—lack of oxygen—this coordination breaks down and chaos ensues. The most effective means of correcting this chaos is to trigger, all at once, the entire heart muscle, causing every cell to fire simultaneously. You do this by delivering a large electrical shock, a sort of stun gun, to the heart. It's called defibrillation. After defibrillation you hope that as the heart recovers from the shock, normal electrical activity can resume. It works well, sometimes. The energy charge starts at 200 joules, the kick from a very large mule, and is dialed up from there. Carolyn huddled over the defibrillator, pulling out the paddles. These paddles, two metal plates attached to plastic handles, carry the charge. She leaned over the bed rails and applied the paddles to the Woman's chest.

“All clear,” she shouted. We all leaned back. If anyone touched any metal on the bed while the shock was administered, they, too, would be defibrillated.

The patient's body jerked—arms and legs jumping. There followed that faint smell of burnt flesh that always goes with bad resuscitations. We all looked up, prayerfully, at the monitor. The bouncing electric point of light settled back into chaos.

“Again,” I said.

Carolyn punched the power button and reapplied the paddles.

“Clear!”

The shock; the flaying arms and jerking legs. All of us stared again at the monitor.

A rhythm, we had a rhythm. And the best kind of rhythm: sinus. Rate 140.

I groped at her neck and then raised a triumphant fist. “We have a pulse here, guys.”

Have we got a blood pressure?

Carolyn punched at the monitor to recycle the blood pressure pump, and we all stood staring at the screen. It felt like waiting for the slot machine to finish spinning and come to rest on the magic symbols. “Please, let there be a good blood pressure,” I whispered. “Please, a blood pressure compatible with life. I don't want to lose this woman. Please, God, give her a chance.”

The monitor came up with slash marks. Blood pressure too low to measure.

“Still, we have a pulse,” Carolyn said. I looked down at the patient. Whereas she once held the hospital gown primly in place, she now lay nearly naked, breasts sprawling, eyes half open and sightless. Blood everywhere. She looked like a murder victim.

“Get Respiratory down here. I'm going to tube her,” I said. Intubation, the breathing tube. “And we need to Doppler her pressure.”

“Bretylium?” Carolyn asked. Bretylium was the next drug on the antiarrhymic hit list, for use after lidocaine.