Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (7 page)

“No,” I told her.

“She's going to need it.”

“She doesn't need it now.”

“What about bicarb?” one of the other nurses asked.

She meant plain bicarbonate of soda. In the chemistry of acid-base, it is pure base. Fads in resuscitation research come and go, and last year everyone thought bicarb, judiciously administrated, saved lives. This year, though, it was yanked from every protocol. Rarely indicated, experts noted. In five years we will all be using it again.

“No, no,” I said. “But let's get a gas.”

“You said you didn't want a gas.”

I looked down. “Well,” I said, “I changed my mind.”

The patient was deeply unconscious now. I intubated. The trachea was clear, easy to see. The respiratory therapist took over the airway, fussing with the Ambu bag, taping the tube into place.

The monitor was still sinus tach—rate 140, then 145, 150, 160—like an inevitable chord progression in music. Carolyn was trying to get a blood pressure with the Doppler when the rhythm collapsed back into V-fib.

“I told you she would need the bretylium,” Caroline said.

We got ready to shock again. Carolyn unsheathed the paddles.

“Now, guys.”

Shock, spasm. On the monitor: V-fib.

Julie, another crabby nurse (she was going through a divorce) punched at the monitor, saying, “I wish she would just
pick
a rhythm and
stay
with a rhythm. This back-and-forth shit has got to quit.”

We shocked the patient back into a sinus rhythm again, but her heart rate was still high: 138. Carolyn triumphantly admin-latered the bretylium. I stood going over the case again and again in my head. What had I missed, for God's sake, what had I missed? Think,
think,
what can it be?

There was no pulse with sinus rhythm now. This meant that the heart was generating electrical activity but the mechanical part of the heart, the working part, had shut down. We needed to pump the blood for her: CPR.

Julie, short and squat, pulled over the footstool, climbed up on it and started rocking up and down with her palms on the patient's chest. I looked back down at the woman's face. A trickle of blood ran from her mouth. It oozed down her neck and pooled on the sheet. She was still bleeding from her IV sites, and it looked like there was even blood in her urine bag. It seemed that she was bleeding from everywhere except her heart.

“Mother of God,” Carolyn said, gazing at the monitor. “I don't believe this.”

Hold CPR.

V-fib on the monitor.

Shock: 360 joules—the highest you could go—the end of the dial.

Asystole. Flat line. Dead end.

I knew this, expected it; the final station of the cross. The heart had now given up, flat line, no electrical activity at all.

“Epinephrine,” I said wearily. This is adrenaline, used in the last-ditch pharmacological effort to jump-start a dying heart.

Carolyn yanked open the top drawer of the crash cart. We took the next step down the ACLS protocol, the ritual of resuscitation, modern last rites.

If someone could put her on a balloon pump…I thought, but the nearest balloon pump from here was a helicopter ride away. Transfixed, I stared at the monitor, which had now taken the place of the patient. Here the process of dying was displayed electronically. “Atropine,” I said, nodding to myself.

Atropine, epi, atropine, epi. The litany for asystole. What else, I thought to myself: pneumothorax?—air in the lining of the lung? That can happen during an arrest. Pericardial tamponade?—an outpouring of blood into the sack that embraces the heart.

“
Please, don't let me die,
” she had said.

It came in small steps. The feeling of inevitability. She's dying, she's dying. She's already dead.

Not yet, not yet.

“Hold CPR.”

Asystole. Flat line. Nothing.

“Restart CPR.” Then I remembered; it really should have come to me before. “The external pacemaker,” I said.

Julie moaned. “Oh, come on now, give it a rest.”

I shook my head, glaring at her.

Julie looked away, shrugging her shoulders. “Jeesh.”

Carolyn was already over by the wall of supplies, pulling open drawers and strewing random pieces of equipment. “Now, where are those damn electrodes,” she kept muttering. And then: “Aha!” She returned waving two large, flat pads. “Every time I look for these, they are stored somewhere else.”

An external pacemaker is a simple device, two giant electrodes, one placed on the anterior part of the chest and one on the posterior. A charge smaller than the one delivered with defibrillation is now passed from one pole or paddle to the other. With this, we hope like crazy, we can jump-start the heart. This is known as “capturing.” You dial up the joules until you find a current strong enough to depolarize the heart muscle. I had used it several times under different circumstances in the past, but it had never worked for me in a patient in asystole.

“Hold CPR.”

We all stood gazing at the monitor screen while Carolyn dialed up the current. There was the charge passing through the heart but no “capture.” Nothing, nothing. Finally, at the highest current, the patient's chest wall muscles started contracting. We were capturing skeletal muscle but still—nothing from the heart.

No pulse.

“Restart CPR.”

I became aware of someone standing next to me. It was Dr. Gupta, fresh from the cath lab. He was still wearing his surgical cap and paper booties. I grabbed the ECG off the top of the ECG cart and shoved it at him. “Anterior wall, massive infarct. She's been in and out of V-tach, V-fib…and now she's in…” I glanced at the monitor to double-check and saw, still, “asystole. I thought it was reperfusion, but I don't think she ever opened up.”

Gupta hmmmed noncommittally. “Yep,” he said, staring at the monitor while Julie paused momentarily. “Looks like asystole to me.”

“TPA hasn't worked.”

“Well,” he said, with a “these-things-happen” shrug of his shoulders.

“Do you think she has a chance in the cath lab?”

Gupta looked around as if I were mad. “She's in asystole,” he said, looking at me quizzically as if to say, “She's dead. Why would I want to take her to the cath lab?”

I looked down at the woman, staring at the blood that still trickled from her mouth, dripping onto the floor. She was now bleeding from every puncture wound.

“Hold CPR.”

Asystole. Nothing.

“Restart CPR.”

Carolyn put a hand on my shoulder. “Nothing's working, honey.”

I hung my head.

“It's time to wave her good-bye.”

Julie stopped CPR and looked down at me—waiting.

I looked at my watch. “One more round of drugs,” I said. I stood looking at the monitor, turning my back to the patient.

Epi, atropine.

“Hold CPR.” I gazed up at the screen, trying to will her back. She must come back, she must.

Asystole on the monitor.

I looked at my watch and raised my hand in the air. “Okay, code called twelve thirty-five.”

Julie stepped heavily down from the footstool and peeled off her gloves. Carolyn stood, arms crossed, staring at a wall. Gupta was looking at the first ECG we had gotten.

“Wow,” he said. “Perfectly normal. Can you believe it?”

I stood watching the monitor until Carolyn disconnected it from the patient. Nothing left. I turned away from them all, mumbling, “I've got to tell the family.”

I walked slowly out through the back door to the waiting room thinking, Pump failure, pump failure, as I shuffled along. I was trying not to think about what could have happened. What if she had come in yesterday? Or the day before, when there would have been a cath lab available?

I stopped at the door to the waiting room and looked in through the window. There the husband and the daughter sat, not looking particularly anxious—after all, the last time he had seen his wife and she had seen her mother, the woman had simply been complaining of some chest pain.

Yesterday…, I thought.

I walked in, feet still dragging, and sat down beside the husband. He looked at me trustingly. I felt like I was about to shoot a puppy.

“Your wife had a massive heart attack,” I told him. “Her heart lost the power needed to pump blood. She had problems with her heart rhythm as well, problems I couldn't correct.” I took a deep breath and stared down at my hands. There was nothing more I could do except just
say
it.

“I'm sorry, sir, but your wife has died.”

The air was empty for a moment. I couldn't even look at them.

“Well,” the husband said in a wan voice. “I lost a partner.”

“We tried everything we had,” I told him. “We gave her TPA and everything else, but her heart…just failed her.” I looked up.

His face was blank. He shook his head but said nothing. There weren't the words; there was nothing at this moment to say. Finally he held up one hand and with the other pulled his daughter close to him.

“I'm sorry,” I said, just to say something. I had been in this room many times under similar circumstances, and I knew—or rather felt—that in all honesty, I had no more to offer this family than some professional sympathy for a heartbreak that would touch me only for a moment.

Neither of them spoke, neither cried. They just sat there huddled together. The daughter rocked her father back and forth, back and forth.

“Dad,” she said. That was the only thing she said.

We sat for a moment in silence. This was not the first time I wished I had the religious faith of some evangelical Christian, someone who was certain, someone who
knew
about God and his plans—because I certainly didn't. The only thing left that I could do, now that I had notified the family, was just the miserable bureaucratic stuff: talk to the coroner, fill out the forms, complete the last medical record ever filed on this patient—all those temporal things where faith, thank God, was not an issue.

I have thought often about that family: the farmer's wife, the farmer and the daughter. I wondered about the two survivors. Who did the laundry now? Who fed the cat?

One day about a year later, I saw the whole family once more in an unlikely spot. I was in the Midwest for a medical conference on—naturally—clot-busting drugs. On the afternoon of the last day, I decided to take a break, go for a walk in the park across from the hotel. It was a brilliant winter day, almost spring, and people were out walking just to take in the sunshine. I had strolled up a hill to a reservoir when I saw them: the husband, the wife and the daughter. They were all younger now, much younger—the parents were no more than a few years out of high school. Already, though, the wife was doughy plump and the husband as thin as a rail. Their daughter, this daughter, was a blond girl in pigtails. She couldn't have been more than four or five. The husband and wife held hands as they walked while the daughter ran on ahead. The couple seemed to radiate a sort of serene security, a security in each other, in their daughter, in their life, that most people I knew could only dream of.

I was standing on a lip of land that dammed a small reservoir, a lakelet at the top of the hill. The couple was walking up toward me along a dirt path. The daughter reached the top first and she stood pointing at the lake, which was invisible from below, shouting, “Can you see? Can you see?” The parents waved, still holding hands, and kept moving slowly up the hill toward her. At one point, the husband stopped, pulled his wife up close and kissed her.

I closed my eyes. A happy marriage, I thought, and this thought produced a prayer. Please God, it ran, please protect that man and that woman from knowing the future. Please never let them see what I can—from where I stand—so clearly see: all happy marriages end in tragedy.

3

L
ESSONS IN
E
MERGENCY
M
EDICINE

How to Deliver a Baby

T
HIS IS YOUR FIRST
real job as a doctor. After four years of medical school and most of an emergency medicine residency, you look like a doctor: handsome, chiseled profile, great abs. You know how to act like one (“Nurse, get me a tourniquet,
stat
”). But you've never had a chance to play one unsupervised. You are still in training, still a resident. (In emergency medicine that's four years of long days and even longer nights.) As a resident you have a degree to practice medicine, but all your moves are still closely supervised by “attendings,” physicians who have finished their training and passed their board certification exams. You still have a way to go for that. But you do have a medical license—you can moonlight as a doctor, especially at jobs where you see simple things, like sore throats and colds. That's what's brought you here, to a tiny ER at tiny Grace Hospital. “It's a breeze,” the ER director told you. “Kids with sniffles, sprained ankles. Most nights you just sleep.”

The downside is that it's an hour and a half drive out here and you are in the middle of nowhere. This particular nowhere is located on the edge of a beaten-down industrial city, a steel town on the skids. This is your first night, and so far you've seen a weird collection of farmers and urban deadbeats. But that's okay. You are on your own now, making the decisions that will help you save lives. You are “the Man.” Also you are getting paid something above the $10 an hour wage you make as a resident. Life is good. Now it has quieted down, and if all goes well, you can get back to the call room and get a few hours of sleep in.…

It's about 2:15
A.M.
—you've just settled down to some Chinese takeout food—when you hear the shouting. It's a woman's voice, but you can't understand what she's saying. The shouting is followed by the voice of a nurse saying loudly, “Just breathe, just breathe.”

Another nurse sticks her head in the door where she finds you, mid-chew, on your moo shu pork.

“You better get in here,” she says. “This one is about ready to pop.”

A delivery, you realize. A baby. You scowl at the nurse. “What is she doing here?” you say grumpily. “Get her up to Labor and Delivery.” This is the routine in your training hospital. OB/GYN residents deliver babies. That's what they're there for.