by Pamela Grim
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 t
o 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.
“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 ra
ndom 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.