back from the dead
It’s that dreaded nightshift when daylight savings ends and you are working an extra hour for which you aren’t getting paid for. In addition, the computer system crashed for three hours after a meltdown with an inability to process the idea of the clock going back an hour. You have spent all night putting out spot fires and so far no one has died despite all that and being a resident a down. As 7am approaches salvation nears and the ‘end is nigh’ after a terrible shift: sans food, sans peeing and sans sleep. All the sudden the ambulance emergency phone (BAT PHONE) rings with its unmistakable high-pitched ring. A nurse picks up the phone: “car 674” ambulance control states. The ambulance telemetry computer coincidently dings into existence in the background craving for attention and displaying an ECG showing widespread ST elevation in all chest leads. What is also colloquially known as a 'Tombstone infarct or 'Widow maker' as many of these patients have poor prognosis. The radio crackles into life and the paramedics radio in: “We are coming to you with a 65 year old female with a STEMI…she is GCS 15, obs stable, afebrile, with central chest pain and diaphoresis since 5am. We will be with you in 7 minutes”.
Knowing this lady needs an angiogram to perfuse her heart you ring the interventional cardiologist on call and mobilise the cath lab. Drugs are drawn. Fluids are hung. The psych patients are moved out of resus. The team is assembled and you end up deciding not to go the bathroom.
“Arrest” is what you hear being yelled out. The patient is being wheeled in with a scurry of panic. The patients head and eyes a rolled back. No signs of life. The defib is charged…200J beeping shrill “VF” someone calls out, “clear” calls another. A shock is delivered. The patient’s lifeless body contracts and their chest is thrust upwards. The patient awakes in a daze, sits up and then collapses into lifelessness. She is transferred over. Get the “Lucas” someone says. All the sudden CPR is being done by a machine with a plunger onto this woman’s chest violently with a large “thump, thump, thump”. She awakes again fighting the machine. Trying to push it off her, the very thing keeping her alive. It’s approaching two minutes. Drugs are drawn, doctors and nurses at the ready. The defib is charged again, the compression machine is stopped she is again lifeless, no output, no evidence of life again clinically dead. The defib alarms into life with its monitor showing VF again the patient is shocked again. The compressions are started and she awakes again to fight the machine.
You think about all the things taught in med school the 4H’s and 4T’s and anything else you can think of. Quickly you realise that none of it applies and recognise its her heart’s inability to pump which is failing to keep her alive. Time is muscle…she needs to have it reperfused. Two minutes approach and you also realise you should have gone to the bathroom when you had the chance. The compressions stop, the patient’s existence ceases. The Defib alarms after the charge, again she is in VF and you shock again. With the addition of amiodarone this cycle nothing has changed. Compressions continue and on cue the patient is again awake and fighting the machine trying to wriggle and writhe from underneath. We decide to paralyse and intubate her despite knowing she will probably not live or wake up again. An echo is done amongst the chaos. The heart ventricles lay motionless as her atria struggle to contract. You remember that the hospital has ECMO this week and summon the cardiac perfusionist and the team is activated. Soon over a dozen people arrive into a cubicle smaller than our dorm room. It’s decided to put this lady on bypass so her weak and damaged heart can rest whilst a machine does the rest and perfuses her other organs. The cardiothoracic surgeons, perfusionists and anaesthetist prepare the patient. Putting in drains, valves and pipes the sizes of hoses into her femoral veins and artery and feed them to her heart and into a box oxygenating her blood artificially. The cardiologist keeps asking you why you gave her amiodarone and whines: why, why, why? You look down at your feet trying and say it's part of the algorithm. She is then taken to catheter lab the cardiologists find that her LAD is completely blocked a bare metal stent is inserted reperfusing her damaged heart muscle. A left ventriculargram is done and shows low output her myocardium is stunned and you hope that it recovers. She is taken to ICU and you finally have a chance to relieve yourself. You go back to ED and the monotony of day shift is about to begin. You leave and your at home ruminating and thinking about what happened is there anything you could have done better or differently? I don’t know. You just hope she will be okay and nod off to a deep, deep, sleep...
Awaking, you realise that this lady would have died if it wasn’t for the bypass machine available at your hospital. She was lucky to get as far as she did and you did everything that you could have done. The hospital was lucky to be on call with the ECMO team that week for the entire state. I hope the rest of the cards fall into that patient’s hand. You don’t hear anything about the next day except she is still alive from all the arterial gases still being done in ICU on the patient as you note in her computer chart. You forget about her and life goes on. Weeks pass and you see a familiar face and looked startled...She remembers it all...
Dr. Jason Wu