- Email: [email protected]
Do You Believe in Miracles?
CHANGE OF SHIFT
Do You Believe in Miracles? Valerie Norton, MD From Scripps Mercy Hospital Emergency Department, San Diego, CA. 0196-0644/$-see front matter Copyright © 2012 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2012.05.036
[Ann Emerg Med. 2012;60:526-527.] At 10 AM on a Wednesday morning on the acute side of the emergency department (ED), an ambulance arrived with a 37year-old man whose chief complaint was “syncope.” “He was getting out of the shower, felt dizzy, and passed out face-first on the bathroom floor,” the paramedics told us as they heaved the patient across to the hospital bed. “He bruised his forehead but is awake and alert. No chest pain— his only other complaint is shortness of breath. BP 130/66, pulse 105, O2 sat 97%.” As we started getting the patient hooked up to the monitor, I noticed that he was just about the palest patient I had ever seen—fish-belly white, with bloodless lips. He had a pretty impressive 3⫻3-cm purplish hematoma on his right forehead, but was awake and talking to me. “I’ve been feeling short of breath and lightheaded since yesterday,” he said in response to my questioning. I asked him about medications (none), allergies (none), and other medical history (just seasonal allergies). Suddenly, one of the paramedics, who was still in the room, yelled out, “He’s flat-lining!” Sure enough, his eyes had rolled back, he had passed out, and was in asystole on the monitor. We began CPR, gave a milligram of epi, and within about a minute had a pulse back and a decent blood pressure. I intubated him, we started fluids wide open, and I called for type O blood, thinking he might have a bleeding triple A or a massive GI bleed, given his pallor. I started working my way through all the things that could cause syncope and then sudden death in this previously healthy 37-year-old man: massive MI (but no chest pain?), massive PE, massive bleed, tamponade, hypertrophic cardiomyopathy? A quick rectal revealed normal stool. ECG showed no ischemic changes or peaked T waves, and the QRS was narrow. Bedside ultrasonography revealed no triple A, no free fluid in the abdomen, no pericardial effusion, and decent cardiac activity. Being an older emergency physician who trained before the era of ultrasonography, I didn’t feel confident trying to diagnose RV strain or other surrogate markers for PE. Despite my ultrasonographic limitations, this was clearly more and more likely to be a massive PE, but the guy had just sustained a pretty good blow to the head—we would need head CT and then chest CT angio to be sure we were dealing with a PE before pushing thrombolytics. He had now been in the ED about 10 minutes. I ordered all the labs and the CTs, but within 526 Annals of Emergency Medicine
a few minutes, the patient had arrested again and the nurses yelled for me to get back in the room. This time he was in and out of asystole, PEA, and VT over the course of about 20 to 30 minutes. We shocked him several times, gave more epi, amiodarone, fluids, and did CPR over and over. Each time, we would get a pulse back, and within a minute or two he would arrest again. Partway into this, I sent a runner to the pharmacy to get us tPA on the premise that we didn’t have much to lose if we couldn’t get this guy resuscitated enough to go to CT. Labs came back in the middle of this and were all normal except for a profound metabolic acidosis on the ABG. I called the CT tech and told them to stand by. About 45 minutes after the patient’s arrival, while we were doing CPR and waiting for the tPA to show up, someone came up to me and said, “Doctor, the patient’s wife is in the waiting room— could you go talk to her?” I went out to the waiting room and found a young woman with light brown hair accompanied by a greying older man, who turned out to be the patient’s father. I introduced myself and explained what had happened so far. “We’re worried this could be a massive blood clot in his lungs,” I told them, “and we’ve ordered a clot-busting medication to try to break up the clot, but that’s the only thing left to try. If that doesn’t work, I’m afraid he’s not going to make it. Would you like to come into the room and be with him?” “Oh, yes,” she sighed. “It’s going to be chaotic in there,” I warned. “There’s trash all over the floor, and we’re doing CPR, and breathing for him with a ventilator—are you going to be okay with all that?” “Absolutely,” she said. I took her in the room and put her in a chair at the head of the bed. She reached out and grabbed his forehead, which was the only part of him she could reach. And then she started cheerleading. “Clay! Clay! Come on, Clay, you can do it! Come back to me, Clay!” she yelled. The nurses looked at me in astonishment. “Clay, I need you! Dig deep, come on, come back to me! Hang in there, Clay!” The security guard poked his head around the door to see what the yelling was about. “Clay, don’t die on me! I know you can do this! Clay, come on back!” Volume , . : October
Norton After about a minute or two of this, we got a pulse back— and never lost it again. At first we were hesitant, because we’d gotten a pulse back many times before in the preceding 45 minutes. But after 2 minutes of strong pulses and sinus rhythm, we looked at each other and said, “Let’s get to CT!” Down the hall we went, hair flying. The CT tech was waiting for us, and the pharmacy tech showed up with the tPA. A quick head scan—no bleed! Down to the chest—massive saddle embolism. One of the nurses ran in and pushed the tPA while he was still on the CT gantry. An hour later in the ICU, he started to move around, and he was extubated by the following morning. I visited him and his wife a few days later in the step-down unit, and he felt no worse for wear except for lots of fatigue. He had no memory of that entire day— couldn’t remember meeting me, or anything after fainting in the bathroom. He didn’t remember his wife yelling at him, but he teared up when we talked about it. “She’s my little cheerleader,” he said fondly. “You were so wonderful,” his wife told me. “We’re so lucky you did your job so well.” “You’re very kind,” I replied, “but I have to say that everything I did was absolutely standard, and what every
Volume , . : October
Change of Shift emergency physician would have done under those circumstances. The only thing I did that was at all unusual— and I sincerely believe this was what made the difference— was to go get you from the waiting room!” I said the same thing to a string of family members who came to the ED over the next few days to drop off candy, cookies, hugs, and compliments. “We were just doing our jobs,” I told them, “and I had a great team. But what really made the difference was that cheerleading!” A week or so later, I went to a Grand Rounds by one of the venerable cardiologists who had helped train me many years before. He was talking about updates to ACLS and mentioned that he was not a fan of having family present during codes. He thought it was traumatic for them and disruptive for the staff, and had had several bad experiences with it. Afterwards, I went up to him and said, “John, I have a story to tell you . . . .” Address for correspondence: Valerie Norton, MD, E-mail [email protected].
Annals of Emergency Medicine 527
Do You Believe in Miracles? Valerie Norton, MD From Scripps Mercy Hospital Emergency Department, San Diego, CA. 0196-0644/$-see front matter Copyright © 2012 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2012.05.036
[Ann Emerg Med. 2012;60:526-527.] At 10 AM on a Wednesday morning on the acute side of the emergency department (ED), an ambulance arrived with a 37year-old man whose chief complaint was “syncope.” “He was getting out of the shower, felt dizzy, and passed out face-first on the bathroom floor,” the paramedics told us as they heaved the patient across to the hospital bed. “He bruised his forehead but is awake and alert. No chest pain— his only other complaint is shortness of breath. BP 130/66, pulse 105, O2 sat 97%.” As we started getting the patient hooked up to the monitor, I noticed that he was just about the palest patient I had ever seen—fish-belly white, with bloodless lips. He had a pretty impressive 3⫻3-cm purplish hematoma on his right forehead, but was awake and talking to me. “I’ve been feeling short of breath and lightheaded since yesterday,” he said in response to my questioning. I asked him about medications (none), allergies (none), and other medical history (just seasonal allergies). Suddenly, one of the paramedics, who was still in the room, yelled out, “He’s flat-lining!” Sure enough, his eyes had rolled back, he had passed out, and was in asystole on the monitor. We began CPR, gave a milligram of epi, and within about a minute had a pulse back and a decent blood pressure. I intubated him, we started fluids wide open, and I called for type O blood, thinking he might have a bleeding triple A or a massive GI bleed, given his pallor. I started working my way through all the things that could cause syncope and then sudden death in this previously healthy 37-year-old man: massive MI (but no chest pain?), massive PE, massive bleed, tamponade, hypertrophic cardiomyopathy? A quick rectal revealed normal stool. ECG showed no ischemic changes or peaked T waves, and the QRS was narrow. Bedside ultrasonography revealed no triple A, no free fluid in the abdomen, no pericardial effusion, and decent cardiac activity. Being an older emergency physician who trained before the era of ultrasonography, I didn’t feel confident trying to diagnose RV strain or other surrogate markers for PE. Despite my ultrasonographic limitations, this was clearly more and more likely to be a massive PE, but the guy had just sustained a pretty good blow to the head—we would need head CT and then chest CT angio to be sure we were dealing with a PE before pushing thrombolytics. He had now been in the ED about 10 minutes. I ordered all the labs and the CTs, but within 526 Annals of Emergency Medicine
a few minutes, the patient had arrested again and the nurses yelled for me to get back in the room. This time he was in and out of asystole, PEA, and VT over the course of about 20 to 30 minutes. We shocked him several times, gave more epi, amiodarone, fluids, and did CPR over and over. Each time, we would get a pulse back, and within a minute or two he would arrest again. Partway into this, I sent a runner to the pharmacy to get us tPA on the premise that we didn’t have much to lose if we couldn’t get this guy resuscitated enough to go to CT. Labs came back in the middle of this and were all normal except for a profound metabolic acidosis on the ABG. I called the CT tech and told them to stand by. About 45 minutes after the patient’s arrival, while we were doing CPR and waiting for the tPA to show up, someone came up to me and said, “Doctor, the patient’s wife is in the waiting room— could you go talk to her?” I went out to the waiting room and found a young woman with light brown hair accompanied by a greying older man, who turned out to be the patient’s father. I introduced myself and explained what had happened so far. “We’re worried this could be a massive blood clot in his lungs,” I told them, “and we’ve ordered a clot-busting medication to try to break up the clot, but that’s the only thing left to try. If that doesn’t work, I’m afraid he’s not going to make it. Would you like to come into the room and be with him?” “Oh, yes,” she sighed. “It’s going to be chaotic in there,” I warned. “There’s trash all over the floor, and we’re doing CPR, and breathing for him with a ventilator—are you going to be okay with all that?” “Absolutely,” she said. I took her in the room and put her in a chair at the head of the bed. She reached out and grabbed his forehead, which was the only part of him she could reach. And then she started cheerleading. “Clay! Clay! Come on, Clay, you can do it! Come back to me, Clay!” she yelled. The nurses looked at me in astonishment. “Clay, I need you! Dig deep, come on, come back to me! Hang in there, Clay!” The security guard poked his head around the door to see what the yelling was about. “Clay, don’t die on me! I know you can do this! Clay, come on back!” Volume , . : October
Norton After about a minute or two of this, we got a pulse back— and never lost it again. At first we were hesitant, because we’d gotten a pulse back many times before in the preceding 45 minutes. But after 2 minutes of strong pulses and sinus rhythm, we looked at each other and said, “Let’s get to CT!” Down the hall we went, hair flying. The CT tech was waiting for us, and the pharmacy tech showed up with the tPA. A quick head scan—no bleed! Down to the chest—massive saddle embolism. One of the nurses ran in and pushed the tPA while he was still on the CT gantry. An hour later in the ICU, he started to move around, and he was extubated by the following morning. I visited him and his wife a few days later in the step-down unit, and he felt no worse for wear except for lots of fatigue. He had no memory of that entire day— couldn’t remember meeting me, or anything after fainting in the bathroom. He didn’t remember his wife yelling at him, but he teared up when we talked about it. “She’s my little cheerleader,” he said fondly. “You were so wonderful,” his wife told me. “We’re so lucky you did your job so well.” “You’re very kind,” I replied, “but I have to say that everything I did was absolutely standard, and what every
Volume , . : October
Change of Shift emergency physician would have done under those circumstances. The only thing I did that was at all unusual— and I sincerely believe this was what made the difference— was to go get you from the waiting room!” I said the same thing to a string of family members who came to the ED over the next few days to drop off candy, cookies, hugs, and compliments. “We were just doing our jobs,” I told them, “and I had a great team. But what really made the difference was that cheerleading!” A week or so later, I went to a Grand Rounds by one of the venerable cardiologists who had helped train me many years before. He was talking about updates to ACLS and mentioned that he was not a fan of having family present during codes. He thought it was traumatic for them and disruptive for the staff, and had had several bad experiences with it. Afterwards, I went up to him and said, “John, I have a story to tell you . . . .” Address for correspondence: Valerie Norton, MD, E-mail [email protected].
Annals of Emergency Medicine 527