Wednesday, February 22, 2012
Spoiler Alert: The patient in this post does not make it. I want to get that out of the way because there's some ups and downs in how it plays out and I don't want to put y'all through the emotional manipulation of wondering if she'll get through or not.
We show up on a DIFF BREATHER call and find a 70 year old woman flat on her back with no pulse. She's a dialysis patient and has pink frothy sputum lining her mouth so it's a safe guess she went into fluid overload from kidney failure and her lungs filled up, effectively drowning her. A FDNY chief has decided by chance to show up on the job with us and she has one of the Medical Control doctors along with her, so we have a physician on scene along with the Fire Fighters helping out with CPR.
This turns out to be cool and works in our favor because the Doc is actually very laid back and not trying to run shit - we're able to circumvent the annoying process of calling Online MedCon to get permission for certain medications. Sometimes, when too many authority figures and egos get on scene together there's an inevitable clusterfuck to be managed, but fortunately that wasn't the case here.
So we put our monitor on the patient to see what rhythm her heart's in. What we see looks like a regular old heart rhythm, a little slow perhaps but basically could be a perfectly healthy person. Except she has no pulse. This is called Pulseless Electrical Activity and happens because sometimes the heart has a little life left in it, just enough for the electrical impulses to keep flickering away but they're not getting capture with the actual musculature of the heart, so there's no beat, no movement to speak of, just a parade of ghost complexes marching past the monitor screen.
So we start CPR, i set up the intubation kit while my partner prepares the IV and the Chief gets the woman's basic information from her son. I'm trying a new technique with intubation, just a simple adjustment on how I grip the handle of the tool we use to open up a patient's airway but it works like a charm: I can see straight down her throat and the two diagonal white lines of her vocal chords open up in front of my eyes, a perfect view. I slide the tube in, we confirm it's in place by listening to her lung sounds and my partner gets the IV as the Chief comes back in to inform us the woman is a leukemia patient, besides the kidney failure.
We stop compressions, check a pulse and low behold, there it is, thumping away a little weakly but still: there. So we start setting up to transport her and are trying to check the blood pressure when she loses pulses again, we jump back into CPR, start pushing medications. When we stop the next time she's in Ventricular Fibrillation. Commonly known as v-fib, this is when the ventricles are just jiggling away uselessly, not pumping blood, not doing much at all but sending crazy wavy lines on the monitor. I charge up the paddles, an alarming wail climbing in pitch till it's a squeal, make sure everyone's clear and then shock - the patient's lifeless body jolts once and we start CPR again.
It happens again- four more times in fact, till we're all looking back and forth at each other like "Really?!" because v-fib is not a rhythm that tends to stick around. When you shock your effectively jolting the heart with the intention of restarting and usually it'll either come back as some living rhythm or just flatline out and that's that.
We've already pushed four different medications into her, meds to stimulate her heart, meds to preserve her tissues, meds to balance her electrolytes, meds to keep her sugar levels up, and now we push another that reduces the irritability of her cardiac cells to keep them from fibrillating. When we check again it's in an extremely rare form of v-fib called Torsades de Pointes (here's another Torsades case i had with a happier ending) which is actually quite beautiful, a spiraling double helix kind of pattern on the monitor and gets a whole other medication to try to tame it back to something healthier.
After we shock her five times the squiggle steadies out into flat with only occasional, large messy blips. This is called idioventricular and it's the end. It means the ventricles have all but given up and are just sending a last, useless series of impulses out. We keep pumping the chest, keep squeezing oxygen into her, keep giving meds but finally the last squiggles pass by and the line is fully flat. At this point, the patient has been down over 45 minutes and we've given her every medication and treatment possible to keep her alive. It's a moment when a medic has to understand that the time has come, our resources are exhausted, we pronounce the patient and begin the careful process of undoing the past hour of messy interventions, pulling out IVs and unsticking the shock pads, finally lifting her lifeless body onto the couch and making her look as peaceful and presentable as possible for the family.