Busy, busy weekend…
I had the resusc rooms. We didn’t have a ton of really sick people, so a lot of what I was seeing was fast-track type stuff to keep the patients flowing. Get ‘em in, get ‘em out type stuff.
Patch phone goes off, “Patient with substernal chest pain, radiating down arm and into jaw. Our field EKG shows elevations in inferior leads…8 minutes out”…
Okay, well this could be something to do… I start getting the room ready, and another nurse heads over to see if I need any help, when in busts the ambulance… “They just coded as we pulled in the driveway! V-Fib, we shocked once but that’s all we’ve had a chance to do…” as they come wheeling into the bay…
Of course, the patient is all diaphoretic, and the first shock knocked the field start IV out of the arm. We get them on the gurney, The doc is in the room and we get them on the monitor. Yep, V-Fib. No pulse. Clear, shock again… Another nurse joins us to record, I am starting a line, a tech is doing compressions. Get an 18 into the AC and tape it down really well….
And on and on it goes… After a couple rounds of drugs, the go into a V-tach that looks a little like torsades, so we try some Mag. Compressions are being passed around every few minutes. (We had a bunch of student EMT’s, so everyone got a turn!)
A couple of episodes of asystole, then a ventricular escape rhythm which we would try and pace, invariable, they would drop back into v-fib before we could get it captured.
We’ve been working this patient for over 30 minutes. We’re all wondering when the doc is going to call it, because nothing is working. We actually have good oxygenation going, but the heart doesn’t want to cooperate. ABG looks pretty acidotic, but oxygenation is still there. Stat labs actually don’t look that bad. Actually, except for the whole no pulse thing, the patient looks pretty good on paper…
Finally, the doc says, “Let’s shock this again” and I charge it up. “CLEAR” and off goes shock number 14. Asystole, then a ventricular escape rhythym, with a palpable pulse of 30. I throw on the pacer, and pump up the impedence. We get capture about 120mA, and work the rate up to 70. The pulse is holding! Levophed up, and we have a decent blood pressure! Doc does a FAST scan, and the heart is contracting well!
The cath lab is already on the way in, and get there a few minutes later. They wheel the patient to the cath lab, and I start reviewing the notes. 42 minutes from arrival to capture and continued pulse. 14 shocks. 6 Epi, 3 atropine, Amiodirone bolus and drip, 2 rounds of Mag, 2 bicarb. 2 Liters of fluid. My large-bore IV, and a femoral line from the doc. An art line.
But for what? Most of us are pretty sure we have salvaged some organs for donation, if they can find some family (none were at the scene when fire got there). We go through the rest of the night rather exhausted. A lot of work, and we’re spent.
Cath lab calls. The patient had a huge thrombus totally occluding the RAD, which they were able to remove. Patient is down in CVICU.
At 4am, CVICU calls (this is 6 hours after the code) patient is extubated, sedated, but arouses and follows commands!!! All of the sudden my feet weren’t so tired, and I wasn’t as exhausted. Maybe we did win one after all!
EDIT - Of course, all patient stories on my blog are randomized to avoid patient identification, so this patient doesn't really exist... but, if they did, when I went back to work and checked on them two days post-code, I would have miraculously found them with no neuro deficits whatever. They would probably be pretty sick with some ischemic bowel and acute tubular necrosis from being coded for so long. Sick, definitely, but still in rather amazing shape, all things considered.
If this wasn't a totally randomized patient encounter to protect patient privacy, that is...
12 comments:
Once coded a baby for 30 minutes. Thought the baby would die that night. She is 4 years old with no residual effect. Amazing. Just goes to show, the final call is not up to us.
Excellent job. I'm too tired to post today so I'm going to link your great experience.
Longest code I ever worked was at least 2 hours, well over 40 shocks because she kept going between VF and viable rhythms. 40 yo. female, drug addict - signed out AMA the next day fully competent but not cured.
Great story-telling John! Thought for sure he was gone until the last line. Remarkable job! Laurie
That is a good feeling, its why i do what i do.
wow, just got home from an exhausting day and needed to hear about a GOOD outcome! ty! :)
I got a little tachy just reading! ;-) And thanks to ernursey for referring us over here.
Haha, I'm glad the students got some compressions in.
I wish my first compressions could have been hospital...instead they were on a deputy...in field...
I was a kid scared outta my friggin' mind.
Good job!
Amazing. Good work. That was a great story.
you can tell Im new to this, because what I marveled at was the fact that a delivered shock blew out a field start!! Its always interesting to me to see ACLS in action!
My first code ever as a GN was last week, went about 20 minutes and multiple shocks before transferring to (higher level of care), where Pt coded again, but is now? Still alive! Still in (higher level of care), but surviving. Unsure of deficits, right after the first round Pt talked to me a bit. Since technically it would violate the hipaa to actively check on the Pt, I'm not going to as the hospital tends to track such things. Worst part was, no warnings, just occasional PVCs, then suddenly VT. Meanwhile my other Pt can't breathe for shit with a probably PE...yeah. I do like the excitement to some extent, and stayed calm, but I don't like the powerlessness as first Pt had no s/s and second Pt had the issue and the doc was like...whatever..until about the third call.
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