Tuesday, January 23, 2007

Famous Last Words...

He came in at 1 in the morning, and I triaged him. His chief complaint: "Well, my chest kind of hurts, and my girlfriend made me come in." His girlfriend sat next to him, appearing fretful and unhappy. The patient was a 37 year old who appeared to be in general good health.

I was tired. It had been a long shift so far, having been spent sticking IVs into dehydrated babies suffering from GI bugs that have been particularly vicious this year. I was shipping demented elderly people to the floor at a record pace, and the nurses in MedSurg were threatening to form a lynch mob. I was 9 hours into a 12-hour shift that I worked because my opposite has decided to break his leg skiing.

But medical emergencies don't care how tired or busy I am. My triage assessment had to be thorough, and that meant that I had to elicit as much information as possible in order to find out what was really going on. I've been doing this long enough to suspect when a patient was not giving me the whole story, and I could tell that this guy was not being very candid about what was going on. Generally speaking, when a patient evades the questions it is likely that either the patient was doing something he should not have been doing, or he is in denial of an emergent problem. So we went through the sparring ritual at triage, with me probing and he evading while his girlfriend fretted on.

The training that has been pounded into my brain took over as I attempted to classify the patient's chest pain. Is this a heart attack, a pulmonary embolism, a bad gall bladder, gastroesophageal reflux, an anxiety attack, or what? I'm trying to get as much information from the guy as I can, but he is not helping.

The patient's vital signs were stable. He was not sweaty, he was not clutching his chest, and he did not appear anxious. Finally, agitated with her boyriend's evasiveness, the girlfriend could stand nor more. She interrupted him and told me: "His brother had a heart attack when he was 35, and his dad had one when he was 36."

This guy was 37.


In that instant, the lesser possibilities were automatically disqualified and I began to operate on the assumption that this patient was having a heart attack.

Now let me acquaint the reader with a big fat truth. If you have a heart attack, it may not necessarily feel like your textbook heart attack. You know, the elephant on the chest, the sweating, the horrible left-sided chest pain that radiates down the left arm and up into the left jaw. People are all unique. While that's a beautiful altruism, the fact also makes my job a lot more challenging.

I had one patient whose only symptom was a severe case of the hiccups. He was having an acute myocardial infarction (MI). I had another MI patient who simply fainted. I had yet another who had pain in both elbows. Diabetic patients often feel no pain at all (called a "silent MI"). These seemingly innocuous manifestations and vague complaints are why thorough patient assessment will always be at the top of the Challenge-O-Meter.

This is also, of course, is why ER nurses tend to jump all over a patient and stick monitor leads and IV lines in them in a hurry any time someone verbalizes symptoms that trigger our alarms- which is exactly what I did to my patient within 0.5 seconds of his girlfriend's statement.

In the Museum of Famous Last Words, three words are at the center exhibit. Here they are:

"It's probably nothing."

(Hah. I bet you thought it was "Hey, watch this." Those actually run a close second.)

And guess what the patient snapped at his girlfriend when she interjected?

"Stop it! It's probably nothing."

But with his familial history, my suspicion index was going bonkers and I was not about to be caught flatfooted if it turned out to be something. So I unceremoniously took the patient back to a cardiac room (dragging a bewildered ER Tech with me) had the patient strip out of his shirt, and slapped the blood pressure cuff, pulse oximeter, and the cardiac monitor leads on him. The patient shot his girlfriend a "see what you did?" look, but cooperated.

Now, a note on the 5-lead cardiac monitor: In terms of monitoring heart rhythm, the 5-lead monitor is great. But for diagnostics, it's like taking a picture of the Grand Canyon using the camera on your cell phone. It's informative, but not precise. So I ordered the tech to do a 12-lead.

The plot thickened.

The patient had some suspicious aberrations in his inferior-septal EKG tracings. That means that the electrical impulses that travel through the part of his heart containing the SA node (the natural pacemaker) and the AV node (which regulates the ventricular contraction) were not traveling as they should. The artery that supplies these parts of the heart may be occluded, and if that part of the heart dies, the result is a "negative patient outcome" (i.e., death). Furthermore, if that region is affected, the patient may not show classic signs of cardiac injury. Isn't that encouraging?

I know that alot of this is arcane to the reader who is not well-versed in heart attacks. Suffice it to say that I was not reassured in any way after looking at the EKG. Could it be that he was having a heart attack? Maybe. But then again, maybe not. But again the old adage applied: when in doubt, assume that the patient was having a heart attack. I was not reassured at all when I showed the MD the 12-lead, and he became immediately suspicious and got on the phone to the on-call cardiologist right now. Meanwhile, I stuck an IV into him and drew blood for more tests. I tossed 325mg of aspirin down his throat. I put him on 4 liters of oxygen.

With every minute that passed waiting for lab results, the patient became more and more impatient. And he was still not communicating his symptoms. We found out that the patient was again having chest pain only because his girlfriend came out and told us. When she did, the MD and I rushed in. I did another 12-lead EKG and as it spit out the results, the top of the page had this:

************************************* ACUTE MI **************************************

I was not reassured.

The cardiologist arrived and reviewed both EKG results with the MD, and then strode into the patient's room and informed him that he was going to be admitted to the CCU and would be going to the Cath Lab for angiography.

"Oh, no I'm not! I have to be at a meeting in the morning."

"Sir, you are having a heart attack."

"I feel fine. You don't understand- I have to be at this meeting. My business depends on it. It's not an option."

"No, sir, you don't understand." The MD countered. If we don't fix this problem right now, you will probably miss your meeting anyway because you will be dead.

The patient opened his mouth to say something to the MD, thought otherwise, and then turned on his girlfriend. "Thanks a lot! None of this would have happened if you'd have just SHUT UP!"

"I don't want you to die," she answered weakly.

"I'm not going to die! I'm FINE!" The patient turned on the ER MD. "You can't keep me here if I don't want to be here."

"That's true."

"I don't want to be here. Take this stuff off of me NOW. I'm leaving."

The girlfriend stood and declared, "If you leave you'll be walking home, because I won't drive you."

"FINE!" the patient roared. I caught the girlfriend's attention and motioned her out of the room and into the waiting area. She turned to me with tears in her eyes.

"I don't believe him! He's in total denial of this. How can he be so stupid?"

"I can't explain his attitude; but I can say that bringing him in was a wise choice on your part. Right now, the most important thing is to keep him calm. Getting angry is the worst thing he could do. How well do you know him?"

"I've been with him for a little over a year."

"Is he under any stress?"

The woman threw her arms up and said, "Oh, yeah! He works two jobs: He owns his own construction company but he's also the top loan officer for a mortgage company. He's their Golden Goose. He works constantly, and he never lets up." She paused, then added: "He has a lot riding on that meeting. Could he really die if he goes home?"

"Yes, he could."

"If he could possibly die, can't you keep him without his consent?"

"Not in this case, no."

"I have to talk him out of leaving," she concluded. I put both hands up.

"No, ma'am. Right now, we need to get him calm. Can I offer a suggestion?"

"Sure. I'm all out of ideas with him."

"Just have a seat in the waiting room for a little while. Let me get you something to drink. Getting away from the room will help both of you to calm down right now. Do you agree?"


I heard commotion in the treatment area, and a lot of feet. I excused myself and rushed to the patient's room to find him ashen, sweaty, and limp. His monitor showed a disorganized and slow rhythm. He was in full heart block, meaning that the connection between his SA node and AV node had been completely severed by the injury to his heart.

Oh, crap.

I joined the rest of the code team and slapped the pacer pads onto the patient, hooking it up to the defibrillator. The MD ordered sedation, which another nurse was in the process of giving. As the patient slipped out of consciousness, he slurred, "Stop it. I'm fine."

The MD looked at me and rolled his eyes. "Famous last words."

After the patient was unconscious, we managed to "capture" his heart and pace its rhythm. His vital signs began to stabilize, and we all started to breathe again. I prepared the patient for transfer to the Cath lab and gave report to the receiving nurse.

As the Cath lab team pushed the stretcher down the hall, I turned and found the girlfriend beside me.

"I'm sorry I couldn't come get you sooner," I said. "Are you going to be okay?"

She sighed. "Yeah. I'm glad it happened this way. Is that wrong?"

"Well, for what it's worth, I would rather he did it here than at home."

The woman paused and then asked: "Is it my fault that he got upset and his heart attack got worse?" She lowered her head and looked at the floor.

I turned to face her and told her, "Look at me." When she met my gaze, I continued: "Consider the possibilities. What if you had not brought him here? Upset or not, it's likely that if he was not here, he might be dead right now. So you tell me: was bringing him in worth making him upset?"
"Yes," She replied. She began to cry. "He's never snapped at me before like that."

"I can't give you an answer for why he did," I said, handing her a box of Kleenex. "You know him better than I do. But I've seen alot of people who come in with heart attacks who refuse to believe it even when they can hardly breathe and the staff is swarming them. It is a frightening thing to face, and people respond to the prospect of mortality in their own ways."

I then asked, "Would you like to go to the Catheter Lab waiting room and wait for him there?"

"I'll go there. How long will it take?"

"Maybe a half hour to an hour. I'll call over so the team will be expecting you, and I'll have one of our Techs walk you over there. I have to finish charting, so I'll say goodnight now."

She extended her hand. "Thank you. You all were very good with him."

"It's our pleasure. Try to get some rest, Okay?"


I found an available Tech to escort the woman to the Cath Lab and turned to the arduous business of documentation so that I could run the chart over to Cath Lab quickly. As I sat down, I looked up at my watch: two hours more, and I would be off. I stretched, yawned a long and obnoxious yawn, and set to work.

Saturday, January 20, 2007

Hey, We Can Fix That.

The ER is a complex and challenging environment where success is not always achieved, and where futility rears its ugly head far more frequently than we would wish. In such an environment, the quick successes can often have the effect of restoring confidence, especially after a long string of difficult cases where success has been elusive. The confidence factor is magnified when the case involves a scared patient with a heart that has decided to do its own thing.

I arrived for the beginning of my shift and received report from the offgoing RN about a patient who had just arrived in one of my treatment rooms. He was an otherwise healthy middle-aged male who came to us with a complaint of dizziness and a "really weird feeling in his chest." An EKG revealed atrial fibrillation, a condition in which the atria of the heart stop working in a organized fashion and simply begin quivering. The condition is dangerous because it can cause clots to form in the left atrium, which can be "sprayed" into the left ventricle and thus to the the rest of the body, leading to heart attack, stroke, pulmonary embolism, or kidney infarct- none of which are happy things. Both the patient and his wife were highly apprehensive, to say the least- and certainly appropriately so. In such a circumstance, it is important for us to establish the patient's and family's trust that we knew what to do, how to do it, and where to start.

I swept into the room with an ER Tech at my heels, exuding confidence and optimism. I wanted the patient and his wife to get the message: This guy knows what he's doing. I made a point of clearly explaining everything I was doing and why I was doing it. I have assisted with synchronized cardioversion many times, and I made sure that the patient and his wife were as comfortable with the process as possible. I made sure they had no doubts that this stuff is our bread and butter. The whole team was on the same page, and the MD running the procedure is top-notch. He's brilliant, he's personable, and he is a pure joy to work with.

I should mention here that when the members of a team are familiar with one another and they have a mutual high professional regard for each other, it is pure magic. It is simply thrilling. There is no easy way to describe it, and the word chemistry is overused in my opinion, but when that strong professional relationship exists, the patient notices. And the patient saw that the MD, the ER Tech, and I were completely "dialed in on each other" (his words).

That goes a long way toward alleviating some of the patient's apprehension, especially when his life is literally in our hands for a split second. During a synchronized cardioversion, the patient is literally one push of the button away from meeting his Maker. If the timing is wrong, we will stop his heart. Technology removes some of the dicey aspects of the procedure, but there is always that chance...

Synchronized cardioversion is a fancy way of describing shocking the heart into a normal rhythm. We don't smack the heart with alot of energy, but just enough to get its attention. But the tricky part is the timing. It has to be done exactly when the ventricles contract. Otherwise, we put the heart into ventricular fibrillation- that means death, which is what we euphemistacilly refer to as a "negative patient outcome." As I mentioned, our machine is able to hold off delivering the charge until it senses the ventricular contraction- that's the "synchronized" part of cardioversion. Better living through technology, eh?

Finally, the forces are gathered around the patient. He gives his wife a kiss. Respiratory therapy is present just in case we need to intubate or if the patient needs to have assistance with breathing. I drew up 15mg of Etomidate, a potent sedative agent with a very short half-life. The drug stays in the system for a mere 30 seconds. After that, the patient wakes up almost immediately. So I have to "slam" it, meaning I push it as fast as I can, but not too fast since it can burn like a mother.

The MD gives me the nod. I push the Etomidate. Ten seconds pass with no response. The patient says, "I'm still here, guys."

Then he is out. Just like flipping a switch. The MD makes sure the patient is unconscious, then he pushes the charge button and makes certain everyone is clear of the patient. The machine emits a beep that rises in pitch, and when fully charged and ready, it emits a noxious warble. The MD pushes the Shock button.


The patient's body jerks with the energy, then settles. All eyes are on the monitor. The patient's heart settles from its previous chaotic rhythm to a normal one. Twenty seconds have passed.

The patient's eyes begin to flutter open. As if on cue, he shakes his head and says, "I'm ready when you are, guys."

I tell him, "We're done."

"You're kidding," he said, incredulous.

"Nope. Take a look," I replied, directing his eyes to the monitor. "You're in sinus rhythm. Nice and normal."

He breathed a huge sigh of relief. His wife came to his side and kissed him on the cheek. They were both tearful with relief.

I finished charting my procedural assessments and asked if they needed anything else. They did not. I discontinued the monitor when appropriate to do so, cleared away the extra paper, and left the room.

It's nice to have one we can fix once in awhile.

Tuesday, January 16, 2007

Weather Idiots, Part Two

I posted a month ago about Seattle drivers who simply were not meant to go outside any any but the most mild weather, and even then only in the kind of cars that have external airbags. Apparently, Portland (Oregon) has its share of weather idiots, too, as evidenced by this video from KING 5 News. Enjoy.

Saturday, January 13, 2007

The Family Fun Pass

I just love it when people get angry at me for telling them they can't circumvent the rules and that they must play fair. It makes going to school for all those years feel so worthwhile.

I had a whole family come in recently: two little destructive spawns of Satan, their unhygienic-looking parents, and the patient who was apparently the matriarch of the family. She had begun feeling poorly over the last two days. Small wonder; she had COPD, heart failure, renal insufficiency and diabetes.

The triage tech walked them all past the nursing desk in my section. I heard the two children roaring and bawling like a couple of sawed-off soccer hooligans all the way from Triage, and looked up from my charting in time to see the mom put her cell phone to her ear and start chattering.

"Ma'am, you can't use your cell phone in here. Turn it off, please." I said to her politely but firmly. She shot me a dirty look, rolled her eyes and kept talking as she passed by. Fortunately, our security guard saw the whole thing and blocked the woman's path. She snapped, "What?"

"You were asked politely to turn off your cell phone, Ma'am. Please do it now."

"What's the big deal?" snorted the woman.

I answered, "Other than the fact that it is posted plainly on the entrance to the ER, it interferes with our telemetry equipment. Please turn it off. Now."

"Just a minute." She turned away and continued to talk on the phone. The security guard faced her once again, deftly took the phone out of her hand, turned it off, and handed it to her. The woman, whose husband had now joined her, voiced her dismay in rather unladylike language. The husband asked me in a challenging tone, "What's the deal, man?"

The security guard (who was just shy of being as tall and solid as Mount McKinley) replied with a smile, "The deal is that if you do not obey the safety regulations of this hospital then you will have to leave... Man." The man (who had no business challenging a guy who could break him into kindling with his eyelids) took his wife by the elbow, shot the guard a sour look, and disappeared into one of my assigned rooms behind the wheelchair-bound, hunch-backed, hacking old woman and the two little hounds of hell snapping behind her.

Oh, this is just prime, I thought. The ER tech hurried out of the room a minute later, handed me the chart while guiltily averting her eyes, and flung the word "Sorry!" over her shoulder as she retreated toward Triage.

Under normal circumstances, I really don't mind having family in the same room as the patient; even a comparatively large family does not bother me if the room is large enough and if they are well-behaved. But I could already tell that this was not going to go well for me if these people continued as I suspected they would. And the closer I got to the entrance to the room, the more my suspicions were confirmed. Just before I knocked on the doorjamb, I heard the man say "Please don't touch that, Satchel. Please behave and come sit by Daddy."

Of course, Satchel ignored Daddy. He instead shouted "No!" and dumped what he was touching- the stainless steel Mayo stand- over with an almighty crash. The little girl screamed and Mommy scolded lil' Satch with a sarcastic "Do you feel better now?"

I decided that now was as good a time as any to make my appearance. Knocking on the jamb, I parted the curtain and introduced myself.

"Oh, it's you," the mom sneered.

"Yes. I am assigned to this section, and I am going to be the nurse for-"

"Where's the doctor?" the dad demanded, cutting me off.

"He's with another patient and will be in after I perform my assessment." As I turned to the patient, the mom said, "Since we are already here... our kids have been sick the last day or so and I'd appreciate it if you could check them out, too." These were the same kids, of course, who had been running and bellowing around the Triage area for an hour and making life miserable for everyone else in the room.

I turned to her and said "No, ma'am, I will not." The woman looked as if I had slapped her.

"Well, why not?!"

"If you want your children to be seen, you will have to take them out to triage and have them checked in, and wait for them to be seen."

"But we are already here!" She insisted. Why can't you just look at them?"

"Because, ma'am, that would be allowing them to go ahead of patients who are still waiting in the triage area to come back to a room. That's not fair. And except in an emergency, I won't see them before they are triaged."

"It's not my fault that they aren't back here. We're already in here, and so I don't understand why you can't just be nice about it and look at my sick kids. Just triage them here," she said, throwing her hands up in exasperation.

"I will not. You have to go through triage like everyone else. I can tell right now just by observing their, ah, activity, that they are actually doing quite well."

"You mean we have to go all the way back to triage and wait in line?"

"That is what I have been saying, ma'am, yes."

"You are such a selfish ass. If you're like this with your patients, God help them." the woman hissed. She stood up, grabbed her kids and dragged them out of the room. The dad stood, glared at me, and followed his wife.

I turned to the patient at last, and she looked up with tired eyes, her lids heavy, like tired water balloons, from fluid overload. She raised a hand to my cheek and patted me softly.

"Thank you."

Thursday, January 04, 2007

A Most Unusual Demise

I reconciled myself to the reality of patient death a long time ago. I came to realize fairly early in my career in the Emergency Department that as hard as we try, we cannot “cheat” death. We can put it off for awhile; we can even snatch a patient out of its very jaws from time to time, and pat ourselves on the back for our determination and ingenuity; but once a person crosses a certain point, there is no hope of bringing that person back. Sometimes the patient’s body shuts down in a manner so baffling that it may only be encountered once in an entire career, or perhaps only read about in a medical journal. This is the story of such a patient. She happened to be the first patient demise of the year at my hospital, and she also happened to be my patient.

At 6:45 PM on January 1, I dashed in the dark through a stinging, wind-driven rain toward the staff entrance of the Emergency Department. I was working a 7 PM to 5:30 AM shift after four day’s rest. The often-tremendous challenges of the holiday shifts behind me, I was eager to get back to work. This was an extra shift for me that I had volunteered to work some weeks before. Since the shift was classified as “high-need,” an attractive pay incentive was involved. The extra money would help to pay off some of my Christmas debt, so I jumped on the opportunity like a starving chicken on a Japanese beetle.

Convinced that I had filled my personal quota of the oddball cases peculiar to this time of year, I was eager for a return to normalcy (or as close to such as can be imagined in a busy emergency department serving a large population). The diminishing number of assault victims, alcohol-related injuries, suicide attempts, and panic attacks coming to the ER indicated that visiting relatives were now leaving town.

In my experience, the lower-acuity cases tend to stay home on New Year’s Day; they don’t want to miss the Bowl games. (Sometimes, even the very ill will wait. A few years ago, I cared for a patient with acute appendicitis who had delayed coming in because he did not want to miss watching his team’s bowl game- a deferral which very nearly killed him. His appendix ruptured at some point during the game and he was in septic shock by the time the medics brought him in. He ended up undergoing emergency surgery and spent a week in the Critical Care Unit and another week on the Medical-Surgical Unit. To add insult to his injury, he was delirious during most of the game and doesn’t remember watching his team win a nail-biter in the final seconds.)

Thus, we braced ourselves for the sudden influx of patients that invariably occurs soon after the conclusion of each game. I was pleased to note that I was assigned to my favorite section, which included one if our resuscitation rooms. I received report from the day shift RN and assumed nursing care for a patient waiting to be transferred to surgery for an emergent appendectomy, and for an elderly woman with pneumonia and mild heart failure who was to be admitted to the Medical Unit for treatment. My nice, ordered world came to an abrupt end when we received a call from an incoming medic unit at 8:20.

The medics were bringing in a 32-year-old female who had been complaining of shortness of breath and general malaise for the last few days. She happened to have also been smoking cocaine and shooting black tar heroin all day. She had been staying with a friend, who called 911 when the patient suddenly became extremely agitated and began coughing up blood and crying “I can’t breathe! I can’t breathe!” By the time paramedics arrived on the scene, she was in respiratory arrest. They inserted an endotracheal tube within minutes, and began bagging the patient with great difficulty. It took a lot of effort to get any chest wall expansion. They suctioned her and observed bright red blood- and lots of it. Hearing no lung sounds, they suspected a tension pneumothorax and inserted large-bore needles into the patient’s upper chest on either side of her sternum. They again noted bright red blood. They put her on the stretcher and initiated transport, at which time they called my ER to give report.

I began setting the resuscitation room up to receive the patient, having asked the Unit Coordinator to page the Respiratory Therapist to come to the room with a ventilator. Five minutes later, the medic unit called to inform us that they had initiated CPR. The MD ordered the Unit Coordinator to call a Code Blue in order to get the necessary people in place ahead of the patient’s arrival, and paged the duty cardiologist- who this night happened to be one of our most brilliant and experienced doctors, with three decades of experience. Within minutes of the call, every essential person was gowned up, gloved up, masked up, and in position. As primary nurse, I stood at the head of the empty stretcher with a clipboard and triage sheet in hand. My role was to take report from the medics and oversee all nursing interventions. Looking around the room, I saw that all of the necessary equipment was broken out and ready: the suction tubes, orogastric tube, Foley catheter, monitor lines, thermometer, IV tray, fluids, ventilator, and crash cart were arrayed around the bed ready for use. Two veteran ER nurses and two ER Technicians stood by to assist me. At precisely 8:35 PM, the patient arrived.

The moment the patient arrived, every person in the room was simply aghast. Of all the patients I have seen in clinical death, this woman was easily one of the most dreadful-appearing. Her entire body was stiffened and inflexible. Her skin was cold, waxy and mottled, and blood had already settled into her back and bottom. Her right forearm was raised from the bed at a crazy angle and hands curled inward toward her body, fingers stiffly bent in spastic flexion at the proximal knuckle. I applied tension to the end of one of her fingers, not believing what I was seeing. Sure enough, the finger would not extend. Her eyes were already dry and dull, with the frosted appearance characteristic of the dead. The woman’s body was already set in unmovable, inflexible rigor mortis. I looked at the monitor.

Her heart was still beating.

The staff immediately swarmed over the patient, cutting the clothes from her body and working feverishly to obtain vital signs. I noted the two huge needles that protruded from her chest capped by small cylindrical flutter valves to keep air from re-entry into the chest cavity. I directed my attention to the medics, who gave me an unusually-sketchy report. They knew next to nothing about this woman. The friend who called 911 was himself high on heroin. I became frustrated because the data we needed was not coming. I snapped requests for data to the techs, who patiently informed me that what I had ordered was done and that there was simply no data to report.

“Does anyone have a blood pressure yet?” I called out.

“No,” the lead tech responded. “We can’t find a pulse anywhere but in the femorals.”

I turned to the MD with a quizzical look. “Do you want to do a femoral line?”

The MD looked at the patient for a moment, shook his head and said, “No. At this point we would only be using it to monitor her pressures. We have a femoral pulse. Her carotid pulse is thready but present. I’m guessing she’s probably around 70 systolic.” He put his hands on his hips and shot me look of exasperation. “What the hell is going on here?” I shrugged my shoulders and shook my head.

In spite of our best effort, we continued to suffer from an infuriating lack of data and it seemed to be many long, long minutes before numbers and values began to trickle in- and it seemed that with every new piece of information the case slipped that much further into the Twilight Zone. Good grief, nothing makes sense! I thought.

When we finally got a rectal temperature, it was 31.4 degrees Centigrade (88.5 F). Her limbs were ice-cold. Her chest x-ray revealed that her lungs were completely obliterated with blood. We were never able to obtain a blood pressure through any means including palpation or Doppler. The respiratory therapist drew a syringe of thick, nearly black blood from the patient’s femoral artery for an arterial blood gas assessment. We also obtained a blood sample for a blood glucose reading. We began to get our first real inkling that we were seeing something that none of us in all our careers had ever encountered before.

Her blood glucose was zero. Her blood pH was 6.1 (far beyond compatibility with life). Her serum creatinine was 3.9, which was far beyond normal. Her hematocrit was 7 percent (normal range for a female is 36 to 46 percent). A Foley catheter was inserted, with no urine output. I ordered a urinary bladder scan, which revealed no urine in the patient’s bladder. The woman’s kidneys were gone. Had she bled out somewhere, somehow? Nothing we were doing was helping this woman. And all the while, her limbs continued to stiffen at awkward angles. Blood was going nowhere. Her vital organs had long ago ceased to function. Her pupils were blown and her eyes were fogged over. She had no metabolic activity. This woman was dead.

But her heart was still beating.

Word travels fast when an unusual case hits the ER. Suddenly, the room was crawling with cardiologists and neurologists, all of whom were standing off to the side discussing the findings, reviewing the figures, and trying to figure out what on earth was going on. I noticed a lot of head-shaking and shoulder-shrugging among them as I glanced in their direction. I went through my hundredth mental checklist, ensuring every nursing intervention had been performed. Nothing had been omitted, and everything was in place. All that remained for me to do was to square away the documentation and prepare the patient for transfer to diagnostic imaging for a CT of her head, from whence she would go straight to the Critical Care Unit.

When I called report to the CCU nurse (a veteran nurse with more than 20 years’ experience) and gave her the story, she was incredulous. I had to repeat myself when I read off the information we had obtained thus far. I repeated myself many times that evening.

At last, we transferred the patient to the CT room for a scan of her brain. The moment we shifted her to the CT table, her heart stopped. We called a Code Blue and within seconds the team was in the room, once again trying everything we could think of to bring the woman back. Finally, after another ten minutes of feverish activity, the MD ordered, “Stop CPR.”

All eyes turned to the monitor. The heart rate slowed to 30… 25… 15… 10… 0.

“Guys, I’m out of ideas. Can anyone think of anything we have not already tried?” Everyone shook their heads, including a couple of cardiologists and neurologists who had responded to the code.

“That’s it, then. Time of death is 9:58 PM.”

We disconnected the defibrillator, transferred the body to the stretcher, and trundled her back to the resuscitation room. The charge nurse took the papers from me and ordered me to take a 30-minute break. I am still uncertain of what I was feeling. Was it grief or bewilderment? I was sad, I was angry, I was frustrated by the slow flow of data we had experienced. But more than anything else, I was completely baffled. What on earth had just happened?

By the time I returned, the charge nurse had done all the after-death paperwork and notified the Medical Examiner’s office. An autopsy was most definitely called for in this case. We certainly had no idea what killed her. Yet as far as this case was concerned, all my work was completed. I called the CCU nurse to let her know that the patient had died; she was still incredulous.

As I walked back toward my nurses’ station, the chief cardiologist took me aside and asked me excitedly, “Do you know what you just saw?”

“No, Doc,” I replied. “I have no idea.”

“You have just seen something that none of us have ever seen before either.”

“What’s that?”

“A stone-cold corpse with a beating heart.”

I stared blankly at the doctor.

“None of us are sure exactly how it happened, but the consensus is that perhaps all of the drugs that were given in the field, coupled with her youth and having a strong heart, may have been enough to keep the heart beating in spite of the fact that there was nothing left to perfuse.”

“So then you all think that she really was dead before she got here?”

“Dude, she was in rigor mortis when she hit the room!” The doctor said, waving his arms. “That’s what we were all talking about. She was dead, dead, dead.” He shook his head in amazement. “I suppose that something like this is chemically possible, but what are the odds that such a thing could actually happen?” He lifted his coffee cup, took a drink, pointed it towards me and continued: “I suspect that we have just observed the amazing automaticity of the human heart. Even when the body is dead, it still has the capacity to continue beating if the conditions are perfect. And in this extremely rare instance, they were.” The cardiologist took a drink, grimaced, and said, “None of my fellows has ever seen anything like this. You and I will probably never see it again in our lifetimes.”

He put his hand on my shoulder encouragingly, gave me a pat, and walked briskly down the hall and out of the Emergency Department, still shaking his head as he disappeared through the doors. I walked into the resuscitation room and looked into the dull, fogged eyes of the first person to die in our Emergency Department this year. I put my hand on her forehead, drew a heavy sigh and said to her, “Lucky me.”