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.”