The Four Cardiacs
It was a Tuesday night. I was on call. I actually got home early enough to have dinner.
Then, the phone rang. It was the nursing home charge nurse. One of my nursing home patients, a fellow in his eighties, was stuporous, and they wanted me to come over ASAP to evaluate him.
Flashback about a year. The man I was called in to see was experiencing significant dementia. He lived with his wife and their children could not help her manage him. After several visits to discuss disposition, the decision was made to admit him to the nursing home. About a month later, the wife was visiting her husband when she was suddenly struck by a severe headache. The nursing home staff wheeled her over to the clinic. The nursing home was on the other side of the hospital, connected by a hallway, so this was easy to do.
The woman was in significant distress, holding her head. A neurological exam revealed deficits. Back in 1983, this was enough to suspect a subarachnoid bleed (bleeding around the brain). As CT scans were still pretty rudimentary then, the definitive test was a spinal tap/lumbar puncture. I prepped her back, anesthetized the area and inserted the spinal needle. When I attached the opening pressure attachment, dark red fluid ran out. This is indicative of a subarachnoid bleed. At the time subarachnoid bleed mortality rate was about 80%. We immediately mobilized the ambulance and I went with the patient in the ambulance to the tertiary care hospital in Duluth. She survived but, unfortunately, she suffered significant stroke symptoms, was unable to communicate, and on return from Duluth, was admitted to the nursing home in the same room as her husband. The man in the rest of this story is her husband.
I ran over to the nursing home and found the man unconscious. His physical exam revealed a heart rate of 30. An ECG revealed that the man was experiencing complete heart block. This requires immediate cardiology assessment and, if not reversible, placement of a pacemaker. We didn’t have an external pacemaker so he would have to be transported to Duluth. The patient’s guardian had designated a DNR/DNI and comfort measures only status for the patient. I called the family member who was the guardian. She verified the DNR/DNI and comfort measures only status. We moved the patient to the hospital into our two bed ICU, which was unoccupied. The family arrived and we used that venue for them to be alone with their likely dying father.
Just as I was completing the nursing home resident’s admission orders, the ambulance arrived with a man having chest pain. We got him on O2 and an IV and did an ECG. He was having an inferior Myocardial Infarction (MI) (Heart Attack). I ordered him to be admitted to our vacant ICU bed, next to the nursing home resident in heart block.
Before I could even write this MI patient’s orders, the nurse aid ran in saying an inpatient was in respiratory distress and coughing up “stuff”. Now, at night at this hospital, there was only one nurse, usually an LPN, and a nurse aid. The in-patient was an elderly woman who was sitting bolt upright in her bed, breathing rapidly and coughing up pink frothy fluid. Exam revealed signs of florid pulmonary edema, a fatal condition if not treated aggressively. Chest X-Ray confirmed pulmonary edema (fluid in the lungs).
The problem was the nurse was in the ER with the man having the MI. The only staff left to help was a nurse aid.
Back in 1983, emergency treatment for pulmonary edema was a protocol named MOISTDAMP. This stood for: Morphine, Oxygen, Intubation, Sit Up, Tourniquets (rotating), Digoxin, Aminophylline, Mercurial diuretic (really, furosemide), and Paste (Nitroglycerine). We couldn’t intubate since we had no ventilator, so we had to do all the other things on the list. I pushed the morphine, digoxin and furosemide. The nurse aid placed the oxygen. I ran to the ER and cared for the MI patient so the nurse could go to this patient’s room hang IV aminophylline and apply the paste. She ran back to the ER and I ran back to the inpatient’s room. Someone had to stay with the patient, keep her sitting up and applying rotating tourniquets. This consisted of placing tourniquets on three of the four limbs and then, every 5-10 minutes, removing one and placing it on the limb without the tourniquet. I had to teach this to the nurse aid and delegate that to her. We used blood pressure cuffs.
I ran back to the ER and got the patient ready for the ICU. The nurse wheeled him into the ICU. I ran back to the inpatient in pulmonary edema. She was improving! I told the nurse aid she was doing a great job and ran back to the ICU.
However, I never made it there. As I was walking down the hall, the ambulance arrived with a man who was in shock! Low BP, rapid heart rate, in a light stupor and complaining of chest pain. His ECG showed a massive anterior MI. The nurse called in a second nurse. I got two IV’s into the patient. The patient was started on dopamine and the ambulance crew was advised that they had to rush the patient to Duluth. At the same time, it really required a physician to accompany the patient and I couldn’t go as I had three other cardiac emergencies going on.
I had the nurse call the other physician who worked with me at the clinic. He wasn’t happy to be called in on his night off, but he came in right away and hopped into the ambulance and sped away with the patient. As I recall, the patient survived!
During the next four hours, the nursing home resident died, the inpatient in pulmonary edema had her condition clear (she survived and went home) and the man with the inferior MI’s condition was stabilized. The four cardiac patient events had all occurred within 90 minutes’ time. One doctor, one nurse, one nurse aid.