When A Save Is Not A Save
It was about 10:00 in the morning. I was an intern where I trained. I was coming out of the stairway that emptied into the main lobby of the hospital on my way to the lab to check on that morning’s lab draw results for my patients after finishing morning rounds. All of a sudden, the loudspeaker blares, “Dr. Ambu, please report to Building 4, third floor, Dr. Ambu, please report to Building 4, third floor.”
You’re probably wondering who Dr. Ambu is. Well, where I did my residency, the hospital decided that people knew what a “Code Blue” was (that’s when someone has a cardiac arrest and they call for the code team). So, they decided to rename Code Blue to Dr. Ambu. Ambu comes from the name of the bag that is used to ventilate the patient, the Ambu bag. There are several stories about this. One is, a patient, who coded and was revived and survived, sent a letter to the hospital wanting to meet with Dr. Ambu to thank him for saving her life. That must have taken a little explaining.
Anyway, I was on the Dr. Ambu team because I was the intern on call for the ICU/CCU that day, and we had to respond to all Dr. Ambu calls. But, I had no idea where Building 4 was, and I thought I knew the hospital campus pretty well, having gone to medical school there.
I ran to the information desk and asked where Building 4 was. The lady there said it was caddy corner to the hospital across the intersection on the north side of the hospital. Without hesitating I ran out of the hospital, down the street to the intersection, crossed the street and found Building 4, a 100 year old brick building. I ran into the foyer, there was no elevator. The loudspeaker had said third floor. I ran up the very narrow 100 year old stairs to find two women doing CPR on a woman just beyond the entry into an office. As it turned out, the two women doing CPR were certified CPR instructors whose offices were on the second floor. I asked if I could spell either of them and they said not yet.
Suddenly, there was a clamor as a bunch of people came up the stairs. It was the rest of the code team with a defibrillator, hands full of meds, syringes, IV bottles and a stretcher. The resident in charge ordered me to get a femoral vein IV in, then a femoral artery blood gas and a femoral vein blood draw. After getting that done, I spelled the person doing compressions. After a couple of injections of epinephrine and lidocaine, a cardioversion from ventricular fibrillation to normal sinus rhythm was successful. We bundled up the patient with her IV, put her on the stretcher, carried her down the three flights of stairs, across and down the street, through the main lobby and up the elevator to the CCU.
We got her in bed, set everything up, got the necessary tests and followed the MI (heart attack) protocol. When I left at about 5:00 PM, she was still unconscious, but her tests confirmed that she did not have an MI. The presumption was she had a spontaneous dysrhythmia, likely the ventricular fibrillation we saw on the defibrillator screen. I went home hoping she didn’t suffer any brain damage, as her prognosis was pretty good if she didn’t have an MI.
Back in those days, you were on call every other night and had to stay until all of your patients were stable, usually about a 30 hours on, 18 hours off cycle. The next day I came into the CCU and went to her room first to do my pre-rounds rounds (you better have seen your patients before the formal rounds with the attending physician). The woman who had coded across the street was sitting up in bed, smiling, talking, like nothing had happened! Her labs and electrocardiogram (ECG) looked normal! What a save! Everyone was impressed on Attending Rounds. The plan was to put her on anti-dysrhythmic medications and discharge her when her oral medication blood levels were therapeutic.
Unfortunately, the plan didn’t go as planned. About 3:00 PM, the patient started complaining of abdominal pain. On exam, there was diffuse abdominal tenderness and absent bowel sounds. Here abdominal pain work up showed an elevated white blood cell (WBC) count. A surgery consult was obtained and the surgeon was very suspicious of a superior mesenteric artery (SMA) problem. This artery supplies blood to most of the intestine and the pancreas.
We sent her down to the radiology department for an arteriogram. The test showed a complete occlusion of the proximal SMA. What had happened was, during the low blood flow state she was in during her cardiac arrest, the SMA had clotted. There was also x-ray evidence that her intestine was “infarcting” (dying). Since the findings were so diffuse and there was no way at that time to open the SMA, the surgeon’s prognosis was that this patient would die within 48 hours. Yes, the person who had survived an out-of-hospital cardiac arrest and was deemed a miracle success story was now expected to die in 48 hours.
The attending, the resident and myself had to go to this patient’s room and inform her and her family that she now had less than two days to live. If you weren’t there, you have no idea what that was like.
We put her on comfort measures, sedated her with morphine and within 36 hours she died peacefully with her family surrounding her. It was one of the most tragic cases with which I was ever involved.