07 December 2009

Futility

At our hospital, the overhead paging system is fairly infrequently used.  At 8:30 PM they announce that visiting hours are over and will all guests please get the hell out go home, and, being a religious institution, they pray at us twice daily.  A little musical scale is played when a baby is born (an arpeggio going up the scale if a girl, down scale if a boy; I've long wondered if there's a subtle message to be had there).  After working there a decade, I've learned to ignore these routine announcements completely.  Then there are the "codes" that are called overhead.  These are preceded by a chimed single note (a middle D, I think) and followed by the specific code.  There's the "Code Blue" which is, of course a cardiac arrest, and there are the trauma codes: these are for me.  Code Red is a fire and Code Gray is for the security team: I ignore them.  Patients must think I have a strange tic because if I hear the chime while we're talking, I stop in mid-sentence and cock my head to listen whether it's a code I have to respond to. If it's not one for me I pick up where I left off, but if I have to run from the room, patients usually understand.

So it was the other day.  I was giving a guy with strep throat his discharge instructions when the Code Blue was called.  I bolted upstairs and arrived at the room as several nurses were heaving a large man back into bed.  There's that "doorway moment" when you hit a code, in which you make an instantaneous, almost subliminal assessment of how bad the situation is.  "Very bad," was my thought as I moved to the head of the bed.  The patient was dusky blue and covered in sweat.  He was a middle-aged man, mildly obese, with a full head of dark brown hair.  He had no respiratory efforts and was completely flaccid.  Within moments I had him intubated, they were back doing CPR, and a monitor was being hooked up. 

There was no pulse and the monitor showed a flat line, meaning no cardiac electrical activity at all.  It was a weird code: an otherwise healthy guy admitted for a simple pneumonia.  Not the sort of patient you expect to drop dead on you with no warning.  He had just gotten up to go to the bathroom, his nurse explained.  The down time before I tubed him was probably five, maybe ten minutes, we guessed.

Generally speaking, when someone dies suddenly, you've got a few minutes to get them back.  Every passing minute makes the likelihood of a successful resuscitation diminish drastically.  And the minutes dragged on and on in this code with no response whatsoever.  There was a progressively increasing sense of fatalism among the dozen or so health care providers gathered around the bed, working to save this man's life.  This guy was dead.  He was not coming back.  Uneasy glances were exchanged.  The urgency and crispness drained out of the room.  The initial energetic, high-quality CPR was replaced by slower, weaker chest compressions.  People shook their heads and checked their watches.  The unspoken question, "How long are we going to flog this?" hovered in the air.

That's my decision, and sometimes it's a hard one.  The really and truly dead are pretty easy to call, but this guy was "still warm," as they say, and I wasn't quite ready to give up.  Besides, he was showing me a few things on the monitor which at least kept things interesting.  We played with it like a mega-code, going through the different arms of the algorithm: asystole, V-Fib, V-tach, bradycardia, PEA and more.  I gave some helpful feedback to the folks doing CPR, even venturing a few bars of "Stayin' alive," to rueful chuckles.  Some gallows humor was exchanged.  But there was a very deep, very firm conviction among the entire team that by this time we were going through the motions, and the outcome was now set in stone.  The chaplain was trying to get the patient's wife on her cell phone, and I called the primary care doc.  The patient's complexion never altered a whit from that deep violaceous hue, and there were no signs of life beyond the squiggles on the monitor, never associated with a pulse.

On a lark, we decided to try t-PA, a clotbuster drug, in case there was a blood clot in the lungs causing the arrest.  I was chagrined to learn, after ordering it, that it was going to take 5 to 10 minutes to prepare.  "We have to keep doing this for another ten minutes?" I thought to myself, but having ordered it I felt like it would have been obscene to reverse myself because it was inconvenient.  So we rode it out and kept going while the drug was prepared and run up from pharmacy, keeping ourselves entertained during the interim by fiddling with pointless vasopressor drips.

Good thing we did: as the t-PA arrived at the bedside, before it was hooked up, suddenly the chaotic cardiac tracing became more organized and normal-looking.  The respiratory therapist murmured in amazement, "Hey, there's a pulse!" 

"It won't last," I thought to myself, "It never does." But to my surprise it did.  This development, if anything, further depressed the mood in the room.  We had been coding him for fifty minutes.  That's an eternity, and without oxygen for that long his brain was so much scrambled eggs.  Someone made a coarse remark about a tracheostomy and a nursing home, which reflected the sinking feeling that it would have been better at this point for him to have died.

When the ICU doc started getting prepped for an arterial line, I knew my part in this drama was over.  The ER nurse and I made our exit, stripping off our gloves.  "It's Miller Time," she quipped, and we both convulsed with silent laughter as we stood at the elevator.  Back downstairs, the guy with strep was really annoyed at having had to wait for a solid hour for his discharge.

Continued



9 comments:

  1. I'm on the edge of my seat... so much for me getting anything done in the near future without this guy & my hopes for him slopping through my head. Whatever the outcome I understand & appreciate the efforts, the 2nd guessing, the desire to save a life.

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  2. Did you cool him as well after that?

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  3. Maybe that "pneumonia," was a Hampton's Hump?

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  4. Like "Thai", I'm curious to know if you induced hypothermia in this patient.

    Either way, it is an impressive story in that there was a ROSC after 50 minutes, but sad because all involved understand the type of life this gentleman is likely to have after sustaining 50 minutes of CPR. Always enjoy your clinical stories.

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  5. Pneumonia + drops dead = Oops, it was a PE!

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  6. This isn't intended as criticism, but wasn't it futile from the outset, if the guy had been down for five to ten minutes?

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  7. Hi, came across your blog recently, and been enjoying it!

    Had a similar experience to this recently, 65 minutes of CPR.. couldn't believe it when I was still able to have a decent conversation with the guy the next morning!

    http://undead-doc.blogspot.com/2009/11/technology.htm

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  8. Ginger: it was my interpreation that it had been 5 minutes without a secured airway (the ETT), but that CPR had been started earlier than that. 5 minutes without CPR is enough time for brain damage to begin, 10 minutes would generally be considered irreversible brain damage. So, if by futile you mean no brain damage, you might be right. It is very possible to "bring someone back" after that time period though. Also, another problem is the ethical dilemma of continuing CPR after a certain amount of time has passed, or if CPR should even be started at all if the patient has been down a while, knowing that they are likely going to be relegated to a nursing home. But, of course, everything must be done as their family usually would prefer that.

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  9. After 15 years in medicine & past 9 years in a hospital specializing in anoxic brain injuries I fear this story won't end well. I really hope it does, but I'm sort of a cynic with the whole miraculous outcomes. I often wonder if the Physicians running the codes have the prescience to think of the long term outcome of the people they "save". Glad to read they do.

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