08 December 2009

I don't like surprises

It's the question an ER doctor hates, guaranteed to make each and every one of us cringe somewhere deep down inside:

"Hey, remember that guy from the other day?"

Oh God, you think to yourself, which guy is she talking about? That one with the funny dizziness? Dammit, I knew that was a stroke and the fucking neurologist said it was OK to send him home. I should never have listened to him! But you remain composed and smile and say "Which guy?"

Then you sit back and prepare yourself for the worst. And it is usually bad. C'mon, we work in the ER. Bad things happen here, and bad things happen to people after they are seen here. So it was with surprise that I saw the charge nurse smile and say, "You know, that guy you coded upstairs the other day? I just talked to Jenny in the ICU and they say he's doing great. He's going to be extubated this afternoon!"

"Seriously?" I was really and truly shocked. That guy was dead. Totally dead. Blue and with no brain activity. We coded him forever, and when the code finished with him still alive, we all knew deep down inside that at best we had saved organs for harvesting, that the probability of a decent neurologic outcome was nil.

Turns out that the ICU doc had gotten started on the hypothermia protocol right away and this may have done the trick. I ventured up to the CCU later that day and thumbed through the chart. No clear evidence as to the cause of the arrest, though smart money is still on PE. He wasn't extubated yet, but all signs were highly positive and he was indeed looking like one of those rare happy outcomes from a cardiac arrest. The ICU doc teased me, "What are you doing way up here? I thought you lived in the basement! You're going to get altitude sickness." I stole a line from Greg Henry, saying "I'm just here to make sure you're taking good care of my patient." I stopped in at the bedside but he was still pretty sedated and there was nobody there at the moment, so I took off back to the ER.

Five years ago, heck, two years ago, we weren't doing the therapeutic hypothermia drill and this would not have been such a happy thing. Amazing what developments creep up on you in the course of practice, and amazing how they translate into human outcomes. I was kind of bummed that I had missed the family, but such is life. Mostly I was bemused and gratified that our rather extraordinary efforts had borne unexpected fruit.

Continued yet again.


  1. We've got a brand spanking new machine (about 6 months old, purchased from Alsius) and a great protocol.

    I met my first save about 2 weeks ago (Her arrest was in May) as she came back to shoot a promotional photograph with us for the hospital about the new technology.

    She was 39, on her way home from being cleared from BrCA, and went into a vfib arrest in the car.

    Sometimes technology is utterly amazing.

    Then, you get the stupid drug OD who comes in with a core temp of 90, who, despite his best attempt at a polypharmacy overdose, lack of respirations, and thrillingly violacious hue, who will walk out of the hospital after being paralyzed on Nimbex because he was so sick, because he unwittingly initiated theraputic hypothermia on himself.

  2. Amazing outcome. Makes me that much more glad that NYC has proposed induced hypothermia in the paramedic cardiac arrest guidelines for 2010. Soon enough you'll have patients arrive at the ER with ice-cold saline running already.


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