A True Trainwreck:
It’s been an exceptionally long time since I’ve shared one of my “vignettes” from the emergency department. Over the summer, I have had many exciting moments in the ED, but this is by far the most memorable.
One particularly busy night, we get a call from EMS that they’re bringing us a pt in his mid 50s with a probable inferior STEMI. His vitals were normal with the possible exception of borderline hypertension. ASA was given, but no NTG was given due to possible posterior involvement.
We start getting ready for the incoming patient, expecting a quick turnover to cath lab. I don’t think anyone anticipated what happened over the next several hours.
As soon as the pt rolls into the ED, I could tell something wasn’t right. He was pale, extremely diaphoretic, and less responsive than EMS made him sound. This wasn’t any fault of their own, apparently he had just started this as the ambulance pulled up to the hospital. His vitals somehow were still normal, but he still looked sick as can be. Our EKG also confirmed an inferior MI, with significant ST depression in V1/V2, which is suspicious for posterior involvement, and he also had some possible signs of RV involvement. So, we get the ball rolling. The cath lab was activated, the cardiologist was called, and paperwork was getting its due diligence. From what we could get from the patient he had a hx of well controlled HTN, but otherwise no significant medical hx except for a remote appendectomy. He did smoke, however.
So, everything seems to be progressing as expected. The cardiologist is on their way, the patient’s vitals are stable, and he was looking slightly improved. We didn’t have labs back, but at that point his CXR was normal as well. The physician needed to go check on another patient on the other side of the ER, so I stayed in the room with the nurses just to keep an eye on the patient.
Well…for all of you new followers out there, I have the privilege of being the owner of my very own black cloud which always chooses the most inopportune moments to make its appearance. About two minutes after the physician left the room, the patient suddenly becomes obtunded, slumps over in his bed, and then of course the monitor shows him going into a pretty impressive v-fib.
All hell breaks loose. We’re already busy and short staffed, and it always makes these situations harder to control. A code was called, compressions were started, and the doctor comes running in the room. The patient gets shocked with no ROSC and proceeds to get intubated. He get’s epi, get’s another shock, and then has a pulse just as the cardiologist walks into the room. We all take one giant sigh of relief, and start trying to stabilize him for transport to the cath lab. His BP dropped significantly, so he was placed on levophed as well. Right after the levophed starts to hang, he arrests again. At that point, a vicious cycle beings where we get a pulse and then lose it a minute later. He gets an amiodarone bolus/drip, dopamine, and a whole lot of epi. Nothing seems to be working, and 30 minutes into this the cardiologist and ER doc begin discussing calling it. Just as it’s about to be called, we get a pulse-stronger than any of the other times. We wait a minute or so to get everything settled, and then he is whisked off to the cath lab.
Unfortunately, following the general theme of the night, the fun didn’t end there.
About 20-30 minutes later, we get an update from the cardiologist. His cath came back surprisingly not as severe as expected, with diffuse moderate vessel disease but no obvious blockage that would cause his MI. He was going to be scheduled for a CABG in the AM, but his case was still perplexing. It was suggested that maybe the clot dissolved with all the CPR he received, but the cardiologist also thought maybe a pulmonary embolism might be the cause so he sent the pt to get a CTA of his chest.
About 5 minutes later, the scout image (basically just a CXR) of his CT is available on the computer to view, so I open it just so I won’t forget to take a look at it later. I jumped out my seat as soon as I opened it BECAUSE OF THE MASSIVE TENSION PNEUMOTHORAX HE HAD. I immediately show the ER doc, and we start running to radiology (which isn’t that far away at all), nearly crashing into the cath lab nurse who was running to the ER to grab the doctor. We get into the CT suite and, in a style reminiscent of a Grey’s Anatomy episode, the ER doctor performs a needle decompression (However, unlike Grey’s anatomy he still manages to find the time to wipe down the area with an alcohol prep). After that, instead of dragging him all the way to the ICU, he got transported to the ER for a quick chest tube and then was sent on his way to the ICU. His tension pneumo was the result of several rib fractures secondary to how much CPR he went through.
Amazingly, and against all odds, several weeks later the patient walked out the hospital-alive. He was extremely lucky. Not many people survive cardiac arrests, even in the hospital, and especially with all of the other complicating factors. Not only that, but he walked out without a single neurological deficit.
In Emergency Medicine, we don’t get to celebrate many victories. Even though we provide the best care possible many of our most critical patients are too sick or too injured. Even for those we save, many suffer from complications and debilitating issues for the rest of their lives. To have that one patient, maybe one of the sickest I have seen in a long time, walk out of the hospital as if nothing happened is a victory that I’ll remember probably for the rest of my life. It’s the victories, no matter how small, that remind each of us how rewarding our profession is.