Got your prozac handy?

After my last post I hate to do another write up of a depressing event, but I can't let this one go by without saying something about it.

Saturday night we got a transfer from our sister hospital, a 57 year old man who'd collapsed while dancing at his son's wedding. There were two EMTs and a nurse at the wedding and they began CPR almost immediately, in addition to delivering 3 shocks from an AED (automated external defibrillator). The medics arrived and transported him to the hospital, but he decomponsated on the way and had to be shocked twice in the ambulance. He arrived at the ER in asystole (flat line) and was given several rounds of cardiac drugs in addittion to TNK (a thrombolytic designed to break up clots causing heart attacks). They eventually re-established a normal hearth rhythym and transferred the patient to us (our hospital handles the cardiac patients for the area). His wife and brother came with him from the other hospital and that night they were both very optimistic that he would come through everything and leave the hospital as good as new. They said that even though he was 57 he was in excellent physical shape and had in fact been preparing to try out for a semi-pro football team in his home state of Texas. They said he had no history of cardiac trouble save for mild hypertension that was well controlled with medication. I don't know if I thought that he would be playing football once he got out of the hopsital, but I was optimistic that he would indeed leave eventually as was the physician who admitted him.

I came in the next day and talked with his nurse about him. Between the time I left at 3:30am Sunday and the time I came back at 7pm that same day, he had gone into acute renal failure, had developed rhabdomyolysis, had stopped breathing over his ventillator, and had lost any sign of cerebral activity. His pupils were fixed and dilated and he didn't respond to any sort of stimuli, including cold water injected into his ear (called a cold caloric test). The family didn't want to give up, but by thursday (after an EEG and MRI which showed virtually no brain activity) they finally agreed with what his doctors were telling them, and resigned themselves to the fact that he would not be waking up. A cerebral perfusion scan was scheduled for the next day, and if that established brain death then they would consent to organ donation.

On Thursday I was working as a monitor tech (we keep track of all the patients on telemetry and communicate any problems with their heart rhythym or vital signs to the appropriate nursing units) and he was not doing well. His blood pressure was getting dangerously low and we were only keeping it up by running 22mcgs of dopamine (a pressor that increases blood pressue). The trouble with using that much dopamine is it tends to cause tachycardia and arrhythmias. That night he went into a rapid Afib with a rate of nearly 150, but we managed to get him out of it with amiodarone. Nevertheless, we knew he probably wouldn't hang on for too much longer. When I came in to work on Friday at 7pm I again spoke with the nurse taking care of him. She said that the tech had read the cerebral study and that there was zero flow, but she couldn't call in the organ procurement folks until she got the official report from the radiologist. While she was giving report to the night shift nurse, the family was in the room saying goodbye for the last time. As they left the unit to go to the waiting room they thanked us for everything and said they were glad that some good was going to come from his death.

We finally got word from the radiologist around 9 and called the transplant organization to come in. The transplant coordinator arrived at about 10:30 and her staff began to filter in (they had to come from all over the state to get to our place). Around 2am they started drawing large amounts of blood for the various lab tests they needed to run. Around 2:30 I went into the room to tell the nurse that his heart had skipped a beat and then his p-waves had inverted (p waves are the first part of a heart beat on an EKG, and they represent the electrical activity of the atrium). While I was still in the room he went into Aflutter (an atrial arrhythmia similar to Afib) and his rate began to decrease. He eventually suffered a brady-asystolic arrest. We began CPR (on a brain dead man) and managed to get him back with two amps of Epinephrine. I asked the transplant folks after his vitals stablizied if they thought he'd make it to surgery tommorrow. They said they figured he would but that they would probably only be able to use his liver. My shift ended at 3:30am and I left hoping that they were right.

I just got back from the hospital (I had to pick up my schedule but really I wanted to see what had happened). He died this morning at 7:30am, before they could harvest his organs.