I’m Going to Die

Image via Wikipedia

As I walked into the bedroom, it looked like there was more drama than necessary – more than I cared to deal with on this laconic Thanksgiving Day.  Our 55-year-old female patient was sitting on the floor, propped against her bed.  She was breathing fast and her CO2 levels were down – it looked like an anxiety attack, so I squatted down and tried to convince/coach her to slow her breathing down.  But something didn’t look right.

She was trying to cooperate with me, but there was no way her breathing was slowing down.  It was fast, about 40 respirations a minute, and deep.  Her eyes were closed and I discovered she had some chest pain – which she was unable to describe.  In fact, all of her concentration went into her breathing and I, as with the other medics in the room, were just a distraction.

It was at this point that I got very concerned.

As I tried to attach the electrodes to get a 12-Lead, I discovered she was very wet, very cool, and very pale. It was at this point that I got very concerned.  I could barely get the electrodes to stick to her skin – the 12-Lead was inconclusive, but no obvious STEMI.  Her BP was only about 80/40, HR was 120, PaO2 was 90%, and her CO2 was only 5.

The IV was in place, and something was seriously wrong.  “Let’s get going!”  I said to my teammates.  They agreed.

As we moved her to the gurney, her eyes rolled back into her head, deviated to the left, and her pupils got huge.  Her arms briefly went decorticate – she stopped responding, stopped breathing, and went flaccid.  Oh, and she didn’t have a pulse.

“Let’s get going!”  I said to my teammates.  They agreed.

Image via Wikipedia

We started CPR and bagged her.  She had a bradycardic rhythm of 30, so we paced her and got pulses back.  Her pressure came up to 90, but her pupils remained fixed and dilated.  It was just a short trip to the local ED – and upon arrival, she would occasionally lose pulses.  After about 20 minutes, they had a viable rhythm, with pulses – but that was only after lots of epi and lots of dopamine.

In retrospect, I saw it in her eyes. She knew she was dying – but she wasn’t verbalizing it.  Her eyes however told me she was scared – very scared.  She was trying to tell me she was going to die.  She was right.

I ran a similar call about three months ago. The man was 40 and living on the streets.  He’d been having chest pain for about three days, and finally he called 911.  At first we thought he was just a wet, cold homeless man – about 40 years old – wanting to get out of the rain.  But as we loaded him onto the stretcher, it became apparent that he was in real distress.

He was complaining of classic Triple-A pain and his skin was cool, wet, and pale.  Over and over he said, “I feel like I’m dying!  I feel like I’m dying!”

The 12-Lead showed a definite STEMI and we began our Code-3 transport to the local ED – which was only five minutes away.  As I transmitted the 12-Lead, our patient coded.  His internal pacer was producing a rhythm, but he had no pulses.  He was right – he was dying.

It’s one thing to arrive on scene and our patient is already in full arrest, it’s quite another to establish a relationship with them – no matter how brief – and then have them code. Both of these calls affected me to the core.  Both of them told me they were dying – and both of them did.  There was nothing I, or anyone else could do, to reverse this process.  Sometimes death is what it is – an end of life.

Yesterday’s call reminded me of an old Far Side cartoon.  A caveman is lying on the ground with an obvious fractured leg.  Two other cavemen are standing over him, one is wearing a white lab coat.  The one wearing a lab coat says: “I’m sorry Thor, medical science hasn’t advanced to the point where we know how to cure broken legs.”

I wonder how much more we can learn about saving those who experience sudden death like my patients above. Will we be able to treat aneurysms (aortic or brain)  in the field?  Will we be able to reverse the effects of STEMI? Will we be able to save patients who have experienced severe blunt-force trauma?  I don’t know, but it sure would be nice.

When I first started in EMS, the save rate for prehospital cardiac arrest was only 3-5%.  Now it is up to 25% in some areas.  I wonder if we’ll ever approach 50% in our lifetimes?  It sure would be nice, wouldn’t it?  What other areas do you see us making major gains in?  Where else do we have room for improvement?

Related Articles

• CPR is no longer as easy as A-B-C (ehssafetynews.wordpress.com)
• Steve Joyce: Too Many Patients Having Heart Attacks Still Wait More than Two Hours to Go to the Hospital (seniorjournal.com)
• Physio-Control Division of Medtronic Receives FDA Clearance to Market Lifenet Systems And Partners & Partners with Airstrip for Integrated Mobile Solutions (ducknetweb.blogspot.com)
• STEMI criteria, STEMI equivalents and Takotsubo cardiomyopathy (doctorrw.blogspot.com)