Time of Death

When I was on call two days ago, my cards fellow called me to say there was an eval in the ED and could I please go downstairs to assess the patient. The only information I had was that he was just discharged 1 hr ago after a 2-day stay s/p BiVICD upgrade, and not long after he left the hospital, he suddenly became unresponsive and his wife immediately drove him back. He arrived pulseless and in V-tach; a shock of 200J pushed him into PEA and it was only with epi that he regained his pulse. The ED residents were putting a central line in him by the time I got down, with the attending planning to initiate the "Arctic Sun" protocol, also known as hypothermic therapy. Studies have shown that if a patient's body temperature is cooled to 33 degrees Celsius for 24 hrs after a cardiac arrest, then rewarmed after 6 hrs, s/he is less likely to have long-lasting neurologic damage. I had seen this method used at the JPS ICU, and this was the first time I'd seen it done here. Once the patient got up to the CCU, they placed cooling pads on him and proceeded to lower his temperature. Then he went into another sustained run of V-tach and I, as the most senior resident in the unit, had to decide whether or not to shock the patient. This was the closest I've ever come to running a code and I was terrified (even though I didn't show it), and I told them to administer the shock. It fixed his rhythm but only temporarily; it took 150 mg of amio to get him back to his baseline A-fib. Even still, I called my fellow and asked him to come to the hospital to help me out. We ended up putting A-lines in my two patients (I got my first successful A-line that night), but they were such hard sticks that we went through 10 A-line kits before we got the lines in successfully (not joking).

The next morning (yesterday) the patient's cardiologist came in to see what had happened. He told us that the patient had a history of cardiac amyloidosis that caused him to have diastolic dysfunction and increasing episodes of V-tach (they'd attempted an AV junction ablation during his last admission but it was unsuccessful). We also learned that his ICD had shocked him twice while he was in the car, but it wasn't enough to correct his V-tach. The patient's wife stayed with him and requested that we call his PCP, who was a prominent figure in the medicine program. He later came to see the patient and spoke to the family at length about the patient's overall prognosis. It also came to light that the patient wanted to be DNR/DNI, and the family agreed that once the patient was brought out of hypothermia, if he didn't regain consciousness, then they would withdraw care.

This morning the patient continued to be unresponsive and comatose even after the Arctic Sun was turned off. The patient's PCP, gastroenterologist, and EP physician all stopped by in the morning to speak to the family and offer their condolences. When all the family members had gathered, they requested that we withdraw care as they didn't want to "draw things out." The end came pretty quickly after he was extubated and the pressors turned off. We left the room but kept an eye on the tele monitor, watching his blood pressure dip lower and lower while his heart raced in V-tach in an attempt to keep his BP up. Less than five minutes later, I was in the room pronouncing the patient dead while his family members held each other and cried.

It had been a good year since I'd had to declare anyone dead, but fortunately I remembered the steps and was able to fill out the death packet and make the necessary phone calls. *sigh* And here I'd hoped to go through this rotation without ever having to fill out a death packet. In this case, however, I'm glad that the patient had made his wishes known and that his family had honored his wishes. Too many times have I dealt with families who could only think about what THEY wanted and not what's in the patient's best interests. I have yet another patient who's comatose after a PEA code, and even though it's been two weeks his wife has YET to find his living will. She says she'll bring it tomorrow; we'll see.

Code 99

I've been on CCU for two weeks so far, and I can easily say it's the most stressful rotation I've had so far. Even more so now that I'm the resident and am expected to know how to read EKGs, assess patients for heart failure vs ACS, and (ideally) run a code. I had only been in one code so far as a resident (this patient ended up coming to the CCU after going into PEA), and at that time there were so many people in the room I didn't play an active role in the code. Even still, I dreaded the day when I would be the first responder in the room and would have to run a code.

My most recent call (which took place on a Saturday) was fairly uneventful until around 3 pm, when the dreaded code pager went off. My intern and I went to see what was going on and I went to grab the patient's information. When I saw the name on the sheet, my heart froze. The patient was a 35 year old woman I had seen just 3 weeks ago while I was on the heme-onc consult service. She had been admitted for abdominal pain and found to have a pelvic DVT, and I had been working her up for a hypercoagulable condition. There had been a MICU eval called on her at that time b/c she'd been persistently SOB and tachycardic, but when a CT angio ruled out a PE, the MICU team decided she could remain on the floor. I remembered she was a very sweet person, apologizing for not having shaved her legs in days and often speaking of her son and daughter (both in elementary school), always hoping she could get better and go home soon to be with them. The last time I saw her, I was under the impression that once her INR was therapeutic she could go home. I had no idea that she was still here, and when I realized that she was the patient coding in the room, my first thought was, "Did she have a PE?"

By the time I got into the room, there was a cardiology fellow standing at the foot of the bed giving orders while the MICU resident and the heart failure resident were already assessing the patient and getting in line for chest compressions if need be. BP 80s/30s and HR 56; it wasn't long before she went into PEA and I took turns with the other residents doing compressions while the nurses pushed epi, vasopressin, amiodarone, and fluids. Compared to the last code I was in, everything in this code was done in a very orderly fashion. The heart failure resident got an ABG with help of chest compressions; needless to say it came back extremely acidotic (pH 6.8, CO2 80s). At one point I roped my intern in to help with compressions while I called the patient's primary team resident to fill him in on what was happening. He later told me that his attending was in the process of getting the patient transferred to the PCU or MICU because of her persistent tachycardia, and that the patient's family had just been at the hospital to visit her a mere hour before this happened. Several residents tried to call the patient's family, but all the phone numbers (much to our dismay) were invalid.

At one point the cardiology fellow asked if anyone objected to his calling the time of death. Someone suggested he check the pulses one more time, and the patient was found to have a carotid pulse on Dopplers. Then I felt a pulse in her foot. We'd finally succeeded in getting a pulse, and the patient was now in V-tach. One of the nurses warned, however, that this could be the drugs working, and once they wore off, she'd go back into PEA. The defibrillator declared that the patient was not shockable, despite the rhythm looking as though she was in V-tach/sinus tachy, and so we resumed chest compressions. Then we had to pace her heart because her HR fell. Things were not looking good. The entire code lasted over an hour; I think the reason we worked so hard was b/c she was so young. My intern and I ended up leaving before the code ended in case anything happened in the CCU.

Later I ran into the resident who'd cared for this patient and he told me that he'd found prescription bottles for Indocet and Ambien in the patient's purse. The team had not been giving her narcotics, and apparently she had her family bring her some from home. So cause of death COULD have been due to overdose or drug interactions, but I doubt we'll know unless there's an autopsy. *sigh* Her poor family.