Watching Life Slip Away

Shortly before Christmas I got a patient in the ED who had undergone PEA arrest but responded after 1 round of CPR and 1 dose of epi. His cardiac enzymes were negative and his EKG was ok, so when his wife asked what caused the PEA, I said it was most likely PE since he had a history of Protein C/S deficiency and wasn't therapeutic on coumadin. Later, the pulmonlogist called me up and said that the PEA was most certainly not caused by a PE. "If he had a PE, he wouldn't have come back after just one round of CPR and epi," he said. "People with massive PEs don't make it."

Last Friday I admitted a 48-year-old woman with metastatic breast cancer who came from her oncologist's office for dehydration and intractable back pain. Apparently she was in her normal state of health (driving her daughters to school, walking around fine) until 1 week ago, when she caught a cold and suddenly became weaker and had some witnessed syncopal episodes at home. Her CXR was clear, and her lumbar x-rays confirmed widespread metastatic disease. She asked me what the plan was now, and I said she'd probably need to talk to her oncologist to discuss goals of care. Before I left her room, I noticed that she looked slightly winded, but when I asked her about it she said her breathing was fine. Even still, I ordered a chest x-ray for the morning to see whether she had developed pneumonia.

Yesterday (Sunday), the on-call oncologist paged me to say he'd just seen my patient, and she "didn't look good." I immediately ran downstairs to her room, and she looked horrible. Her skin was pale, her hands were cold, and though she was able to follow commands, her speech had become terribly slurred. "What's wrong?" I asked, and she said, "Can't...breathe." Her X-ray that morning had been clear, so I quickly left the room to order a stat CTA chest. "She needs to go to the ICU," the nurse said, and I agreed; with a clear CXR and her history of breast cancer, she likely had a PE. I went back to her room after the orders were in, and I was immediately horrified by how much worse she looked. Her eyes looked blank, and suddenly, right in front of me, she stopped breathing. Her SpO2 rapidly dropped from the 80s to the 70s in seconds, and I immediately grabbed her wrist to feel for a pulse. Nothing. "Should I call rapid response or a [Code Blue]?" asked the nurse. I told her to call a code.

The woman had become unresponsive, and was only taking breaths every 8-10 seconds. Once she was hooked to the monitor, we saw her HR fall to the 40s and then asystole. By then CPR had started and the ED attending arrived to intubate her. Critical labs showed a K of 7.8 (it was 5 earlier that morning) and bicarb of 10, pH < 7. We regained a pulse and made arrangements to transfer her to the ICU. The ED attending and I stepped outside the room to write our notes when suddenly the Code was announced overhead again. My patient had once again lost her pulse, and another round of CPR, epi, atropine, and bicarb was given before she was stabilized enough to transfer to ICU. Fortunately during this time her mother called the nurse's station and was told what was happening, and she immediately drove toward the hospital.

I wish I could say my patient got better, but not long after she arrived at the ICU, she lost her pulse again and CPR resumed. The on-call cardiologist poked his head into the room to see what was happening (one of my partners saw me and thought yet another of my patients had coded), and when I explained the situation, he said I could pace her, but unless I fixed the underlying cause (presumed PE), she would continue to deteriorate. There was no end to this at all. Fortunately her mother arrived at the ICU, and the nurses encouraged me to bring her to the bedside to let her see what was happening. By that time the patient was stable again, and the mother said that if it was just her, she'd want to withdraw care, but that decision would have to be made by her 20-year-old son. I spoke to her son by phone and explained the situation, asking what his mother would want in this situation. "We talked about it a little, but never really made a decision," he said. I then encouraged him to come to the hospital as soon as possible. ("Drive safe," his grandmother said.)

I had taken the mother to the pre-op room to talk, but when we arrived back at the patient's room, she had lost her pulse a fourth time and CPR was resuming again. "Is she getting oxygen to the brain?" her mother asked. "How long has this been going on?" When I told her this was the fourth time she'd dropped her pulse in one hour, she was shocked. "Oh no," she murmured. "She wouldn't want this." She immediately called her grandson to let him know what was happening, and he said he needed to talk it over with another brother. By that time my patient was hooked to a pacer and maxed out on Levophed, Dopamine and Epi, yet her BP was only 55/32. This was a losing battle, and I think everyone was silently hoping that someone would make the call to stop the code. And that someone had to be me.

The patient's son called back, and after listening for a few seconds, her mother nodded and said, "I want you to tell the doctor what you've told me" and handed me the phone.

"My brother and I talked it over, and we know that my mom did not want to be a vegetable. She wouldn't want to be hooked up to life support."

"Okay. Right now, there are machines breathing for her and keeping her heart beating. Are you saying that you want us to stop everything we're doing?"

"Yes."

"Thank you," I said. Beside me, the mother nodded as I handed her the phone, then turned to the nurses and techs in the room and said the words everyone's been waiting to hear: "Stop everything."

The pacer and pressors were turned off, and almost immediately both HR and BP fell to zero. The patient's mother approached her and whispered, "I don't know if you can hear me, but I love you so much." That almost brought tears to my eyes. Time of death was called at 13:02, and I asked RT to extubate her before her son arrived. I felt horrible for the rest of the day and wondered what I could have done differently. A PE had not been on my differential when she arrived in the ED with generalized weakness, anorexia, and intractable back pain. But even then, I couldn't have given her anticoagulation because there was a questionable subdural hematoma on her CT head. It was a near hopeless situation. Maybe if I had more experience, I could have anticipated this earlier, but now it's too late.

We will never know what happened, but it's most likely she died from a massive PE. When I talked about this with the pulmonologist who attended the code with me, I remembered what the other pulmonologist had said: "People with massive PEs don't make it." Now I know what he meant, and this is yet another in a growing list of experiences that I will take to heart so that next time, I don't make the same mistake again.