Jul 302014

Myrna Aquitana_LighthouseI would like to share the following riveting  Pulmonary Embolism story sent to my attention recently by Dr. Jep Palo , an Intensive Care Specialist, who works at the Medical City Hospital in Mandaluyong, Metro Manila.

One misstep and it would all be over, even doing everything right, we could still lose this day and in the days to come.

When death comes knocking, few people are ready to receive Him.

Tonight, my patient is a woman, young enough to be out of place in the ICU, though by far she was the one who needed our full attention.

She was rushed to the ER late this morning  with blue lips, unable to breathe and within minutes her athlete’s heart  gave up on her.

Resuscitation was underway when I arrived in the ER.  Our hospital staff gave the best demonstration of a coordinated life-saving effort that I have never experienced in recent memory.

In our book, she was beautiful, but she kept slipping away, so we administered electric shocks, chest compressions and adrenaline injections to restart her heart.  Repeatedly, the calls rang out loudly: “Code! Start compressions,” even though our medical team never left her bedside.

Whew! Watching her face, I remembered thinking, “she’s much too young to go through something like this, but I must  focus on the monitor.”

During “near end” situations like these Catholic doctors like us would pray the “Hail Mary.” An ultrasound machine was brought to the ER revealing clues of the would-be killer. Our patient’s heart flitted in and out of view, in between CPR compressions, which clearly showed the unusual enlargement on her right ventricle, the chamber that feeds all blood to the lungs.

Our coordinated diagnosis was Pulmonary (lung) Embolism.,We found a clot, coming from a major vein which may have passed into the lung, knocking out the blood circulation, thus making the heart fail in a particular way.

One immediate treatment I suggested was to give the patient “Alteplase,” a clot-busting medication, the kind used in major heart attacks or strokes. This was an extremely dangerous and expensive medicine, but its the only one that could work fast enough to make a difference.

In times of crisis like this, I had to act fast to consult with and get the medical opinion of senior physicians in the room, even breaking my own rule on democracy because this was a novel situation, passively unattempted in the country, and I had to admit, I was scared, though both the cardiologist and the ER consultant immediately agreed with my suggestion.

I conferred with the husband who was in a special ER unit and he was in a state of shock. I explained to the husband that in medicine, “any life-saving procedure can cause harm and any drug is a potential poison. However, we as doctors are required to discuss both the benefits and risks, with the immediate family.” By doing so, they will decide either on signing a written consent for the risky procedure or not at all.

Further, I explained to the husband what I could do in about half a minute, with no real alternative diagnosis, the chance of dangerous bleeding later, but which is the only hope of reversing the possible clot.  Within five seconds, the husband agreed to the procedure by saying “do what you can, Doc I can’t think right now,” as he was holding his face in his hands.

I immediately ran back into the room to give orders to administer Alteplase to the ER staff, who must all be used to this, because within a minute, the drug was being reconstituted for infusion. This is not to exaggerate because as the saying goes, “ time acts funny when death is at the door.”

I remembered verifying the dose on my phone and checking  on the ongoing resuscitation which had settled hundred-a- minute chest compressions, ten-a-minute respirations and adrenaline every four minutes.

A few minutes after the first injection, and with a drip running, the patient’s heart started to pump under its own power and continued to do so after a few minutes..However, the fast beeping of the cardiac monitor suddenly slowed, and again the rush to find the pulse and the calls for “Epi” and “Compress” followed.

One more electric shock. One more round of resuscitation and then the patient’s heart rhythm stabilized., but there was no measurable blood pressure. She was within an inch of her life and we had to fight for fractions of that inch. One misstep and it would all be over. Even doing everything right, we could still lose on this day and in the days to come.

Suddenly, I caught the eye of the Critical Care Fellow. I showed her my shaking hands. I will admit to choking occasionally in a resuscitation response and I have never frozen up nor had the shakes before, but I badly want this patient to live and come back whole.

So I ordered to “infuse more fluid!” But deliberated on it because the “right heart was too large and it’s cutting off the left side.” At that very moment some questions kept creeping on me: “which medications can help to stabilize the pressure?” “What mode of breathing support to use?” What procedure can wait until ICU?”

Some questions were easier answered than others. But there were immediate concerns.

Within half an hour, the patient’s heart reading holding, we bore a large IV access into a vein in her leg. and a smaller one into the artery beside it.

For the first time since her heart stopped, we wre able to get a blood pressure reading direct from the artery 120/60.

To combat the potential brain damage from cardiac arrest, we sedated her heavily and started to cool her body with ice packs. A Kidney specialist was called in to plan for Dialysis. Then, we were able to move her to the ICU and performed the next wave of procedures: a catheter to ease pressure directly inside the heart, another to allow Dialysis. Somewhere in these maze of machines, was a patient still at death’s door.

It was early morning when things have settled enough so I called the family for an update. The husband, her siblings, parents and in-laws all gathered in a conference room, where I explained what had happened and what we were going to expect. I told them that “some things were predictable but most things were not.” Their loved one was comatose after two cardiac arrests and remained in shock. Dialysis was being performed to control dangerous blood acid levels.

The bleeding risks from the Alteplase and other blood thinners would be greatest in the first twenty-four hours, as our brain-protective cooling therapy also increased the tendency to bleed. The heart would be expected to be stunned and weak for a couple of days but all invasive monitors were already in place, to allow in immediate adjustments in therapy.At that moment in time, we had leveled the playing field, but the final outcome was still unknown. I also explained to them that “we can never promise outcomes, but we can promise an epic fight.”

The family meeting in a time of crisis is the most difficult part of our job. The challenge  is to paint a picture without confusing details, deal with emotions in the room and still get a sense of the overall stance of the family in coping with the patient’s critical illness.

As practising doctors, we advise our medical students that the goal of critical care is “to protect the quality of life of a patient, not simply to save a life.”

After our meeting, I stayed a few more minutes at the patient’s bedside and read the monitors heart rate at a reasonable 95, Bp 140/80, saturation 97% and temperature down to 33. This is the new baseline. I instructed all the nurses on duty, that if the patient wakes up whole, I will buy pizza  for everyone in the ICU and ER departments, as a show of my confidence because our patient was pulseless for more than half an hour; had seven cardiac arrests which occured over eighty minutes. Those eighty minutes were one of the longest in my life, but could also have been the last in our patient’s life.

Three days later, I fulfilled my promise by buying pizza for everyone because thankfully, our patient woke up and survived.

 Leave a Reply