Mostly Dead...

Man in his late 70's is rushed back to the trauma room complaining of chest pain. History of MI and CABG (open heart surgery). He's diaphoretic, pale, and does not look good. Blood pressure's in the 70's with a HR in the 30's. Complete A-V block on the monitor. EKG shows inferior wall MI. We start pacing him, get him aspirin, and await the chest x-ray. With the pacer, BP's improved to 130/80 range. His chest x-ray looks good, we don't have a cath lab at this hospital, so we call the transferring facility and helicopter, start lytics and heparin. He's in a paced rhythm, stable blood pressure, tolerating the pacer well at about 20 mA with good capture.

Gradually, his pressure starts to drop. 110's....90's...80's...70's....nothing. Electrical activity on the monitor, no pulse. We start CPR, open up the fluids. I turn around to talk to the wife, as the patient had requested "no life support" (whatever that means). I get the sense that what he had really wanted was to not be on a ventilator for the rest of his life, so I explain to her that this may reversible if we can get him to the cath lab, and that this is probably worth a round of CPR. She agrees, so we continue. After a couple of minutes, recheck the pulse...still nothing. Push epi and continue CPR. We intubate him. Couple of more minutes and we get a pressure. A good pressure. Funky wide-complex rhythm bordering on V-tach, which is either epi effect (for non-medical folks still reading--you can pump epinephrine into a dead heart and make it beat for a few minutes until the drug wears off...bad) or reperfusion rhythm (a rhythm frequently induced by lytics that resolves on its own...good). But still...it's a good blood pressure. A few more minutes and more narrow complexes...things are looking good.

In the meantime, the helicopter has arrived. They're getting him ready for transport when his pressure starts to drop again. He arrests again. We start CPR and I again turn to the wife. At this point, she's not as enthusiastic about things and we decide to stop efforts. The code is called. Nurse pushes epinephrine. There is some dispute (in her mind) about whether she heard the code being called and pushed epinephrine anyway. In any case, I glare at her and ask her to turn off the monitor so the wife doesn't have to sit and watch her dead husband's heart beat for the next 5 minutes. Our nursing coordinator takes the wife into another room so that we can "clean up things in the room".

For the next few minutes, we watch the heart predictably start to beat, with palpable pulses. He occasionally takes a breath here and there, but nothing that you wouldn't expect from the epinephrine. I leave the room to discuss things with the family and contact the receiving facility. Soon, the nurse interrupts me, "Doctor, can I borrow you for a minute?". As I come into the room, she says "this patient's not dying". We turn back on the monitor to see that he still has a funky rhythm but a pretty good pressure. He's also breathing on his own. Problem is, the coroner's been called, the transfer's been cancelled, the helicopter's gone, and the code has been called. This guy's been dead, not once, but twice. This HAS to be the epi. It WILL wear off. And anyway, the wife asked us to stop resuscitative efforts. We all agree to turn off the monitor and try to delay the family from seeing the body for a little longer.

To make a long story short, over the next 30 minutes, this guy continues to "stabilize". Now he's breathing regularly, albeit with a tube in his throat. He's making purposeful movements. "Sir, can you hold up two fingers?" He holds up two fingers. "Do you want this tube out of your throat?" He nods. This guy is alive and functioning. He has a good BP. He's in sinus rhythm off of the pacer--best rhythm he's been in yet. I haven't seen the cath report yet, but I do know he made it to the facility without any problems.

A true resuscitation.

Being a believer most of the time, with the occasional moment of doubt, I have to wax metaphysical here and wonder what God's role is in all of this. Before I was in medicine, I used to think of death as being this black-or-white thing, and when it's time to go, God takes you. There are plenty of medical folks who think this way--the flight nurse was helping to comfort the wife and said to her, "He's just got somewhere else to be now"--a very sensitive way of putting it that she seemed to really appreciate.

So what happened here? Did God just come down and say, "it's time" only to come a few minutes later with "well, maybe not"? And then only to change His mind two more times?

Or did Billy Crystal have it right all along?