Half an hour later his pulse had decreased to 180, but his blood pressure was still too low and he remained in an abnormal heart rhythm. I telephoned a cardiologist for advice. He agreed the optimal treatment was electrical cardioversion, but felt that given the circumstances we could give a second cardiac medication a try. Two doses of the alternate drug had no discernable effect on Johnny’s rapid heart rate, so I restarted the procainamide.
By midnight his pulse had declined to 150, but his blood pressure was fading and he was nearly comatose.
I told his mother if we waited any longer to perform the procedure, he would probably die. She consented resignedly. My colleague Serge sedated him and I performed a synchronized cardioversion at 50 joules. His rhythm remained unchanged. I increased the power to 100 joules and shocked him again.
Johnny’s heart stopped beating. Stone-cold asystole.
“No pulse!” the emerg nurse shouted.
Time stood perfectly still. The silence was deafening. My body locked up. My brain turned to mush. I couldn’t think. I could barely breathe. Serge and I stared at each other blankly. We hadn’t anticipated this outcome, and as a result we weren’t mentally prepared for it.
Serge’s lips twitched spasmodically as he tried to decide what to do next. Finally he said: “Electricity got him into this and it’ll get him out of it. Shock him again.”
I looked stupidly at the paddles in my hands. The urge to do something was overwhelming. From the deepest recesses of my frozen mind a thought struggled to rise. I waited for it. Finally it burst to the surface: You don’t shock asystole!
“No,” I said numbly.
“Okay,” he said. “Put the paddles down, then.”
I think I was making him nervous. I woodenly returned the paddles to their slots in the defibrillator and watched in a haze as Serge strained to think us through this mess. He was as rattled as I was, but at least he was fighting it.
Suddenly his eyes widened.
“Start CPR!” he yelled. The ambulance attendants sprang into action. “One milligram of epinephrine IV!” He had broken free of his mental gridlock. He grabbed an endotracheal tube and intubated Johnny. Now everyone was moving but me.
The events unfolding around me seemed to be occurring in a surreal, molasses-like slow motion. Although I was fully aware of the fact that I had skillfully dealt with cases worse than this in the past, for some reason I was completely paralyzed. I remained in a near-catatonic state; a fly in amber. I tried to focus on the asystole algorithm, but I simply could not stop thinking, “What did I just do? I’ve killed this boy.” It was awful.
Although my sang-froid completely deserted me, fortunately for Johnny my teammates kept their wits about them. They performed excellent chest compressions and lung ventilation. They administered the correct drugs at appropriate intervals. Six inconceivably long minutes later Johnny developed a recognizable rhythm on the cardiac monitor. Seconds later his femoral pulses returned and a blood pressure of 70 systolic was recorded.
By that time my miasma was clearing and I was semi-functional. I ordered a dopamine infusion and got on the phone to the closest ICU with an available bed. Within an hour he was airborne.
Johnny went on to a full recovery and had his cardiac electrical problem fixed a few months later. He has not had any further heart rhythm issues.
As for myself, that night taught me the danger of getting caught flat-footed. I now try to be a good Boy Scout and prepare myself for every eventuality, even though in my heart of hearts I know that there’s no way that you can be ready for everything all the time. ER workers are, after all, only human.
Rick’s Tears
When they told me Rick was coming in by ambulance, I knew right away something was very wrong. Rick never called EMS, no matter how sick he was. To him, coming in by ambulance was tantamount to admitting defeat. I went to the resuscitation room and started preparing my gear.
Rick was a 35-year-old man who had been waging an intense chess-like battle against cancer for the past five years. Although he wasn’t my patient, I knew him fairly well because I had treated him in the ER on several occasions. One thing that always impressed me about him was his relentlessly positive attitude. Rather than walk around in a blue funk bemoaning his fate, he focused his energy on getting better. He had more important things to do than die of cancer. He wanted to spend more time with his wife, Tammy. He planned to help his kids make the awkward transition from childhood to adolescence. He had a business to run and projects to complete. Most cancer victims hope they’ll survive. Rick intended to. Death simply wasn’t an option.
He demonstrated his indomitable will to live in many ways. When the initial staging tests revealed the cancer was much more widespread than originally expected, his response was, “Well, we’ll just have to work a bit harder to get rid of it, that’s all.” When his first chemotherapy cocktail failed miserably he moved on to the next line of treatment without so much as a backward glance. Plan B was followed by plans C, D, E… . One day the cancer disappeared. Extensive testing failed to show any trace of malignancy within his body. Rick was in remission. He was thrilled, but he wasn’t surprised – he had fully expected to conquer his foe.
A year later the cancer recurred. At first Rick was despondent, but before long his unflagging optimism returned. Conventional chemotherapy proved to be completely ineffective this time, so he signed up for oncology trials involving experimental drugs. If he was quoted a mere five percent chance of success for a given regimen he’d say, “That’s all right – I’m going to be in the lucky five percent.” When the drug proved to be a failure he’d shrug and say, “Let’s hope the information they got from studying me will help the next guy beat his cancer.”
Once in a while a treatment regimen would look promising in the early stages – Rick’s tumours would shrink, his blood counts would improve and he’d start to feel better. He would predict with unshakeable confidence that it wouldn’t be long before he was rid of his disease. Within a few months, though, the cancer would invariably regroup and resurge, stronger and more resilient than ever. Eventually it became apparent to everyone but Rick that he was not going to win the war.
The attendants hit the door running. “He was awake and talking the whole way here, but when we pulled into the ambulance bay he slumped over and became unresponsive!”
Rick looked sepulchral. He was propped up in the stretcher and leaning heavily to the left. His eyes were vacant and he was barely breathing. I put two fingers to his neck. His carotid pulse was weak. I cupped my hand to his ear and said, “Rick, can you hear me?” He didn’t respond. I put my hand in his. “Rick, squeeze my fingers.” His hand remained limp. I was reaching for the blood pressure cuff when I noticed his left eye glistening. I stood transfixed as a solitary tear broke free and tracked down his cheek. A tear from a dying man. Endgame. I felt someone walk over my grave. Turning to one of the attendants, I whispered, “What’s his code status?”
“I’m not sure, but you can ask his wife – she’s right next door in the triage room.”
Tammy was distraught. I explained that Rick was moribund and asked if he had ever given any indication as to whether he wanted aggressive interventions in the event his heart stopped beating. She said he had requested no heroic measures be undertaken. We went back to the treatment room together. His blood pressure was hovering around 60 systolic and he was nearly unconscious. It didn’t look as though he was going to last long. She held his hand and stroked his thinning hair. The rest of us stood by and waited.
Impossibly, several minutes later he opened his eyes and looked around. He was too weak to talk, but he seemed to recognize Tammy. He obviously wasn’t yet ready to relinquish his fragile hold on life. I sequestered his family in the triage room for an impromptu conference and asked if they were in favour of giving him a rapid infusion of intravenous fluids in an attempt to boost his blood pressure. I explained any improvement would likely only be temporary, but that it might give him a few more hours of consciousness. After deliberating for a short time they decided to give it a try.