The Doctor Will See You Now [Non-Fiction]

Chapter 77: Acute Medicine

My pager goes off on the dot at 9am. (We start work officially at 9am, although because I round slow, I start at 8am if I'm to have any hopes of finishing first round by midday.) 'Ward 4, CPR'. Great start to the day.

I get to the ward to see a village of people in tense expectation. Not a good sign. Many, many expectations of a successful resus on a background of years of medical television showing them ROSC (return of spontaneous circulation, i.e. getting a pulse back) rates of over 80%.

The patient is a 50-something-year-old lady with not much in the way of background history except mild depression not requiring medication. The nurses are jumping away on her chest. She was already intubated. As the resus runs, I manage to get the history together. This lady had epigastric (upper abdomen) pains yesterday, for which she attended A+E, but DAMA before admission to the ward because it was her son's birthday and she didn't want to spend it hospitalised. Earlier this morning, her husband woke up to find her sitting up in bed very short of breath before she collapsed. Nobody did CPR on her -- either they didn't know how to or were in too much shock. Unknown down time (time until CPR was started and then succeeded in getting a pulse). She was intubated in A+E before being taken up to the ward. Because her downtime was unknown -- therefore her chances of actual meaningful neurological recovery uncertain -- ICU declined admitting her as they felt it would not be of any extra benefit to her. She had been on the ward for about two hours before arresting again.

I speak to the family. Naturally, there is no way they would consider stopping CPR before we finish ten rounds of adrenaline (which was how much time we'd give a 'full' resuscitation, although after twenty minutes of downtime (equates to about six or seven rounds) without a pulse back, the brain is essentially dead, too. We continue until the eleventh round. I stop the resus and tell the family -- a mum, a dad, a few brothers and sisters, some cousins, and a primary school-aged nephew -- that we didn't get a pulse back. She has died.

Floods of tears. Which is natural.

"Isn't there anything else you can do?" her mother said in disbelief. "Can't you--" She mimicked causing defibrillator pads.

The patient remained in asystole throughout, i.e. there was never any electrical activity in her heart to begin with. To shock a heart rhythm, the rhythm has to be shockable. Asystole is not one of them.

"No. She never had a rhythm that we could shock," I explain. I know none of this will make any sense to her. I know she just feels hopeless, lost, and possibly a bit let down we couldn't do the miracles medical TV does. The little boy screams with sorrow. It breaks my heart. I explain to the family I have to refer her to the coroner as I didn't know the cause of her death. This causes them further sadness. She will probably need an autopsy because I can't issue a death certificate without a certain cause of death. She was already dead when I first met her.

A month later, I call up the pathology lab as the autopsy result was available.

Cause of death was aortic dissection up to the heart with pericardial tamponade. Her aorta (the largest artery in the body) had torn -- which explains the epigastric pain -- and ripped all the way up to her heart -- which explains the shortness of breath. The cardiac tamponade means blood had filled her heart sac, making beating very difficult, which would explain her collapse. Treatment is with surgery to replace the torn part of the aorta and very strict blood pressure control to stop the tearing from worsening.

If she hadn't DAMA the previous day, she might have had a very different outcome.