Wednesday, July 13, 2011
LIVE, DAMN YOU, LIVE!
Had an amazing, busy, hectic weekend at work. The first case I’d like to share, and the most dramatic of my life is “Dudley,” a 3 year old black lab mix. I met him 3 days after he had been admitted to the hospital. On July 3rd, Dudley was tied in the back of his family’s pickup (always a bad idea), and he jumped out of the moving vehicle, As a result, he was hit by the car, as well as dragged for a distance until the driver realized and stopped the car.
At his initial admission to my colleagues, he was a severe multi-trauma patient; he had blood in his chest (hemothorax), air leaking from his lungs (pneumothorax), broken ribs, severe road rash, a large laceration in his left axilla (armpit region). He was not able to stand, but had been stabilizing over the first 72 hours in the hospital. Just prior to my arrival, Dudley had received a blood transfusion due to ongoing mild bleeding, probably due to a low platelet count, and potentially the start of DIC (disseminated intravascular coagulation; see previous posts).
This is when I met Dudley for the first time (my first shift back to the hospital). My colleague and I discussed his case in rounds, and I performed my initial physical exam. Although Dudley’s red blood cell level was improved with the blood transfusion, he looked shockingly worse; his gums were pale, his breathing was labored, and his urine began to discolor. Dudley’s bruising was more than expected for a patient in his condition.
I went to work. SPO2 revealed that Dudley was hypoxic on room air; I provided him with supplemental oxygen and rechecked his labs. Something wasn’t right; although his electrolytes were normal, his arterial oxygen saturation was way, way too low. I rechecked chest radiographs looking for ongoing bleeding or leakage of air. The radiographs were identical to those taken 24 hours previously, ruling out this as a cause of his deterioration. I tried to contact his owners, but was unable to reach them.
A dedicated assistant was assigned to monitor Dudley closely, as I was concerned for his imminent arrest. His respiratory rate and effort worsened, and about 2 hours after I had examined Dudley for the first time, it happened. His heart rate shot up to 220 beats per minute. We raced to administer lidocaine, an anti-arrhythmic drug, and applied an ECG. As I applied the ECG clips, we noted that the lidocaine had made no change in his rate or rhythm. Just as I pushed more lidocaine into his IV line, the ECG revealed the most serious of all cardiac arrythmias : ventricular fibrillation.
Ventricular fibrillation is a terminal rhythm if it is not corrected immediately. V-fib basically means that instead of working as a functional pump, the heart was fibrillating, or twitching, without actually moving any blood forward. The electrical activity of the heart needed to be reset to provide a chance for the muscle cells of the heart to work together once again.
This is where the story gets amazing.
With only seconds to spare, I performed a precordial thump on Dudley. (This is like in ER, when the doctor pounds on a dead patient’s chest screaming, “LIVE, DAMN YOU, LIVE!” and the patient miraculously is revived. Only it usually fails.) The precordial thump, or a strong well placed strike of the heart, can sometimes provide enough energy to reset the electrical currents. I’ve perfomed this twice before, and had never seen it work.
This time, it worked. (I can’t quite put into words how unbelievably amazing this is!)
Dudley’s rhythm converted back to a life-sustaining rhythm. I’m pretty sure I screamed, “OH MY GOD, IT WORKED!” High - fives all around the hospital, and then back to work - as you can imagine, post arrest patients are among the most fragile, and a high percentage of them crash and arrest again within minutes or hours.
I continued to try contact the family; and was still unable to reach them. 3 hours later, despite his death, and despite the seemingly insurmountable odds, Dudley’s family finally received my voice mails, returned my calls, and shed tears of fear, joy, fear and then joy again. He had survived ventricular fibrillation.
Sparing the medical details and lots more hard work, 2 days later, Dudley is eating. He’s off all heart medications, has normal blood pressure, improved bloodwork, his platelets have rebounded, and is still recovering. He has a ways to go, including healing his wounds and a possible limb amputation, but he is expected to survive.
This will truly be one of the most memorable cases of my life. I can’t wait for the next one.
+1 for the home team :)