Hate it when they come in talking and die

[dchristismi]

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So I really hate it when someone comes in talking... and dies.

This gent looked so-so when I first walked in, EKG worrisome, not a straighforward story - that not-quite typical chest pain/dyspnea story that sets the spidey sense tingling (usually for me, those are dissections.) Repeat EKG looks worse, call my awesome interventional cardiologist and ends up going up to the cath lab within minutes... lovely wife at bedside really freaking out, manages to get a kiss in before he's wheeled into the room...

where he suddenly becomes agitated, then goes purple from the chest up, and becomes unresponsive. Got him intubated and he coded.

I almost never accompany my patients to the cath lab. Not practical, and besides, they're darn good at what they do. But for some reason, today, I did. He didn't even give me the "I'm going to die" warning. Very calm, almost too calm. Looked worse in the 10 minutes to discuss with cards and cards pushed to cath immediately.

I have been back over it a dozen times. I'm pretty sure he had a big PE - and if he didn't have those damned ST elevations, he would have coded in my scanner. Not that it would have mattered (although I did lobby for it, I figured he was already getting heparinized and he did have elevations - it very well might be his RCA.) And yes, I pushed TPA during the code. It's all I had. Not that it mattered.

Just hate that.
And needed to vent, I guess.

 

[Birdstrike]

So I really hate it when someone comes in talking... and dies.

This gent looked so-so when I first walked in, EKG worrisome, not a straighforward story - that not-quite typical chest pain/dyspnea story that sets the spidey sense tingling (usually for me, those are dissections.) Repeat EKG looks worse, call my awesome interventional cardiologist and ends up going up to the cath lab within minutes... lovely wife at bedside really freaking out, manages to get a kiss in before he's wheeled into the room...

where he suddenly becomes agitated, then goes purple from the chest up, and becomes unresponsive. Got him intubated and he coded.

I almost never accompany my patients to the cath lab. Not practical, and besides, they're darn good at what they do. But for some reason, today, I did. He didn't even give me the "I'm going to die" warning. Very calm, almost too calm. Looked worse in the 10 minutes to discuss with cards and cards pushed to cath immediately.

I have been back over it a dozen times. I'm pretty sure he had a big PE - and if he didn't have those damned ST elevations, he would have coded in my scanner. Not that it would have mattered (although I did lobby for it, I figured he was already getting heparinized and he did have elevations - it very well might be his RCA.) And yes, I pushed TPA during the code. It's all I had. Not that it mattered.

Just hate that.
And needed to vent, I guess.

What was the arresting rhythm? Sounds like classic witnessed vfib arrest, needing quick sparky spark, no?

 

[dchristismi]

PEA. Lots of PEA. More PEA. Then a little something that looked fibby, so we shocked, PEA, asystole, back into PEA. Those pesky Hs and Ts... That's why I think it was a saddle PE. I love a good TECO consult (insert your local electric company here), but it wasn't the answer. Unfortunately, I'll never know. But ooh, I hate losing.

And the ST elevations weren't really big - half a box at first, then a whole box after I slowed down his tachycardia. Certainly not a slam dunk RCA.

 

[WilcoWorld]

Yeah, and maybe your gut was right...might've been a dissection involving the root/coronary arteries. Given that he died within 10 minutes of arrival, and that his code rhythm was PEA, it's doubtful that anyone but an ECMO team who just happened to be trolling the ED for a patient, at the very minute he coded, could've saved this one.

Sucks.

 

[dotcb]

Sounds like you gave him great care!

 

[Janders]

Agree. Nothing as haunting as having a conversation with them (especially when you think they are sick... but not SICK-SICK), and then coding/tubing them 20 minutes later.

Had a nice 'ol guy with ESRD/HD and COPD a while ago. Thought he was having a lil COPD thing and came in with a wheeze. No he was fluid overloaded. But super nice guy, we chatted a few minutes... and then he rapidly progressed to severe pulm edema, delirium, shock despite typical measures. Got him tubed, got him to the mecca for HD, etc. Did ok for a day then just died. sigh.

Similar one who thought he had a virus (fever) and a lil dyspnea. Seemed like a standup guy, joking with me. 30 minutes later he's in florid pulmonary edema, clawing at us, pulse pressure wide as can be. Endocarditis ate a couple valves, not a virus... got tubed, a hemodynamic mess... but didn't code at least.


Feels nice to remember them. Certainly presentations we are not going to forget.

And I bet you are right; youngish people who have witnessed arrest direct to PEA (i.e not a hypoxic brady down, not Vfib) without a good reason (severe acidosis from DKA/sepsis) are FREQUENTLY due to massive PE. Kline mentioned this on twitter recently.

 

[Birdstrike]

We all went into medicine, and particularly emergency medicine, to save lives. Deep within even the most cynical of us, is still that pre-med hopeful that believes we can and should restart each non-beating heart, make the non-breathing breathe and fill with blood those who've bled, filling them back with life. We expect that a patient's condition will improve while under our care, or at least not worsen. Intellectually, we know we'll not be successful every time. None of us became doctors to helplessly watch others die. Yet, we know there will be times, that no matter what we do, nor how perfectly we do it, that's exactly what we'll be forced to do, though not for lack of trying.

Ultimately, regardless of what any of us says, you'll go over this case ad nauseum to determine "What could I have done differently?" Ultimately you may conclude you could, or couldn't have, done something different. But the crux of it, is that the answer to that medical question is irrelevant to the what is ultimately a human experience we can't fully control.

As medical as we try the be, it hurts to watch someone die. And the thing very few understand is the tremendous emotional risk we take as physicians, in having to be part of that, while at the same time charging ourselves with the responsibility of not allowing it to happen. Ultimately, we set ourselves up to fail. Some we can save. Many we can't. Uniquely, we bear that emotional burden. The hospital CEO doesn't feel that. The insurance adjuster who pays (or refuses to pay) the hospital claim doesn't feel that. We share the burden with the family. I've seen partners, grown men, cry over patients lost. What you have to do, after you've done the analysis, ultimately are two things:

1-You first have to give yourself permission to be, and forgive yourself for being, human. You have to have compassion, not only for your patient and the family, but allow some for yourself.

2-You have to remind yourself, regardless of whether or not you ultimately decide you could/should have done some thing different, that by your being there, you took a large risk (an emotional one) and by doing so gave your patient a much greater chance of surviving, than if you hadn't taken that risk. Even if the outcome wasn't what you or the family would have hoped, you took a great emotional risk by choosing to be there if and when that patient would need you, and increased their chances much greater than if you weren't there. Sometime their chance was never more than zero, but you did what the rest of the world didn't have the courage to do. You placed yourself there and were willing to risk taking the emotional bullet. Why? Because you're a good human being and you care. I don't know if that helps, but either way, I can assure you I've been there. I have cases like this that I think about years later; not all the time, but when something like this triggers the memory. For what it's worth, I feel your pain.


"Midnight, our sons and daughters, Were cut down and taken from us, Hear their heartbeat, We hear their heartbeat."
-U2 (Mothers of the Disappeared)




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(This post ultimately was shared here, also: http://www.kevinmd.com/blog/2015/01/doctors-lost-patients.html )

 

[dchristismi]

Beautifully put. Beautifully, hauntingly put, Birdstrike. And spot on, as usual. Thank you.

I hope you don't go on to delete that in the future. I'm half tempted to quote you to preserve that.
I don't think anything I could have done would make any difference in his outcome. But I am so, so thankful that I held the gurney for that last split second so his wife could give him that last kiss...

 

[RustedFox]

Dear God. You're kidding me.

Wow.

Grammatical gender-disagreement aside:

You might be THE (wo)man... but you're only ONE (wo)man.

Take it easy. You didn't stop until you did everything that you could.

 

[RustedFox]

- and... here's where bedside cardiac code-ultrasound comes in big-time. Still quivering? Shock 'em like its hot. RV dilation? Push the TPA hard.

Hey, I know I'm Monday-Morning Quarterbacking. No clue if I would have been savvy enough to think of it in that hot minute.

 

[Birdstrike]

I hope you don't go on to delete that in the future.

I won't.

 

[met19]

I imagine we all had cases that remain with us. They help us form who we are, how we think as long as they don't dominate our thinking.

Mine was just as not fun- work in a place with veterans/military. Not exactly die in front of me but....

Had a WW2 Marine (battle of iwo jima) next to a 67 y.o. retired marine gunny sergeant. The 67 might as well has been talking to his idol through the curtain. I connected really close with both patients as I was an MD in Afghanistan in a bad area on a marine base.

The 92 y.o. was AAOx1 but could remember the war like it was yesterday- got to discharge him back to SNF.

67 y.o. beat bladder ca several times, but is technically stage IV due to a small "blip" on his adrenal that has lingered. Chief complaint: vomiting for 3-4 days and abdominal discomfort. AAS: non specific. labs: acute renal failure, NSTEMI. CT scan: looks really bad to me but sign out get official read and then call gen surg if needed plus oncology or ICU to admit. Left telling patient and the family, Dr So and So is taking over and will f/u CT. Tell family I work in about 36 hrs so I'll stop by to visit him.

Walk in for am am shift- look at the EHR: patient had severe SBO, pneumotosis in his small bowel, etc. Surg took to OR tried but BP was diff to control so they left open and took him to ICU where they washed him out again 12 and 24 hours later at the bedside. Ended up needing 5 pressors and family withdrew care.

I ended up calling the wife (who was there when I took care of him in the ED) and expressing condolences. She said I was the only doc who did that and she appreciated it. Gave me some closure on the case too.

Birdstrike's post was amazing.

 

[Lysinee]

How often do you get talk and die cases? Every few months?

 

[The White Coat Investor]

I'm sorry. You did everything you could. So did the patient. I also think the talk and dies are the worst. They're even worse than the pediatric come in dead stay deads. The very, very worst, of course, are the pediatric talk and dies. Thankfully I haven't had one yet in the ED, although I did in the PICU as a resident.

 

[DocEspana]

We were discussed massive PE as a cause of PEA two weeks ago. The take away was basicallly that there is new approaches and ways to look at PEA where the usual H's/T's are more or less ignored unless an obvious H/T is staring you in the face and you treat it physiologically. Since PEA under ultrasound almost always shows cardiac wall motion that should be creating a pulse, it should be treated as obstructive shock or hyper-severe hypotension. We discussed it at length and then an attending just said (and im paraphrasing) "When you actually have a patient who goes from healthy to unsustainable rhythm to PEA you dont really think about physiology. You're pushing everything you have and touching sternum to spine because the only thing you know is that his heart has just went from working to not working to effectively dead and there is nothing in medicine, even the new physiology argument, that shows there is any good way to reverse that"

IDK if it means much to you. But he's right on this: when this stuff happens you can be the best scientific thinker in the world or the most reactionary "muscle memory" doc in the world... it doesnt really matter. we dont have any way to stop it and sometimes a patient just doesnt have the ability to be saved and when they change that quickly you dont have the signs and symptoms to prevent it. An abnormal EKG minutes before croaking is not sufficient for anyone to make preperations for such a complex issue.

 

[Rendar5]

How often do you get talk and die cases? Every few months?

I won't say never in 6 years including residency because that's asking for it but speaking with colleagues I'd say it's a once a year thing. Had one colleague that had it happen twice at the end of a nightshift. One of the two was a broken hip that he had just admitted. Talk about a black cloud. Prolly a fat embolus.

 

[Rendar5]

Agree with white coat. Kids are horrible. Still haunted by 3 cases I remember vividly even though it's be 5 years. I don't remember the faces but I remember everything we tried and I remember telling the parents and seeing them die inside.

 

[Colbert]

Sounds like this is one of those unfortunate cases where the train had already left the station and there wasn't anything any of us could have done. Chin up, we've all been there. I had a 20 year old heart transplant pt (history of myocarditis) that I came in talking and even told his mom to wait in the waiting room. I coded that kid for an hour and a half and held his crying mom and his transplanted heart gave out. Still think about that kid. I learned a lot from it, and that's all we can do in those situations.

 

[dchristismi]

The talk-and-die phenomena isn't common, but it really hurts.
Similarly, the talk-die-shock-wakeup phenomena isn't common, but totally kicks ass.

Fox, I actually did grab the ultrasound, well, it was a huge echo machine that no one knew how to use. There was a tiny electrical kick, but minimal wall motion with nothing that could pass for squeeze. I was going to look at the RV specifically, but ultimately just used it to call it in PEA.

 

[Doctor Bob]

Reminds me of the 3 groups of patients who come into the ED.

Those who will get better no matter what you do
Those who will die no matter what you do
And those who will live or die based on the decisions you make.

The 3rd group is the one that deserves most of your mental anguish. Most patients fall into the first 2 categories. This patient sounds like he was in the 2nd group.

So it goes.

 

[CajunMedic]

I won't.

Wow, amazing piece of writing. May I share it with my classmates?

 

[Birdstrike]

Wow, amazing piece of writing. May I share it with my classmates?

Of course.


(Great profile pic, BTW. Great Buffett album.)

 

[Birdstrike]

Beautifully put. Beautifully, hauntingly put, Birdstrike. And spot on, as usual. Thank you.

I hope you don't go on to delete that in the future. I'm half tempted to quote you to preserve that.
I don't think anything I could have done would make any difference in his outcome. But I am so, so thankful that I held the gurney for that last split second so his wife could give him that last kiss...

I imagine we all had cases that remain with us. They help us form who we are, how we think as long as they don't dominate our thinking.

Mine was just as not fun- work in a place with veterans/military. Not exactly die in front of me but....

Had a WW2 Marine (battle of iwo jima) next to a 67 y.o. retired marine gunny sergeant. The 67 might as well has been talking to his idol through the curtain. I connected really close with both patients as I was an MD in Afghanistan in a bad area on a marine base.

The 92 y.o. was AAOx1 but could remember the war like it was yesterday- got to discharge him back to SNF.

67 y.o. beat bladder ca several times, but is technically stage IV due to a small "blip" on his adrenal that has lingered. Chief complaint: vomiting for 3-4 days and abdominal discomfort. AAS: non specific. labs: acute renal failure, NSTEMI. CT scan: looks really bad to me but sign out get official read and then call gen surg if needed plus oncology or ICU to admit. Left telling patient and the family, Dr So and So is taking over and will f/u CT. Tell family I work in about 36 hrs so I'll stop by to visit him.

Walk in for am am shift- look at the EHR: patient had severe SBO, pneumotosis in his small bowel, etc. Surg took to OR tried but BP was diff to control so they left open and took him to ICU where they washed him out again 12 and 24 hours later at the bedside. Ended up needing 5 pressors and family withdrew care.

I ended up calling the wife (who was there when I took care of him in the ED) and expressing condolences. She said I was the only doc who did that and she appreciated it. Gave me some closure on the case too.

Birdstrike's post was amazing.

Wow, amazing piece of writing. May I share it with my classmates?

For what it's worth, I put the post on Dr. White Coat's blog, since you guys liked it. Someone could nominate if for KevinMD and send him the link, if you think others would want to read it ([email protected]). Otherwise, we'll keep it right here.

http://drwhitecoat.com/doctor-lost-patient/

 

[la gringa]

i had a rough "came in talking and died" right around when this was posted. totally different case and waiting on the autopsy... thanks for the stories and words of encouragement.

and they aren't frequent for me, to answer the questions about how often they happen. i can remember all of my medical and most of my trauma pts i saw alive and then pronounced (all of the traumas were in residency and i was 1 of many docs).

 

[BrennMan]

Extremely inspiring thread. Thank you for taking the time/guts to post.

 

[BAM!]

So I really hate it when someone comes in talking... and dies.

This gent looked so-so when I first walked in, EKG worrisome, not a straighforward story - that not-quite typical chest pain/dyspnea story that sets the spidey sense tingling (usually for me, those are dissections.) Repeat EKG looks worse, call my awesome interventional cardiologist and ends up going up to the cath lab within minutes... lovely wife at bedside really freaking out, manages to get a kiss in before he's wheeled into the room...

where he suddenly becomes agitated, then goes purple from the chest up, and becomes unresponsive. Got him intubated and he coded.

I almost never accompany my patients to the cath lab. Not practical, and besides, they're darn good at what they do. But for some reason, today, I did. He didn't even give me the "I'm going to die" warning. Very calm, almost too calm. Looked worse in the 10 minutes to discuss with cards and cards pushed to cath immediately.

I have been back over it a dozen times. I'm pretty sure he had a big PE - and if he didn't have those damned ST elevations, he would have coded in my scanner. Not that it would have mattered (although I did lobby for it, I figured he was already getting heparinized and he did have elevations - it very well might be his RCA.) And yes, I pushed TPA during the code. It's all I had. Not that it mattered.

Just hate that.
And needed to vent, I guess.

I know this isn't the point of your thread, but did you call the coroner to find out why he died?

 

[dchristismi]

Wife didn't want an autopsy, so we'll never know. Clinically, massive PE fit the bill, but it could have been any number of catastrophic thoracic etiologies. Death certificates, especially from coroners, are best guesses. The ME getting involved would be the only way to know, and the guy did technically meet STEMI criteria.

 

[Alejandro]

Reminds me of the 3 groups of patients who come into the ED.

Those who will get better no matter what you do
Those who will die no matter what you do
And those who will live or die based on the decisions you make.

The 3rd group is the one that deserves most of your mental anguish. Most patients fall into the first 2 categories. This patient sounds like he was in the 2nd group.

So it goes.

MS3 here, but for the 3rd group, do you feel like residency prepared you well enough for them? See enough of them before the real world as an attending? I feel it would be harder to cope outside outside of residency, because you could displace your guilt as a "trainee?" Even though its just a defense mechanism?

And birdstrike, thank you for your post.

 

[Doctor Bob]

MS3 here, but for the 3rd group, do you feel like residency prepared you well enough for them? See enough of them before the real world as an attending? I feel it would be harder to cope outside outside of residency, because you could displace your guilt as a "trainee?" Even though its just a defense mechanism?

I think training for that third group is the entire point of residency. Early on, a lot of the people I thought that I should have been able to save were in fact non-salveagable. And as time went on I got better at realizing it. Not to say I tried less, but I got better at knowing when to say when.

I feel that having a sense of guilt only comes into play when I feel as though I could have or should have done more. If at the end of the code (like a game of football) I've left it all on the field, then even if the person dies I don't feel guilty.

To answer your question, yes, I feel adequately prepared.

 

[Daiphon]

I think training for that third group is the entire point of residency. Early on, a lot of the people I thought that I should have been able to save were in fact non-salveagable. And as time went on I got better at realizing it. Not to say I tried less, but I got better at knowing when to say when.

I feel that having a sense of guilt only comes into play when I feel as though I could have or should have done more. If at the end of the code (like a game of football) I've left it all on the field, then even if the person dies I don't feel guilty.

To answer your question, yes, I feel adequately prepared.

Well said.
-d

 

[engineeredout]

I had someone the other day when covering the ICU overnight. Guy was admitted to the floor evening before for chest pain and afib w rvr. Patient had your typical risk factors, htn, hld, DM etc. He was tachy so ended up getting a CTA. No PE, but it did show an incidental Thoracic aortic aneurysm. Surg consulted, doesn't think it's related to his pain. He ends up being a Rapid Response on the floor for tachycardia in 140s, came down to 70s with a little bit of lopressor. Guy hemodynamically stable. Says his chest hurts a little but that improved with the lopressor.

This is all at an inner city hospital which does not have CT surg in house, so we transferred the patient ASAP to our tertiary referral center where CT surg could evaluate him. Transfer happened so fast we didn't do any additional tests. Ends up getting a CTA there that's timed for the thoracic aneurysm. He has a god damn dissection that goes from the arch, down to the origin of the coronary arteries, and down the other way, allllllllllllllllll the way down INTO THE ILIACS. Goes to surgery, dies in the OR

All I can think about how he did not look anywhere near as bad or as sick as he was. Makes me want to CTA everyone