Imagine being toned in the middle of the night for an “elderly female, status post cardiac arrest.” If you are like me, the moment you hear “post cardiac arrest” something deep inside of you begins to surface–almost a “savior mode.” You start running through differentials and how to treat those diagnoses. It’s almost like a game to try to anticipate the correct diagnosis. Is it a heart attack? Pulmonary emboli? Trauma? Overdose? You start playing scenarios in your mind about what you might encounter when your boots hit the ground. Obviously something caused this person to arrest, it’s our job to figure it out and fix it.
Our patient, Judy, was a female in her early to mid-60’s with an extensive medical history and surgical history, including Diabetes, Renal Disease, and Crohn’s Disease with an ileostomy. She had a syncopal episode at home and her husband called 911. When the ambulance (EMS) arrived, Judy was awake and talking, however quickly became unresponsive with agonal respirations. EMS confirmed a pulse and transported her to the Emergency Department (ED) with respirations being assisted by mask ventilation (BVM). Upon arrival to the ED, Judy was found to be in PEA arrest. CPR was initiated, and her ileostomy was noted to be full of dark red blood. CPR continued and Judy received multiple doses of Epinephrine, Calcium, and Sodium Bicarbonate. Spontaneous circulation (ROSC) was achieved approximately 15 minutes later. Judy remained hypotensive, and it was thought that she was suffering from a GI bleed of unknown origin, complicated by Diabetic Ketoacidosis (her blood glucose was >450mg/dL). Judy received 8 units of packed red blood cells (PRBC), 8 units of plasma (FFP), 8 units of platelets, and Tranexamic Acid (TXA). She required a Levophed infusion to maintain Mean Arterial Pressure (MAP) > 40 mmHg. An insulin infusion was also started. While Judy initially appeared to have stabilized, 3 hours after her initial presentation, she suffered another PEA arrest. After approximately 10 minutes of CPR, Epinephrine, Calcium and Sodium Bicarbonate, Judy once again achieved ROSC.
When we arrived, I placed Judy on the monitor and performed an assessment while my partner Joetta received report from the ED staff. Our assessment revealed fixed and dilated pupils. The ED staff informed us that after the 2nd arrest, no neurologic activity had been noted. The doctor informed us that a head CT had been done after the first arrest but was unremarkable. Judy was found to be asynchronous with the ventilator due to agonal respirations. The ventilator was constantly alarming with high peak inspiratory pressures due to her fulminant pulmonary edema. Judy was cool and mottled with absent peripheral pulses and weak central pulses. She was also noted to be coagulopathic with oozing noted at the IV sites and large bruises noted predominately on her chest and bilateral arms. A large amount of sanguineous drainage was noted from her ileostomy.
Judy was noted to be hypotensive with systolic blood pressures in the 70 mmHg range. A fluid bolus was initiated, and her Levophed infusion was increased to 0.5 mcg/kg/min. Extra blood products and medications were requested to the bedside. At this point, Joetta and I felt it was crucial to draw a venous blood gas (VBG) to determine our acid base and electrolyte baseline. What we found was a pH-6.77, PvCO2-79 mmHg, PvO2– 37, HCO3– – 11.6 mmol/L, Lactate- 11.6 mmol/L, Sodium- 144 mEq/L, Potassium- 5.3 mEq/L, Ionized Calcium- (iCa) – 0.97 mmol/L, Hemoglobin- 8.5 g/dl, Hematocrit – 25%, and Glucose 365 mg/dl. In response to the VBG, Calcium was administered, and a concentrated Sodium Bicarbonate infusion was requested. Judy’s NG tube then began producing a large amount of sanguineous drainage in a very short period of time.
It was at this time that we met at a crossroad. We started questioning if our patient was too far gone to transport. Would she even survive the transport, or the move to our stretcher for that matter? Could we gather as many blood products, calcium chloride, and sodium bicarbonate and limp her back to the University of Michigan, or do we have the honest and difficult conversation with the staff, including both the referring and receiving physicians and family about Judy’s condition. It was then Joetta said to me, “just because we can, doesn’t mean we should”. We have to think about what the “RIGHT” thing to do for Judy and her family.
Throughout nursing school, I struggled with the psychosocial dimension of the nursing model. I hated all the “touchy feely” stuff and wanted to focus on pathophysiology and understanding the core of the problem as well as how to fix it. Over the years, I find I lean more into the medical model where there is a problem, and I need to fix it. Unfortunately, with this mindset I can lose sight of the nursing model which has a more holistic approach to patient care.
In this case, I found that while I knew there wasn’t much, if anything, that the University could do for Judy, a part of me still wanted to transport. Upon reflection as to why this was my initial response to an obviously despairing situation two main truths became evident. The first is that I strongly dislike those uncomfortable situations and conversations. I feel incredibly inept and unable to provide the family with what they need. It seems as though I never have the right words to say, or know how to best support them.
The second reason I struggle with embracing the reality of not transporting a patient is because I see it as a failure. I have failed the patient if we are unable to transport. There is something I could’ve, should’ve, would’ve done differently to fix the patient. If I had made different decisions, this patient would have survived. I failed the patient and took away any hope the family had.
Thankfully, Joetta helped me see the truth: Judy was gone. All signs pointed to the obvious fact that this was non-reversible. At this point it was most important for Judy’s family to be able to spend time with her, hold her hand, and tell her they love her. By continuing with the transport, it is likely we would rob this family of those precious moments. There was an incredibly high likelihood that Judy would die before her family made the hour and a half trip down to Ann Arbor.
We ended up having a team meeting with our medical control and the outside hospital staff to discuss the situation. We all agreed that there was nothing more the University could offer Judy at this time and the decision was made to cancel the transport.
We had the privilege to help give Judy a bath and clean up the room to prepare her family to see her. We then brought in her husband. He was clearly in shock and did not comprehend how his best friend of 50 years could be dying in front of him. We answered his questions and extended our deepest sympathies. Ultimately we just sat with him while he grieved. It was uncomfortable and difficult to witness such grief, but the decision to not transport Judy, while difficult, was clearly the right decision. It pains me to think that my “fix it” attitude nearly robbed this family of these last few precious moments with her. While in the eyes of the medical model, we may have failed, in the eyes of the nursing model, we were able to help provide Judy with the greatest gift possible: a good death