J.’s First Patient Who Didn’t Make It

Post-dated post from an undisclosed time in an undisclosed location. And looking at the circumstances, it’s kind of sad that it’s not an entirely uncommon situation.

One day, one of my patients didn’t make it.

From the time she came in, the odds were stacked against her:
– Over 90 years old
– Multiple co-morbidities of hypertension, hyperlipidemia and ischaemic heart disease
– Recent heart attack 2 months prior
– A left-sided intertrochanteric fracture

So here she was, stuck between a rock and a hard place.

Even without a cardiac consult, it was obvious that she would have at least a moderate to high risk of cardiac event (e.g. 5-20%). At least. Excluding the risk of intra-op stroke, adverse reaction to anaesthesia (well… by itself <1 in 10000). Yet if she didn’t have the operation and had to be bedbound on traction for weeks to months, she’d likely fall prey to sepsis from pneumonia, urinary tract infection or bed sores, unless she had an excellent caregiver who’d change her diapers quickly, keep her working on the incentive spirometer and turned her every 2 hours.

How? How?

It was a question who struggled with as we sent off a blue letter for a cardio consult and spoke to the family at length. Days passed as she remaind on traction. We listed her for an operation, figuring that it was easier to cancel an op than to squeeze it in, and waited for the family decision.

The night before the possible operation, they decided to go ahead with it. It was too late, however, we had already given the operation slot away to two other patients, but we scheduled the operation for the day after.

It turned out that all our discussion, all our family conferences, were for naught.

The next morning, I was sitting at the computer, typing away frantically at discharge summaries, when the nurses alerted me “Mdm GenericSurname’s blood pressure’s 70/40!” What? Was she sure? Did she check again? Let me see!

I found it to be 75/45 from a previous level of 120/70. That’s not a good sign. So we did a battery of tests and she had the most obvious electrocardiogram (ECG) changes with ST elevations from V1-V3 with reciprocal changes in V4-V6 and the inferior leads II, III, aVF. The cardiology registrar on call came to review the patient and after discussion with his consultant, decided that medical therapy was indicated (not procedural) and started with a loading dose of 300mg aspirin, 300mg clopidogrel (Plavix). The patient went into supraventricular tachycardia (SVT).

All this time, Mdm GenericSurname was asking repeatedly in Cantonese for her daughter and family. We called her daughter and her grandson to let them know that Mdm GenericSurname was seriously ill and could go into cardiac arrest at any time and would they rush down to the hospital pronto? The patient knew. She knew it was her time. She knew… and she wanted to say her last words to the family.

We knew the prognosis was bad, but it was all systems go to make sure she didn’t die on us. A green plug was set at the left cubital fossa by me, and 5 vials of adenosine ordered (each vial being 6mg). After a struggle to get an monitored bed, the sister of the ward cleared one bed for the patient and we moved her there, catheterised her to monitor input/output and prepared for medical cardioversion of the supraventricular tachycardia. I was ready to push 6mg adenosine (with a half-life of 6 seconds) into the IV plug, flush with 20ml of NaCl and elevate the arm, and was waiting for the cardiology registrar to come.

Before administering it, a curious thing occurred. The patient’s pulse rate dropped to 60 beats/min, hardly normal for supraventricular tachycardia, with the blood pressure still low at about 80/50 despite a pint of gelafundin being poured in. A stat ECG was taken that showed she was now in slow atrial fibrillation (AF).

Hold off the adenosine! A dopamine infusion was started. 5min later, her heart rate was up to 170 bpm. Another stat ECG was done. She was hypotensive in fast AF, with the BP still around 80/50. The dopamine infusion was stopped.

What could we do? She was hypotensive, so we couldn’t give propranolol or a calcium channel blocker to slow the heart down and decrease the cardiac oxygen requirement. We couldn’t give inotropes to boost the blood pressure because she was tachycardic.

All this time, as I stood by the bed and washed the rhythm monitor show up Lowne’s classification V (R on T phenomenon), the thought kept coming into my mind that at any moment she would go into ventricular tachycardia and we would have to jump on her to commence CPR and defibrillation.

The family arrived, and we would hold the oxygen mask off her face so that her words to the family wouldn’t be muffled. The cardiologist spoke to them about the poor prognosis… then it fell to me to give them the talk regarding how far they wanted us to go to keep her alive.

Did they want us to go the whole way? CPR, intubation, SICU care? Or for maximal ward management, where we would do everything we could medically short of CPR/intubation/SICU care… which actually isn’t a lot in terms of a patient who’s collapsed. They decided, however, that at over 90 years old, she had suffered sufficiently and with her poor prognosis, should not be left to deteriorate slowly on a respirator. The status of maximal ward management was ordered at about 2pm.

So that was that. I handed over her care to my colleague in charge of the High Dependency unit.

Outcome:
Despite supportive medical care for her heart attack, Mdm GenericSurname suffered a stroke at 7pm.
She passed on at 2am that night.

The first is always the one you remember. Now I’m morbidly awaiting, and dreading, the first patient whose death is directly/indirectly contributed to by me.

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