I was called into the room to see a young, healthy woman who had abdominal pain, vomiting and diarrhea for several days. I found her to have abdominal tenderness and low blood pressure. She was clearly ill. Of specific concern was that her finger tips were blue, a clear sign something bad was keeping her blood from flowing well. It was not at all clear just what would be causing her illness. I told her, her mother and her boyfriend I was worried and I reviewed with them what I was going to do to get some answers and start treating her.
My first focus was on the abdominal pain, vomiting and diarrhea. I ordered pain medication, fluids and antibiotics in case she had an infection. I was thinking maybe her low blood pressure and the poor circulation to her fingers were just from being severely dehydrated. But, we are always thinking of more unusual, bad reasons our patients are sick, so I ordered more tests than I would normally have done. I also had the charge nurse move her to the room right next to my work area so I could keep a close eye on her.
Her lab tests confirmed she was sick but didn’t answer any questions as to why. I wanted to get a CT scan of her abdomen but because her blood pressure was so low, it was not safe to send her to the Radiology Department. Second best, we did an ultrasound at the bedside. It didn’t show anything in her abdomen but, very much to my surprise, it showed a huge pericardial effusion. That is a collection of fluid between the heart and the sack the heart sits in. It usually occurs because of inflammation and, if it is large enough or develops too quickly, it can press on the heart, keeping it from filling adequately with blood. This could cause low blood pressure and poor blood flow to the fingertips.
The treatment of a pericardial effusion is to pass a big, long needle through the skin in the upper abdomen. It is directed up under the ribs, into the heart sack. The hope is that sucking that fluid out will give the heart a better chance to fill with blood so it can pump more efficiently, raising the blood pressure and fixing the circulation.
Draining a pericardial effusion is done very rarely but, if done quickly and correctly, it can be life-saving. I spread antiseptic over her chest and abdomen. I passed the needle up under her ribs into her chest and was immediately able to start drawing fluid out with a syringe. With the ultrasound, I could see when I had removed it all. Unfortunately, I could also see that, even after the fluid was out, her heart was beating very weakly. Taking the fluid out didn’t help her at all.
Now, at least, I had my diagnosis. Cardiogenic shock. That means the heart is beating so weakly it is unable to keep blood moving well enough to get oxygen into all of the tissues. I then was able to concentrate on her heart as I continued treating her.
Unfortunately, she continued doing poorly. Her blood pressure got so low she went unconscious. I intubated her and ordered multiple medications to keep her blood pressure up enough to send her for the CT scan of her abdomen. I still didn’t understand what could cause vomiting, diarrhea, abdominal pain and cardiogenic shock.
He blood pressure improved just well enough for me to risk sending her to Radiology. The CT scan showed inflamed intestines. Nothing else. It looked like she was probably very ill with a virus. That would cause her intestines to be inflamed and give her pain, vomiting and diarrhea. A virus can also inflame the outside covering of the heart, causing the pericardial effusion. Worse, it can inflame the heart muscle itself, causing viral myocarditis, which can cause the heart to beat weakly. Though I had not found anything I could easily fix, at least I had a picture of what was going on. I didn’t feel like I was missing anything.
While all of this was going on, I had also been making phone calls to get her admitted to the hospital. I talked to our cardiologist who said the patient should go to the bigger hospital in the large city a few miles from us. When I contacted them, they said she was too sick and should go to a “university hospital.” The closest place like that to us had no beds and would not accept her. The next closest place was so busy, I could never even talk to a doctor. Finally, I got ahold of an intensive care doctor at a big university hospital about two hours’ driving time from us. He was very helpful, giving me recommendations on how to treat her as we got ready to fly her to where he was.
Unfortunately, I soon learned the helicopters were grounded because of weather. I knew if she went by ground she might die en route. I also knew if she stayed here, she was certainly going to die.
All this time, she just got worse and worse, eventually requiring CPR. I stood at the bedside with the ultrasound probe over her heart. When it stopped beating, we would do CPR for a while and give her adrenalin injections. This would keep her heart beating weakly but when the effect of the CPR and adrenalin wore off, her heart would stop and we could do it again.
Her mother was kneeling on the floor next to me, holding her daughter’s hand, and begging her to live. Her upset, but remarkably under control, boyfriend was by her head. At one point, the boyfriend’s mother came in as well. She put one hand on the patient and one on her son and prayed, asking God to intervene in the patient’s behalf. I stood there with them, feeling I had done everything possible but that she was certainly going to die.
For almost two hours we were there like that. The patient was too sick to be admitted to our hospital and too unstable to be transferred. She got everything I could possibly use to pull her through, but her heart just kept getting weaker and weaker. I was standing there, watching the family cry and pray as her heart slowly gave out. There was nothing I could do about it. Eventually, her heart stopped completely and she was pronounced dead.
I felt physically and emotionally spent. After the family had some time alone with her, I went in and talked with them. I explained what I thought had happened. I reviewed with them what I had tried to do for her. I cried and said I was so sorry for them.
By the time this was over, I could hardly do anything else. I had a hard time focusing my attention elsewhere because my mind would immediately circle back to this case. Though I am good at leaving my work at the hospital, I was not able to do so in this case and it took a long time for me to work through my feelings and get back to normal.
A measure of how difficult this case was is how it affected the emergency department staff. For a couple of weeks, people who were involved with her care were talking about how challenging it had been. For about that same time period, every time I would come in for a shift, the other doctor would say something like, “Hey, I heard about that case you had…” Everyone was talking about it.
So, a young lady that may have just had the stomach flu, died from cardiogenic shock. It could happen to anyone. Why did she have such bad luck? Why did I have the opportunity to be the one with her and her family while she died? Just my luck. Good or bad?
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