Friday, July 27, 2007

Sounds of Life

7/27/07 0550
It’s early morning after my call night. I can’t get back to sleep now after being awakened at 0440 with a STAT page to the ICU and still being on Pacific Standard Time. It has been quite a night, which should come as no surprise to anyone who has read Mary’s blog last month. Didn't I just say that things were quiet in the ICU?

It was the first time I ever really heard it. The sound of a heart coming back to life, that is.

One of my ICU patients, who we’ll call Ruth, was taken urgently to surgery for an exploratory lap by one of our brave surgeons around dinner time last evening. She had been diagnosed with metastatic choriocarcinoma last week when they removed a huge mass from her belly. She was recovering well, started on chemo (a rarity here but her prognosis is relatively good) this past week but was oozing from her wound constantly. She became progressively short of breath and her abdomen distended with blood so she was rushed to the OR to drain the blood and stop any ongoing bleeding. The surgery appeared to be a success and I was called that they would be bringing her, after extubating her, to the ICU for me to care for.
I decided to go down to the “Theater” to meet the patient there and speak with the surgeon to get a report. I met him outside the OR and he reviewed the case. As we were talking, the anesthetist brought the patient out to us. As we stood over the bed and spoke for a few more minutes, we suddenly noticed she had stopped breathing. No respirations, no pulse.
The nurse anesthetist quickly re-intubated the patient and we gave her several breaths. We wheeled her into recovery to hook up our ambu-bag to oxygen and started CPR. The surgeon bagged, I did chest compressions and the RN scrambled to get meds. He agonized “I’ve killed her, ahhh, I’ve killed her.” I reminded him he just took 7 liters of blood out of her belly, so there is nothing he needed to apologize for.
At Kijabe it is said that precious few survive codes – often due to the advanced stage of disease one sees before they come here for help.
I listened to Ruth's chest after 1 minute of compressions and several minutes of ventilation. Good breath sounds on the right, not so great on the left. We pulled the endotracheal tube back 2 cm and the breath sounds were fine. Resumed CPR. Our anesthetist appeared with some syringes.
“What do you want?”
“Epinephrine – 1 mg – IV ” I said.
More chest compressions, bagging the patient for another minute. I listened again – no cardiac activity. We continued compressions for another minute. “More Epi – 1 more milligram, do you have any vasopressin?”. The answer was no.
More chest compressions and bagging for another minute. We paused the bagging so I could listen again – I heard a soft tap – tap - tap. Then Ruth’s left ventricle surged to life. On about the 10th soft beat, it suddenly coordinated its strength and you could feel the pounding of her heart through her thin chest wall. She held her own but I needed to put her on an old Sieman’s ventilator, the only one that is working right now at the hospital. I placed a subclavian line to have better vascular access as we continued to resuscitate her.
A few minutes ago, now about 6 hours after Ruth’s heart stopped, she was laying in her ICU bed. I walked by and listened to her lungs and heart. She is still on a ventilator as I didn’t want to extubate her overnight, but she opened her eyes. I can only pray that she fully recovers and has a chance at life again. She has a long haul ahead of her. As for me, I was stunned by privilege of hearing her heart come back to life. A miracle.


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