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Hi TL.
First of all, let me thank you guys for featuring my blog "A doctor with a broken voice, and dying well" in Pony Tales #7 central pages. You sure made me blush. It's an honor I was not expecting, so I really thank you all for your kind stars and the people involved in making the e-zine for thinking my blog post had cut the mustard to be in it. <3
I bring you another tale. This story is about a case I attended 3 days ago.
My patient was a 85 years old lady. Mother of 5 children, all grown up now of course; 3 men and 2 women. She had diabetes and had high blood pressure. Her husband passed away 10 years ago and since, she stopped taking her medications and went away into the far countryside to spend some time alone.
A few weeks ago, her elder son took her from the countryside into his house... A little closer to my town, but still in the countryside. Yeah, as you've already figured out, this town is pretty much surrounded by agricultural farms and bovine raising farms. He had NO IDEA of his mother's medical history until he found a little "patient's notebook" with citation schedules and her treatment.
10 days ago, she began having hallucinations. Then complaining about temporarely losing sight or seeing "flying lights". And finally, she had seizures.
That's when her son called to our family health centre and asked for a house visit into the countryside.
The next day, I drove 20 miles and found his house. He is a peasant in one of the largest bovine farms around here. The house was small, but cozy. Lacking in luxuries, since peasants around here aren't generally well payed. It was a poor house. But humble and full of that unexplicable human warmth, none the less.
He led me into his mother's room. She was resting in a small bed, very pale. I said hello, but she did not turn to look at me. Instead she was staring into the infinity, torwards the ceiling. She said hello. I then politely explained that I was a doctor who came to visit her because her son was worried for her health, because he didn't know her medical history.
The old lady was absolutely dissoriented. She thought we were in another town. That it was 1948. That she knew me from a long time ago.
I begin controlling her vitals. She had a very strong pulse, regular, at around 60 beats per minute.
Sat was at around 90%. Strange...
Blood pressure...
Wait, what? -I look at the blood pressure gauge in disbelief. I take it again.
This can't be... What the hell?
Her BP was at a scarcely believeable 250/140 mmHg.
That is very, extremely, SEVERELY FUCKING HIGH.
Normal BP for a regular adult is hovering @ [90/60 - 140/90] mmHg.
But the old lady had other issues.
Took my stethoscope and listened to her heart and lungs.
Lungs were filled up with liquid. Pulmonary oedema.
And then, without any warning, she begun seizing again. Full tonic-clonic generalized convulsions. I push an amp of Diazepam IM. Seizing stops. Then inmediately call the ambulance.
They get there in about 25 minutes. I intubate the patient and push an IV amp of Furosemide.
She seizes again. Another amp of Diazepam. Seizing stops.
A severe hypertensive emergency. We needed an infusion pump with to give her IV antihypertensive meds.
I then recall that her son told me she was losing vision for a few moments, then claiming to see "dancing bright lights"...
We rush back to our hospital to try to stabilize her. She had stopped seizing. Her sat improved to 99% with the intubation and assisted breathing. We just needed to control her blood pressure. There was no IV pump equipment in the ambulance. We had to get back to the ER...
We take an in-route EKG. It was remarkabely normal. Capilar glucose levels were surprisingly good for a lady who had not recieved treatment for her diabetes in over 10 years: 150 mg/dL...
All of the sudden, only 10 minutes after we left her home, the heartrate monitor goes flat. I thought an electrode had come lose. I check the pulse first and ask the EMT to check the electrodes.
No pulse.
Electrodes were fine.
Fuck.
We begin CPR algorythms. The EMT starts the cardiac compressions.
We arrive at the ER.
We rush into it. A colleague and friend of mine is waiting. He takes over the compressions. An IV pump is readily prepared.
Another colleague comes in after the ER's CPR alarm goes off. She takes over the ambu bag and keeps ventilating the patient.
I take an ophtalmoscope and look into her eyes searching for any signs of increased intracranial pressure (ICP). She might also be bleeding into her brain because of the extremeley high blood pressure and her brainstem could have herniatd.
Pupils were reactive. No oedema in the papillae. There didn't seem to be an increase in the ICP.
I took over cardiac compressions. She was still in asystole. Full flatline. Even though we followed the algorythm all the way, thought of every other possibility why she flatlined, asked for quick bloodtests which came back negative... And being performing CPR for over 35 minutes, she was still flatlining.
It was time to call it.
My colleagues look at me. I was atop the old lady, giving her chest compressions.
The attending ER doctor then states... "It's time to let her go."
Nurses let her son go in. My colleague delivers the bad news.
Then my other colleague pronounces the words you never want to hear then you're reanimating a patient.
Time of death? ...
Her son puts his hand on my shoulder, eyes weeping, and says "It's ok. You did your best... Her time has come."
It was a quarter past 4 in the evening.
As her son stated, her time had come.
 
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Wow, always sucks to lose someone but I'll be ecstatic if I get 85 years out of this life. Great blog!
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Very touching. Your passion for what you do shines through the text in your posts.
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I have no idea how doctors and other emergency medical personnel such as yourself deal with this job emotionally. I know I couldn't. You're truly miracle workers.
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Wow...nothing but the highest regard and respect for you. You did your best.
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A fitting story for me as I'm about to go to work at the ER right now. I feel like I will definitely think of this story if a patient comes in with cpr.
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TLADT24920 Posts
250/140? Holy shit >< That is so high ... Great blog!
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Wonderful way of writing, did you consider writing a book with these kind of stories? I think you have talent.
EDIT: I didn't mean to be rude about the emotional part by the way.
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Greece713 Posts
You have talent my friend. It is so rare to read something that moves me to the point of wet eyes.
Wonderful way of writing, did you consider writing a book with these kind of stories?
I seriously think you should.
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Truly touching. The world needs more people like you. Keep serving them patients and do the best.
Good luck for the future!
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i liked your blog, sad story tho 
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What a great, but sad story.
Question though: Why didn't you mention use of a defibrillator? Surely there was one in the ER if not the ambulance. Was it contraindicated in this case? Or was it a part of your "CPR algorithms"? I'm currently a med student and I'm just curious.
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Lost my grandpa last week. My family all watched him go. It was one of the most surreal moments of my life, and one of the saddest. But it was his time to go.
Nice story, thanks for sharing. As always.
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On January 26 2013 23:35 subV wrote:
What a great, but sad story.
Question though: Why didn't you mention use of a defibrillator? Surely there was one in the ER if not the ambulance. Was it contraindicated in this case? Or was it a part of your "CPR algorithms"? I'm currently a med student and I'm just curious.
It's not too sad, sometimes you just need to let people go, if she stopped taking her medication and at that age her will to live was probably not that strong anymore.
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Donde es esto?
also, you think her death time had been the same had you never went there?
she was in the same condition for some time...
i kinda dislike medical everything... my sister is an MD
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On January 26 2013 23:35 subV wrote:
What a great, but sad story.
Question though: Why didn't you mention use of a defibrillator? Surely there was one in the ER if not the ambulance. Was it contraindicated in this case? Or was it a part of your "CPR algorithms"? I'm currently a med student and I'm just curious.
In asystole you cannot defibrilate, since in order to do it you need disordered cardiac electrical activity (fibrilation). If there is no cardiac actovity, defib is pointless, so you use CPR and drugs such as epinephrine, athropine or others to improve chances of cardiac activity
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On January 27 2013 00:35 Inzek wrote:
Donde es esto?
also, you think her death time had been the same had you never went there?
she was in the same condition for some time...
i kinda dislike medical everything... my sister is an MD
I think the reality is that doctors do very little to affect patient outcome in a majority of cases, especially in the hospital setting.
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On January 27 2013 01:01 jackstitties wrote:Show nested quote +On January 27 2013 00:35 Inzek wrote:
Donde es esto?
also, you think her death time had been the same had you never went there?
she was in the same condition for some time...
i kinda dislike medical everything... my sister is an MD I think the reality is that doctors do very little to affect patient outcome in a majority of cases, especially in the hospital setting.
From my experience with television shows, this is absolutely not true. They actually save them in a majority of cases!
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On January 27 2013 00:35 Inzek wrote:
Donde es esto?
also, you think her death time had been the same had you never went there?
she was in the same condition for some time...
i kinda dislike medical everything... my sister is an MD
Southern Chile, 10th region.
And that is one hell of a tricky question... But I believe it might have not mattered. Her heart was already failing. She could have died a few minutes earlier, probably, if the BP hadn't been handled. And of course, without CPR, she would have died earlier. CPR actually sustains your heart activity artificially...
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Death is so scary!!! The thought of not being able to do anything about it sometimes bothers me. It will come to everyone someday. No one is exempt from it. It is so scary.
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On January 27 2013 01:01 jackstitties wrote:Show nested quote +On January 27 2013 00:35 Inzek wrote:
Donde es esto?
also, you think her death time had been the same had you never went there?
she was in the same condition for some time...
i kinda dislike medical everything... my sister is an MD I think the reality is that doctors do very little to affect patient outcome in a majority of cases, especially in the hospital setting.
Well then you should come to Norway. We do everything we can to affect patient outcome. I'm 3rd year medical school now. So I have been seeing a lot of operations and working with patients. The reason I chose to become a MD was to help people.
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On January 27 2013 15:46 number01 wrote:
Death is so scary!!! The thought of not being able to do anything about it sometimes bothers me. It will come to everyone someday. No one is exempt from it. It is so scary.
By the time you've been stuck watching shit happen here for 70+ years you probably won't be particularly interested in staying around, if that helps.
By the way, I love your blogs, the jargon goes over my head all the time, but it's all a part of the experience! Keep up the excellence at your profession.
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your blogs are always so interesting to read 
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EPT
