The other night I was called urgently to the ICU. A 20 year old girl had arrived intubated from a nearby hospital. She had about a week of pain in her side and the night before had vomiting and diarrhea. At the outside hospital, she was hypotensive and tachycardic. She received a total of 5 liters of fluid with no response in her blood pressure. Her initial chest x-ray showed “fluffy infiltrates” bilaterally (her lungs had some junk in them). Four hours later when she was not responding to fluids, another x-ray showed even worse infiltration. She was intubated and sent over via helicopter. She was started on dopamine, a hormone to help elevate the blood pressure and provide oxygen to the brain and heart. Another chest x-ray showed a complete “white out” of her lungs. She was on 18 of PEEP on the ventilator (continuous pressure was required to push her lungs open, even after she had exhaled). Her blood pressure continued to drop, she was started on a 2nd and then 3rd blood pressure agent.
Her kidneys had shut down, her liver was failing, she was starting to bleed from every place she was poked by a needle. Her belly was distended, her lactate climbed from 7 to 12; and her pH was 7.1. Her oxgyen saturations never read higher than 70%. The ICU team was convicned that she had suffered from a ruptured appendix or a perferated ulcer from all the ibuprofin she had been taking over teh past week. I called the attending surgeon at home, at 1:30 AM, and told him the grim story. She’s not responding to medical treatment, I told him. If she has a surgical problem, it may be the only way to save her. But if she’s not, she may not survive the operation.
We took her to the OR around 4am. Imagine trying to move a critically ill patient around the hospital with three infusions of blood pressure medicines, red blood cell transfusions, clotting factor infusions and a ventilator. When the ventilator was disconnected to trasfer her to the anesthesia machine in the OR, orange fluid gushed out of her lungs. We didn’t have time to suction it out and she was placed on high pressures again .
I scrubbed in with the surgeon and we opened her belly. More orange fluid gushed out. But her appendix was fine. There was no blood, no stool, no abcess, no pus, no perforated hollow organs. “Her kidneys seem large” was the only comment by the surgeon. We closed her back up.
Her blood pressure started to plumment, her heart rate slowed, we started CPR. No one could believe that a 20 year old was dying and nobody could figure out why. We gave her epinephrine, atropine, calcium…no response. I stopped CPR and the little blood pressure she had left went away completely. Her heart stopped. She turned blue. The code was called, she was dead.
A minute later, the monitor came to life again. Her heart rate climbed to 120. Her blood pressure read 200/100. She had come back around…mabye the calcium kicked in and stabilized her heart? We rushed her back up to the ICU for them to continue to figure out the mystery.
The next morning on our ICU rounds, her bed was empty. She had lived for only another 6 hours after returning from the OR.