A slow way to go

I knew he was dying the moment he came in and I watched him slowly die. I was called to the bedside on three different occasions to evaluate a man with shortness of breath. The first time, he got a stat duoneb and got better. The second time, he was hypotensive. We put in central lines and started dopamine. A stat cardiology echo showed something flopping around in his right atrium and ventricle. Was it a clot? A ruptured cord? The third time was after his massive PE had reared its ugly head once more. This time I didn’t leave the room until he was dead.

We intubated him and he became bradycardic. His sats were in the 80s. It was really inevitable and everyone in the room knew it. His wife was at home, she can’t drive at night. We told her that he was very sick and might die. She said, “I knew he was sick, I told him to go to the hospital sooner.” We could squeeze all the oxygen into his lungs that we wanted, but that wasn’t going to get rid of the clot in his pulmonary arteries. Cardiology considered doing thrombectomy. The whole time we watched his heart rate slow. We all knew he was dying, and all we could do was go through the motions of a bradycardic arrest, which was of course followed by a PEA arrest. Occasional episodes of asystole prompted rounds of CPR. I even put in an external jugular 16 guage IV…his femoral veins were full of clot and the meds just wouldn’t flow. SO that was it. We gave up after about 40 minutes of CPR, Epi, Atropine, Fluids and more. Four attending physicians…ER, Cardiology, Cardiothoracic Surgeon, Invasive Cardiologist, all standing at bedside helpless.

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