VT, or ventricular tachycardia, was where a ventricle, one of the lower chambers of the heart, beat too fast; it could lead to ventricular fibrillation, where the heart contracted but didn’t pump blood around the body, and it was life-threatening.
‘OK. We know the drill,’ David said wryly. ‘Crash team. Mina, can you remove the clothing from Rod’s upper body, so we can position the paddles more easily?’ he asked the first-year foundation doctor.
Mina did so while David checked Rod’s intubation and Becky checked his pulse. ‘He’s in pulseless VT,’ she reported.
David sighed and put one paddle on the apex position and the other on the right of Rod’s breastbone, just below the clavicle. ‘Charging to two hundred,’ he said. ‘Stand clear.’
Everyone took their hands off the patient.
‘Shocking now.’
Becky glanced at the ECG. ‘No response. He’s still in VT.’
They waited ten seconds to see if the ECG trace changed—the protocol was that you didn’t check the pulse after a shock unless the heart rhythm changed.
‘Charging to two hundred again,’ David said, keeping the paddles on the gel pads. ‘And clear. Shocking now.’
Still no response.
‘Charging to three-sixty,’ David said, ‘and clear. Shocking now.’
To everyone’s relief, the ECG showed a clear sinus rhythm—the normal beat of the heart.
Becky checked Rod’s pulse and her stomach plummeted. ‘No pulse. He’s gone into PEA.’ PEA, or pulseless electrical activity, was where the heart rhythm seemed normal on the ECG screen, showing that there was electrical activity within the heart, but the heart wasn’t actually pumping blood around the patient’s body.
He was intubated, on oxygen, and there was no sign of a bleed; they also knew from the history that the patient had given them that he wasn’t on any medication and hadn’t taken any drugs. So that narrowed down the likely causes of the problem.
David grimaced. ‘My money’s on thrombosis—a huge MI.’
Which meant the chances of a good result were slim. Becky knew that when a patient had gone into PEA, if they couldn’t find the underlying cause fast enough, they treated the patient as if they were in cardiac arrest. The odds weren’t on their side, but she drew up a milligram of epinephrine and handed it to David. ‘Want me to bag while you do the compressions?’
He nodded. ‘Sure I can’t persuade you to come with me? We could do with a really good nurse on the team. Especially one who’s a nurse practitioner.’
‘Thanks, but I’m happy here in Manchester,’ she said. Maybe a year or eighteen months ago, she would’ve jumped at the chance to get away from the mess of her failed marriage—and the even messier bit she’d never told anyone about, even her closest friends—but she’d stuck it out and her life was back on an even keel now.
‘Hmm.’ David looked at the ECG monitor. ‘As the underlying rhythm’s bradycardia, let’s try atropine as well.’
She drew up a milligram and checked it, then David administered the drug.
Just respond, she begged their patient silently. You’ve got a family on its way to you, needing you to wake up. Rod Hawes was a family man who’d been out with his wife and kids, having fun. Why the hell did this sort of thing have to happen? Why couldn’t it happen instead to someone who’d made his family’s life miserable and wouldn’t be missed?
She pushed the thought away. Not here. Not now. Despite the two rotten days she’d just spent in London, this wasn’t the time or place to think about that. She needed to stay detached, do her job.
Ten sequences of basic life support over three minutes, checking for a pulse after each one.
‘Still no pulse,’ she reported.
‘No change on the ECG,’ Mina said.
Another milligram of epinephrine. She counted the rhythm: fifteen chest compressions to two breaths.
Still nothing.
Come on, come on, she thought. Go into VF so we can go back to shocking you. Get your heart started again.
Irene, one of the staff nurses, came in. ‘His family’s here,’ she said.
David nodded, his face grim. ‘Now’s not a good time for them to see him. Can you take them to the relatives’ room and look after them? I’ll be with them as soon as I can. As soon as we get him to respond.’
‘Will do.’
But after they’d been working for twenty minutes, David stopped. ‘It’s not going to happen,’ he said softly. ‘His brain’s been without oxygen for twenty minutes. He’s gone. Everyone agreed that we call it?’
One by one, very quietly, the rest of the team agreed.
‘Right. Time of death…’ he looked at the clock ‘…four forty-seven. Thanks for your help, team. Sorry we didn’t make it.’ He raked a hand through his hair. ‘This sucks. Big time.’ He sighed. ‘Better go see his family.’
‘Do you want me to do it?’ Becky asked.
He patted her shoulder. ‘You’re a sweetheart for offering—but it’s my responsibility. I’ll do it.’
‘I’ll call his GP, then, and inform the coroner,’ she said. ‘And fill out the forms for you to sign.’
‘Let’s hope I’m a bit better than this when I get out to Africa,’ he said, shaking his head in apparent disgust with himself.
‘Hey. Don’t beat yourself up. You know as well as I do that PEA doesn’t have a good prognosis—and one in three patients with an MI don’t even make it to the emergency department in the first place. You did your best. We all did.’
Neither of them said it, but she knew they were both thinking it: their best just hadn’t been good enough.
And although Becky was based in the minor injuries section for the rest of her shift and concentrated on treating each patient, there was still that underlying misery she felt whenever they lost a patient. A dull, heavy feeling that wouldn’t shift, even by the time she got home.
‘Bad day?’ Tanya, her housemate, asked as she walked in.
‘Does it show?’
Tanya nodded. ‘From the look on your face, I’d say you lost a patient.’
‘Yes.’
Tanya gave her a sympathetic hug. ‘That’s exactly why I could never work in emergency medicine. At least in paediatrics most of our patients make it.’
‘We don’t lose that many,’ Becky protested.
‘You know what I mean.’
