"Shit! Don't give me any bullshit!" said Dr. Mike Carlucci under his breath as his gaze locked on the unusual rhythm displayed on the EKG monitor. His warning was meant mostly for his patient, Mr. Rakovic, who was scheduled to undergo an arthroscopy of his right knee. Mike's plea was also directed at God, just in case he was listening, and at the monitor itself to cover all bases. Mike didn't expect a reply from any of them. Mr. Rakovic was deeply unconscious with an endotracheal tube sprouting from his mouth. Mike had just induced general anesthesia and was preparing to fill out his chart when the trouble began.
Mike stared grimly at the potentially lethal dysrhytmia known as ventricular tachycardia, or V-tach, and felt the first raw edge of fear scrape lightly across his nerves. It occurred to him that he had never actually seen V-tach during a routine induction in his six years at Mercy Hospital, or during any induction for that matter. It was something that happened in the case reports, not in real life. He wondered if Doug Landry, his best friend and colleague, had ever seen it.
His first instinct was to doubt the EKG. Frequently movement of the patient or electrical interference caused the EKG to register falsely. He rapidly scanned his array of other monitors. Modern anesthetic workstations had upwards of ten sophisticated computer-driven monitors. Substantial redundancy of these instruments allowed him to check one machine's errors against another. The pulse oximeter, a small finger-clip sensor, beeped at a heart rate exactly the same as the EKG. This unfortunately ruled out the possibility of EKG artifact; there was no false reading this time.
Mike absently fingered the gold crucifix dangling from his neck. Grandma Carlucci had brought it back from Lourdes, and had given it to him when he had graduated from med school. The medallion always comforted him. He punched his Dinamap, the automatic blood pressure machine, for a stat reading. The mass spectrometer system, which continually monitored the gasses going in and out of Mr. Rakovic's lungs via the endotracheal tube, registered normal carbon dioxide levels. Mike breathed a sigh of relief; it meant the breathing tube was properly positioned in his patient's trachea and not in the esophagus. He quickly checked breath sounds with his stethoscope to ensure both lungs were being ventilated normally. They were. The pulse oximeter showed a ninety-eight percent oxygen saturation level, confirming beyond doubt that his patient was being adequately oxygenated. Again good. However, nothing to explain the sudden appearance of V-tach.
The blood pressure reading would be key for a number of reasons. First and foremost, Mike knew he must treat the offending rhythm; its cause was of secondary importance at the moment. A normal blood pressure reading would mean Mr. Rakovic would still have adequate blood flow to his vital organs -- brain most importantly -- in spite of the rhythm disturbance. Mike knew that as V-tach accelerates, the heart can beat so fast it doesn't have time to fill and fails as a reliable pump. The blood pressure can fall drastically or disappear altogether.
"C'mon you piece of shit! Read, damn it!" Mike hissed under his breath to his Dinamap. Fifteen seconds never seemed so long. While waiting for the blood pressure, he opened the top drawer of his anesthesia cart and pulled out two boxes of premixed Lidocaine, a first-line emergency antidysrhythmic drug. He ripped open the boxes and assembled the syringes. He glanced up at Diane, the circulating nurse. She was busily filling out her paperwork, oblivious to any problem.
"Diane," Mike called out, "I got trouble here. Get the crash cart!"
"Jesus, Mike! Are you kidding?" asked Diane, eyes bugging wide, pen frozen in mid-task.
"Serious badness," Mike said trying to keep the dread he felt out of his voice. "Looks like V-tach." His voice sounded a little higher than he had intended.
"Oh shit!" she said as she hurried out of the room, almost tripping over the trash bucket. Mike was thankful that Dr. Sanders, the orthopedic surgeon was still out of the room scrubbing his hands. No time to tell him just yet; he wouldn't take it well. If the blood pressure were unacceptably low, Mike would need to shock the patient back into a normal rhythm. He injected one of the syringes of Lidocaine into the intravenous line and simultaneously felt Mr. Rakovic's carotid pulse. It was bounding, arguing against a low blood pressure.
250/120! "Holy shit! Where'd that come from?" Mike asked the leering LED face of the Dinamap. Accusatory alarms screeched from the Dinamap in response. Mike truly had not expected such a high blood pressure and was momentarily confused. The temperature in the OR seemed to have jumped twenty degrees, and he felt rivulets of sweat coursing down his arms. The fear was back and not so easily dismissed this time. Think, damn it, think! What would Doug do?
He quickly reviewed what he knew of Mr. Rakovic's medical history and his own induction sequence. Mr. Rakovic was a sixty-two-year-old hypertensive with a history of coronary disease and a prior heart attack. But, his hypertension was well controlled on his current regimen of beta and calcium-channel blockers. Mike knew his patient had a bad heart, and had taken care to do a smooth induction along with all the usual precautions to avoid stressing the heart. A blood pressure of 250/120 and V-tach at 160 beats-per-minute were about the worst stresses any heart could undergo. Mike knew this, but was still baffled. Be cool, Mike. Be cool.
He had been stumped before; medicine was by no means an exact science, and anesthesia was one of the frontiers. Mike also knew better than to waste precious time pondering this. As long as he had reviewed it sufficiently to make sure he hadn't overlooked something, it was time to move on to the immediate treatment. He could replay the case to search for subtle clues when Mr. Rakovic was safely tucked in the recovery room.
What lurked in the back of Mike's mind during these first few minutes, prodding him along, was the specter of ventricular fibrillation or V-fib. V-tach was reversible with rapid proper treatment. V-fib, on the other hand, was often refractory to treatment, leading to death. The problem was that V-tach had a nasty habit of degenerating into the dreaded V-fib without warning. The longer V-tach hung around, the more likely V-fib would appear. So Mike knew time was of the essence.
"Gotta bring that pressure down," Mike mumbled to himself. He reached back into his drawer for Esmolol, a rapidly acting, short duration beta-blocker designed to lower blood pressure. He drew up 30 mg and pumped it into the IV port. He also punched in the second syringe of Lidocaine. Mike tried hard not to take his eyes off the EKG monitor for long as he drew up and administered the drugs. He wanted to see if the V-tach broke into a normal rhythm or converted into V-fib. Irrationally, he felt that if he continued to watch the rhythm it wouldn't convert to V-fib; if he took his eyes off it for too long, the demon might appear.
His Dinamap on STAT mode continued to pour forth BP readings every 45 seconds. 290/140.
"What the hell!" Mike said. Alarms were now singing wildly in the background adding to the confusion.
Just then, Dr. Sanders charged into the room demanding answers. "What's going on here, Carlucci?" roared Sanders.
Mike didn't have time to deal with the irate surgeon. A wave of nausea swept over him as he felt events slipping out of control. Things were moving so goddamned fast. Fear threatened to engulf him. He managed to blurt out, "Hypertensive crisis!" while he grabbed for some Nipride, his strongest antihypertensive. Unfortunately, it had to be mixed and given as an intravenous infusion rather than straight from the ampule. This would take a minute Mike and his patient could ill-afford. Diane returned with the crash cart and several other nurses. She looked at Mike and said, "Do you need help?" It certainly sounded like she thought he did.
"Get Landry in here stat!" Mike yelled in response. He took his eyes off the monitor as he worked on the Nipride drip. Just as he got the Nipride plugged into the IV port, he heard an ominous silence.
The pulse oximeter had become quiet. Usually the pulse ox signaled trouble, such as a falling oxygen saturation, by a gradual lowering of the pitch, not an abrupt silence. Mike could think of only three possible causes and two of them were disasters -- V-fib or cardiac standstill. The third reason could be as simple as the probe slipping off the finger. Although this third possibility was enormously more likely, Mike doubted it. As he turned his head toward the EKG monitor, he knew with eerie prescience what awaited him.
V-fib greeted him from the monitor. He had failed to get the blood pressure down fast enough. The V-tach had degenerated into V-fib as the strain on the heart had become too much. His Nipride was now useless; in fact, it was harmful. He immediately shut it off. Mike knew that in V-fib, the heart muscle doesn't contract at all; it just sits there and quivers like a bowl full of jello. No blood was being pumped. High blood pressure had ceased to become a problem; now there was no blood pressure. Brain damage would ensue in two minutes, death in four to five minutes.
Doug Landry, the anesthesiologist on call that day, burst through the OR door. "What d'ya got Mike?" he asked slightly out of breath. Doug glanced at the EKG monitor and said, "Oh shit! Fib!"
"Paddles!" shouted Mike, comforted by Doug's presence. "He went into V-tach, then shortly into fib," said Mike nodding at the monitor.
"Yeah, I see." Doug said. His large sinewy frame looked like it was coiled for action. Diane handed Mike the defibrillator paddles.
"400 joules, asynchronous!" Mike barked.
Diane stabbed some buttons on the defib unit and it emitted some hi-pitched electronic whines. "Set," Diane said shrilly.
"Clear!" Mike shouted.
Mike fired the paddles and a burst of high-energy electricity pulsed through Mr. Rakovic's heart and body. The EKG monitor first showed electrical interference from the high dose of electricity, then quickly coalesced into more V-fib.
"Shit!" Mike said. "No good." He had never appreciated how ugly those little, spiky waves of V-fib were.
"Hit em again, Mike," Doug said.
"OK. Recharge paddles." The paddles took several seconds for the high amperage capacitors to charge between countershocks. "Better start CPR," Mike said as he began pumping on Mr. Rakovic's chest. His hands soon became slimed from the electrolyte gel left by the paddles on Mr. Rakovic's chest. God, he hated chest compressions.
"Paddles are ready, Doctor!" said Diane. Her eyes were wider than before and her mask ballooned in and out, as she gulped air.
"Boom" went the paddles again and Mr. Rakovic's body convulsed a second time. Mike stared at Mr. Rakovic's face as it contorted, reminding him of a medieval exorcism. Mike held his breath and waited for the monitor to clear, pleading with it to show him some good news.
"Still fib!" Mike growled. He resumed chest compressions as he nodded to the circulator to recharge the paddles yet again.
"Epinephrine? Bicarb?" asked Doug.
"Doug, I don't think he needs epi," Mike replied quickly. Mike wondered if Doug was also feeling the pressure. His voice was too damn even, though. "His pressure went through the roof on induction. I don't know why, but I just can't believe he needs epi."
"Okay," Doug said. "The paddles are ready." Doug's forehead creased momentarily, then he added, "V-fib in an elective case. Unusual. Any history, Mike?"
Mike stopped compressions long enough to fire the paddles a third time. He smelled the ozone coming off the arcing paddles. The V-fib continued. Gimme a break, Mr. Rakovic!
"Shit! Charge the paddles again," Mike said to Diane. He turned to Doug. "Yeah, prior MI, stable angina, hypertension. Doug, I think we better try Breytillium. I already gave him two doses of Lidocaine." Sweat was now soaking through his scrub top, pants, and surgical cap, and running down his face.
"Yeah, sounds like a good idea," said Doug. "I'll take care of it."
Mike glanced over at Doug and cursed his calm efficiency. He knew "the Iceman" was a veteran of the OR wars. Doug had worked at Mercy for twelve years. He had been on the front lines before and had always performed well. Doug reminded Mike of his mentor in residency days, Dr. Hawkins. Mike thought he could hear Dr. Hawkins now: "Retaining control and being cool are critical in these situations. Split second decisions need to be made. Panic is a luxury you can't afford." The advice sounded hollow.
"Any allergies, Mike?" Doug asked. "Malignant hyperthermia? Breytillium's ready."
"No allergies." Mike was breathing hard now and had to space his words with short gasps. "Doesn't look like MH -- no temp. Hurry Doug. Run that shit. He's been in fib for a while. We're running out of time. He may never come out."
"I'm bolusing now," Doug said as he injected a large quantity, "and here goes the drip."
Mike clung to Doug's steady voice like a lifeline. Mike realized that he was in danger of losing control. He could see it in the trembling of his own hands and hear it in the huskiness of his own voice. He wondered if Doug noticed. Deal with it, Mike. Deal with it.
Hawkin's words floated back to him again. "It's just like being in combat. Soldiers can train and drill all they want, but they never really knew how they'll react until the bullets are real and start to shriek by their heads. Will they turn tail and run, or fight back?" Leave me alone, Hawkins!
Mike looked around the room. He felt they were all staring at him; he could read the expressions in their eyes: "It's your fault! You screwed up!"
"Try it now, Mike," Doug said, jolting him back to reality.
Mike grasped the paddles tightly to prevent them from slipping from his slick hands and applied them to Mr. Rakovic's hairy chest for the fourth time. He pushed the red trigger buttons on each paddle simultaneously to release the pent-up electricity. All 280 pounds of Mr. Rakovic's body heaved itself off the OR table again and crashed down, sending ripples through the fat of his protuberant abdomen. Mike now smelled an acrid, ammoniacal odor and realized it was coming from the singed hairs on Mr. Rakovic's chest. He frantically wiped the burning sweat out of his eyes so he could see the monitor. The V-fib continued stubbornly and had begun to degrade into fine fibrillations. "Damn you!" Mike yelled at the monitor.
"I'll give you some bicarb," Doug said. Out of the corner of his eye, Mike thought he could see Doug shaking his head slightly.
The next fifteen minutes were a blur to Mike. More chest compressions, more emergency last line drugs, many more countershocks were tried. Nothing worked. Mr. Rakovic continued to deteriorate, his pupils widening until at last they became fixed and dilated. His skin was a gruesome, dusky purple-gray. He was dead. Doug finally called the code after fifty-three minutes and gently persuaded Mike to stop chest compressions. Dr. Sanders walked out of the room without saying a word.
Mike was numb as he stared at the corpse in front of him. One portion of his brain, however, continued to function all too well. It kept replaying his initial encounter with Mr. Rakovic in the holding area. He could see Mr. Rakovic in vivid color and hear him plainly, as the rest of the OR faded to silent gray. They had joked about the Phillies' pitching staff. They wondered whether Barry Bonds would break Big Mac's homerun record. God, he wanted this to stop, to get his laughing, living face out of his mind. But he couldn't. His mind was a demonic film projector playing it over and over. He felt very sick to his stomach and had an overwhelming need to get out of the room and get out of the hospital with all its stinking smells. Just go, anywhere but here.
God, this was what he hated about anesthesia. One minute you're having a casual conversation with a living, breathing, laughing, for God's sakes, human being and the next you're pumping on his chest. He becomes subhuman before your eyes as his face turns all purple and mottled. He cursed his decision to ever become an anesthesiologist. What in God's name was I thinking? Frail human beings were not meant to hold someone's life in their hands. The responsibility was just too awesome.
"Mike. Hey, Mike. You OK?" Doug put his hand on Mike's slumped shoulders. Mike came out of his trance enough to nod his head. Several tears rolled down his cheeks. "Mike, there's nothing else you could've done," Doug continued. "We were all here too. He must've had a massive MI on induction. Not your fault. Some of those guys just don't turn around no matter what you do. Don't blame yourself. We tried everything."
"Yeah, I know Doug. But I just can't get his face out of my mind. We were talking, joking just an hour ago. Now he's dead."
"C'mon, let's get out of here." Doug led Mike out of OR#2. "I know you might not be up to this, but Mike, you've got to talk to the family. Did he have any relatives here with him?"
Mike didn't answer immediately. As the adrenaline haze faded, he struggled to regain control. He felt completely drained with an enormous sense of loss but coaxed sanity back into place. "Yeah, he came in with his wife. Nice lady." Mike paused, feeling his vision blur again, this time with tears. "What do you say, Doug?"
"Listen, I'll go with you. Just tell her what happened. Everything was going fine. He went to sleep and then bam, out of the blue, he had a massive heart attack. Nothing in the world was going to save him. We worked on him for almost an hour and tried everything. Tell her we're really sorry."
"OK. Help me, Doug." He would've rather stuck nails in his eyes than face Mrs. Rakovic at that moment.
The two men walked through the electronic entrance doors toward the OR waiting room. Mike swallowed hard and entered the small windowless room. Doug was right beside him. Mike searched the faces until he found Mrs. Rakovic. It wasn't hard. As soon as she saw him, she immediately leapt out of the chair with a quickness that belied her bulk. Her frantic gestures revealed the depth of her hysteria. Mike walked over and she collapsed into his arms. "Tell me is not so!" she wailed in her thick, Slavic accent. "Tell me Doctor Sanders made mistake. Not my Joey!" She cried convulsively.
"I'm so sorry, Mrs. Rakovic," Mike said blinking fast. "He had a massive heart attack. We tried everything." He felt her tears burn into his shoulder and then felt his own tears stream down his face. "I'm sorry." Her wracking sobs shook them both.
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