His blood pressure disappeared. The arterial tracing, a red line on the monitor reassuringly undulating with every beat of his heart, falling from 122/83, 99/64, 80/50, 67/42, then a flat line at 48.
I had just come off the elevator, ushered in by the surgery resident who found me in the hallway searching for the right room.
Epinephrine. Get the code cart. Check for a pulse. The nurse screwed the two halves of the code syringe together and forced the medicine into his vein.
Too much epinephrine. Now his blood pressure was 280/142. The surgeon stood at the foot of the bed watching the red line bouncing and hoping every stitch he tied on this man’s heart eight hours earlier was a perfect stitch. Too much pressure for the freshly sewn coronary after bypass grafts, too much power for the tiny oozing vessels tucked underneath the metal wires that held his chest together.
I came up here to bring him back to the operating room. After today’s surgery blood had oozed out of the drains sewn into his chest, a little more than usual but not enough to make anyone nervous. Into the evening the drains stopped oozing, but the severed veins in his chest did not. The drops of blood, unable to escape out the clotted drains, slowly gathered in the space around his heart. This space, walled in by lungs and a chestbone held closed with strong metal wires, could not expand to make room for the new blood. This blood surrounded his heart, pushing in from the outside, finally building up enough pressure to make it impossible for his heart to fill with the blood returning from his veins. The word for this is beautiful: tamponade.
As I watched the blood pressure tracing fall, enough blood finally surrounded his heart and pushed on its thin walls to prevent any blood from filling it on the inside. His empty heart beat angrily in his chest. No blood came in or out. His blood pressure disappeared. A nurse got the code cart.
The epinephrine tightened his arteries and veins and gave the muscular fibers of his heart a new strength. His heart squeezed hard enough to fight the pool of blood crushing in on it. His blood pressure returned.
The epinephrine was a transient blast of power. In a few minutes it would be gone, and I would be in the elevator with him on the way to the operating room, blood pressure falling again, eyes looking at me.
I rushed back down to the operating room. I collected syringes with labels colored purple, green, red and yellow, filled with medicines to squeeze his arteries, to speed his heart, to paralyze his muscles and keep him asleep. Now I was ready. It was past midnight and the elevator took me back up unimpeded, fast.
Downstairs in the operating room the anesthesia overnight call team was starting a transplant. They were bringing a bleeding intra-abdominal catastrophe into another operating room. The cardiac anesthesiologist had been called in and she was driving. It was a clear spring night, not so cold anymore that your breath would freeze when you exhaled.
Back upstairs I was watching the arterial tracing bounce. The numbers were perfect now. I opened the chart and with a blue ballpoint pen started to write: tamponade, stabilized, still intubated, no time to call his wife to get consent, heading to operating room. I scrawled my long cursive signature and looked up from the page. The arterial line was flat again.
This time I had drugs. I scrambled for the IV and gave a small dose of epinephrine. Nothing. Double the dose. Nothing. Double that. The flat line began to bounce again. I emptied the syringe.
“He has a blood pressure. We need to get in the elevator now.”
I was a resident and the cardiac anesthesiologist was still driving. The patient barely had a blood pressure and it was falling. We edged the bed away from the wall, disconnected the ventilator and the monitors, reconnected to a transport monitor and an oxygen tank.
Slowly we pushed the bed down the hall, through the double doors and onto the wide transport elevator. I emptied another syringe into him. With every breath from the oxygen tank his blood pressure plummeted. His heart could barely battle the blood pushing in on it; the pressure of inflated lungs was too much for him to fight against.
“Slower. His blood pressure drops forty points every time he gets a breath.”
Three nurses, a surgeon, a respiratory therapist and I crowded into the elevator, surrounding the bed on one side so the doors would close.
“Ninety-five over fifty and holding.” There were six of us in the elevator with him but I was the one pushing the drugs that kept the blood flowing to his brain.
Once we got to the operating room there were plenty of people to help. The cardiac anesthesiologist arrived five minutes later. The surgeons opened his chest and removed handfuls of clotted blood.
“Sorry we couldn’t wait for you to get here. He didn’t have a blood pressure. I’ve never seen tamponade. Real tamponade, like no blood pressure at all tamponade. It was scary.”
“You did great. You got him downstairs alive.”
In the fall I will be finished with my anesthesia residency. There will be a night when I will be the only anesthesiologist here in this vast hospital. It will be cold outside with the winter starting to return. At home my kids will be sleeping upstairs and the heat will be cracked on, the radiators singeing the summer’s dust for the first time. My pager will ring and I will go upstairs to the Intensive Care Unit because someone needs to come to the operating room right away, and I will take them down in the elevator by myself, and I will keep them alive.
Felicity Billings is an anesthesiology resident who blogs at One Case at a Time.
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