During the first six months as an ICU nurse, I vividly recall seeing my first balloon pump — a cardiac assist device sitting in the aorta that helps the heart pump blood more effectively and improves perfusion to the coronary arteries. I became mesmerized by the possibilities of mechanical circulatory support. I was nowhere near ready to tackle a patient like this independently, but I found myself immersed in all the literature I could get my hands on about counterpulsation. I studied and read concept maps until my eyes hurt. I would be ready when my card was called to take that STEMI gone bad. Or at least, so I thought.
One humid June day, I arrived at work as I always did, met by the charge nurse telling me of an admission. She explains that the patient was a 49-year-old woman presenting with abdominal pain. She had a vagal episode on the toilet in the ED and cardiac arrested. Post-arrest, she was bradycardic with EKG changes warranting a STEMI activation, and she was whirled off to the cath lab.
Up until this point, I still felt confident and able to care for this patient. Even in my inexperience in the ICU, I knew a few things concretely: She was young, she had a negligible medical history. Plus, it was a witnessed in-hospital cardiac arrest with minimal downtime — all good prognostic factors. I began reassuring myself: A STEMI leading to an arrest meant that it was a potentially fixable problem, an intervention to be performed, a stent to be deployed — these are all positives.
The clock reads 7:45 p.m., and the family is crowding the entryway to our ICU. I decided to lead them to our waiting area to clear a path. There are about 15 of them, concerned and anxious.
Before I say much more, a man wearing a worried expression looks to me, “Is she going to be OK?”
It was a fair question to ask — a question that I did not have the answer to. Truthfully, I did not want to tell them that she would be OK. Being honest with our patients and family members, and with ourselves, is surprisingly more complicated than one outside of the medical field might imagine.
An internal struggle weighs our professional obligation of veracity and our personal obligation of being human. We are often in a unique position as the narrator of a total stranger’s greatest tragedy. The weight of this becomes impossibly heavy at times. Then there is our humanity, which yearns to ease that devastating look of concern on their faces and the tears that swell in their eyes as they ask, “Will she be OK?”
False reassurance will not cushion the blow. It may ease their anxiety and my own momentarily, but even if I am well-intentioned, it is selfish and unfair to promise something that cannot be promised.
I tell them that our cath lab is very good at what they do, and I’m sure they are doing all they can to help her. I walk back into the unoccupied room, gently closing the door behind me. I sigh. It hurts me a little.
As I am mentally preparing myself, the secretary hands me a note. Before I can hear or understand what she says, I glance down at the paper in front of me, and I see the words “balloon pump, swan Ganz catheter, dopamine, levophed — vasopressin to be mixed by ICU and ready to infuse on arrival.”
I feel a pit in my stomach. Warmth floods my face. “They are finishing up the case, and they will be on their way with the patient in 15 minutes.”
“Shit,” I mutter under my breath.
I started mixing and priming the vasopressin, wondering why she had such a pressor requirement after a procedure that should’ve fixed the problem. It is only Melissa and me in the room, and I’m not talking. She senses my anxiety, and asks “Why are you priming vaso?” I reply, “The cath lab asked for it. They just pushed some before they left to hold her until they got here.”
She read me like an open book.
“Do you think we should put the code cart outside of the room? Yanno, ward off bad juju?” We both knew this wasn’t merely a superstitious gesture and that we’d be opening it within the hour. “Yes,” I say.
I hear our double doors open across the unit as my patient makes her way to room 11, where three other nurses and I stand waiting. Our unit is U-shaped, starting with the double doors and room one, looping around two bends, terminating with me, and the code cart — Room 11.
I listen for the sound of the balloon pump, a sound that used to flood me with excitement. That excitement was immediately replaced by the feeling of impending doom. It didn’t sound like I remembered — it was irregular, skipping beats. Slow. She was bradycardic, I think to myself as she passes room 8.
A stretcher swiftly rolls in front of me, followed by what seemed to be a parade of cath lab staff. It’s worse than I thought. She’s gray, she’s surrounded by tubing intricately tangled like Christmas lights you bring down from the attic, woven in cables upon cables to monitor her heart rate, stiff transducer tubing to monitor her arterial lines, the ventilator tubing to deliver breaths.
I hear the cath lab nurse giving me a report, but it just sounds like a distant hum, “Her coronaries were clean, but her EF is only 25%, and that’s an ‘extremely modest’ estimate. No apical ballooning and no culprit lesion.” “He was going to place an impella, but she was so vasoconstrictive that he couldn’t cannulate the artery.”
The fear that brewed inside of me grew exponentially, like a balloon ready to burst with each word she uttered. I glance briefly at the drips. Maxed on dopamine, maxed on levophed, maxed on neo, vaso was running, she’s on an epi drip. I look at the rate — I can go up another five mcgs with an MD order. Her heart rate is 43. Her blood pressure from the balloon pump central lumen is 60/43. “Her pH in the cath lab was 6.6”. She’s on a bicarb drip. As much as I hated to admit it to myself, no amount of any medication was going to fix this woman.
I open my mouth to ask my first question: “Does she have a pulse?”v
I begin searching and admittedly praying — for even the slightest bump against my fingers as I press them on her carotid. Nothing.
I hardly remember starting CPR; I only recall being about three feet in the air with the top of my foot squeezing tightly against the side rail so that I didn’t fall off. I can feel the balloon pump counterpulsation against my compressions. I’m pushing hard. I look to the end of the bed and yell, “Pull off the balloon pump leads!”
Our intensivist rounds the corner. I glance up to meet his eye once he’s in the visual field of me perched over the patient’s chest. He is closely followed by Dr. Peters, the interventionalist that performed the case. Both appear defeated, but neither of them surprised.
We pushed epi after epi, four amps of bicarb, calcium, mag, atropine. We intermittently got a barely detectable pulse. She begins oozing from every line she has. Blood stains the previously white sheets. I can’t tell where it’s coming from, only that it’s everywhere. My heart continues to sink — DIC. Two units of FFP are running, epi drip is now double our “recommended max,” and there’s no room to go with any of the other pressors.
We give her a few liters of fluid wide open. We try to use her PA line to push meds, but she’s so clamped down that it isn’t even patent. I watch as my syringe of epi empties out onto the floor as I push with all my might through the proximal infusion port. Useless.
We’ve been coding her for 45 minutes. We’re on our last epi in our second code cart. Ripped up pre-packaging of atropine and empty bags of blood product scatter the floor. You can’t see the sink faucet behind the sea of piled-up vials, tubing, syringes that were emptied into this woman.
Someone said the words I was dreading, “We need to bring the family in.” I pause and recall the look on their faces in the waiting room just an hour before. I scan the room to observe what they’d be walking into, and it was utter chaos.
We knew this was organized chaos, but they didn’t. They would see unfamiliar faces in scrubs and white coats and unfamiliar machines all working on someone they loved.
I look at Annette: They would see an unfamiliar version of their wife that they kissed before work this morning, their mother that was just in the ED the previous day and sent home on antibiotics, their sister that they’d probably gossiped with recently over coffee.
They would see a version of this woman that they should never have to see. I remember thinking, “This is why you can’t promise people that someone will be OK.” Out of all the points, I had felt my heart sink leading up to this; I was sure that my heart could not possibly sink any lower at that moment. It had hit bottom. I couldn’t brace myself.
Her two daughters and her husband walk through the door. I don’t want to see their expressions. I look away. We continue to code her. Her daughter Sarah meets my eye, looks at me sternly and wails, “Please, don’t let her die!!” They cling to her. They speak to her and plead with her to stay with them. “I’m only 25. I’m not supposed to lose you right now, Mom!”
I crumble inside. We continue for their sake. We continue until we cannot anymore. None of us wanted to stop, but we all knew the grim reality — she was gone. We were not going to save her life as Sarah asked me to. She was not going to be OK like her brother inquired earlier.
Time of death 8:56 p.m. My first balloon pump.
Lauren Powers is a critical care nurse.
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