Can't save everyone

Last night I signed up for a back pain. I had about five other active patients at the time so I figured a back pain wouldn't hinder me too much. I walked in to the room just as EMS was leaving. I heard them mention to the nurses that they had given him 75 mics of fentanyl, 4 mg of morhpine and 4 mg of zofran. I could tell this guy was really uncomfortable. He was diaphoretic and his blood pressure was 225/115. I ordered 1 mg of dilaudid and 10 mg of hydralazine (his pulse was 65). We waited a few minutes, cycled the pressure and saw no change. This guy was in his 30s so I looked at his wife and asked if he did any drugs. She looked at her husband and then looked at me with remorse. She didn't say anything, but her eyes had YES written all over them.

The patient then began to say he felt the pain tearing up his back. I looked at the monitor and saw a once normal heart rate now beating at 150 bmp. The patient grabbed his chest, and then he took his last breath.




I couldn't believe it. This guy's presentation was so classic it was surreal. I blogged a few weeks ago about how useless pneumonics and "classic presentations" were in real-world medicine, and then this guy classically dissects his aorta right in front of me. Of course we started ACLS on the guy, but it was useless. While chest compressions were being performed, one of the other residents grabbed the ultrasound machine and placed the probe on his abdomen. We all saw the dissection clearly.

I went to talk to his wife as she had been escorted out of the room while all this was going on. She looked at my face, and with tears in her eyes I knew that she knew there was no good news coming. I was blunt but compassionate when I explained the circumstances of her husband's death. I concluded with saying "despite out bests efforts, your husband died today." I find there is no substitute for the "D" word. If you say "he passed away" or "he didn't make it" a patient will, for one reason or another, maintain the faintest bit of hope that there is chance for their loved one. Death is death, clear, and unmistakable.