Otso’s Hail Mary

It’s one of the first warm days of spring, and my first patient is in the hall. She was out with her walker, when she tripped and fell onto her knee cap, shattering it. She’ll need admission and surgery. I see a woman with appendicitis, and a woman who is screaming that her bones are sticking out of her leg (she has a cut) and I’m called to see a woman found unconscious outside of a storage locker. She’ll spend over a month in our psychiatry ward.About an hour into my shift I’m called to see Otso Virtanen (not his real name), a 94-year-old from a nursing home. An hour earlier, after a late lunch, he developed searing abdominal pain that radiates into his back and in his chest. He was noted to be less responsive than usual (he’s normally alert and oriented) and his blood pressure and oxygen saturation have dropped. As I approach his room, I notice the monitor. His blood pressure is really low, only 75 systolic and he’s moaning. He’s tachycardic at 120, and a non-rebreather is strapped onto his tiny, withered face. He doesn’t speak English, I’m told, but when I speak to him, loudly, he is able to nod yes, or no, in a meaningful way. He nods yes to chest pain and yes to abdominal pain. He points to his sternum. He nods no when I ask if he has any diarrhea or vomiting and no when I ask if he’s had this pain before.I review his chart. There is a Do Not Resuscitate order signed by his family doctor and I think that it may be relevant in the next minutes or hours. He was recently admitted for a fall, a fractured vertebra and functional decline.His eyes are closed and he’s moaning. When I ask him to open his eyes, he does, just for a few seconds—long enough to show me he’s annoyed that I’m asking him to do this. There are no signs of trauma to his face. His lips are pale. Auscultation of his heart and lungs reveal clear air entry and rapid but normal heart sounds, other than a mild systolic ejection murmur. When I palpate his chest and abdomen, he moans, and nods yes, when I ask if it hurts. However, I can’t localize his pain. Everything from his shoulders to his hips hurts. I will later find that this is Otso’s usual state of chronic pain.His arms and legs move easily in my arms and don’t cause him any additional distress. He has no pedal edema, no signs of fluid overload.His ECG is negative for a heart attack, and shows only tachycardia.“What do you think is wrong with him?” a nurse asks.“No idea, but sudden chest and abdominal pain radiating to his back with low blood pressure, I’m going to send him to CT to rule out either ruptured aortic aneurysm or aortic dissection.” I call the radiologist and she agrees to take him right away. Blood has been drawn, and I’ve ordered a bolus to be started before he heads over to CT. “Any issues,” I say, “call me back.”Ten minutes laterTen minutes later, the nurse calls. “They’re ready to take Otso to CT, but we can’t get an IV for contrast.”“So no bolus I guess either?”“No.”“What’s his pressure?”“Worse than before, sixty over forty.”I rush back. There is no palpable radial pulse so I understand why they can’t get an IV. He’s completely shut down. I ask for a central line kit and pump the lever at the bottom of the bed to raise him as high as possible. I then lower his head so that he’s in Trendelenburg. I need gravity to bring blood to his internal jugular so I can see it with the ultrasound probe. I clean his neck, and infiltrate the area with xylocaine. I ask him not to move, in English, which he understands.When I put the probe on Otso’s neck, his jugular is so big and juicy, I ask the nurses to confirm that his pressure is actually so low. I withdraw blood and feed the guidewire through the syringe and then feed the catheter over the guidewire, before suturing it in place.Otso and his nurse rush off to CT, and I’m almost expecting a Code Blue to be called while he’s there. Less than 10 minutes later, the giant internal jugular coupled with the hypotension and tachycardia make sense. Otso has a massive pulmonary embolus. The clot is so big, it’s causing blood to back up in his superior vena cava and his neck. It’s also causing obstructive shock.He needs thrombolytics quickly or this embolism will be fatal. At his age, the risk of intracranial hemorrhage with thrombolytics will be high. He’s also at risk of bleeding from other sites such as his GI tract.On the chart, there are two people to notify in case of emergency. The first is Peter, his son. I call, but there is no answer. I leave a message. The second is for Lumi, and she also shares Otso’s last name. It turns out that Lumi is the granddaughter and she’s in her 20s or 30s. I explain the situation and the advanced directive on the chart and suddenly she’s hysterical. She can’t understand why her grandfather is sick, he’s in perfect condition, she tells me (although I will later find that he’s been bedridden for six months). Intubation, chest compressions, vasopressors, she wants everything done because her grandfather will fight through anything. She’s wailing now, and I ask her if Peter is her father and if she can get him to call me.Five minutes laterFive minutes later, Peter calls. He’s irate that I’d called his daughter, and I suggest that she may not be the best candidate for “person to notify in case of emergency.” He patiently listens while I tell him about his father’s condition and the signed DNR. He tells me their doctor discussed it briefly and felt that chest compressions would be a bad idea for someone in their 90s. “I’m not medical,” he says, “you tell me what we should do.”I tell him that Otso may have catastrophic bleeding with thrombolytics, and if he does have bleeding in the brain and becomes comatose, then comfort measures would likely be the preferred course, rather than intubation and ventilation.“And what if we don’t give him the medicine to break the clot.”“Then he will surely die,” I say. “This drug is a Hail Mary,” I say, knowing that most of the idioms I’ve used throughout my life are no longer universally understood. I look at the monitor and his blood pressure is now below 60 systolic. He looks terrible. Peter tells me he is about two hours away, but that we can go ahead and he’ll come as soon as possible.I call the ICU and tell my colleague the story and that I’ll need a bed there. Within minutes, he’s with me at the bedside.The usual dose of the clot-buster, alteplase, is 100 mg IV, over two hours. Otso is almost 100 years old and frail. He is also near-death. We decide to push 10 mg IV, and then give him another 40 mg over the next two hours. If he gets worse, we can push more and hope he doesn’t bleed to death.The medication is given and an hour later, when Otso is transferred to the ICU, he still looks like he’s at death’s doorstep with his vasopressors at supra-therapeutic doses. Over the next 24 hours, the intensivists are able to decrease his vasopressors, but Otso develops renal failure, and he starts to bleed. He doesn’t bleed in his brain, or his gut, but strangely, into the tissues of his right thigh. His hemoglobin drops about 20 points, but then settles. Forty-eight hours after thrombolysis, his kidneys start to improve slowly, and he’s weaned off vasopressors. He’s becoming alert, he’s oriented, and at 72 hours, he’s transferred to a ward bed. He continues to improve slowly until, on day 10, he’s discharged back to his nursing home.Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from 25 years of practice.

Otso’s Hail Mary

Register for free access or login.

Related Topics