I’d just come on shift and was getting report from the day nurse. The patient had had a temporary pacemaker removed earlier that day. This is a wire that’s threaded up through a catheter in the femoral vein to the heart and is hooked to a pacer box. It’s a stopgap measure until the patient can have a permanent pacemaker put in surgically, or until the cause of the patient’s heart problem is fixed.

She was sitting up in bed eating a late lunch. Her family was with her, surrounding the bed. Family members get a look about them when a patient has turned the corner in a good way. It’s as though they’re still on edge, but also bathed in relief. Her family looked this way.

Before we even finished report, though, one of the family members came out and said that the patient was feeling nauseated. From eating hospital food? That’s a stretch! I briefly looked at her EKG on the monitor and wasn’t alarmed. I told the family member who I was and that I would be in there shortly to see the patient.

I went in there much sooner than I had expected to.

While getting report on my second patient, my first patient’s alarm went off. She was becoming tachycardic. I figured that it was due to the nausea making her anxious. I decided to check her on real quick before finishing report on the second patient. I found her looking basically okay, but definitely anxious. I asked her if she was still nauseated. She said yes and I leaned out of the doorway to ask the off-going nurse if she could get me an antiemetic. I took the patient’s blood pressure and it was a little lower than I liked. Low BP could definitely explain the nausea and tachycardia… but why the low BP?

I checked her groin site, thinking that maybe the clot dislodged from her vein where they took the pacer catheter out. If she were bleeding, it would cause her BP to drop. The site was soft and non-tender… no sign of bleeding. That didn’t mean she wasn’t bleeding retroperitoneally, though. I had the charge nurse page the cardiologist.

I removed the tray table and put the patient’s head of bed flat. I was only the tiniest bit worried – I figured we’d give her some fluid, send her for an abdominal CT to check for bleeding, and go from there. This sort of thing doesn’t happen often, but it does happen enough that I knew what to expect.

My patient started vomiting. Vomiting is hard to do (not to mention dangerous!) when you’re laying flat, so I helped her to her side to prevent aspiration. I rechecked her blood pressure and it was even lower; her heart rate climbing higher. I calmly asked the charge nurse to page the cardiologist overhead and call her office to have them page her directly.

By now, of course, the family had completely lost their glow of relief. The patient could tell by my repeated request for the doctor that something wasn’t right. I briefly explained what I was thinking (possible bleeding = low BP = high heart rate = nausea/vomiting) and they all seemed somewhat pacified for the moment.

It was a short-lived moment for all of us.

My patient’s oxygen saturation started falling. My worry-meter was slowly climbing. Maybe she ended up aspirating after all. We put some oxygen on her, but not before she vomited everywhere again – it ended up on her sheets, in her hair, on her gown. It wasn’t the most pleasant smell, and her nose was pretty much right in it. I tried to cover most of it with a towel. Right before I put the oxygen mask on her, she grabbed my wrist. I looked at her and she asked very earnestly:

“Am I going to die?”

And I looked her straight in the eye and said: “No.”

“It’s clear that you’ve had a setback here, but we are going to figure out what’s wrong and will fix it. We’re trying to contact the cardiologist now.” (WHERE THE HELL IS THE CARDIOLOGIST????)

It’s a long-standing truism in healthcare that when patients think they’re going to die, they usually die. However, that thought didn’t even so much as cross my mind, because I was too busy thinking that whatever was wrong with her was a Fixable Problem, and it was happening in a hospital in the ICU where there was lots of support and equipment and where We Saved Lives all the time.

I asked someone again to get ahold of the cardiologist any way they knew how, someone started a fluid bolus, someone started trying to clean the vomit up a little, and I… well I took a few seconds to take everything in, to make sure I wasn’t missing something.

And then she coded. V tach. No pulse.

Usher family out, get crash cart in, start CPR, hook up defib pads, someone’s bagging her and within a minute we shock her. No change. Times three. Ok – meds (Where. The hell. Is the cardiologist???), CPR, ER doc is here to intubate, I give him a quick rundown of the situation. Someone flings my carefully placed towels out of the way; now there’s all the vomit again, still on her gown, still in her hair and my denial regarding this Fixable Problem is finally shattered.

By then, someone has overhead paged any cardiologist to CCU stat and one shows up…. and right behind him is the patient’s cardiologist. FINALLY. She asks for someone to come up and do a stat echocardiogram and there happens to be an ultrasound tech a few rooms down that we seize. After a second of viewing the screen, the cardiologist sizes up the situation and asks for a 60cc syringe with a needle and before I know it, she has plunged this needle into my patient’s chest and blood, all this thick dark blood, starts coming back.

My patient had cardiac tamponade. The sac around her heart had filled with blood and her heart was unable to fill and squeeze due to the compression. We regained a rhythm on the EKG monitor, but we did not regain a pulse.

My patient, the one I had confidently assured not 15 minutes before, died. My naivety died with her.

I didn’t know. When she asked her last question, I had been 100% positive that she was going to be just fine. I don’t really fault myself for not knowing anymore, but I do regret that the last person she spoke to was me, and not her family. I regret that she died with vomit in her hair.

I regret that I did not at least entertain the notion that I was wrong.