Had a rough experience the other night and I'd appreciate any reflections anyone might have, story as follows. For context, I'm a PGY-2 IM resident.
Patient is a 56 year old woman admitted February 1st for COPD exacerbation secondary to flu A. Intubated that day, extubated the next. Had multiple episodes of v tach on the monitor, so the team consulted cards who recommended LHC and ICD, but the patient left AMA before that could occur. They sent her with amio, but who knows if she took it. She re-presented a couple nights ago with complaint of frequent palpitations. In the ED, they observed v tach on monitor and attempted electrocardioversion three times. After the third shock, she was pulseless so they started CPR. 1 mg epi, 300 mg amio plus drip, got ROSC after 3-4 minutes, at which time they called me, the ICU resident. At this hospital, a medicine resident takes overnight ICU call alone. You staff the admissions over the phone with the fellow, but no one is in house unless you call them in.
I go see her and she's unresponsive and hypotensive but perfusing. On amio gtt at this point and I think she'd even gotten a second bolus. Having NSVT on monitor. While I'm in the shock room, she codes a second time. I give 100 mg lidocaine, and we again got ROSC after maybe 2-3 minutes. Post-code EKG looks kinda STEMIish so I activate cath lab. They decline to take her because there are no reciprocal changes, but tell me it's fine to treat as ACS with heparin gtt and aspirin. Still seeing NSVT on monitor despite amio gtt and IV mag, so I ask the cards consult fellow if I should start lidocaine gtt and she says sure do it.
We get the patient up to the floor and for the next ~45 minutes we're on and off coding her. Mostly v tach arrests with some PEA mixed in. Lots of shocks. Probably arrested and got ROSC 3 more times. Early in the process of coding her on the floor is when I finally had a moment to call my fellow. He says he has nothing to add to the management. I ask him "How long do I code her…Seems like electrical storm, I don't know if this v tach will stop." He tells me as long as I'm getting ROSC to keep going.
Throughout all of this, one of the NPs is trying to contact family but cannot get anyone on the phone
So after like 40 minutes of coding I say to the room that I think this is medically futile and I have no more ideas. I invite people to share their thoughts and I say I think we should stop if there's no pulse at the next pulse check. I told the fellow this was my plan and he agreed. There is a pulse at the next pulse check, but it doesn't last long until she's pulseless v tach again.
And this is the time where I became more and more ethically confused. I felt that more compressions would not be helpful, but it's a really weird decision NOT to shock v tach. Then at some point she was pulseless and I decided not to shock it anymore. RT disconnected her from the vent and although she was pulseless, she had agonal respirations, so I was like fuck I guess connect her to the vent again.
Anyway it was a really terrible experience and I didn't know how to handle it. The patient was not going to survive no matter what. But I couldn't figure out when and how to end the code. I have run codes before, and I was comfortable with the medical management, but I have never called a code before and did not know how to do so.
tl;dr: Patient had electrical storm and I did not know how to handle it.
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