Jack

Jack was about 45 years old. He looked like an ad for Harley Davidson. Long hair, black leather, tough attitude. When the ED brought him to the unit, we all were wondering "Why does he need to be here?" like we do so often. He came in to the hospital with chest pain. Downstairs, he had the typical cardiac workup. Negative troponins, lytes were fine, ECG didn't show any evidence of acute MI or ischemic changes. He received sublingual nitro, aspirin, and was getting morphine PRN. Nothing that one of the cardiac floors can't handle, right? Jack wasn't actually MY patient, I happened to be the float RN that day (which means I don't have an assignment of my own, I'm there to travel, cover lunches, and help out the nurses who are busy). I helped get Jack settled in, and periodically came back to see if the nurse needed any help.
At one point, I was looking through the chart and saw that the ED nurse had charted that he went in and out of a third-degree heart block. Hmm, that would have been good to have gotten in report! But looking at his ECG now, he was in NSR, no ST elevation- it looked pretty darn good. His nurse said they were fine, so I left and said I'd check back in with them later.
When I checked back, the nurse said that he wasn't looking so good. He was now on a 100% non-rebreather mask, experiencing anxiety and dyspnea. He kept trying to get out of bed to pee. He began having some small runs of v-tach. While his nurse was on the phone with the cardiologist, I was in the room trying to keep him in bed. In our unit, we have those great Philips monitors at the bedside, with a larger monitor in the hallway with about 10 patient's rhythms on it. Throughout the runs of vtach, Jack said he couldn't feel a thing. We'd have him cough/bear down, and that was enough to bring him out of it.
I went to talk to his nurse, and the cardiologist said he'd be there as soon as he could. Looking at the monitor, his rhythm was changing once again. He went into a slow, wide QRS rhythm... looked like some sort of complete block/idioventricular.. again, ran into the room and he was sitting there looking at us like WE were the ones trying to die! And then he'd be back to NSR. So strange. Meanwhile, we'd run 3 12-leads and had been unable to catch the abnormal rhythms. We'd drawn stat labs, ABG's, but nothing was coming back abnormal.
Finally, Jack went back into his wide-complex, bradycardic rhythm. Upon going into the room, Jack was slumped over on the bed, agonal breathing. I hit the"code" button, yelled for help, and then he lost his pulse. FULL ARREST! We ran the full code, rounds of epi and atropine, shocked him x2, intubated, and finally got a pulse back. We started dopamine, levophed, and epinephrine gtt's. He was without a perfusing rhythm for at least 20 minutes. As we wrapped things up, no one thought Jack would ever regain consciousness. He was unresponsive to painful stim, pupils were dilated to about 4-5mm. By that time, it was change of shift, and I went home.
The next day I came to work, and was assigned to Jack. I was absolutely shocked with the nurse told me that overnight, Jack woke up! He began bucking the vent, was able to follow commands- amazing! We performed a spontaneous breathing trial, and he passed with flying colors. We ended up extubating him later that morning.
The first thing Jack said to me was, "Boy, I feel like shit". He had that awful, death-is-near coloring to him. But, miraculously, he was neurologically intact. I guess our CPR was effective!

Unfortunaely, Jack passed away the next day. He later coded x2 and the final time, they were unable to resuscitate him. Jack's code was one of the first in which I felt like I knew what I was doing. A great learning experience, but a sad outcome in the end.