Last night, I received a patient via EMS that had a syncopal episode... they 'fainted.' Bystanders attempted to help, yet when the patient did not respond they called 911.
Upon arrival of EMS at the scene, the patient had a heart rate of 40-ish and a blood pressure in the 70/40 range. Not very conducive to consciousness. This patient's MAP (mean arterial pressure) was 50. A MAP of about 60 is required to perfuse coronary arteries, brain, and kidneys...
Upon arrival to the ED, their initial blood pressure was about 90/60 (MAP of 70), HR was 65. Conscious, alert, no complaints.
Working as a Team, my peers and I quickly initiated interventions as we gathered information. The patient appeared stable, yet guarded... given the patient's immediate history (syncope), age, sex, and physical stature, these vital signs were not normal.
I stepped out of the room to begin entering the Intake/Triage into the computer charting system. I was 10 feet from the room, 15 feet from the patient. The patient has been in the ED for 6 minutes. I could see both the patient and the bedside monitor from where I was charting.
Then, the WARBLE.
I look up. My first focus was to the monitor. What is the alarm? I see a heart rhythm scrolling across the left half of the screen... and a flat line on the right. I look at the patient, there is something wrong.
I jumped up and started for the room, speaking loudly (commanding might be more accurate) I tell the Unit Coordinator to get help and call for the Attending Physician. As I reached the patient's side, 4 seconds of flatline has elapsed. There has been no heartbeat. The patient's head is to their side, eyes open, a glassy stare into nothingness. A quick check of the monitor leads to make sure they are all attached, and yelling/shaking the patient... no response. I flatten the stretcher, look back at the monitor, I see a two complexes... then flatline again...
At this time, I turned to the UC, to see her answering my phone and I hear her say, "He's already at the bedside." I yell out to the UC, something to the effect of "get me some help." Four more seconds have elapsed.
I am literally about to find my landmarks, about to place my hands on the patient's chest, preparing to begin CPR... I look back up at the monitor, still flatline. I look down at the patient, preparing... when they suddenly take a deep gasping breath and literally bolt up-right!
The WARBLE stopped.
Twelve seconds had elapsed.
My patient's heart rate had been... zero. My heart rate was about... 100!
The patient had been clinically dead for twelve seconds.
Long story short...
After two hours of monitoring with no re-occurrence, and multiple Nurses and Physicians all explaining what had happened, the proposed plan of care, additional testing needed, and potential outcomes... the patient decided to leave AMA (against medical advice).
In retrospect, this morning this patient probably was clinically dead at least twice. Once at the scene, once for sure in the ED. Yet, as an adult, of sound mind, now fully conscious and alert, has the right to make their own decisions.
I saved the telemetry strips. Since the patient's information had not yet been entered into the telemetry system, there were no identifiers on them.
As they left, I said to them, "I think you are making the wrong decision, yet it is yours to make. Take care my friend."
The patient stopped, smiled, and shook my hand. Simply saying, "Thank you. I really have to go."
I learned later that they went out into the lobby and asked the Frontline Nurse, "Can I stay here until the buses start running again in a few hours?"
Upon hearing this, I smiled.
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