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kk095 · 2 days ago

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Renee’s Respiratory Distress

It’s a slow weekday in our emergency department just around lunchtime. The ER is relatively quiet, and most of the trauma bays and exam rooms are open. Our team chats casually amongst themselves, sipping coffee, reviewing charts, and checking their phones.

The calm is interrupted when the automatic doors slide open, EMS wheeling in a stretcher. Dr Lindsay’s head snaps up at the sudden motion, her easy conversation with Nurse Nancy cut short. On the gurney sits a barefoot woman in loose black slacks, her blouse removed in the ambulance. EKG electrodes dot her fair skinned chest, wires trailing from the portable monitor. The woman is gasping, her lips tinged faintly blue. Her straight, shoulder length red hair is a tangled mess, strands clinging to the sweat on her temples. Sharp, bright blue eyes flick frantically between the faces around her, wide with terror and uncertainty. There’s a slight crease between her brows, as if she’s trying to keep control but failing. The paramedic at her side keeps a firm grip on her trembling shoulder.

Nancy is already moving, stepping toward the stretcher. “What do we got?” Lindsay asks, following Nancy, voice stern but professional. The lead EMT fires off a rapid report as they push through the hallway: “This is Renee. 38 year old female, sudden onset of severe shortness of breath and chest pain at work. Hypoxic, tachycardic, hypotensive. Maybe a PE? No signs of trauma. No history of asthma or respiratory issues.”

In a breathy, winded tone, Renee speaks. “I… c-can’t… breathe…” she struggles tremendously to get each word out. Nancy places a steadying hand on Renee’s shoulder. “You’re okay, hunny. We’ve got you. We’re gonna take a good look at you, ok?” Nancy reassures. “it… it… hurts… w-when… I… breathe…” Renee tries to respond, barely getting enough air. “it’s ok sweetie, we’re gonna make you feel better.” Nancy soothes.

Once Renee is wheeled into trauma one, Dr Sarah and Nurse Heather follow close behind. Monitors beep incessantly as the team transfers the redheaded woman from the EMS gurney onto the trauma room table. Nancy moves quickly but gently, adjusting the oxygen mask and checking the IV lines already in place.

The 38 year old sits upright on the trauma room table, her chest rising and falling quickly, taking shallow, uneven gasps. Her anxiety is visible, her blue eyes darting around the room. Dr Lindsay steps in first. “Renee, I’m Dr Lindsay. You’re in the ER. Can you tell me what’s going on?” asks the doctor. Renee shakes her head weakly, her chest heaving. She grips tightly at her sternum, fingers pressing against her ribs as if trying to hold herself together. “W-what’s… happening… to… me?…” she mumbles, the words barely escaping her lips. “You’re safe, hun. We’re figuring this out, okay?” Nurse Nancy intervenes.

Dr Sarah and Nurse Heather work in tandem. A d-dimer is drawn for clot detection. An ABG is taken to better check the patient’s oxygen saturation. A bolus of IV fluids are started to counteract her hypotension. A portable echocardiogram is performed by Dr Sarah, which displays evidence of right heart strain.

Even after these interventions and tests, Renee’s heart rate is climbing into the 150s, her systolic BP is in the 80s, and her O2 saturation is in the 70s.

Renee sucks in another dramatic, broken breath, her hand weakly grasping Nancy’s scrub sleeve. Her fingertips are cold and clammy. “my… my… chest…” she gasps, feeling as if there are a million tiny, razor sharp bits of glass inside her lungs. “Stay with me, sweetheart. You’re doing great. Just focus on breathing, okay?” Nancy tightens her grip on the patient’s hand. Renee’s eyes flicker to the monitor, taking in the blaring alarms and the flashing red numbers. She knows something’s wrong. Her gaze shifts to Lindsay, pleading silently for reassurance. “We’ve got you, Renee, you’re doing good.” Lindsay tells her. But behind Dr Lindsay’s composed face is a subtle sense of worry, and Renee picks up on it.

Over the coming minutes, Renee starts experiencing rapid, terrifying deterioration in quick succession. Initially, her heart rate spikes significantly, shooting into the 160s as her body struggles with severe respiratory distress. She gasps desperately for breath, struggling to draw in air, as her lungs and heart begin to fail under the weight of whatever’s happening to her body. It’s almost suffocating. Renee’s breathing becomes more and more labored and erratic, the sound of agonal gasps filling the room. Her chest heaves violently with each frantic gasp, but each inhalation is shallow and desperate. Her skin becomes pale, lips bluish, and there’s an almost grayish hue around her face as hypoxia sets in. This isn’t just the cold medical stuff, it’s visually disturbing to the staff and to the patient herself, who is acutely aware of her body failing on her. Her heart rate spikes dramatically- 160s, 170s, 170s, and the EKG starts to show signs of v-tach.

Despite the chaos, Renee’s mental clarity remains fully intact as she slowly realizes that something much more serious is happening to her. She’s not just experiencing a panic attack. She’s aware that she’s rapidly losing control. She gasps in a panicked voice, choking on her breaths: “Am… I… dying…?” Her voice is frantic, each word more strained than the last. There’s no crying, but her face is contorted in terror, her eyes wide and glassy. Her hands clutch the edge of the table in a desperate bid to hang on. “we’re gonna make sure that doesn’t happen hunny. Just try to relax for me and take slow, deep breaths, ok?” Nancy answers.

Our team’s urgency builds as her condition continues to deteriorate. While they’re still moving with clinical precision, the panic is very palpable. Nancy, despite the mounting tension, tries to keep the redheaded woman calm with quiet, reassuring words: “You’re going to be ok, Renee. Just stay with me, ok?” But even Nancy’s voice wavers as the minutes tick by, and it’s clear that things are slipping away.

In the coming minutes, Renee’s eyes widen In pure terror, as if understanding that the end is near. Her body quivers for a moment- one last desperate attempt to breathe. Then, her body goes limp, her eyes flicker once more before glazing over. A moment of silence hangs in the air as the team processes the sudden, brutal reality: she’s in pulseless v-tach!

The room erupts into a flurry of motion, but there’s an undercurrent of precision and expertise to every action. Dr Lindsay stands at the end of the bed, her hands steady despite the growing urgency. “Vitals are crashing, let’s move fast. Heather, on her chest, let’s go!” Lindsay commands. Nurse Heather lowers the table and gets on the patient’s chest, beginning compressions, her hands pressing down hard and fast on Renee’s sternum. Dr Lindsay looks at the monitor, confirming v-tach. “Hey Linds, I need to intubate now. 7.0 ET please.” Informs Dr Sarah. Sarah wastes no time. She stands at the head of the bed, positioning the intubation tube with practiced ease, and quickly slides it into the redhead’s airway, securing it with some surgical tape. Nurse Nancy connects the ambu bag, squeezing much needed oxygen into Renee’s lungs. Lindsay turns to Dr Sarah, who is putting the defib pads on her chest. “Let’s go with epi first. 1 mg IV push.” Dr Lindsay orders. Sarah administers the meds intravenously while Heather pumps away at Renee’s bare, skinny chest. The redhead’s chest caves in, her belly ripples out from the force of Heather’s chest compressions.

After a minute or so, the patient remains in pulseless v-tach despite intubation, 1mg epi, and a few CPR cycles. Lindsay decides it’s a good time to shock Renee. “ok, let’s charge to 200. Everyone… CLEAR!” Dr Lindsay calls out. KA-THUNK!!! There’s a pause after the shock, and all eyes are on the monitor, hoping and praying for ROSC. “No change. Resume compressions, Heather. Sarah, push 300 mg of amiodarone.” Orders Dr Lindsay. Another round of epinephrine is administered in swift silence. Heather completes two cycles of compressions after the second dose of epi is administered. At that point, the defibrillator charges again, the team holding their breath as they await the jolt. “Ok, recharging to 300. Everyone… CLEAR!” Barks Dr Lindsay. The electricity rips through Renee’s petite body, her chest heaving with the force of it. The monitor briefly catches a moment of regular rhythm, only for it to plummet into v-fib. “Crap! She’s in v-fib. Let’s push another milligram of epi, then shock again.” Dr Lindsay says, her tone a mix of frustration and determination. The team is relentless. Dr Sarah prepares the IV meds, while Dr Lindsay keeps a watchful eye on the monitor. The drugs flow through Renee’s veins, but still, the monitor remains unforgiving. “Ok, meds in. Let’s shock again at 360. Everyone… CLEAR!” The defibrillator charges for the third time, and the cute redhead’s body tenses up again, shoulders shrugging forward, eyes wide open, but the result is the same: nothing. Lindsay sighs following the shock. “She’s not responding. Let’s go for another 150 milligrams of amiodarone and shock her at 360.”

The next amiodarone dose is halved, and Dr Sarah administers the medication with a calmness that contrasts the panic in the room. The defibrillator makes a rising, high pitched hum as it charges, and once again, sends a quick jolt through Renee’s chest. Her hands make loose fists, and the upper half of her body shivers for a second or two. Nothing. The 38 year old’s heart doesn’t budge. “Still nothing. We’re not giving up.” Dr Lindsay directs Nurse Nancy to ensure the ambu bag is being squeezed at full capacity. Heather resumes chest compressions. The team remains laser focused, and administers another 360 joule shock when Heather finishes her cycle of CPR. The jolt, more violent than the others, leaves the room holding its breath. Renee’s feet kick up at the far end of the table, slamming back down hard half a second later, showing off the soft, smooth soles of her size 6 feet. Even after this shock, v-fib persists.

The team continues their efforts, almost on autopilot at this point. CPR, ambu bagging, and another 1mg push of epi, but v-fib remains. Lindsay then orders the team to shock the patient for a sixth time. “Charging to 360. Everyone… CLEAR!” Lindsay calls out. Renee’s chest shoots up, her back arches dramatically, and her body plops back down on the table ungracefully a second later. All eyes shift back to the monitors. “Still in v-fib, Linds.” Sarah shakes her head.

Dr Lindsay takes a breath, steps back, folding her arms, looking at the team, her face unreadable. “She’s in refractory v-fib, we’re gonna have to call time of death.” Lindsay explains to the team, succinct and to the point. “heather, hold compressions.” Lindsay continues. Heather stops, and steps back from the table, away from the patient. Nancy detaches the ambu bag from the ET tube, a small amount of air hissing out. “Alright. Time of death, 12:37pm.” Announces Lindsay, her bluish gray eyes looking at the clock in the lefthand corner of the room, pulling off the latex gloves on her hands.

The room becomes eerily quiet, the frantic chaos of the code blue replaced by an unsettling calm. Dr Lindsay stands back, looking down at Renee, her eyes still WIDE open and unblinking, face still pale and distorted in terror, detached ET tube sitting between her pale, cyanotic lips. The heart monitor that still displays the jagged waveforms of v-fib is turned off. Nancy stays at the head of the bed, taking a moment to look down at Renee’s face. Her eyes are wide open, frozen in a moment of sheer terror. Nancy swallows, her throat tight, before reaching forward to gently close the redhead’s eyes for the final time. “I’m so sorry, hunny.” Nancy whispers under her breath, her hands lingering just a moment too long.

The rest of the team methodically moves through the motions, detaching the EKG wires and removing the IV lines with almost robotic efficiency. Defibrillator pads are peeled off of Renee’s battered chest, the adhesive strips coming away with a slight tug, leaving a red imprint on her skin where the pads had been.

Dr Lindsay fills out the toe tag, her movements deliberate and almost ritualistic. The tag, printed with Renee’s name, age, and the official time of death, dangles from her left big toe, brushing against the soft, smooth soles of her feet. Nurse Nancy places a sheet over her body, her hands trembling slightly as she covers the redhead’s lifeless form.

Lindsay glances over to Dr Sarah and then to Nurse Heather, the weight of the moment settling into their collective silence. Finally, she turns her attention to Nurse Nancy. “I’m going to request an autopsy.” Lindsay says, her voice clinical but with a slight edge of concern. “We never confirmed the PE. It might help us piece everything together.” Continues Dr Lindsay. Nancy nods silently, her face still pale, her eyes lingering on the covered body. She takes a deep breath and steps back, looking at Renee one last time. “What a shame. She went down so fast…” she mutters, her voice thick with emotion.

The room stands still for a moment, the weight of what just happened hanging heavily in the air. A life taken too soon. A woman who had been alive, pleading for her life just minutes ago, is now toe tagged and under a sheet. A nameless, faceless statistic in a death report. The rest of the team turns and leaves the room, each of them silently processing the brief but intense encounter.

Later on, Renee’s autopsy report and labs came back. It was determined that her cause of death was a massive, acute saddle PE. These types of blood clots can sneak up rather quickly and unexpectedly, leading to a deadly progression of events. When Renee woke up this morning, she never in a million years would’ve expected she’d have her time of death called in our ED. But just like that, Renee became the latest beauty to pass away in our emergency department.

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