During my fellowship, I have seen the sickest of the sick who die, and the sickest of the sick who survive. I've seen the mildly sick and seemingly stable patients walk out of the hospital good as new, and I have seen similar patients suddenly drop dead out of the blue. We are always anticipating certain outcomes, and prognosticating patients based on data from years of research and observational studies on various conditions--Where person A may have a 10% chance of dying, and person B may have a 80% chance of dying based on their diagnosis, age, co-morbidities, and how sick they are... But you never REALLY know do you? There is always that little bit of unknowingness about every person and their condition. Because nothing in medicine or in life is 100%. I think what it comes down to is that everyone has their time... And nobody really knows when that may be--except perhaps God, and often times, the patient themselves...
Take the lady I met 2 days ago. She is 87 (yes, she is pretty old...), but a very functional 87 year old lady who cares for herself, goes grocery shopping, cleans the house, etc. She came to the hospital by ambulance one week prior with severe sudden onset shortness of breath. She was found to be in pulmonary edema (her lungs filled with fluid) and ended up having to get intubated and put on a respirator to help her breathing. An echocardiogram (heart sonogram) revealed a very weak heart--pumping with an Ejection Fraction of 20%, where normal is 65%. We also saw a very leaky mitral valve (meaning half the blood was going back to her lungs and not forward), and her blood tests and ECG suggested she was amidst a heart attack which was complicated by severe heart failure (hence the fluid in the lungs). She was too sick to take to the cardiac catheterization laboratory to try and fix anything blockages, so we tried to "tune her up" with medications in the CCU. We managed to stabilize her over a few days, and then took her to the cath lab to see her coronary arteries. We found severe blockages in all 3 of her arteries--one chronically occluded arter, and two others that we could potentially fix. So over the course of two days we put stents in the two 95% blockages that she had to try and restore some blood flow so that her heart muscle could improve, and perhaps even the leaky valve. Unfortunately her kidneys failed as a result of the dye we used, and she ended up needing dialysis for several days--not good. Yet remarkably her kidneys recovered over the next 3 days, and she came off dialysis. We did another echocardiogram showing a little bit of recovery of both her heart function and the leaky valve. So all in all it looked like things were getting better. So this 87 year lady survived acute heart failure, a major heart attack, and the need for acute dialysis all within one week. I think each of those situations in themselves probably carried a 50% mortality rate in this lady! She just refused to die. She looked so good by the next day or two, she was ready to be shipped off to rehab. Well, until....
She was all set to go. She was sitting in a chair for half the morning. Then she went to have a bowel movement, and after that she suddenly didn't look so hot. She became pale, and sweaty, and complained of nausea and her heart rate dropped and blood pressure dropped. It all seemed like a vaso-vagal reaction, (which is a reaction that is caused by nerves innervating the heart and blood vessels that can cause someone to faint, and can be precipitated by a variety of emotional and physiological triggers--one of which could be a bowel movement) ... She recovered after some atropine, but about 20 min later it happened again for no apparent reason. But this time, she didnt' perk up so quickly. In fact she lost her pulse and blood pressure and essentially went into a brief cardiac arrest. We urgently intubated her, had done about 2 min of CPR and dosed her with some medications to try and revive her heart and blood pressure, and we were able to do so... But what the heck had happened? In our heads we were thinking of the most likely culprits that could be causing this: Could her heart wall have ruptured? Could a stent have closed off? Could she be bleeding internally? Something else? We did a quick bedside echo of the heart which showed no rupture or fluid around the heart, and her blood count didn't suggest bleeding. We rushed her back to the cardiac cath lab and saw both her stents were open. We placed an intra-aortic balloon pump to try and support her blood pressure. Before our eyes her blood pressure plummeted even more. We then inserted a swan-ganz catheter into her pulmonary artery, to look at the pressures and output readings in the right side of her heart. They were bizarre. The saturations in her pulmoary artery were 15%, where normal is 70%-- which suggested there was almost no forward pumping function of the heart.. But why?? Finally we did an urgent Transesophageal Echocardiogram right there in the lab to look at her heart closer. We then saw two things. One was that the right side of her heart was essentially not moving, it was "blown" -- but it was fine 1 hour earlier. The only thing that could do that so quickly was a giant blood clot in the pulmonary artery--a pulmonary embolism. Luckily with our TEE snogram we saw the pulmonary artery, and it was filled with a gigantic blood clot! At this point she was near death on multiple medications for blood pressure. We urgently called the cardiac surgeon, and he rushed her to the operating room...
We had low hopes at this point. An 87 year old who just had a heart attack, and now has a massive pulmonary embolism causing cardiac arrest. The mortality for this is probably upwards of 60 or 70% in this lady. But the only lucky thing for her is that it happened exactly at the moment it did -- during the day, right in the CCU, with the cath lab available within minutes.
She was in surgery for only about 2 hours. They put her on bypass, cracked her chest open, and cut into her pulmonary artery. this is what they pulled out of both her pulmonary arteries:
This was by far the largest clot I had ever seen! Most of the time, if you have a clot this big, you are dead. But this lady didn't die. She recovered from the surgery within 3 days! She is now talking, sitting in a chair, and almost back to heself. She is going to be discharged tomorrow.
It is amazing sometimes what people can survive. And it is always the old peopel! This lady was 87 and survived a huge heart attack with heart failure and severe mitral regurgitation, kidney failure needing dialysis, and a giant pulmonary embolism with cardiac arrest. She refused to die. If this happened in the middle of the night or on a weekend, or outside the hospital, she would not be alive. She is one lucky lady. Everyone has their time, and it just was not her time to go...
Like I said, you can never know for sure. And in some cases, we may say someone's chances of dying are 80% to 90... But a 10 to 20% chance of survival is not nothing. That is the beauty of cardiology. You can literally bring people back from the dead. And let them live their life until their true time has come....
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