Trial by fire: Fighting for lives in the ER

September 16, 2009 at 7:34 pm Leave a comment

DrTonyTheir limp bodies came in to our ER at Purdue one by one, victims of a house fire. Tragically, the dogs had been sleeping in the one room in the house where the fire started and was contained: the laundry room.

They came without much warning, leaving us little time to prepare. Our ER exists in a state of perpetual readiness for most emergencies, but this level of trauma strained the seams of our system. Students, residents and faculty all scrambled to impose some order on the chaos, and we divided into teams along random lines: A surgeon and I did CPR on the first one to enter, several students and a medicine resident attended to “dog #2” (we had no identification or clue as to their names yet; I have omitted their actual names). The third dog, who seemed less affected than his housemates had two students hovering over him, administering oxygen and hooking up monitors.

Smoke inhalation is a devious killer, and kill it does; the carbon monoxide that burning materials throw off holds onto hemoglobin and prevents it from delivering oxygen to tissues. Since it is so tightly bonded to hemoglobin in the blood, blood appears a healthy cherry pink – not the ghoulish blue color we usually associate with low oxygen levels. In addition to preventing blood from giving life-sustaining oxygen to tissues, smoke contains a witch’s brew of toxic gasses…and then there is the heat. Hot gasses can cause burn injuries to delicate airway tissues, and dead and dying tissue clogs airways and prevents oxygen from reaching the blood. Angry lung tissue responds by weeping fluid in a flood, further reducing the ability to get oxygen to tissues. The body is starved of oxygen, but the lips and gums maintain the robust pink of good health, as if mocking our efforts.

The first dog, whose name I never learned, was the biggest of the three and was not alive when we got to him. Nonetheless, we tried to resuscitate him. As we intubated him and breathed for him, a flood of fluid issued from his lungs, blocking the breathing tube and making a joke of our efforts.

As it became apparent that our efforts were perhaps better used on one of the other patients, we performed that cruel math that happens from time to time in an ER: Who is the least likely to die? Human ER’s have a color code system for massive trauma that can overwhelm the staff on point when the fertilizer hits the ventilation: Green are the walking wounded, unlikely to die. Yellow are those with serious, but non-life-threatening injuries. Red are the ones with immediate and life-threatening injuries. Those who draw a black card are beyond saving.

By our reckoning, we had one black card and two red, so we moved on. The surgeon and I, almost simultaneously, wordlessly stopped our efforts and went to the side of the other two dogs. The smell of smoke in the room was almost overpowering, as if one of the dogs was still smoldering and we had yet to put him out.

We had a tough choice on our hands: We have only one critical care ventilator, and a duo of patients who potentially needed life-support. Mechanical ventilation in veterinary medicine is the Holy Grail of critical care, requiring 24-hour care, and a person a hair’s breadth away at all times lest something happen to the machine or the patient. Patients are sedated so the machine can breathe for them, and require monitoring of every vital sign they make a monitor for, and few that they don’t. It is the zenith of veterinary medicine, save for those few places that do cardiac bypass or dialysis.

The same fate that befell the first dog gradually descended on the two survivors like a dark, damp and wet fog.

The first dog, we surmised, was closer to the source of the fumes and took the biggest hit; his lungs developed the signs instantly and furiously. The other two must have been further, and their smaller body size and proximity to the ground meant that they got a lesser immediate dose. But this was not enough to save them. The first night, we placed one on the ventilator as the other seemed to be holding his own. That same fluid began to build up and flow from the second dog’s lungs like water seeping from a sponge. All the fluids we gave him IV did nothing to keep his vitals stable; they just dripped out of the breathing tube and fouled the ventilator.

Despite our efforts, he died (as many cases seem to) at about 3 a.m. on the first night. As the first dog passed, the second seemed to worsen and needed the services of the newly-available ventilator. The irony was cruel, but we didn’t have time to dwell on it.

With the stakes as high as I can ever remember, we fought the fluid that built up in the third dog’s lungs. We learned a few things from our first two cases, and used these tricks on dog #3. In the middle, we had a brief respite when the tide seemed to be turning; the fluid abated, his numbers leveled off then started to improve. We thought that we might be able to do it for this family who had lost nearly everything. We started to hope, which is one thing that I have learned you should never do in ER until all four feet are on the ground and out the door.

That night I learned the lesson again, as we lost the battle. Again – 3 a.m. It’s like death is just outside, smoking a butt and says to himself “OK – 3 a.m. Showtime.”

These three poor dogs didn’t stand a chance, but we tried to give them one. In the end our efforts proved useless. No human lives were lost, but the grief experienced by that family was plain to see as they held on to a slimming fraction of hope that slipped away.

It would seem in retrospect that this was an exercise in futility – that we should have predicted this outcome and advised the owners against the extremes that we went to to try and save at least one of their pets. We did tell them that the odds were long, so I can hope they made informed decisions every step of the way.

But I take some small comfort that there is honor in the trying; these deaths had at least one good thing about them – learning. Even though the outcome was tragic, the techniques and experiences gained by the doctors in training (and myself as well, a 13-year veteran of ER work) justify at least some of the effort.

Enough so I can sleep at night, anyway.…

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