MEDICINE, SCIENCE, AND SOCIETY

The Arrest KEITH WRENN, M.D., Nashville, Tennessee

T he lounge in almost every ED I’ve ever been in looks pretty much the same. A mixture of sev-

eral different types and styles of second-hand chairs, mostly uncomfortable, surround a wooden, all-purpose table littered with discarded paper and the debris from hastily eaten meals. In the book- shelves on the walls are an eclectic group of out-of- date journals and books-donated or abandoned- that have rarely been opened or moved in recent years, judging from the dust. Dust, and slightly ran- cid grease, and stale coffee.

It was in such a lounge that we converged one evening: Steve, a young second-year resident, Dr. Mitchell, a grizzled but well-regarded old internist who had been around forever, and me, a “new at- tending.” We all knew of one another but had not interacted closely.

“That was a fairly typical EMD arrest,” I was saying somewhat pompously as I entered the room.

“Thanks for helping me with that central line,” answered Steve.

“Yeah, it’s good practice. You have to be able to get them in quickly sometimes.”

We were ignoring Dr. M., who sat in the corner leafing through a journal. His half-glasses, perched on his nose between unruly and profuse grey eye- brows, gave him a fierce look, even in repose. “Hmmph!” he snorted.

We both glanced in his direction, but he contin- ued to leaf through his journal, seemingly oblivious to us.

“In truth, that old lady was dead before she got here,” I continued. “After being intubated, given two rounds of epi and atropine, and a shock in the field, there’s not much more we can offer. In medi- cal arrests, if the EMTs don’t get you back, you’re usually dead.”

“Hmmph!” came from the corner of the room again but he still seemed intent upon the journal.

“I remember when I was at your level, Steve, the

From the Vanderbilt University Hospital, Nashville, Tennessee. Requests for reprints should be addressed to Keith Wrenn, M.D., Room

1368, Emergency Department, Vanderbilt University Hospital, Nashville,

Manuscript submitted September 16. 1992, and accepted in revised

EMTs didn’t do anything except ‘Scoop and run.’ We would then work on people for up to an hour, using all sorts of drugs like calcium and isoprotere- no1 that, for the most part, did nothing and may have been harmful in some settings,” I said in my most pedantic tone. “The truth is, when you’re dead, you’re dead. We’ve begun to tailor our resus- citations accordingly. I rarely go more than fifteen minutes now,” I said proudly.

Again came the snort from the corner of the room, more loudly now with the associated squeaks and thump8 of a vigorous change in position. He was still not looking at us though.

I smiled indulgently at Steve and shrugged. He looked sheepish and smiled back. Now acutely aware that Dr. M. was listening to us, I wondered why he was there.

“As I was saying, now we can actually image the heart in EMD with the portable ultrasound unit and, at least qualitatively, measure perfusion with the end-tidal CO8 detector. We’re no longer blind.”

“Blind. Look who’s blind,” he muttered loud enough for me to hear.

“Why didn’t you give high-dose epi?” Steve in- terjected quickly before I could respond to Dr. M.

It took me a moment to answer, as I shifted gears from righteous anger back to the teaching mode. “Sometimes ten milligrams of epinephrine will start the heart beating again. The problem is, of course, that while it may help the heart, it doesn’t often help the brain. If we had gotten a pulse back, she probably would have been brain-dead and just used up a unit bed for a couple of hours or days.”

“HMMPH!” even louder this time. When I looked over at him this time, he was glaring back at me over the top of his glasses. His face was red. I had a fleeting vision of a balloon blown up to its limit just before it explodes.

“Have you got some kind of a problem?” I asked. “Yeah, you! I’ve been listening to what you’re

saying and while I don’t disagree with you, it’s a crock!” he snorted.

“Excuse me, but I wasn’t aware that I was ad- dressing you. You weren’t even involved in this case. . . .” I started defensively. Meanwhile, Steve was withering into his chair.

“That case, the ‘old lady,’ went to the same

May 1993 The American Journal of Medicine Volume 94 543

THE ARREST / WRENN

church as me for over thirty years. Don’t tell me I wasn’t involved. You’re pretty proud of the way you handled her arrest?”

“I think we ran it quite well,” I ventured more tentatively.

“The arrest isn’t over yet,” he said ominous-

ly. “What do you mean?” I asked, now confus-

ed. Just then the charge nurse stuck her head in the

door. She looked at us and could tell something was up. “Excuse me, but the husband and son of

the lady in room one are here,” she said hesitantly to me. “They’re in the quiet room.”

We were all silent for what seemed like a long time. Dr. M’s eyes returned to his journal. The nurse stood in the doorway, not knowing whether to stay or leave. Steve coughed. Finally I respond- ed, “I’ll be right there.” I turned to Steve but was unable to say anything more for a moment.

Dr. M. looked up at me and said with remark- able gentleness, “Go finish what you started. The ending is always the hardest part. That hasn’t changed much over the years.”

544 May 1993 The American Journal of Medicine Volume 94