Did a Snowstorm Kill My Patient? A True Story about the Challenges Faced in Rural Rocky Mountain Emergency Medicine

[COERRN]

Details have been changed to protect the patient and her family. The facts of this case are true.

The ambulance page pierced the silence. Most nights it could barely be heard over the din of a busy ER, but tonight the snow had fallen in heavy layers and this seemed to keep people in their homes. The nurses, slouched at our stations, straightened to attention upon hearing the dispatcher's voice crack over the radio, "28-year-old female, difficulty breathing, conscious." The address was announced and everyone gave a concerned glance. The call was to a narrow, notoriously treacherous dirt road, high in the mountains on the west side of our small Colorado town. In good weather and broad daylight, it was a 30-minute response time. That night we had unforgiving snow, whipping winds, and a dark, moonless sky. The ambulance crew rounded the corner past the nurse's station, bundled in their coats, and headed out the door.

Twenty-five minutes later, we heard the ambulance crew speaking with dispatch. They were hopelessly stuck in a snow drift- forcing dispatch to page another ambulance to the address. Thirty-five minutes later, it was stuck too. The woman was still having difficulty breathing, now admitting to the dispatcher that she had huffed two cans of commercial keyboard dusting spray just a few moments before her respiratory distress began. She stated her heart felt like it was racing.

In our small Rocky Mountain community, we have a team of highly skilled volunteer fire and emergency medical services who had also been activated when the initial call came an hour earlier. One of these responders had managed to get his oversized pick-up truck near the cabin where the patient was waiting for help.

His voice came over the radio, "Patient is pale, diaphoretic, tachypneic. Her heart rate is 140 beats per minute. She is having chest tightness." He measured her oxygen saturation at 90% on room air. She had no medical history other than occasional street drug use. As per the previous report, he confirmed that she had huffed a propellant just minutes before the start of her symptoms. He made a judgment call - this woman needed the ER right away, so he did a rather unconventional thing and hiked the woman through the thigh-high snow, bundled her into his truck, and began the unpredictable journey to the hospital.

On the way, he encountered one of the stuck ambulances and was able to help them back onto the road. Over two hours had passed, but the patient was finally in the back of an ambulance and headed our way.

The phone rang and the charge nurse took the ambulance report. The woman's heart rate and respiratory rate were still elevated, but supplementary oxygen had improved her condition. Her heart rate was 105 bpm and her respiratory rate 24 breaths per minute. On a simple mask at 8L, her oxygen saturation was 100%. The EMTs thought perhaps she was having a bit of a panic attack and that the delayed response had increased her anxiety, but they felt that she was relatively stable.

We prepared our cardiac/respiratory room, just in case. Everyone was optimistic - this patient was young, relatively healthy, and she was already improving. This was no big deal.

The patient arrived. The updated ambulance report was relatively the same. The patient was a slightly overweight Latina female with hot pink hair. Tattoos snaked her arms and calves. She was indeed pale. Smeared mascara was streaked all over her face - she'd been crying. Her initial vital signs were reassuring. Mild tachypnea was present and she was still slightly tachycardic, but otherwise she looked good.

The ER doctor working that night was a gentle and highly skilled provider with over three decades of experience. He immediately evaluated the patient upon her arrival and told her he suspected a mild reaction to the inhalant she had huffed with a subsequent panic attack. Reaching for his hand with wide eyes, she said to him, "I feel so scared." He comforted her and ordered labs, an EKG, a small dose of IV Ativan, and a chest x-ray. He assured her we would do a thorough work-up and get her some medicine to help her stay calm. She nodded and appeared relieved.

I left to obtain the Ativan, the charge nurse went to get the EKG machine, and a phlebotomist began to set up for labs. As I was preparing to administer the IV Ativan, the phlebotomist began to draw her blood. The patient's heart rate suddenly spiked to 110, then 120. I thought she was anxious about the needle stick, so I said to her, "Try to stay calm, take a deep breath." Eyes wide, she looked at me with pleading desperation and said something I'll never forget, "I'll never do it again. I am sorry. I am trying," she gasped. The monitor began screaming. HEART RATE 186. "SVT," I thought. Then it quickly converted to ventricular tachycardia. And before I could even blink, ventricular fibrillation. She was coding.

I snapped into autopilot, a rush of adrenaline hit my body. I checked for a pulse, but it was obvious she had none. I rolled her onto a board and began compressions. The phlebotomist smacked the code blue button and our ER team streamed into the room. We ran the code for 55 minutes before the doctor announced that he was going to talk to her family, who had arrived in the waiting room 10 minutes before.

We continued the code while he was gone. When he returned he informed us that the patient's mother, father, and 5-year-old son were in the waiting room. The room fell into a hush. "She has a child?" I asked. I felt totally deflated. There was no promising sign that she was going to make it. The only sound in the room was the rhythmic, mechanical thrusting of the LUCAS machine, an automated chest compression device we had placed on the patient 15 minutes after she coded, relieving the staff of the breath-taking work of chest compressions. The doctor nodded, then said, "Let's continue for another 15 minutes, and then I'll have to call time of death. Does anyone have any ideas? Anything at all?" No one in the room spoke. "Okay," he said, "another round of epi please."

Fifteen minutes later, we called time of death - 0428 - almost four hours after she initially called for help. She was translucent, still, and mottled. I began post-mortem care. I cleaned her, changed her gown, wiped the mascara off her face, gently closed her lifeless eyes, and tried my best to smooth her hot pink locks, only able to guess which way she parted her hair.

The doctor guided her mother and father into the room. Her mother wailed, screamed, her knees buckled. We had to hold her up so she could say goodbye to her daughter, her baby. The rest of the night is a blur of tears, tissues, crushing hugs from her mother and the reverberating question "why?"

The young woman's body went to the morgue and I left for home. On my way, I saw her son, unaware of what had transpired, sitting on the lap of the grandmotherly woman who works registration. He was coloring and drinking apple juice - a picture of complete and blissful innocence. I hope someday he will know how hard we tried to save his mommy; how sorry she was for making the mistake to use drugs. But it is likely he will always wonder those things.

I got in my car and the tears began. First, a hot stream down both cheeks, then a sob. I cried the whole way home.

My 5-year-old daughter was awake when I walked into the house. "Mommy!" she laughed as I gave her a big squeeze. My heart was breaking, but I smiled at her. My husband rubbed my back, encouraging me to get some rest and go to bed. "No," I said, "Today, I am going to have breakfast with my baby."

Author's note: You may be wondering about the more clinical aspects of this story. There are many different chemical compositions to propellant-based keyboard dusters. According to the pharmacist in the room during the code, this particular dusting compound is known to bind to cardiac muscle and deplete the body's stores of calcium. When the patient's initial labs resulted, approx. 30 minutes after she arrested, she was found to be profoundly hypocalcemic. Many efforts were made to restore her calcium levels during the code, but clearly, it was too late. I often wonder if the precious hours wasted getting the patient to the hospital would have allowed for us to correct her hypocalcemia before it led to cardiac arrest. We will never know.

[vampiregirl, BSN, RN]

Thank you for this thought provoking article, well written!

I've worked both as an EMT and as a nurse. Sometimes there are so many things stacked against a patient. Wondering if there would have been a different outcome if outside influences (weather, road conditions, delays) had not presented... These are the patients and circumstances we carry with us, those that influence our practice going forward.

It can also be even more challenging in circumstances when a patient's decisions contributed to their medical condition. It made my heart smile though by the caring and competence you captured by those involved in this patient's care - from the prehospital providers to the hospital staff.

[FullGlass, BSN, MSN, NP]

Thank you for this article. I have ended over a year as a rural primary care NP and you really captured the transportation challenges. I want to laud the fantastic EMTs and paramedics that serve many of these communities. In addition, there are a lot of small rural hospitals that are doing the best they can with very limited resources.

Honestly, I would not advise anyone with serious health issues to live in a remote rural area. I was in a remote small mountain town and in bad weather, the road to the nearest big hospital (50 miles) might be shut down. There is a good air transport system, but in bad weather they can't fly.

Kudos to the first responders, nurses, and providers serving these communities.

[MSO4foru, ADN]

Kudos to those who tried to - and did help her. I am sorry that this pt died. It's not your fault. We can't be responsible for circumstances beyond our control.

[ruby_jane, BSN, RN]

The patient had a lifetime of choices which may (or may not) have contributed.

The snowstorm contributed, but nobody could do anything about it and incidentally, bless that first responder who made the choices he did.

RJ Junior is in school in the rural upper midwest. They're desperate for doctors there and your survival of your cardiac event definitely depends on your access to all the services you just described - which breaks my heart.

Thank you for this thoughtful contribution. Counting my blessings!

[jeastridge, BSN, RN]

So very sad. Thank you for sharing your story and for doing your best under tragically difficult circumstances.