Feeling guilt over put unexpected death

[regerterb]

Just having a bit of trouble getting over a recent death in resus with ongoing guilt.

i had a man in his 50's come from acute beds on morning shift....he presented with chest pain, on a background of aortic valve replacement, cardiac disease..smoker etc.

the nurse looking after him moved him up the bed lying down..immediately became diaphoretic, pale, grey...moved to resus to me...

was hypotensive at 86/56, sa02 95% on nasal prongs when I was able to get a good trace as was so so sweaty and peripherally shut down......heart rate 89...temp 35.5, resps 22.

i put him on 6L 02, he had fluids running....monitoring..I even put defibrillator pads on him as he just didn't look good. Cardiac team present at time and did an echo...was all cleared of Stemi or non stemi.....had an echo done...all clear...they were thinking infective endocarditis. Commenced him on antibiotics ? Cold sepsis.....has some frusemide as had small amount of fluids in bases on CXR....clopidogrel loaded, and had digoxin.......had a small non productive cough.....BP best we got was 98/65 systolic.....refused to lie flat.....but was talking with cardiologist etc.....after than remained as above...sa02 96%, Bp as above.....still extremely diaphoretic. For about 45 min...then later on.....dr in room, nurse educator in room.....was getting ready to put a Catheter in...ICU dr reviewing him when he became agitated, pulling leads off..pulling oxygen off.....Doctor notified...put him on 15L 02....was going to commenced him on bipap when he voiced that he couldn't breathe...sat bolt upright.....100% 02 applied..stated he was dying then became cyanotic...into cardiac arrest and died.

Struggling with the "did I miss something". What more could I have done...I followed all drs orders...but maybe he should have been on more oxygen initially? I read the echo report later on saying he had a small pericardial effusion....but...I just can't shake feeling guilty that maybe I didn't pick up on something..even though I can think of what.

😩

[Kuriin, BSN, RN]

Huh. They were going to place bipap on him? That seems so contraindicated when he became agitated -- it is a marked sign that he needs to be intubated.

As for you, wow, this is all very difficult. Was his temperature that low rectally? If so, were warming measures initiated?

Makes you wonder if he threw a massive PE clot -- a saddle clot.

This - in my opinion - never presented (the way I read it) as a STEMI/NSTEMI, though. You were smart putting DPads on, though. Why were they thinking infective endocarditis? Any vegetation on the valves? Any history that would warrant it?

To be frank, it sounds like YOU DID NOT miss anything. The physicians missed something.

[TuxnadoDO]

You should feel no guilt. Sounds like an extremely difficult case. Massive PE is on the differential, sounds like he was in heart failure (cardiogenic shock), may have been critical aortic stenosis. Very difficult situation for anyone, even intensivists/cardiologists/EM Docs to manage.

if you were the nurse and I was the doc, I would have de-briefed and addressed your actions to acknowledge the good care you delivered. Putting pads on him was a fantastic idea. That's what your docs appreciate - that initiative and intuition.

[offlabel]

Tough to be one of the last people (if not the very last) to talk to someone in their entire life. Done that a few times. Whatever the echo showed when someone said it was OK, that wouldn't be what it showed right before he died. Very odd it didn't turn up something serious before he arrested. I suspect the post mortem exam would tell you that you had nothing at all to do with his death, nor could you have done a single thing to prevent it or even help to prevent it.

Just a point of order for discussion purposes...was this pre-aortic valve replacement or post operative?

[Nurse SMS, MSN, RN]

Had one almost freakishly similar a few years ago. It was a PE.

Sending you comfort. Sometimes it is just their time and nothing we do can change that. Hang in there.

[Medic/Nurse, BSN, RN]

Sounds like you had a very sick patient that was going south when you got him.

You did the RIGHT thing. You anticipated needs. You stayed with him.

I'd bet you were a calming presence.

Often, we do everything right and things still go very wrong. It's a terrible feeling.

We play the "what if" "if only" game. DO NOT continue to do this. While I think review of action/inaction is worthwhile (and that's how we learn and improve) after the once over (or what should have been a MD debrief) it's of little value to get stuck in the rut.

You did GREAT. Really. {{{hugs}}}

I concur with the others, I will put differential on a PE (most likely) vs good ol' flash edema vs. mechanical valve defect/sepsis.

Onward, my fellow ER warrior!

:angel:

:angel:

:angel:

[AnnieOaklyRN, BSN, RN, EMT-P]

I am guessing he either had a dissecting thoracic aneurysm that ruptured or a large PE.

Annie