m&m

Within most fields there are a lot of conferences. One of ours is M&M: morbidity and mortality, where cases are discussed where life was lost or damaged, and the process is examined in order to determine what went wrong. During an M&M a couple weeks ago, I found myself wondering how I traversed from the M&M of happy chocolate to the M&M of this. I even found myself in a remote elementary school memory. I'm sitting on the carpet of my parents' bathroom with a phone, voting repeatedly for the next M&M color. The choices were pink, blue, and purple. I wanted purple. My brother said no color was going to beat out blue. As you know from M&M packages these days, he was right.

The day after I was studying EKGs and abnormal heart rhythms (arrhythmias) to prepare for my rotation in the emergency medicine department, I had a patient whose heart went into a life-threatening arrhythmia. As they say, he coded. As I've learned, learning in medicine has a lot to do with hearing the same phrase tossed around and observing by association what it means. For example, Code 5 means that an alarm goes off throughout the hospital and the assigned medical staff races to the location of the code. In the emergency room, this location often encompasses the space of maybe an elevator and a half. A crammed elevator and a half. A curtain separates each patient's space from another's, and as a student it's difficult to not be in the way.

The patient was a very nice elderly man with kidney failure on dialysis, which means that three times a week he's connected to a machine that does for him what his kidneys should be doing for him every second. He also had no legs, but I'm not sure why that was. His EKG showed signs of hyperkalemia, or too much potassium in his blood, which can happen with kidney failure since the kidneys filter potassium out of the blood. This is bad for the heart, because too much potassium in the blood means the potassium will enter the cells. Since potassium has a positive charge, this makes the inside of the cell positive (depolarized). Normally it's this depolarization that sparks off the action potential that allows hearts to beat. But when the cell is continuously depolarized, certain sodium channels close and don't allow any more action potentials, so the heart can't beat normally anymore. All this damage leads to decreased blood flow and thus oxygen to the heart. It tries to compensate by sending off random beats in its ventricles, which creates the arrhythmia this patient had. Ventricular tachycardia: beats are going off rapidly in the ventricles. It's bad because the heart keeps contracting, leaving no time for it to relax and fill up with the blood it needs. (I'm pretty sure that no matter how much training I'll get in my lifetime, my poor brain can only think in these simple terms).

We'd been having a nice conversation about his children (he had a daughter with my name) when his heart when haywire. Throughout the code, he was awake and could speak to us, and would always say he was doing fine. He shouted in pain when they had to shock him to bring his heart back into a normal rhythm, but continued with his polite responses to the doctors asking him loudly if he was all right. They stabilized him to bring him to the Intensive Care Unit, but he went into an even worse heart rhythm there (I heard the alarm go off throughout the hospital calling Code 5). He was shocked again. I don't think he wanted much more help, but his family did, and there was confusion, misunderstanding, and hurt. I don't really know what happened after that, because I was still in the emergency room and he wasn't. I think I lost the M&M game again.