The Mystery of the Double Cardiac Arrest

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p> Displeasure showed on her face. I had been pushed out of the way by senior residents within a minute. They had her well-ventilated with the mask and "lined up" (all the IV's inserted, fluid pouring into her circulation to increase her dangerously low blood pressure). Same for the old man on whom she had passed-out.

The concentration of activity was incredible; two full codes going on in the same smallish room. The medical people had squeezed in; there was a knot of them around each patient, hands on chins or EKG strips. We were working away but could only get their pressures up a little. They were both doing well lung-wise. The old man was completely out and intubated now; the nurse was breathing and reacted weakly when needles were inserted ,but that's all. There was a moment of stability and everyone seemed to look up at everyone else — the surgeons looked at the medical guys, the medical guys looked back. What the hell was going on? What do we do next?

I was an intern; I looked for the oldest nurse.

"What was this girl doing in here?" I asked.

"Well, I just sent her in to check his vital signs and put him to sleep."

"Any meds given? Did she call out?"

"No."

"Any idea why she would have rolled him to prone (put him face down)?"

"Well, maybe to give him a backrub before going to sleep." (Hospitals were nicer back then).

With that last comment I saw the medical senior resident's eyes shoot over to the bedside table. Mine followed his, but he got it first: "Get towels and rubbing alcohol — and we have to roll the man back on his face."

On the bedside table was a familiar yellow and red tube and it was almost empty. Nitropaste is a transcutaneous cardiac nitrate — a form of the more familiar 'nitroglycerin' that heart patients put under the tongue to relieve anginal chest pains. They both work by opening up certain blood vessels. Because it is well absorbed through the skin, it's given by squeezing a little out — like a half-inch long squeeze of toothpaste — onto a piece of paper or plastic and sticking it onto the patient's skin. Patients usually can do this for themselves — that's why it was left at his bedside. Nitropaste is pretty potent, too; a smear of it the size of a quarter can bring down blood pressure enough to cause a headache.

The riddle the smart medical resident solved was this: the student nurse had come in to say goodnight to her patient. She then gave him a backrub. And what did she use for the backrub? The cream on the bedside table — Nitropaste. The huge surface area of his back gave the patient a walloping dose. Even the surface area of the nurse's hands was enough to knock her out. Smiles went all around. Though the two weren't awake yet, we all knew that they were safe — a good thing about Nitropaste is you can "turn it off," rapidly stopping its effects by simply wiping it off the skin. Within 15 minutes of getting the stuff off, both patients were awake and alert.

We also knew that we had been through the oddest of codes, and that few ever ended this happily. I went back to finish evening rounds and fell asleep thinking — about an old Avengers' episode in which Diana Rigg's black leather gloves keep her from being affected by a transcutaneous hallucinogen that bad guys have put on children's toys. And how lucky I was to be sleeping that night, in this great, big hospital.