The Setup
Saturday night. Full waiting room. We're already running two active resuscitations — a hyperkalemic dialysis miss in trauma 1 and a GI bleed in trauma 2. Both ICU beds upstairs are full. The wait time on the board is 4 hours.
A 58-year-old man walks through the front door, says "I don't feel right," and collapses on the floor in front of triage.
The First 90 Seconds
- Bystander CPR started by triage RN immediately (good).
- Defib pads applied within 60 seconds (good).
- First rhythm check: fine V-fib.
- Shock at 200J biphasic. ROSC briefly. Lost it. Back to V-fib.
We had no trauma bay open. So we resuscitated him in the lobby. On the floor. In front of 40 strangers in waiting room chairs.
Decisions Made (Right)
- Did not wait for a room. Bringing the team to the patient was the only viable option.
- Early double-sequential defibrillation at minute 6 (4th shock cycle, refractory V-fib) — we had two defibrillators and used them.
- Mechanical CPR (LUCAS) applied at minute 4 — freed up two providers for the lines and airway.
- eFAST after second ROSC showed no tamponade, no pneumothorax — let us focus on the cardiac etiology.
The Call We Got Wrong
We delayed the airway. We were so focused on rhythm and lines that we kept BVM'ing for too long. ETT didn't go in until minute 11. In retrospect — we had three docs in the room within four minutes. One of us should have peeled off and tubed earlier.
ROSC at Minute 17
Sustained pulse. BP 86/52. Sat 94% on tube. EKG showed an obvious anterior STEMI. Cath lab activated. He went from the lobby floor → cath lab → coronary stent → CCU in 90 minutes.
He walked out of the hospital 11 days later.
The Family Conversation
His wife arrived at the hospital while we were still in the lobby — she'd been parking the car. She watched the last six minutes of his arrest. She watched us tube him. She watched us shock him for the seventh time.
We talked with her in the family room afterward. She didn't ask about prognosis. She asked: "Was he scared?"
That's the conversation that stays with you.
Clinical Pearls
- Refractory V-fib gets aggressive sooner. Double sequential. Esmolol 500 mcg/kg bolus. Lidocaine + amiodarone. Don't run the algorithm passively when minutes 8–15 keep coming up shockable.
- LUCAS earlier, not later. It frees hands. Hands are the rate-limiter in a small team.
- Airway during arrest is a discrete role. Assign it explicitly. "You are airway." Don't let it diffuse.
- The lobby is a place you can resuscitate. Operational doctrine: bring the team to the patient if no bay is open. Don't lose 4 minutes finding a bed.
- Family witness has evidence behind it. When safe, supportive, and facilitated by a dedicated person — better grief outcomes. Not for every case. But not as rare as we sometimes think.
Resources
- AHA 2020 ACLS Guidelines
- Cheskes S, et al. Double Sequential External Defibrillation. NEJM. 2022.
- Jabre P, et al. Family Presence During CPR. NEJM. 2013.
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