September 18, 2003
Monsters & Goblins

Another night, another code, another lost patient. During this month's rotation, the Night Floats the past two weeks had no worse than calling security to help catch a disoriented, combative little old lady; and now in the last three days there've been two codes on the floor. This last one we ran for 35 minutes, shocked more than I can count, and ran through just about every med in the cart, to no avail.

My pager goes off: "There's an emergency in room X". The JAR and fellow are already in the room. He's bagged. V-Fib. Clear. Epi. Shock. Shock. Shock. RT is here. Intubate. She starts compressions. I shoulder in and relieve her--compressions are extremely fatiguing and you need to relieve the person delivering them. Rhythm? Pulse? Clear. Shock. Pulse? Compressions. The JAR and fellow start placing chest tubes on both sides. Stop compressions. More Epi. Rhythm? Pulse? I hit the charge button and grab the paddles. His chest is a slick of conductive gel. Clear. Shock. Pulse? Round after round. V-Fib. Pulse? Shock. Shock. V-Fib. Vasopressin. Bicarb. Amio. Lidocaine. Torsades. Magnesium. Do we have Bretylium? We're running out of ideas. Finally we call it. The pitched whine of the defibrillator charge chime in the background. We've given the unfortunate fellow every chance we could. A medicine resident turns it off.

His mother is a huddled wreck wrapped in a blanket in the waiting room. The Chaplain is stuck in another code situation. We sit down with her.

Later, after the rest of the family arrives, there's a horrific wail that echoes down the corridors. The other residents are dealing with an MI in the unit. I'm sorry, we tried everything. I know you all did. Thank you. His wife's knee is quaking.

Monsters & Goblins come out at night.

Posted by erich at 02:53 PM
September 17, 2003
Code

This week I've been serving as the "Night Float" for the Cardiothoracic service, meaning the interns during the day hand their patients off to me at 1730, I tuck them in and take care of any issues that may crop up overnight, as well as attend to any work that couldn't be finished during the day.

Unfortunately I lost a patient the other night. We still are trying to piece together why. His family dealt with it with as much aplomb as you could imagine, but declined an autopsy, meaning that we'll never have a definitive explanation of what happened. I've made clear to the upper levels that I am completely open to any advice on things that I omitted to do, or should have done better; but overall, I think we ordered the appropriate tests, and made the appropriate moves. In retrospect, (and the attending physician called me directly the morning after to discuss this--a slightly nerve-wracking experience), it would have been better to have transferred the patient to the intensive care unit.

The patient likely would have coded there as well, but these are the places to be if something like this is going to happen.

The problem is that while he was foremost in my mind among the patients I was covering, I didn't see him as being so precipitously unstable. His family also notes that he seemed fine all the way up to the moment that he became unresponsive. Interestingly, the nurses tell me afterward that the family would have rather have let him go quietly rather than calling a code.

I get heartburn less than once a year, but had to guzzle a quarter of a bottle of Maalox to prevent my stomach from auto-digesting the rest of the evening. The nurses sympathetically minimized calls the rest of the night.

Posted by erich at 02:05 PM
September 15, 2003
Odds/Ends

The other day, I sat and watched the HBO special on 9/11/01. I had to--for instance I'd never allowed myself to watch footage of those unfortunate souls that threw themselves off the towers, tumbling obscenely to their ends--I was afraid I'd forgotten how horrific it was, especially footage right after the collapses with the downtown covered in ash, no sound but the shriek of locators; firemen and policemen bent over, stunned as all the trappings of modernity precipitated softly about them. And seeing the benign, dolphinoid form of a passenger liner disappearing in a tower is still barely believable. You could almost imagine something like that scene in the original Matrix when Keanu Reeves rescues Trinity out of the helicopter and induces a glitch in the computer program that doesn't quite accept the improbability of this act, allowing glass to ripple like water; the problem is that 9/11 happened, and there was no real glitch.

I'm currently on a Thoracic surgery rotation, having been switched in from Neurosurgery for logistical reasons. So far it's been a pretty good rotation except yesterday where I cross-covered all the Cardiothoracic services for one complete Earth's rotation. I was outnumbered, and never even made the attempt to apply my head to a pillow. I've slept 4 hours now and still am very tired.

Posted by erich at 02:41 PM