On Call, early morning Sept. 10, 1996
Just back from a code at the Mass Eye and Ear Hospital (connected to the Mass General). Someone, somewhere had little heartbeat and little breath to speak of. The sundry members of the code team had their beepers squawk, and rushed from various corners of the hospital.
Its been a relatively quiet week on the Pediatrics ward. The Code call announcement came on overhead speaker. My medical student and I, high up the 16th floor pediatrics floor, looked at each other, and having nothing better to do at ten to midnight, made the not insignificant treck from the Mass General over to the connected but otherworldly Mass Eye and Ear hospital. As interns, if its not our patient, we certainly aren't expected or usually needed to go to codes. More a moribund curiosity and opportunity to help when possible and see how they are run-as I will be the one running the codes in a year or so. The flavor of a code changes dramatically if you know (as happened to me when one of my patient coded while at radiology) , or are responsible for the patient, which fortunately , we weren't.
The strangely surreal but becoming familiar scene of many residents and nurses crammed into a room greeted us. CPR in progress. Someone was trying to put in a central groin line. It was worse than usual- the patient, an 80 year old, who was fine 30 minutes early when checked by the nurse, had just undergone a reconstructive facial procedure following a carcinoma removal, and had what the anesthesiologists would call a " a difficult airway". Having just been operated on about the neck- normal endotracheal intubation was not an option. After a few rounds of epinephrine, a few shock with the defib- and very little ventilation going by via the bag mask into the lungs- the ENT senior resident tried for the bed-side surgical airway (a first for him). I held a couple of flashlights to light the impromptu surgical field. Tracheotomy incision- and the endotracheal tube shoved tight directly into the trachea. A weak pulse on the monitor but nothing palpable. The arterial blood gas came back with a pH of 6.9 (acidic), and a oxygen level of 6 (normal is >50) and Carbon Dioxide of 140 (way high). The situation was obviously futile. Any brain was long past salvage 25 minutes into the code. Finally the senior medical resident "called" the code. It was over and the patient was now without a return ticket to the netherworld.
Five seconds after she said "lets call it" and CPR and respirations were halted... The patients phone rang.
Everyone, about to leave, froze in place.
"I don't think we'll answer that one" said the ENT resident.
I'm back online and up for air. Now I've survived 2 months of internship (that's 1/6th of the year) (though who is counting?)
After the 1st 5 weeks on the general medical wards- it was out of the frying pan and into the kitchen- to a stint in the Medical I.C.U., which I recently completed.
Intensive Care Units are intense in more ways than one. Intense medicine, intense living, intense dying (and lots of it), intense attendings, tense tense tense. The place where patients which are medical disasters come to be 'flogged' and in a few cases great 'Saves' are to be made.
All in all- it was great fun...
The Team: A senior resident, and three paired sub-teams consisting of a junior resident and an intern. There is a pulmonary and critical care fellow who helps out, and an attending whose name is on the chart and rounds with team each morning Every third night call. One of the other residents kept a moribund tally of Hits (admissions), Patients on each sub-team, Deaths, and Saves (i.e. someone who really benefited and made it out of the ICU)
Every third night it was me and my junior, alone, taking admissions and running the unit with the fellow and attending somewhere asleep at home.
The patient my resident and I picked up the morning we started had been in the unit for a week already and was pretty amazing. Ms P. , an otherwise healthy 36yr old mother, had a gum infection which spread down to her neck, and into her chest. Required an operation to debride the infection. Post-operatively she developed "ARDS"- adult respiratory distress syndrome while on the ventilator. Her lungs were shutting down and despite the best ventilator and other tricks in the books she was about to die. In comes the ECHMO (extracorperal membrane oxygenation) team. Two big catheters placed in the groin take out blood, which is oxygenated in a big contraption with many tubes, and pumped back in. Basically a bypass bypass used while the heart is still pumping. It allows us to essentially turn off the lungs to allow them to heal and get a break from mechanical ventilation while the blood is oxygenated outside of the body. Until very recently this was only done on premature babies, but now has been tried on less than 2 dozen adult patients. To make a long story short, Ms. P was a true ICU 'Save', and in my time in the ICU we got her off the ECHMO, then extubated and breathing on her own off the ventilator. And finally after 5 weeks in the ICU, to the general medical floor- and finally home.
Our first day/night on call we had five admissions. My junior resident (who had all of 2 weeks as an intern in the ICU), was terrified.
Our first patient: a very large chef from New York- a true heart attack victim with a very nasty EKG, who had received thrombinolysis to break up the clots in his coronaries while in the emergency dept. He was finally pain free after loads of morphine in the ER, but required full IV doses of Nitroglycerine and Esmolol drip to keep his pressures below 150. The high blood pressure and heart rate monitors kept ringing and I'd have to run into his room and give him extra slugs of IV Beta blocker to bring his heart rate down. Then his chest pain came back... He made it out of the unit to the Cardiac care unit a couple of days later after having cardiac catheterization.
Number two: A suicide attempt- 38 year old who had taken 2 bottles of his anti- Tuberculosis medicine (INH). A poor choice for suicide- he'd been found confused, taken to the ER, stomach pumped with charcoal, intubated for airway protection. And then sent up to me, very combative despite 100mg of Haldol (enough to snow a horse). We sedated him with propofol ( a short acting benzodiazapine) gave him the antidote (vitamin B6), and sure enough in the morning he was extubated and sent wide awake and talking to the medical floor.
Number 3: A 58 year old with widely metastatic lung cancer- with trouble breathing. With his unstable respiratory status they thought that he might "buy the tube" as its called, and since per family wished he was a 'Full Code' ie. everything from intubation from CPR was to be done (essentially futile in end stage cancer patients) he came up to the MICU. I put my 3rd arterial monitoring line in after a couple of sticks. This allows us to follow blood pressure and heart rate in real time (and makes the alarms go off when parameters are out of wack). By the next day, he remained actually quite stable and was transferred to the oncology unit, where after appropriate consultation with his oncologist, he was made DNR (Do Not Resuscitate) and sadly, died a few days later.
Number 4: 3am up from the ER, a unidentified 60ish year old male, who was found down at a subway stop without a pulse. After 45 minutes of CPR and grams of epinephrine etc. in the ER, they got a pulse back. Now ironically, he had maintained his weak pulse on full pressors, and hadn't died as expected. The attending ER physician needed the room in the ER, so up to the ICU the nameless patient went with a systolic blood pressure of 60-70. My junior handled this one. Despite full IV meds, his pressure fell. There was nothing left to do. And he died. What my resident resented most about this lousy admission, was that she would have to dictate the entire admission, and discharge (to the morgue). More futile paperwork.
That was only the first night of many sleepless in the medical ICU. We survived the night to bagels and coffee brought in by the relief team the next morning. I left to a glorious summer afternoon in Boston, and the past 30 hours of rounding, bells, whistles, ventilator settings, sedation orders, DNR orders, beepers, thick charts, tragedy, triumph and stale coffee were left behind as I rollerbladed home to sleep.
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