Sunday, October 21, 2007
Saturday, October 20, 2007
Okay, it’s time to start posting again. I was officially found to be satisfactory on my pediatrics rotation thus it is time to Rip Them a New One! But first, I have to tell you about call last night. A comedy of delays and saving the day while getting in trouble for it. Exactly what I do best!
I’ve been on Academic Medicine this month, which is my third of four call months. I only have one more call left in this month. I am post call now, which means I was on call (working) from 7a on Friday until 1p today, but I actually got to leave around 8a. When one is on call, they typically admit five new patients (which is the cap) and covers (deals with any issues the nurses or patients have) the other patients on the team. What is worse, is you have to cover patients for other teams and we, unfortunately, have to cover 2-Ell (cross-cover). These are the patients that are on dialysis and are the sickest of the sick. Cross-cover is very rough.
During a weekday call, you start admitting new patients at 5p and you usually get all five right away. With my prior calls, it has generally taken until 5a work up all five new admissions while dealing with cover and cross-cover. I’ll have to explain why that is later. Yesterday, I actually got my first admission especially early…around 3:30p. I was really ahead of the game and I completed my portion of the admissions around 1a! But, my senior, was busy and we did not finish the staffing until 4a. I was (So) looking forward to getting some real sleep, but it did not happen. I was back in my call room around 4a and I took a quick shower and then laid down. I had just dozed off when I heard the following over-head page:
“Attention, please. Code-Blue, 6 West. Code-Blue, 6 West. Code-Blue, 6 West.”
I jumped out of bed, tossed on my shirt and jacket and trotted down the hall. The code was in the exact opposite side of the hospital, 7 stories up. I took the elevator, which was right there, and trotted down the long hallway to the room. By the time I got there, there were already a half dozen residents in the room and another half dozen nurses working the code. I helped by getting some blood tests ready for the lab, but there was not enough room for me to do too much more. As minutes passed, some of the upper level residents left. One of the seniors I worked with tapped me on the shoulder and said, “Save this guy!” I told him I would if I could get in there.
Chest compressions were being performed by a couple of the nurses and I told them when they get tired to let us know. There was another intern with me ready to work. The patient had not had a shockable rhythm in this period of time so the protocol is compressions and drugs. Minutes go by. The nurses get tired and my fellow intern steps up, checks for a pulse…none. He starts compressions. I feel for a femoral pulse to make sure his compressions are perfusing the body. It’s thready at best. The senior running the code, my senior, is standing at the foot of the bed with the MICU senior occasionally giving the order to give a certain med or check for a pulse.
After a couple of minutes of the seniors looking at each other and at the patient, my senior calls for pulse check. I look over at the rhythm strip and, for the first time, it’s a shockable rhythm--ventricular fibrillation. I look back at my senior and I get nothing but a black stare. I look a the rhythm, still V. Fib. I look back at the seniors and they’re just staring.
“We have a shockable rhythm. V. Fib. Let’s prepare to give a shock.” I said authoritatively.
“Do we have the pads on yet?” Asked the nurse. I replied, we must since we have a rhythm. We quickly checked and found they were not on yet! We were reading the rhythm from the small EKG leads, not the shock pads. I was astounded that the pads had not been placed!
“Restart CPR while we ready the pads. [Time keeper], is it time for any meds?”
“There should only be one person running this code.” Says my senior to me. I shrugged my shoulders and said, “I was only trying to help.”
I was thinking, “Yup, you’re right! And you better step up to the fucking plate and do something instead of standing there with your mouth hanging open while the dieing patient is in a shockable rhythm for a few seconds and, oh yeah, we’re here to save this patient so get to fucking work at it!”
“We’re ready to give the shock! Everybody clear!” said the nurse. We all stand clear and deliver the shock.”
Someone calls out, “Check for a pulse.”
Firmly I said, “No. Continue CPR immediately. We will check for a pulse after two minutes.” And my fellow intern did just that.
Someone must have questioned the senior on that statement and she reiterated what I had said. That is the new protocol.
A minute goes by and my fellow intern fatigues. I asked him if he wants to switch out and we do.
I continued chest compressions for another minute when the senior called for a pulse check.
I place my hand on the patient’s right carotid. “I have a pulse! It’s strong.”
My fellow intern said, “I’ve got a femoral pulse, too. It’s good!”
One of the nurses checks the blood pressure. One of the other seniors goes to feel the pulse in the left carotid. I can still feel the pulse on the right when one of the ICU nurses politely requests that we don’t check the pulse on both carotids at the same time. It was a good point.
"Pressure is 150 over 97."
