Thursday, November 15, 2007
It was so warm yesterday that I actually washed my cars...one last time.
I switch over to the day shift as of tomorrow. I think it will be less interesting, but also less stressful since I won't be abandoned in the middle of the night to fend for myself.
One quick story: I was working in the Acute sCare module night before last and a new patient was brought in. I was just about to go "work-up" the new patient when I heard the nurses say that they were not able to get IV access. One of the surgeons who was seeing another patient said to me, "You should just move her into resus because she coded last week and has no good IV access." So I unlocked the bed and moved her into resus and as I pushed her in and told the resus team what was going on (fever, rule-out sepsis with Zero IV access), and locked her bed into place, I realized something. This was the woman who's heart stopped while I was listening to it a few days ago!
I've obviously been a doctor too long (already) because I'm not paying close enough attention to who my patients are. But, in all fairness to me, she looked SO much better than when I saw her last that it took a moment to realize it was the same person. Oh, and I did not know her name last time. It was the person that was not my patient but I went to go check-out anyway since I was near by. But still, those are reasons...not excuses.
Friday, November 09, 2007
Ironically enough, however, there is very little consensus as to the actual date of our anniversary among my family. So, each year, we receive a smattering of cards, e-mails and phone calls around this time of the month because they know we were married around this time. Each of the members of my immediate family thinks they know the date, but they each pick a different date! If I were really smart, I'd start taking bets on the date and I know the "house" will win! I think much of the confusion started when we held a reception in Atlanta and the invitations listed the wedding as having taken place on the incorrect date. I suspect the problem not only stems from the observations I made above, but also to the fact that ML and I eloped. But, for the record. So I don't have to do this each and every year:
Our anniversary is TODAY! Novermber 9th, 2002
And, although I spent the majority of the day sleeping because I just happened to have this evening off from work, it's time to go start celebrating! Thank you all for you wishes and thoughts that we've received this week and I suspect will continue to receive for a few more days. ;-)
Love and Peace to us all,
(El&ML)
Monday, November 05, 2007
I’m on the night shift the first half of this month and I have had 3 shifts already. I’m actually off today and desperately trying to stay away for most of the night tonight to keep on schedule. But, I’m starting to fade. Thus I’m hoping that blogging a bit will keep me up—at least for a little while.
My Second Night
Intercom announcement around
I asked my attending if I can go and he said, “sure!” I finished up some paperwork, there is a surprisingly large amount of paperwork in the ER which really slows things down significantly. I walked over to the resuscitation module with which I am very familiar from my time on my MICU rotation and let the folks know that I was happy to help with chest compressions. Around the corner the paramedics wheel the patient in and start telling us the story. The young man had been sitting with his wife when, all of the sudden, he stood up, his turned blue and passed out. It was reported that he was having an asthma exacerbation and that he was a “tight-bag” meaning it took an abnormally high amount of pressure the get air into his lungs. That is consistent with an asthma exacerbation.
We moved the patient onto the resuscitation bed (“cart”).
I announced, “No carotid pulse.” The resus nurse, “No femoral pulse.” There was a normal EKG which means he was in PEA (Pulse-less Electrical Activity). I start CPR. The attending announces, “Let’s go through the causes of PEA.”
“He’s not hypothermic because he’s still warm-to-touch” I said.
He was already receiving fluid. Hypoxia was a possibility. Hypo- or Hyper-kalemia were a possibility, but unlikely and would take an hour to get the labs back. Hydrogen ion (acidosis) was possible, but not likely given that he was an acute onset and the lab. We had ruled out Hypoglycemia with a finger prick test like those used for diabetics. There was no reports of Toxin or Tablet ingestion, Thrombosis (heart attack or pulmonary embolism) was a possibility. Tension pneumothorax was a possibility, but there was no report of Trauma. Those are the Five H’s and Five T’s of PEA.
I continued compressions for about two minutes when we stopped to perform a rhythm and pulse check. One of the resus techs who is pre-med started next. It was his first time doing chest compressions and, just like my first time, he started out going too fast. More epinephrine was administered and after two minutes we paused for a rhythm check and a third tech switched in for chest compressions. I was assessing femoral pulse as a sign of quality chest compressions. We rotated for about 15 minutes. At each check, he was still in PEA. It is a non-shockable rhythm which means you can only give medications and perform compressions. We use an ultrasound to visualize the heart which showed no movement. I announced, we should continue with compressions. The pre-med started compressing again. It was brought up that we could perform needle thoracostomy in case of a pneumo-thorax. I encouraged the idea and one of the nurses when to get the needles. At the next rhythm check, the patient was in ventricular fibrillation so I said, “let’s deliver a shock” and I continued my compressions while they set-up and charged the defibrillator.
“Defibrillator is charged. Everybody clear?”
“Not clear. Not clear.” I said. They had hooked up the wires to the pads around my back and I could not back up. I continued compressions until there was enough slack to step back over the wires.
“Clear?”
“Clear.”
“Delivering Shock.”
“Continuing CPR.”
Thoracostomy needles arrived. One of the techs noted that sweat was starting to show thrown on my back and offered to switch out. I giggled, and finished out my two minutes. At the next rhythm check he was still in V-fib so we delivered another shock.
I caught my breath and me and the other ER resident got ready with the thoracostomy needles. At the next rhythm check, he was back in PEA. Mid-clavicular-2nd intercostal spaces, we inserted the needles. No air rush, which meant no tension pneumo.
“Continuing CPR.” It was my turn again.
The attending comes over and asks while I’m doing my compressions, “Who are you?”
“Oh, just a transitional year-intern” I said with a little grin on my face.
For the next several rhythm checks, the patient was in V-fib so we continued to deliver shocks and medicines. We had been resuscitating for about 30 minutes and I asked her (the attending) if we should consider calling-it. She said, “so long as we have a shockable rhythm, we can’t.”
Another 10 minutes went by and his heart starting beating again. I checked the blood pressure, “94/46.”
I checked it again, “I’ve lost the pressure. No pulse.” The pre-med asked, “should I start CPR?” “You bet!” I answered.
Another couple of minutes went by and his heart had started again. BP 150’s/90’s. I was standing by the attending when she looked at me and said, “What are you going in to?”
“Radiology.”
“You should go into ER!”
My Third Night
I went up to the MICU to the room I hear the resuscitation patient from earlier that morning went to. I walked by only to see an empty room. Knowing that patients get moved around frequently, I leaned my head into another room where there was one of my nurse buddies working. I told her I was looking for the young man I resuscitated early that morning. He had passed away in the early afternoon.
I spent the rest of the evening with an eclectic parade of patients ranging from back-pain that could have been from breast cancer mets but turned out to be arthritis, most likely, to a car crash to shoulder pain. The shoulder pain was actually in a different module from the one I was assigned to, but the attending asked me to work it up. While writing up my findings at the nursing station around
I toss my hands up, “I don’t know anything about that patient, I’m not actually working this module.” My shoulder pain was in room 1. But, not wanting to totally fall victim to, “not my job,” I walked over with the tech to take a look.
She was somnolent, but bobbing her head a little bit. I put my stethoscope on her chest. “Lub-dub…Lub-dub…Lub-dub………………..................................”
“I lost the hear sounds!”
I opened her eyelids.
“Pupils are blown”(Dilated and no longer round.)
The tech pops the lock on the bed and says lets get her to Resus! Three of rush the bed down the hall. As he head through the door the tech calls out, “Clear a bed! Clear a bed!”
No one was there. We slotted the cart where there was a gap. I started listening again and undraping her. We got the leads hooked up and she was in V-fib. (Yes, it is a common cardiac arrest rhythm.) I was just about to start compressions while they put on shock pads.
“I’ve got hear tones!”
“Thready femoral pulse,” one of the techs announces.
I checked the pupils, they were round an normal sized. I performed a sternal-rub (which is exactly what it sounds like and surprisingly painful) to try to wake her. She moaned a little and, by that time, the module was filling up with doctors and nurses.
She would go into V-fib several more times that night but spontaneously converted back into a normal rhythm each time. The nurses were joking that it was my fault and did not want me to touch anyone!
Towards the end of the shift I was talking with the ER resident that I had worked the resuscitation with the day before. She asked me, “seen anything interesting this shift?” I laughed! “Well, other than the patient that went into cardiac arrest while I was listening to her heart…”
Well, it’s
