ICU: Crazy Code Day

After having a relaxing day off yesterday, it was back to work this morning. I saw my two patients (pancreatitis man and dissecting aneurysm man), who are the same as usual. Another 4th year interested in the FP program here joined us today; she's from DMU and wants to go to residency in FW b/c her parents have moved here. I originally offered to let her be on call tomorrow with Aaron, but Garrett told me to take it back. "She's just an FP student," he said. "We're here for the whole month. We're already second to three interns (I corrected him saying that Loan was a second year and not an intern, but technically she's still learning and not at Aaron's level), and the only time to learn anything is on call." So later I told the girl that I'll be taking call tomorrow after all, and she said it was fine. I told Garrett that I have a tendency to be too nice (which people have taken advantage of, I'm sure), and he reminded me that I'm learning, too, so I shouldn't have to give up good learning opportunities to others.

We had barely begun to see our first patient when we heard a Code Blue from Tower 6 over the walkie talkies. Kate (who's on call) and Garrett immediately headed over there to see what was going on while Aaron called Tower 6 to see what happened. All we got was that a woman with metastatic breast cancer had coded and that she was being intubated as we speak. When Kate and Garrett returned, I asked Garrett if the woman was alive. He said yes, and she was soon brought to our unit. All thoughts of rounding forgotten, Dr. ML immediately went to her room and said he needed someone to do a femoral line, another to do an IJ (intrajugular line). Heather started on the femoral line while Kate did the IJ. A nurse put a Foley in the woman and I saw some blood come out of the Foley; it made me wonder if it was possible to puncture the bladder if the Foley is pushed in too hard. Not too long afterwards, the woman coded again, and everyone immediately began feeling for a pulse. One nurse started compressions and then asked for someone to take over, so Garrett jumped in. I told Garrett to switch with me if he got tired, but I had the feeling he wouldn't get tired anytime soon.

A few thready pulses were felt once in a while, but in the end, it was decided that there was nothing that could be done and Dr. ML told Aaron to bring the husband into the room. As the chest compressions continued, the patient's remarkably calm husband entered the room and Dr. ML explained what was going on and asked the husband if he wanted them to stop the code. His reason for bringing the husband into the room was so that the husband could actually see what we were doing to keep his wife alive (pounding her chest, bagging her, etc.); many families have some false idea that we keep patients live by injecting them with drugs, nothing physically demanding like CPR. The husband told us to stop the code, and time of death was listed as 9:35 a.m. And yet when I looked at the monitor, she was still breathing on her own and her heart was still beating, albeit erratically. Why were they calling time of death so soon?

All tubes were removed, and the husband went to his wife's side and held her hand. Her eyes were open, and even though he tried to close them, they stayed open for a while. I kept an eye on the monitor and watched her HR drop from 80 to 70, then 65, then 40, then 35, then 0, then back to 30, then 0 again. Her breathing eventually flatlined, and soon, so did her HR, not to beat again. The husband never once lost his composure; maybe he prepared for this a long time ago. Dr. ML murmured some words of condolence as he left the room, and one by one we left too, leaving only the husband, the patient, and the chaplain. I did look back in the room once, and I noticed that the patient's eyes had finally closed.

Needless to say this reminded me of the death of little AJ back in Corpus Christi over a year ago. Back then, they didn't call time of death until his heart had stopped beating, and we had to listen to the screams of his brokenhearted mother throughout the code. But in the end she, like this patient's husband, knew not to prolong their loved one's suffering, and was willing to let them go peacefully.

After our patient passed away (Garrett left the room early and didn't realize she'd passed until later), rounds resumed as though nothing had happened. Then we had another emergency; our patient from IPA had somehow extubated himself (even though he was in restraints; maybe he coughed up the tube?) and needed an emergency trach. Kate got to do the intubation, and she struggled a bit, too, but she got it in. That's part of the learning experience. I also saw another familiar name on our patient list: the name of a homeless man familiar to the ER whom I met on my first day at JPS in medicine. Back then he came to the ER almost every night after getting drunk as a skunk for a place to sleep off the alcohol, and I specifically remember him calling me a "f***ing p***y." Aaron, too, asked if he'd been admitted to the hospital for being drunk or if he developed sepsis (his reason for being in the ICU) later. "Looks like he finally got sick for real this time," I commented, and Dr. O agreed. Someone made a semi-joke about how maybe he liked our new ER and ICU so much that he decided to figure out a way to stay here long term. It's not worth his while though; he's suspected of having TB and had to get a trach. My pancreatitis patient got a trach, too; hopefully he'll be more comfortable now.

There were lots of procedures going on this afternoon (3-4 trachs, 1 bronchoscopy, one core biopsy of the breast), but because I had to write a transfer note, I missed out on the trachs (though I did get to see part of one). Hopefully I'll be able to do more on call. Heather commented that when she was a 4th year, taking call was optional. It still is, but if you think about it, the only time I really learn anything is when I'm on call, and q4 isn't too bad as long as there are no codes during the night. Garrett said he got 6 hrs of sleep last night (lucky him). We'll see how things go for me.