MICU: Overnight Call

The last week of MICU went pretty smoothly. I got to be pretty good at transferring patients out of the unit. Two of my patients who had been in the unit since July finally got well enough to transfer to the PCU (much to the dismay of the PCU intern, who said that every other transfer note coming to the PCU was written by me) One of my calls was hectic b/c a nurse kept pestering me about a patient's BP being 220/104 (she was asymptomatic), and when I called the fellow, his response was to ask me whether I knew the difference between hypertensive emergency and hypertensive urgency. Ohh. *sigh* Good thing I called while he was eating dinner and not in the wee hours of the morning; he must have thought I was dumb.

As "luck" would have it, my very last shift of MICU fell on a Sunday, and I was overnight until Monday morning. It was just me, the overnight PGY3, and the pulm/crit care fellow for the afternoon and a good part of the evening. One of my patients developed a bad leak in her trach (which, after what happened with the patient in my last entry, had us very worried), and after way too many tidal volume readings of 50-200 ccs, we had anesthesia come to reintubate her (but not before she got bronched and had a huge mucus plug that had been blocking her left carina sucked out; that was part of the reason why her tidal volumes sucked). No one wanted to take the chance that her trach would last until morning. My PGY3 wasn't around while all this was happening, and later the fellow asked me if this sort of absence was normal. I told the fellow that my PGY3 was easily reachable by phone if I ever needed him, but silently thought, "Yes, this is normal." We had a patient close to death after her family withdrew care, and when I asked him if he wanted to be notified of her passing, he said no. "You know what to do, right?" he said. Yes, I did (he made sure to teach me when we had our first death), so I pronounced her, filled out the packet, and called the fellow when it happened. Don't get me wrong, I liked having independence in the unit, but I thought the PGY3 could have shown a bit more interest in the patients. He never even asked about her until the next morning.

Another of my patients, SS, had continual bleeding from her permacath site (oozing). Not wanting to bother Zael, I ordered thrombin spray and gave her platelets, blood, and FFP. Nothing truly worked, not even after I applied pressure for 15-20 minutes. When my resident showed up in the morning and I told him what happened, he asked if I gave her DDAVP. -__- Nope. He asked me why I didn't call the PGY3 for help or advice. It hadn't occurred to me b/c I'd asked one of the overnight triage residents for help, and she'd never mentioned DDAVP to me. *sigh* That was negligence on my part; I guess I should be lucky she didn't bleed to death or else I'd really be in trouble. I felt bad for letting my resident down; just last Friday, when I asked him how I did on my rotation overall, his only critique was that I had to know when to ask for help so that I won't get overwhelmed on the job. And what happened? I didn't ask the PGY3 for help about my bleeding patient because I didn't want to wake him up. *sigh*

Now I'm starting ambulatory, which involves spending half-days at different departments and specialties (ENT, rheum, cardio, nephrology, to name just a few) to get an idea of what outpatient medicine is like. I'll have weekends off, hours are 7:30-5:00 pm. No complaints =)

MICU: Death on Call

When my resident was last on call, he admitted a very ill woman with a history of ovarian cancer who was dying of septic shock (I almost had to write an H&P on this woman last month, but then triage gave her to someone else. Otherwise I would have known her better). Yesterday evening the family decided to withdraw care, and after she died (surrounded by about 15-20 family members), I was called to pronounce her dead. It was very unnerving to be listening for heart/breath sounds, feeling for pulses, and checking the eyes in a completely silent room full of strangers, but when I explained my findings and said she was gone, the family took it well. After that, while the family grieved, I went to make the necessary phone calls (to admissions, her heme-onc attending, Gift of Life) before filling out the death packet. Needless to say I wasn't too amused when two of my fellow interns came into the MICU and tried to trick me into thinking that I'd be covering their patients for them tonight. Lousy timing on their part.

Shortly before midnight I got a call about a patient named Melvin whom the nurse suspected had aspirated on tube feeds, so I got a CXR that turned out to be normal. Several hours later the nurse called me again saying that he was making gurgling sounds in his (relatively new) trach (he had end stage HIV and was completely out of it mentally). Since it was close to morning at the time, I said I'd pass the news on to the R3. Everything was fine until around 7:30-7:40 a.m., I was writing notes on another patient when one of the nurses asked me to call surgery because he was really having trouble breathing. I got the pager number for the surgery intern/resident on call, but before I could do anything with it, I heard a lot of people saying that he was bradying down and someone called for the crash cart. Oh #$@%!!

Even though I'd already handed my code pager off to Dave, I was close to the room and immediately went to see what was going on. The overnight R2 was giving chest compressions and I immediately went to help him out. This was my first time doing compressions and the fellow said I wasn't pushing it deep enough. "Don't stop, keep compressing! One inch depth!" he yelled. It was a messy code. There was a lot of moving and shifting around as the patient had his trach changed (assuming it was the trach that caused his intial hypoxia), and then anesthesia came to intubate him. The table was too high and I had to stand on my toes to do compressions, and even then I knew my compressions were subpar. At one point the nephrology attending (who just happened to be nearby when the code happened) had to do compressions while I had to move to the other side o the bed. The fellow kept yelling for someone to call the code officially so that more housestaff can come and assist (the R2 and I each got tired out pretty quickly), but unfortunately no one ever called the code. Surgery did arrive because he got paged overhead, and then he and the fellow got into an argument about whether or not the patient was shockable or not. "He's in asystole!" the fellow yelled. Surgery yelled back, "He had a shockable rhythm!" Fellow: "That was with compressions!" Surgery: "No, it wasn't!" It went like that for a while, and despite the injections of epi, bicarb and more, the patient was still in asystole. Now that was definitely unshockable Finally the fellow said, "Any other ideas?" The surgeon shrugged and said, "I'm ready to call it if you are." Time of death: 8:06 a.m.

The atmosphere in the room was grim as we left, and I couldn't help wondering if there was more I should have done overnight aside from ordering a CXR on him to rule out aspiration. Later the fellow asked me if I'd done codes before. I told him that was my first code, and he said he was sorry that had to be my first one. "That was a very disorganized code," he said. "It was never called out, so it was just you, me and R2. There should have been 4-5 housestaff here. And I shouldn't be trying to keep the airway open, look at the monitor, and give orders at the same time; I should have been at the foot of the bed keeping an eye on everything going on." It made sense. Afterwards, it took about 2 hours for anyone to get ahold of the patient's family and inform them of the patient's passing (apparently they didn't visit often), but in the end, they came. Thank goodness for that.

That was more death than I wanted in one night. Thank goodness I have Labor Day off.