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.
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2 comments:
I was generally pretty lazy as a med student, but the one thing I did was attend a whole bunch of codes, doing chest compressions on about 5-7 patients. Hopefully, this will serve me well when it comes time for my first code this year.
In my program, the job of R1 was to do chest compressions, the R2 does lines and intubations, and the R3 runs the code. My arms get so tired after doing compressions for only a couple of minutes. Oh, and I hate it when the bed is too high and there's no stool to stand on in the room. Once, while in the ICU, you can see on the monitor how hard you're doing compressions and the pulmonologist would say to push harder until the number was like ~20 (I think) and you could tell if I or someone else was getting tired as the number got smaller.
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