In-Service Exam Blues

The results of our inservice exams from last fall are in. Not surprisingly, I didn't do very well, and it wasn't much of a consolation to hear that I was not the worst of the intern class. I'll be taking Step 3 at the end of the month and I don't feel ready at all. Granted, Step 3 won't ask me totally detailed questions like the inservice exam did, but I still worry. *sigh* Oh well. Nothing to do about it now but study.

Five Days in Texas

As part of our "Holiday Block" I got 5 days off for Christmas and chose to spend those 5 days at home with family. It was very memorable for sure. First we got SNOW on Christmas Eve that lasted well into Christmas Day (yay for White Christmas!) Then my sister and brother-in-law completely surprised us by flying to Texas to celebrate the holidays with us (the sister actually hid behind my bed and jumped out at me after I got home from visiting a neighbor. Scared the crap out of me but it was a fun surprise regardless). We went to Japan House TWICE for great all-you-can-eat Japanese food, and I also met up with high school friends for our annual Christmas get-together. The familiar faces was not restricted to family members; this morning I met up with Anita at IHOP for breakfast, and this afternoon I ran into Doug at the airport; we were flying back to Philly on the same flight. Not bad for a five-day visit =) And while I'm a bit sad to be back in Philly, it's time to get back to work. I had my five days off; now I got a black weekend ahead of me while the other half of the medicine residents get New Years off.

Snowed In

Ever since last week, news was abuzz that a huge snowstorm was scheduled to hit the Northeast this past Saturday and Sunday. When I went to the grocery store on Friday, the lines were ridiculously long as people scrambled to stock up with food in preparation for the storm. On Saturday I had the day off so I watched the snow fall from my window, marveling and how beautiful it was to watch the snowflakes dancing in the air as the world turned white.

All that marvel disappeared this morning when I went to my car and found it half-buried in nearly 2 feet of snow. I couldn't believe it; I had to be at work in 1 hr and there was no way my car was going to be properly shoveled free by that time. The only "digging" tool I had was an ice scraper and a dustpan, which helped a little but not much. One man walked by and offered to shovel the snow around my car for $25 but I didn't have that kind of money on me anyway. At 7:30 a.m. (I was due at work at 8) I called the chief resident and overnight PCU resident to let them know I'd be late. One hour later, when my car was still stuck, I called my resident and asked if she could fill in for me until I got to the hospital (she lives across the street). She immediately got angry (apparently she had a bad day at work yesterday and was really looking forward to having her day off) but said she'd go to work after she showered. I could tell she was pissed at me and knew that taking the day off was not an option.

Fortunately one of the landscapers on site walked by with a shovel and offered to dig me out. I got in my car and he was able to help push the car out of the snow blanket into the freshly paved driveway, where I thanked him and drove to work. I arrived at around 9:30 a.m. and my resident couldn't get out of there fast enough, saying that we're never to speak of this again. I had no idea what it meant but took it to mean she forgave me for calling her to work on her day off (since she was only there for about 30-60 min). The nurses, however, had noted her foul mood and said they were glad I showed up. Of the two of us, I'm definitely the nicer one.

The work day was, fortunately, fairly uneventful, though I didn't get out until 5:30 pm (which was expected since I arrived late) Of course, the day was not without its costs. I didn't have any waterproof pants so when I changed out of my wet pants into dry ones, my legs were bright red and I had to soak them in warm water to get feeling back in them. From what I can tell there was no real damage done (just an area or two of blotchiness), but even now there's a prickling sensation on my legs that doesn't feel quite right. My new Uggs are completely soaked (though I'm impressed that my feet stayed dry). And on top of it all, I feel like crap. Hopefully I won't get sick; all I need is to get through the next two days and then...back to TEXAS. Goodness knows I need to get away from Philly for a while.

The Story of B.L.

Back in late August when I was working in the MICU, my resident (who was overnight) got called for a code on a 65-year-old woman who'd been found unresponsive in her bed. The attending had last seen her awake and alert at 7:30 pm, and the code was called at 7:45 pm. No one knew how long she had been without a pulse during that time (she had PEA), and like most codes, she was resuscitated, intubated, and rushed to the ICU. Her name was B.L. She was one of the trainwrecks signed out to me on that one day in the MICU when everything went wrong, a vasculopath with ESRD who had come to the hospital days prior for left foot pain and toe gangrene due to arterial insufficiency. Hours before she coded, she had refused to have her foot amputated. Everyone--the MICU team, her vascular surgeon, her nephrologists--expected her to be dead within days.

The first time I saw B.L., she was seizing, a bad sign indicative of anoxic encephalopathy. Her EEG later confirmed that she had low brain activity. Her left big toe looked dried up and withered. I wondered if she could become septic from that toe, but the surgeons who saw her said it was dry gangrene and not a source of sepsis (she was constantly hypotensive). Finding access on her was a problem because most of her veins were too scarred or damaged to use; her only access (later put in by surgery) was a permacath for dialysis. No one could really declare her brain dead because she still had her corneal and gag reflexes, and we couldn't call her a vegetable because it takes 3 months to declare someone to be in a persistent vegetative state. Despite our low expectations for her survival, however, she hung on. Regularly scheduled dialysis and antibiotics kept her going. At one point the surgery chiefs even pulled me aside and asked why she was still alive.

B.L. had a daughter, who also served as her power of attorney. She came to visit every once in a while, and despite doctors' numerous attempts to talk to her about making B.L DNR/DNI, she insisted on keeping her mother full code. My resident tried several times to bring up code status with her, but each time she'd say that she needed to talk with family or some other excuse. Even after 1-2 weeks passed, she still wouldn't discuss the subject. I was able to arrange a family meeting between her, the ICU attending, and the neurologists so that they could explain the poor prognosis of anoxic encephalopathy, and the ICU attending asked whether she wanted to take her mother out of the hospital to a hospice center, or if she wanted a trach and PEG to keep her alive longer. The daughter immediately requested the trach and PEG (much to the dismay of the surgeons, who believed that the woman should be allowed to die peacefully since she would never have good quality of life again), leaving everyone wondering what the purpose was of keeping this poor woman alive. B.L. got her trach and PEG, but not without problems. On my last call in the MICU, she had to be reintubated because her trach was leaking. After I left the MICU, I didn't know what became of her, only that she was sent to the PCU.

Before she coded, B.L. was a fairly frequent flyer to the hospital for her PVD and ESRD. During her hospital stays, she had developed close relationships with the nurses and nephrologists, who later filled us in on her family situation. She lived with her daughter, who often neglected her and didn't give her enough food or blankets to keep warm. B.L. often ended up getting better care at the hospital because the nurses knew of her sad home life and tried to make her as comfortable as possible. Her nephrologists also told us that her daughter was taking advantage of her by living in her home (rent-free) and cashing her Social Security checks for her own use, and they suspected that her daughter wanted to keep her alive for those same purposes.

Three months later, I attended a case conference with "Futility of Treatment" as the main topic. My MICU resident had a case to present: a 65 yo woman with hx of CAD, PVD, ESRD who presented at the hospital for left foot pain. That description could have fit any lady in this hospital, but as soon as he said the pt had a PEA code and was found unresponsive for an unspecified amount of time, I knew he was talking about B.L. I then learned what happened to B.L since I left the unit: she was discharged from the PCU in mid-September and went to a long term care facility for one day before her daughter brought her back for hypotension. The pt's status was still full code, and despite numerous attempts by both the medicine and nephrology attendings to talk to the daughter about making B.L. DNR/DNI, the daughter refused to do so. She would always change the subject whenever it was brought up, and yet had the gall to ask the medicine attending to sign a form that would allow her to pick up and deposit her mother's Social Security checks. The Ethics committee was consulted three times to meet with her, but each time there was no resolution, either because she wouldn't show up to the meeting or else she'd have to "discuss" with some other family member. I couldn't believe that this had dragged on for three months, and yet I was also amazed that B.L's body had lasted this long.

Last week I started my rotation in the PCU, and one of my patients was B.L. Her left foot, which had a slow-growing gangrene when I first saw her, had been amputated (a BKA). Her eyes opened spontaneously and she sometimes moved her head from side to side, but that was the most of it. Now she could be classified as being in a persistent vegetative state. Interestingly enough, on my first day of PCU, the nephrology attending decided that she would no longer dialyze B.L, since every time she's dialyzed her BPs fall to 50s-60s/30s-40s and then we'd have to bolus her to get her BPs up again. "There is no benefit to this," she said, and stated that by stopping dialysis she was willing to be the "bad guy." After all, without dialysis, the patient would surely die within a week or two, and that would be letting death take its natural course.

Needless to say the daughter was pissed when the nephrologist and told her that they would not be dialysing B.L. anymore (the rationale being that HD dropped her pressures dangerously low and that it could no longer be safely done). My attending later called the daughter to once again bring up code status, and while the daughter agreed that chest compressions and defibrillators would be "excessive" for a dying woman, she refused to change the code status to DNR/DNI. No hospice center would take B.L. as long as she's full code, so essentially she'd be staying at the hospital until she died. And despite the daughter's claims that she'd come visit her mother at the hospital, I never once saw her (and I worked every day last week). Nephrology also recommended that we stop drawing labs on her, to minimize anything we do as much as possible. Everyone seemed to be in agreement...for a while.

Then last Sunday, everything went to hell. B.L.'s blood pressures became dangerously low once again, and her nurse asked me why there were no labs on her for the last five days. "You need labs to know what you're treating," she said, so I ordered basic labs on her. As it turned out, a week of no dialysis didn't really budge her electrolytes at all (K+ was less than 5) Then nephrology came by and asked why the heck I ordered labs on her, saying I opened a new can of worms because if she was uremic, then she'd have to be dialysed. My attending said I should start her on pressors, but pressors can only be given in the ICU. The pulm/critical care fellow knew her well (as did everyone in the ICU and PCU) and did NOT want to take her back, asking us instead to give her albumin and see if that would help her pressures. I felt bad for leaving the nurses to deal with her that night, but honestly, I was at the end of my rope, and I went home secretly hoping that I wouldn't have to deal with her the next day.

As it turned out, she did get transferred to the ICU, and my PCU resident expressed her hope that it would be a "terminal transfer" (meaning she'd die in the ICU). When the nurse called the daughter to let her know that B.L. was being transferred to the ICU, she asked (again) why her mother wasn't receiving dialysis. I couldn't believe it. Did this woman really not have a clue what was important, or was she just playing us for fools? And no, she wasn't coming to the hospital.

Early this morning, as told to me later by the social worker and one of the MICU interns, B.L. coded...three times. And because she was full code, everything was done: chest compressions, bagging, epinephrine, everything. I had half-expected the team to run a "slow code" but they went all out. She lasted about 30 minutes before she coded for a second time, and the third time they couldn't bring her back. Each time she coded, someone called the daughter to ask her how much she wanted done for her mother. The first time, she suggested (sarcastically?) that the team do "whatever was ethical." The second time, she got mad and hung up on the doctor who called her. The third time, she didn't even answer the phone; another family member had to answer for her. I'm just afraid that now there'll be hell to pay.

But even still, as news spread through the ICU, PCU, and beyond that B.L. had finally passed away after 3.5 months of living in a vegetative state, I think everyone felt relieved. From the nurses who cared for her round the clock and the doctors who coordinated her care, we were relieved that her suffering was over, and that she was truly in a better place now.

PCU: Flying solo

This month I'm working in the Progressive Care Unit, known here as the PCU. It's the step-down unit from the ICU, but is also a place where patients go when they're not quite sick enough for the ICU but need closer monitoring. I thought that a month of MICU would prepare me for PCU, but as it turned out, the two units were quite different from each other. First and foremost was the patient load: I saw 4-5 patients on average in the MICU, while in the PCU I have about 10-13. Next, the entire PCU is run by only one resident and one intern, and for what seems like the last week or so, I feel like I've had to run the floor by myself (which is NOT a good thing).

First and foremost was my resident, who was probably one of the laziest people I've ever met. Intern and resident start dates are staggered by one week so that the exiting resident can teach the intern about how the service is run and what is expected of the intern. My resident flat-out said on the first say there'd be no teaching and the goal of each day was to leave by 5:00 pm (a great rule to have). And while I was struggling to get my notes written (to give him credit, he saw 3-4 patients for me when our patient load was greater than 10), he'd be on the internet checking his email, chatting online, or otherwise being unproductive unless it's to his cause (like doing dictations). My second day of PCU, he left the floor for about 30 minutes for a meeting without telling me and left me freaking out when two separate attendings arrived for rounds. He was also lazy about documenting central line placements and important telephone conversations with patients' families (he rolled his eyes when I documented a central line removal), which caused him to butt heads with 1-2 attendings (one of them later told me my resident was flat-out stupid). To make things worse, he'd worked a black weekend before I signed on, and so I had to work a black weekend my first week as a PCU intern.

On weekends the earliest I can sign out is 2:00 pm, but I didn't leave the hospital until 6 pm on Saturday and 4:30 pm on Sunday (and that was only because I prewrote all 11-12 notes the night before). And because I was the only doctor in the unit, there was rarely any time for rest. I didn't even have time to eat, drink, or pee on Saturday aside from eating a granola bar here and some graham crackers there. Sunday was a little better b/c my patients were more stable, and today I got a new resident (fortunately it was someone I'd worked with in the MICU and I knew she was good). Unfortunately for me, she had worked the night before and left at noon, leaving me to run the PCU for the afternoon. And as expected, I didn't leave the hospital until 6:00 pm.

The PCU nurses have told me that I'm doing a good job and keeping myself together, but most days I just can't wait to go home. One of my patients became very hypotensive yesterday (among other problems), and I went home secretly hoping I wouldn't have to deal with her the next morning. Got my wish; she'd been transferred to the MICU. One of these days I'll have to tell you about this patient; it's a very sad case.

Hopefully today is my last day to work alone until this weekend, when I'm guaranteed at least ONE day off.

Coming Full Circle

Interview season has begun, and since I'm still waiting for the official approval to start doing research this month, I had time to meet with the applicants and chat with them while they waited to be called for their interviews. At first I didn't know what I could talk about with these applicants; I was, after all, just an intern and still not as familiar with Philly as some of my other classmates who lived downtown. But in the end, answering questions was no big deal and actually kind of fun. It reminded me of when I was interviewing here exactly 11 months ago, and I recalled what drew me to the program in the first place: the sense of camaraderie among the residents, the impression that people here cared, and the down-to-earth interactions with the faculty. That hasn't changed a bit. My firm leader (faculty advisor) came to pick up a student for an interview, and the first words out of his mouth were, "Hey there. Have you used the bathroom? Need a Foley?" That's just the way he talks, but I think it definitely broke the ice.

I've also found that I've been a pretty good source of info for the osteopathic applicants, and there's usually a few in each group. They had the same questions I had when I applied here, i.e. is the hospital DO friendly? How is resolution 42 approved? The upper level DOs had been a great help to me on my interview day, so I was determined to do the same here for the future applicants. I think helping out on interview days is refreshing and exactly what I needed to remind myself of why I ranked this program high, because at the end of the day, I'm happy with where I've ended up =)

Getting out on time

The rule in medicine is that you're not supposed to work more than 30 hrs straight. That if you worked overnight and are still at the hospital at 1 pm post-call, the residents will do whatever they can to help you out so that you can get out of the hospital in time. They have your back.

Lies.

There's only so much that residents can do to help their interns leave on time. They can see a patient or two for you and write notes. They can put orders in the computer or call social work for you. But they can't fill out discharge forms or transfer forms for patients that aren't their own, because they don't know the patient like the primary team does. During the weekday it's not bad, because the resident can help the intern get out on time. But during the weekend, when there's only one intern/resident per team seeing anywhere between 6-14 patients and hoping to get out by 11-12 pm (the earliest time you can sign out on weekends), the intern really doesn't get much help from the other residents. For the most part s/he's on his/her own.

I was overnight last night, and ended up not getting any sleep because one of the night float interns had an emergency and had to leave the hospital for about 4 hrs. I had to cover his half of the hospital until he returned, but thank goodness I only got about 4-5 calls in that time. It could have been much worse. I also had one patient who had both elevated cardiac enzymes and Strep/Serratia sepsis so I was keeping an eye on her for most of the night anyway. And while I saw all my patients and wrote all my notes on time, there were a lot of things keeping me from leaving at noon. I had 3 patients being discharged. One patient needed neurology follow-up, and when I paged the neurologist on call, he said the patient wasn't on his service and told me to read the last neuro note. "Maybe you should check the chart before calling me, that's just laziness," he said. Well, excuse me for being post-call. As it turned out, I'd paged the wrong neuro group anyway, and the pt's neurologist was a much nicer person. The second discharge was a patient we'd had for 3 weeks who had a very caring/overbearing wife, and when she found out we were discharging him, she insisted on making sure all his medications would be ready at the nursing home before they left the hospital. The attending originally asked me to call the nursing home with his (very long) med list, but I think he sensed I was swamped and said he'd make the call instead (thank goodness).

On weekends, we are technically not allowed to leave until we round with the attendings on each patient. The problem was that in geriatrics (my current rotation), different patients have different attendings rounding on them, so I had to touch base with about 5-6 attendings before leaving. Some were nice and responded immediately to my pages, others never returned my pages and I was sitting there wondering what to do. If we don't follow the attending's recommendations, they can call us up on it, but I didn't want to stay late and wait for the attending to arrive. Not when I was post-call. On top of that, the hospital I'm rotating through is huge; it takes aout 5-10 minutes to run from one side of the building to the other. And I did a lot of running around, i.e. I forgot to put a script in one patient's chart on one end of the hospital, then had to run back to the opposite to do a discharge form. It was miserable to say the least.

It's not to say that the residents didn't offer to help out. The two 8 pm residents called from time to time to see if I needed help, and one of them ordered morning labs for my patients for me. But they could not do the things that were taking me the longest to get through: fill out discharge forms, touch base with the attendings, making my sign-out sheet for the night floats. That was all on me, and at one point I got so overwhelmed I had to hide in the bathroom to catch my breath and keep from losing myself completely in front of the nurses, patients, and families. It didn't help that at 1:00 pm, the triage resident called me and asked if I was almost done. I felt like screaming, "NO! I am not done, and no one is helping me either!"

One resident told me to stay where I was and that she was coming over to help, but when 10 minutes passed and she still didn't show, I gave up. I was through with counting on residents to help me out, so I just did what I could and signed out to the night floats. I won't say what time I left the hospital, but having skipped lunch aside from a granola bar, I was both exhausted and hungry. Someone expressed concern about whether I could drive home (it's a 30-40 min commute), but I assured him I'd be fine. As long as I could get away from the hospital and get some freaking sleep, I knew I'd be fine. It had been a rough night and morning, and it didn't help that I'd been working every day since October 18 (2 weeks straight) and was very burned out.

Two months ago, my MICU resident told me that I should never hesitate to ask for help when I need it, but after today, I know all too well that help doesn't always come even if you ask for it. Feel free to comment on this, but for all I know, no one reads this anymore.

It's the little things that matter most

Normally I don't watch Grey's Anatomy on Thursday nights, but since this week's CSI was a rerun I switched over to ABC to watch Grey's for the first time in ages. And the episode was a very good one: a woman suffering from burns dies in the ER and the events leading to her death are seen through the eyes of all the doctors who were working with or beside her (in flashback form) in order to figure out how and why she died. And in the end, we find out that the woman died because the doctor who examined her forgot to look inside her throat. And because of that, no one saw that she had soot in her throat from the fire that later compromised her airway and set off the chain of events leading to her death. The doctor was then fired for her negligence.

That episode shook me to the core, because this is something that can easily happen in real life. As an intern, I've made my share of mistakes whenever I had to fly solo and didn't have a resident around to help out (whenever he/she was in clinic, post-call, or taking an inservice exam). I once didn't think to order blood cultures on a feverish patient while I was overnight, and the next morning the resident asked me why I didn't do so. To this day I'm convinced she thinks I'm a dumb intern. Another time I didn't order a CXR on a patient who sounded wet (even though the attending later said that was her baseline CHF), and more recently, I ordered a lidocaine patch on a patient without checking to see if she was allergic to it (she wasn't). But looking back, there are many ways in which those things could have gone wrong. The feverish patient could have been septic. The patient who sounded wet could have developed ARDS. And if I'd given my third patient morphine without checking to see if she was allergic to it, and she was, she could have died.

Which makes me wonder, how well are we protected by the hospitals that we work for? Would my program be quick to fire me if I accidently prescribed a patient allergic to sulfa some Bactrim and he went into anaphylactic shock? I'd like to think no, since the program is so dependent on its residents that if one resident leaves for any reason, things become way more chaotic (the current R3s are having this problem since one of them didn't pass Step 3, and now people are getting pulled left and right to cover her duties). But what constitutes as an unexcusable mistake that would cost a resident his/her job? The scenario from Grey's Anatomy seemed a bit unrealistic, to fire a resident after one mistake, because what would happen to that resident after that? Would she never be able to complete her residency because no one would take her into their program after she made a single deadly mistake?

If I learned anything from watching this episode, it's that you can never be too careful.

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.