My last 24 hour ICU call was definitely the toughest shift of residency so far. Not because of the hours, but rather because of this one patient. She just had so much going on with her that I was afraid to walk away from the room for more than a few minutes

She was an 82 year old female who had a stroke several years ago, which left her severely contracted, unable to speak, and depending on her family for all her care. She was literally dropped off in the ED waiting room with a note pinned to her listing all her medical problems and medications (In fairness though, a concerned family member did show up eventually). The story I got from the ED resident was that she had decreased mental status for the last two days, doing the whole thousand yard stare thing, and not eating or drinking anything, oh, and her blood pressure is 64/42 (wicked low). When family showed up, they confirmed that this altered mental status was their main concern, that mom just wasn’t acting her normal self.  Given her presenting blood pressure, and altered mental status, I was expecting this to be a fairly straight forward septic shock work up.  She had horrendous ulcers on her legs, a stage 4 sacral ulcer on her back, feet that were obviously gangrenous. A sad sight, and a good source for infection. But, the ulcers didn’t actually look all that infected when we unwrapped them. And she didn’t have a fever, nor a white count, nor a lactate, and she had a nice normal heart rate of 65, so maybe she wasn’t in septic shock? Maybe just good old fashioned hypovolemic shock from being dehydrated. But why wasn’t she tachycardic then? Regardless, the ED gave her two liters of saline, and started some antibiotics and called me up in the unit to come down and take the patient.  I found her to be in no apparent distress, her pressure had responded nicely to the fluid and had climbed to 90’s/60’s BUT…When we got back her blood work, she had a sodium of 175. That is WICKED high. Like, you should probably be in a coma high. So we brought her upstairs, scanned her head on the way, which was normal, and started to treat her for her hypernatremia. At this point it was about 7pm and the ICU attending had left for the night (there is no intensivist in the hospital from 7pm-7am each night. We can call them at home at any point, but there is no one physically there with us).  It always seems to figure, that as soon as your back up leaves, things start to get interesting.  Her pressure started to drop again, so we started to bolus her with normal saline. Maybe she IS septic after all, for if she was just volume depleted, the initial bolus should be keeping her pressure up. But her repeat labs were still okay in that regard, no white count, afebrile, and her repeat lactate that was even lower than the first one. But these additional fluids boluses were now not helping. Her pressure continued to drop and she was not hanging out at like 80/50. It didn’t make sense. PLUS, when someone’s sodium is so high, you want to bring it down, but VERY slowly. Doing it to fast can cause damage to the brain, a condition called central pontine myelinolysis.  So if we kept dumping fluid into her, we ran the risk of inducing this condition.  When I looked at her sodium, it had actually gone UP after the 2L in the ED, and only dropped 1 point since then after a third L in the unit, so I figured we were well within the safe zone so far. We had calculated her free water deficit to be nearly 6L, and planned to correct this over the next two-three days. But dammit, her blood pressure is not cooperating. She needs more fluid now. We gave her a total of 5L of saline, and still her pressure was not budging. Surely, there must be an infection somewhere, and her body is just not mounting a reaction. It’s now about 1am and the intern and I are going to place a central line. If she IS indeed infected, she needs this line for giving pressors (drugs that increase the blood pressure) and invasive monitoring, as it will allow us to indeed tell if she has been adequately fluid resuscitated.  In the near 30 lines I have done to this point, this one was the hardest I have done. Unfortunately, you don’t want your hardest one to be in the middle of the night, when there is no one else there to help you get it. Her internal jugular was just so collapsed, the intern couldn’t even get any venous blood return with her needle. When I tried, I could hit the vein fairly well,  I could get the needle in fine,  but I couldn’t advance my wire.  After this happening about 4 times, and kinking two wires, I started to hear that “shit…shit… shit” alarm going off in my head. What’s the back up plan?  I’m not sure where the idea came from, as I have never heard of anyone doing it, or seen it done during a central line, but I remembered back in med school that if you push on a patient’s liver, it causes all the blood in the liver to surge into the IVC and can essentially create a backwash of blood up towards the head. So I had the intern break scrub, and perform the hepato jugular reflex, (I think that’s what its called, if that’s not right, let me know in the comments), which gave a nice dilating surge of blood to the internal jugular and finally let me pass my wire. So after about 45 minutes of struggling, we finally got this line placed and transduced a central venous pressure (which tells us if she has enough fluid in her vessels). Her CVP was 9, a nice number that says she has is tanked up, so it’s time to start giving pressors if her blood pressure is staying low.  Okay, fine, we started some pressure, and got her pressure to a safe level. Sent off another set of labs, and SHIT her sodium has dropped 12 points. TOO fast! Dangerously fast. Stop her fluids! No more fluids okay, so long as she hangs out here, she’s good, the sodium is okay so long as it does’t’ go much lower, her BP is okay for now on a little pressors. What’s that nurse? Her heart rate is slowing down? How slow? 50? Okay fine, for now as well, her pressures are staying fine.  Surgery comes by at this point and offers to take her to the OR immediately for a bilateral amputation of her legs. What? Okay I guess. They are convinced the gangrene in her legs is the cause of her problems, which it very well could be, and her legs need to come off. But hey, can’t have general anesthesia with a sodium that high, so surgery will have to wait.  What’s that nurse? Her CVP is now 3 (meaning she doesn’t have fluid in her vessles)  and her heart rate has dropped to 40. Crap.  Okay, she needs more fluid, but if I give her more fluid, I’m going to drop her sodium. If I drop her sodium, I will gork her brain, but if I don’t give her fluid, she won’t perfuse her organs and that will cause a whole other world of problems. Oh, and her heart rate is now 38? AWESOME! Thank you. Lets get a little atropine at the bedside please. Despite all this, her pressure was amazingly holding steady on 10 mcgs of levophed (the pressor).  So fine, I’m going to give her some albumin, which will buy me some oncotic pressure and hopefully counteract those dropping sodium levels. If her pressure drops further, but the heart rate stays the same, she lets more levophed, if it drops with a further decrease in heart rate, she get’s atropine and we put pacing pads on her and prepare to transthoracically pace her. I knew I was doing the right things for her. None of these things would hurt her, but maybe I wasn’t thinking of something? Was there something else I should be doing? Something that could make a difference. Maybe some dopamine, but the night attending said no when I brought it up earlier. At this point, I really just wanted to hear from someone with more experience than me, just to hear them say something to the effect of “keep calm and doctor on”, you’re doing the right things.  But it was 530AM.  That gray zone between calling the overnight attending and the next day attending.  So I resolved to wait it out if the patient held the course, and she did, thankfully. I can honestly say though, when my phone finally rang at 7am with the morning check in call, despite the day shift attending being notoriously tough on us residents, I was never so glad to hear her voice as I was then.  In the moments before my phone rang, I felt battered, weary, on edge, fretting all at once. Hearing her voice, unburdening all that had happened overnight, was a feeling of pure relief, help is on the way. And her saying that “your plan sounds good, nice job, I’ll be there soon” was like 1000 bricks being lifted off my shoulders all at once. 

 

It’s only now, that I write this tale three days after it happened, that I realize just how emotionally taxing it all was. I wrote the above paragraph earlier today and when I finished writing it, I walked away from the computer to tend to some other things, I got about 20 steps before I was simply overcome with emotion. It was cathartic to write it out, to admit I was scared, worried. You don’t allow yourself to acknowledge these feelings while it’s happening. Maybe most people don’t acknowledge that they are having these feelings at all. Maybe most people don’t even have them, lol. But I suspect they do. 

About ER Jedi

I’m a resident doctor in Emergency Medicine and I’ve learned during the past few years that 1) I’ve had some pretty amazing experiences 2) I have a very bad short-term memory. So this blog is just a place for me to write about some of these experiences, from the ER, medical school, the wards and life in general. At least that way I’ll have some idea as to where I’ve been all this time. A scrap-book of sorts, a place to vent, organize some clinical tools and post a few good songs I’ve heard along the way.

Posted on July 15, 2012, in Emergency Medicine. Bookmark the permalink. 6 Comments.

  1. Wow, that sounds crazy! I don’t know how you guys do that stuff.

    This wasn’t just standing around her bedside all night either, was it? You no doubt had to do this in fits and starts as you worked on other patients, kept up on charting and paperwork, and the other trivia of your job. So how many discreet interventions would this have been for you, and what percentage of your evening did she take up?

    • Thankfully, by and large the rest of the unit was pretty quiet and I only had one other admission over night, so I actually had a smidgen of time to stop and think, and read a few things about her disease process. Plus, it’s now the job of the interns, which I no longer am, to write all the notes and charting. Yay for that at least.

  2. What a gripping story and well told. Great that you’re recording these events.and, just as importantly, your reflections and reactions as I can guarantee that it will soon all become a blur .

  3. Cases can and DO stick with you. Decompressing definitely helps, whether it’s fifteen minutes or fifteen days later. I think the day the hard cases, or the awesome cases (or both, really) STOP sticking with me, is the day I need to reconsider my job.
    While I admittedly work in veterinary critical care, not human critical care, I suspect the experience is analogous: http://vetsbehavingbadly.blogspot.com/2012/07/guest-post-nursing-in-icu.html

    You have my infinite admiration for working in human medicine. Gimme a critical cat, dog, ferret, or rat and we’ll central line the heck out of it. But show me your scar, and I’ll puke all over the triage table.

    • Do you REALLY put central lines into a rat? A dog or cat, sure, but how the heck would you do it to something as small as a rodent?

      • Put a regular sized “peripheral” catheter into a rat’s jugular or a longer peripheral, and you can be snuggled right up to the vena cava. It’s usually more of a side bonus than a goal.
        -Cats and dogs, yes and yesser. Triple lumens (or double lumen, if it’s a tight squeeze and you don’t mind your coworkers teasing you about it) as well as single lumen sampling lines. The ventilator patients usually earn themselves an arterial line in addition to a venous central line and a peripheral line. (Crazy cool– in dogs, if we just need the art line for serial ABGs, we’ll use an ear. Easy peasy.)
        -Chickens get IO caths, or peripheral lines in their wings.
        -Rats usually get jugular cathers, tail catheters, and if they’re sick enough saphenous catheters (but they need to be Real Sick to put up with that, and real sick rats? They don’t live long…)
        -Rabbits get cephalic or ear peripheral lines. Can get also art lines in their ears, easily. And if you look at them wrong, or pick them up wrong? They die. Just, fall over and die. Like something out of a bad cartoon. Sometimes I think they die just to scare the shit out of everybody. And CPR on a rabbit? It’s a mess. (Next time a human doctor student complains about a difficult airway, tell them to imagine trying to tube a rabbit. Or an obese bulldog. NO SPACE to work, at all. And if you get it wrong? Don’t.)
        -Ferrets get cephalic or IO catheters. Trouble with their IO catheters is they tend to pop them out, despite getting a “cone of shame”. (They’re just TOO flexible and determined, even when they’ve got the Real Sick.) Interestingly, they’re not too difficult to intubate. A bit like a small cat.

        Pocket Pets (Gerbils, guinea pigs, hamsters, mice, chinchillas…): Remember, the cost of cannulation *alone* will buy you a new one or three. That’s not even counting the emergency fee, exam fee, hospitalization fees (ward time), meds, labs… Some of these guys stress out so easily they DIE from all the handling when they’re sick/injured. It’s shitty, and we warn clients of it, but some of them still want to go for it. And by “go for it” I mean some of the ED docs have landed in the OR doing an emergency cystotomy on an obstructed guinea pig, doing a tail amputation or leg amputation on a gerbil. Most recently one of them was doing a c-section on a Chinchilla. (When day shift nurse rounded me the post-op chinchilla, I thought she trying to be funny!)

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