Monday, January 27, 2014

two codes for the price of one

Yesterday we had two codes happen, at the same time, in beds 8 and 10. Yes, right next to each other.

We were all congregated around bed 10, who was getting a paracardiocentesis for cardiac tamponade. Exciting stuff. He was also on 100% FiO2, PEEP 20, nitric oxide, and two pressors (for non-ICU folks, just think MAX life support). Suddenly, alarms and the nurse in bed 8 yelling, "guys I need help!!!" Her patient bradied down, lost a pulse, and almost everyone (except the cards people who were doing the cardiocentesis) ran into bed 8 to code him. We did a round of epi and atropine, got a pulse back, and no sooner did we get it but we here shouting from bed 10. Everyone stampedes back over there, because he's gone into Vtach and the cards people are doing chest compressions.

We have only one crash cart for the ten beds on our south side and one for the other ten on the north side. Since we had just cracked a cart for bed 8 and he was wearing the defibrillating pads, we had to go running full speed to the other side of the unit for their crash cart. Hope no one over there codes now!

This brought a few nurses from the north side over to help us, as that side was currently coasting on easy and we were drowning. I had finished helping stabilize bed 8, so the code was in full swing in bed 10 and I asked around, "has anyone gotten the family?"

It's important to have at least one family member there to witness the code. We have someone stand with them, a nurse or social worker, to explain what is happening. We want them to see the sequence of events, so that it isn't a surprise, and so they can see how much effort we put into resuscitation.

The code was 15 minutes in, and everyone knew that this young man had a large, very involved and concerned family. I ran down the hall to the waiting rooms, asking anyone if they were here for him. I finally found someone, explained that he had gone into cardiac arrest, and asked her to come with me immediately. She got the wife, and the brothers, and we stood with them as they prayed and cried.

And he did not make it.

He had been diagnosed with AML on Sunday, at the ED, where he had driven himself for "flu-like symptoms". He had been admitted to the ICU with respiratory failure which turned into ARDS. He developed a large cardiac effusion, and then tamponaded. Seven days after his diagnosis of cancer, one week after eating dinner with his family on a normal weekend evening, and on the day of his birthday, he died after a 40 minute code. His family was hysterical. His wife looked bad, in shock, unable to cry or walk.

I carried them all home with me, last night.

(By the way, bed 8 recovered and as far as I know didn't code again that night.)

Saturday, January 25, 2014

just give him some ativan, already

As someone who suffers from anxiety disorder (or suffered, I should say, since it's very well controlled now with paxil) I find myself advocating for my anxious, panic attack-laden patients.

You know how nothing is more annoying than a patient who is anxious? Because you can't fix it for them and you can't get the docs to order benzos, because oh-my-god benzos will make the patient STOP BREATHING and become a crazed addict!

Seriously, doctors, 0.5mg of PO ativan will NOT hurt your very anxious patient, the patient with physical signs of having a panic attack, nevermind his subjective reporting. If he's this worked up, a little ativan will only bring him down to normal, the same amount of ativan that had he been normal and just a drug seeker would've brought him down to a RASS of -2.

It's like stairs. A small, appropriate dose of benzos will only bring you to the next step down from whatever step you're already on!

This particular patient is homeless and a known substance abuser with chronic pain. He came in with altered mental status after OD'ing on benzos at an ECF, benzos that were not prescribed. Maybe he wouldn't have felt the need to self-medicate had the staff there been able to give him an appropriate dose that gave him relief from his panic attacks? Maybe not, but still. What's the end goal for this guy? He's old, bed bound, and lives at a facility. He's not going to go through intensive psychotherapy or life style changes. Treat his anxiety and his pain, don't just give him nothing. And if he continues to self-medicate and use, oh well. At least we tried.

Give him nothing and I guarantee that he will self-medicate again, and probably OD again. And we will be right back here where we started, with me paging YOU every time he pushes the call light, which is every 2 minutes, for more pain meds/anxiolytics. No one's having very much fun right now!

a mother says goodbye

As a baby loss mom, it was hard for me to watch. He was only 31, diagnosed with leukemia 9 months ago, an only child. We asked his mother to make the most difficult decision of her life. I turned off the pressors, respiratory decreased his FiO2 to 21%, his rate to 4 bpms.

It only took two hours. His mother was standing with her arms around me when his heartrate hit 0, his EKG rhythm a flat line. She begin to shriek, and writhe, and flail her arms and legs. I jumped back out of the way. She fell to the ground and thrashed with everything she had. It took two large guys, members of their family who were present, to get her to her feet. A few minutes later, she was covered in sweat and hyperventilating. We brought her ice water, told her to breathe in, breathe out, big deep breaths.

I said to her, "this is the worst feeling you will ever have, this is as bad as anyone anything can ever feel."

An intern said to her, "you ended his suffering, you took his pain onto yourself so that he wouldn't feel it." A perfect thing to say to a mother.

We rarely have such physical grief reactions, we are rarely witness to keening or loud displays of emotion. I guess that's just the majority of our culture. We wait until we are alone, in private, to break down and punch and kick and scream.

I'm glad she didn't wait. Her reaction was the purest, rawest form of the worst of the worst kinds of grief and loss. I wish everyone could express their emotions so accurately, and in the moment of their peak poignancy.