the end is near!

yes, that's right, the end is near. the end of my 2 contiguous months of call--a 54 day stretch of being on call every 4th night. i am happy for many reasons, not the least of which is because in another week i will be on vacation. i have to work approximately another 24hrs in the ccu, and then it's back to ED town! hooray.

the last week has been pretty tough; i've been sick, first with a virus and now what i believe to be a bacterial infection that is rapidly progressing to a sinus infection. try staying awake for 30 hours straight and making decisions that could change someone's life while you have the sensation of having an icepick driven into your forehead; not so nice. it's also difficult to get better when you get so little sleep. my call days have also been tougher for the past week as well--sicker, more complicated patients. what this means is that it takes more time to figure out what is going on, and it also means i have to spend more time with that patient because their situation is more tenuous. yes, these cases are often more interesting, more fun, and i certainly learn a great deal, but it is also very physically and mentally demanding. getting 2 such patients in a day is one thing, but try 4, and that's something else all together. furthermore, when i am on call, i not only admit new patients, but i also take care of the old ones; and once the other team goes home, i deal with all of their patients.

so at 1045pm last thursday, i have 6 old patients, 4 new ones--2 of which i have yet to see--and i'm covering 15 patients from the rest of the ccu team; that is a lot of sick people. i'm sitting in the ccu, trying not to let snot drip onto a patient chart, calculating that if nothing major happens that i can be in bed by 1am, when the code pager goes off. a "code" is short for "code blue," which means that someone has been found unresponsive, ie, they are dying or dead, although about 20% of the time it's something totally bogus and a code was called simply because it's a great way to get lots of people to come and help very quickly. the on call ccu team is the primary code team--this means that they run the show. specifically, the ccu senior resident "runs" the code--he/she is on charge and tells everyone else what to do. as one might imagine, a code code can be quite teh clusterfuck. there are usually more people in the room than necessary which can create spatial problems, in addition to organizational and procedural ones. this is why the ccu senior is in charge; it is vital to have one person in command during this type of incident. the ccu intern (me) does physical tasks for the patient such as cpr, and procedures (eg, putting in lines, etc).

this was the second code of the day. we arrived and heard a few quick words about the patient--one of the most salient details was that he was hiv positive. i feel a bit guilty saying that, but a code is extremely chaotic, with many pointy objects and plenty of opportunity for needle-sticks. i've seen this happen three times this year during codes. the dangerous part is not necessarily what you are doing, but what the person next to you might be doing. trust me, it can be frightening.

this patient already had a central line (large IV) in his neck--this is important to know because one of the first tasks that needs to be accomplished it establishing IV access in order to get blood and give medications. IV access in place, i went to work with chest compressions. cpr looks and sounds easy, but it is quite tiring. the other thing that many people don't realize is that it's fairly common for a patient to suffer rib fractures during cpr, since studies have shown that the depth and rate of chest compressions are what lead to the best outcomes, meaning that there are many over-zealous chest-compressors out there.

this gentleman was quite small and thin and i am rather tall and large. i don't remember what his main illness was, but he was cachectic [cachexia ca·chex·i·a (kə-kěk'sē-ə) n.Weight loss, wasting of muscle, loss of appetite, and general debility that can occur during a chronic disease.], and i could feel ribs crunching with every compression of his tiny chest. he was initially pulseless, but after about 20 minutes we brought him back; he also received a surgical airway--his mouth was clenched shut so he couldn't be intubated so instead, a hole was cut in his neck through which a breathing tube was inserted. off to the micu he went. i learned the next morning that he died about 4 hours after we brought him in.

participating in a code is actually rather fun; it is stressful but exhilarating. i enjoy the rapid pace at which one if forced to think and act. the downside is that once the code ends you have a bit of a rush going, but often you are forced to deal with more prosaic issues, and this can be a difficult transition. for example, the code lasted about 40 minutes, from the time the code was called until we got him to the micu. during this time i was paged by 3 different nurses a total of 7 times. i heard the senior resident's pager beeping as well, so i was pretty sure they were paging him as well once i hadn't answered. i had a twinge of fear that something bad had occurred; it hadn't. all 3 issues were non-urgent. i won't turn this into another tirade about the innumerable asinine pages i get on a daily basis and the subsequent rage i spew forth, but imagine, if you will, the juxtaposition of the following situations, in rapid succession: sticking a needle through someone's chest wall and into their heart to make sure there is no fluid collection in the sac surrounding the heart that is preventing the heart from properly contracting. this task completed i leave the room to answer the pages and here is what i get from those bastions of intelligence, the telemetry floor nurses: 1) doctor, i saw that you ordered 10pm labs for patient X, did you still want me to send them? 2) doctor, mr z refused to take his colace (a stool softener). 3) doctor, mrs s would not let us weigh her this morning; i'm not making this up, this nurse called felt the need to pass on this information nearly 14 hours after the fact. i thought i might be missing something so i asked her how this could be important at 11pm and i was told that she just wanted to keep me informed. i thanked her and went about my business. the point of relating that information is to illustrate how difficult it is to go from the former situation--the code--the the latter, and not lash out at someone, especially when someone wants to know why it took me so long to call them back.

following this, i went back to my work, finished up with my remaining two new patients, and headed off to bed about 215am, not far off my estimated time of horizontality, adding in the extra time for the code. i was nodding-off to sleep around 230am, after responding to yet another page relating to a patient's bowel activity, when i felt a familiar vibrating in my pants--the code pager. it's a bit funny, the alert made by the code pager is so feeble that everyone leaves it in the "vibrate" setting since that is more likely to get one's attention. shouldn't this be the loudest pager on earth?

so i jump up and run off down the hall sockless, with my wallet and iphone in the call room (this was all i could think about during the code, since the rooms do not lock). this lady was not so fortunate--we worked on her for about an hour, but she died. she had no iv access and when the code occured and she happened to be a vasculopath (the end result being someone in whom it is extremely difficult to gain iv access) so it took about 45 minutes to establish it, despite 3 people working simultaneously at 3 different locations. we tried to get an inter-osseous line ("io," which means into the bone), but she was so portly that the io needle was too short, that is, she had too much leg fat for the needle to get where it needed to be. someone finally arrived with a special device for situations such as this--basically a drill that had a long enough needle to get through her fat hock and bone into the marrow cavity. by that time it was too late; we continued for a bit longer, giving the medications that we previously were not able to give due to lack of an iv, but it was hopeless, so the code was called: time of death, 337am.

i got up at 610am that morning to start my daily work, but i probably only slept for 15-20 minutes, and i bet you can guess why that was. it was an interesting night, to say the least, and there was even a moment when my anger morphed into something sublime, given all that i had seen in the previous 12 hours. but alas, it was fleeting, erased and replaced by questions about turds.