Friday, December 19, 2008

My Code (continued from previous post)

The nurse who was taking care of Mrs. Wilson in the Neuro ICU seems a little reluctant to leave, but she tells me what she needs to and goes. I keep busy getting the room organized. I am still getting acquainted with the tangles of IV tubing when Mrs. Wilson’s blood pressure drops out and her heart quickly slows to a standstill.

I call out for help and the room is soon flooded with staff. The code cart arrives and a nurse opens the drug drawer and begins screwing together the syringes of epi, atropine, bicarb, etc. I am with the IV pumps, on the opposite side of the bed from the IV ports that need to be used for pushing the code drugs, so another nurse starts pushing the drugs the doctors are calling for while I increase the doses on the drips that are already running. The epinephrine drip was already over the suggested maximum dose. Following the doctor’s instructions I max out the levophed as well. Mrs. Wilson is a big lady, so two of the techs perform chest compressions in tandem – one on each side of the bed pumping in unison. The respiratory therapist takes Mrs. Wilson off the vent and uses an ambu bag to ventilate her by hand. She says Mrs. Wilson’s lungs feel stiff. The nurse documenting the code keeps track of the timing of the doses of code drugs, calling out every two minutes when another round can be given. I call out to the room that Mrs. Wilson’s PH is below 7, but it does not seem to register. The pumps are now taken care of and I am feeling uncomfortable that I do not have an active role in the code any more. It is my patient. I should be pushing the drugs. It is like someone else is doing my job for me. The other nurses may feel I am not up to the task. Nothing to do now but endure it though. We keep pushing bicarb every two minutes. That should help if anything can.

We keep going for ten minutes or so. Suddenly Mrs. Wilson’s heart starts to beat 120 times a minute. Her blood pressure shoots up to the 230’s. The chest compressions have pumped the code drugs to her heart apparently and it has resumed its function. There is still no pulse-ox reading. Everyone stops and watches the monitor for a few minutes. When it becomes clear that the rhythm is stable for the time being, the room begins to clear out. One of the doctors tells me to start backing down on the levophed, but I do this conservatively. He seems to think she will be fine now, but with her low PH I am not so confident.

Soon word comes that the surgeons will be performing an operative procedure on Mrs. Wilson. They will do it here in the room since she is too unstable to transport to the OR. A team of nurses will be arriving from the OR shortly. I am to get the room and the patient ready.

It is just me and Hal in the room now. I pace up and down the room trying to clear space and do anything else I can think of while repeating out loud to Hal, “This is beyond my experience. I have never done anything like this before.” Eventually Hal replies that he has only seen it a couple of times himself. Apparently what mainly needs to be done is to pack absorbent pads under the patient’s body so that the bed does not become entirely soaked with blood. I help Hal get the pads tucked in from mid thigh to mid chest on both sides. They will be opening Mrs. Wilson’s belly.

Someone calls in that all the OR nurses need is an extra suction set. The charge nurse has been staying nearby and he goes of to get the supplies. While he is gone, the OR team arrives. Two OR nurses wheel in a cart full of instruments and begin to set up shop. They ask about the suction and we tell them it is coming. Dr Lew, the attending, will perform the surgery. Suddenly the room is full of doctors. The residents and interns will watch. A new fellow is also in the room. She ran the code, but her background is apparently not in emergency surgery. The attending jokingly invites her to do the surgery and she puts up her hands and takes a step backwards. Maybe by the end of the year she will be ready.

There is a dreamlike sensation for me as the world of the OR, which I have never really seen before, now invades my room and my territory. Standing at the side of the bed, I watch as Dr. Lew, who I have worked with before but never seen in surgery, takes a scalpel and makes a deep incision from just below Mrs. Wilson’s sternum down towards her navel. A faint smell of barbeque wafts through the room as Dr. Lew uses an electric cauterizing probe to stop any bleeding. We have the suction set up now, but when we hand the end of the tubing to the OR tech he barks at us, “This is not sterile tubing!” We stammer, ashamed “All…All we have up here is clean tubing…” One of the OR nurses has an idea and cuts the one section of sterile tubing they have brought with them in half. We use a connector to hook it to our tubing and the OR nurse gets the suction into Dr. Lew’s hand just a moment after he reaches for it for the first time.

I am pushed out of my bedside spot by a surgical resident who feels more entitled (fair enough), and I find myself standing in the second row, next to the fellow. As we observe Mrs. Wilson’s dissection, a thought occurs to her. “Have we given any anesthesia?” she asks me. I look into her eyes and shake my head slowly. For just a moment we both shudder, but it passes quickly. You would not, could not give such an unstable patient anything that might have a depressing effect on her physiology. Besides, Mrs. Wilson is not moving a muscle. She has been as still as a stone since she came from Neuro.

To be continued:

1 comment:

Jay said...

OMG! Not anesthetized? Holy crap. Even unconscious, I'll bet she experiences the pain in some fashion. I find your blog just amazing and mind-boggling, and am in awe of your humanity and ability to do a vital job that can't be easy in the best of circumstances. I appreciate your willingness to share. Thanks for taking time to do so.