Thursday, December 25, 2008

My Code (continued from previous post)

Dr. Lew has cut through to Mrs. Wilson’s abdominal cavity now. A clump of fatty tissue, the size of a squashed loaf of bread, is removed and placed to the side exposing the intestines. Dr. Lew probes with the suction, looking for pockets of blood. He sucks out 2 liters, but they had been expecting more. Through a translucent membrane at the bottom of the abdominal cavity we can see a large pocket of blood that has collected in Mrs. Wilson’s thigh (where the catheter was inserted for the original procedure). The doctors decide not to go after it. We have not found the cause of Mrs. Wilson’s decline here. “How is her lung compliance now?” Dr. Lew asks the respiratory therapist. “It is much easier to bag her now,” she replies. At least we have taken some pressure off of her lungs.

As the young doctors gather round, Dr. Lew rummages hand over hand through Mrs. Wilson’s guts like a boy digging in a sandbox. He takes her large intestine in his hand and shows his students the areas that have been denied blood flow – “this area is normal… this area may recover… this area will not recover and will need to be removed, but we will come back and do that later.”

As they finish, Dr. Lew takes sterile towels moistened with saline, lays them across her intestines, and tucks them in around the edges of the incision (an opening about two feet long and one-and-a-half wide), “so she does not eviscerate while being turned.” A plastic vacuum dressing is then applied and attached to the wall suction unit with plastic tubing. A steady trickle of pinkish fluid begins making its way over Mrs. Wilson’s shoulder on its way to the canister on the wall.

The whole procedure is over in less than half an hour. My dreamlike feeling returns as I watch the OR nurses counting out their instruments, making sure nothing has been left behind. “5-6-7 of this kind of clamp I have never heard the name of before, 5-6-7 of that clamp,” etc. I conclude that OR nurses are entirely different creatures from unit nurses. These two middle aged ladies are cool, calm and collected. As they focus on their work, they seem to see only an operating room around them. The OR must have sent their best.

Mrs. Wilson’s blood pressure has remained high throughout the procedure. I have been slowly backing down on the pressors and her systolic pressures are now below two-hundred. I have not had time to check orders since the code, what to speak of documenting vital signs. Labs must have been ordered after the code. I draw the blood from Mrs. Wilson’s arterial line and hand the tubes off to another nurse who labels them and sends them to the lab through the tube system.

Mrs. Wilson maintains for the next half hour or so. The charge nurse asks me how she is doing now. “She will code again soon.” I reply. “Don’t say that!” he says, but I need him to know I will need him to stay around. The fellow hangs around also, catching up on other work on the computer just outside the room.

The first labs come back just as Mrs. Wilson’s blood pressure drops out and her heart slows to a stop again. Her blood PH is still below 7. I call for the fellow and the charge nurse, max out the pressors on the IV pumps and take my position at the head of the bed where the IV access is. I lay out saline flushes and use them to chase the code drugs in. Maria, he nurse who was pushing the meds last time asks me if I want her to do it again. I shake my head and ask her to fill out the code documentation. The charge nurse continues to assemble the syringes of code drugs and hands them to me when it is time. I call out, “Epi is in, Atropine is in, Bicarb is in.” as I push them. Maria writes it all down. I call out, “Her PH is 6.97,” again, but it falls flat again. Compressions go on, the bagging goes on, more liter bags of saline are hung on pressure bags and infused wide open. After another ten minutes we get her back again.

The room clears out again as Mrs. Wilson holds her blood pressures of over 200 again for now. Soon it is just me and the fellow in the room. “What do you think is going on?” she asks. “I think her acidosis is stopping her heart and that it is also causing massive tissue death which is feeding her acidosis in a viscous cycle,” I reply. She seems to agree. I had assumed the doctors were on top of this, but I begin to wonder if I was wrong. “So what do we do?” asks the fellow. “Well, I think the bicarb is what is bringing her back, but it is only going to be temporary. She is going to continue to code. I think you need to talk to the family.” She agrees. I suggest turning the bicarb drip up to buy time. She agrees to that also and I turn the rate up to one liter an hour.

Soon the fellow and the Mrs. Wilson’s daughter are in the room talking. I go to a computer to check orders and to give them space. From the hallway I hear the daughter, who appears to be in her late twenties, protest, “What is going on here!? First they told me her heart had only stopped for a minute and now you are telling me it was stopped for ten minutes! What is happening here?” The fellow must be telling her that there has probably already been a lot of brain damage and that it might not be the best thing to continue trying to save her.

The fellow leaves the daughter in the room. I go in to check the pumps and clean up what I can. Mrs. Wilson’s body is covered with a sheet to hide her incision. “Oh Mom,” says the daughter, her voice cracking a little, “I’m sorry I did not come around more.” She asks if pink fluid in the suction tubing is coming from the procedure that was just done. I tell her that it is. She stays for a few more minutes in silence before returning to the waiting room.

To be continued.


dethmama said...

To be be continued...Oy! Leo, you're killing me here!

(Great story)

Jay said...

Amen, dethmama! TBC again?!

Oh, my - the things you have seen.