Sunday, December 14, 2008

My Code

There had been a question as to whether Hal (another floater like myself) or I would take the patient that was coming down from the Neuro ICU. I was assigned the empty room, but Hal, who was both more experienced and better known to the nurses on the SICU, had initially been given the patient and had taken report by phone already. I do not know what kind of calculations went on, but it was decided that I would take the patient after all.

Hal sat down with me at a computer and pulled up the patient’s chart. As we looked through her labs, Hal told me her story: Mrs. Wilson had come to the hospital for treatment of a brain aneurism. A catheter had been inserted at her groin and passed all the way up into her brain. When the aneurism (an out pouching of the blood vessel) had been reached it was “coiled” or filled with some kind of springy string (that is what it looks like in the pictures anyways). This had gone smoothly, but when the surgeons had tried to treat another aneurism they had found just past the first one, they “lost the coil” (in Mrs. Wilson’s body) and she had been spiraling down since then.

The exact cause for Mrs. Wilson’s rapid decline had not been determined, but she appeared to be going into multiple organ failure. She was coming to SICU to be started on continuous dialysis for treatment of a metabolic acidosis. Hal and I looked at her blood gasses (labs that show blood oxygenation, PH, etc). The metabolic pathways of the body require a slightly alkaline environment. Normal PH is 7.35-7.45. Anything below 7.20 is generally considered critical. At 7.0 the heart will stop beating.

It was 11:00 am. At 6:00am Mrs. Wilson’s PH had been 7.06. The latest blood gas had a PH of 6.98. Mrs. Wilson was about to code and die. “They should not be transporting her, they should code her there.” I say. Hal and I discussed what was going on. The neuro ICU is generally slow and they do not generally have a lot of codes. Perhaps they did not feel up to it. It is an ICU though and they should have been able to handle it. A nurse could be sent from another unit to help them with the continuous dialysis machine if they were not comfortable with it. Perhaps the doctors were trying to spread the blame. Mrs. Wilson would die under the care of General Surgery instead of under the Neurosurgery service.

The charge nurse, Mark, headed into the empty room to make sure everything was set up properly. “What is going on with that neuro patient?” “It is a dump, (on us by Neuro ICU), she is about to code.” Hal concurs “It is a dump,” he says. We will need backup.

Mrs. Wilson arrives with an entourage of two nurses, a neurosurgeon, a respiratory therapist pushing a ventilator, and a tech pulling two IV poles packed with at least 6 IV pumps - all running fast. Her blood pressure is low, her heart rate high, but the levels are alright for the time being. There is no pulse-ox (blood oxygenation) reading. We rush to get her settled in the room. I check Mrs. Wilson’s IV access. She has a central line in her neck and one on each side of her groin. There is a femoral arterial line also. I make sure I know which is which. There is no dialysis catheter. One will need to be inserted before she can get dialysis, if we ever get that far. I find the IV ports I will use for injecting the code drugs and another two ports that will be used for fluid boluses and blood products when they are ordered.

I turn to the pumps. Dobutamine, Levo, Epinephrine, (pressors for low blood pressure) all running near of above maximum allowable doses. At normal doses, a bag of these drugs can last a couple of days. These bags will need to be changed every couple of hours. I check to see that they have brought me spare bags. They have. Sodium bicarbonate is hanging. It is running at the standard rate. It is used for treating acidosis, but it will be like a garden hose on a forest fire at this point. I make sure there is a spare bag. Still no pulse-ox reading. No way to know if she is getting air or not. The mechanical ventilator is on high settings with 100% oxygen. That will have to do for now. Epinephrine causes vaso-constriction and can shut down peripheral circulation. The pulse-ox reads from peripheral circulation, so we may be out of luck. We can send blood gasses to the lab instead – it just takes half an hour or so to get the results back.

To be continued:

No comments: