I checked about that patient from Saturday. The confusion had been cleared up: somebody (not me) had disconnected her oxygen when she was moved to the CT table, which explains the code, and the quick recovery once she got a face mask, very nicely, and exonerates all of us in the ER. Very nice all around; and of course she’s doing well now that her oxygen is being kept carefully in place.

The attending, bless his heart, is determined to make me take responsibility and make decisions. I’ve figured out by now that his management style is far on the “every possible test” side, as ER philosophies go, so if I suggest several tests, I’ll be right in his eyes; unlike some of the other attendings, who don’t want me to order a test unless I have a very good rationale for what I expect to get from it. (And even then, of course, I’ll agonize about whether I expect to get any return from a BMP, and then on all their patients they order it regardless, and it never shows anything. . .)

We proceeded through the morning with various stomach flu or respiratory presentations, which all looked like they might potentially be something serious, but turned out to be only viral. I would rather in any case work up a patient who looks sick, like I might find something interesting (pneumonia, PE, intestinal obstruction, etc), and be disappointed, than work up a patient who is obviously not sick to start with.

I talked to one sweet elderly lady, who started off taking me for I don’t know what, a high school student. She was fairly well informed about her medical conditions, and was explaining them to me in words of one syllable – while I was trying to figure out whether her shortness of breath and chest pain indicated a heart attack, and she was about to crump on me, and I needed to get the attending within five minutes, or whether it was just a viral pleuritis, and I could spend another ten minutes talking to her. When I had got the whole history and physical and was about to leave, she asked, “So are you going to be a nurse, or a doctor, or what?” I told her, a doctor. She said, “Oh, you’ll be a good doctor, as long as you listen to patients.” I walked down the hall thinking, such a tactful way of telling me I was being incredibly rude. Tsk, Alice, not to interrupt patients! I need to figure out a good way to get the important information quickly, without making the patients feel like I’m cutting off their story. Later on, after the attending went back with me to see her, she stopped me on my way out and said some more encouraging things, and started reminiscing about how she was once engaged to a doctor.

After a very slow, even quiet day, something seemed to break. The red phone, reserved for squads to call ahead on, started to ring, and kept on ringing every time the nurse hung up – while the squad radio also started going off. The first arrival was an older man with schizophrenia who had become psychotic and started attacking his family. He ended up taser-ed and handcuffed to a backboard. In spite of a fair amount of drugs being given en route, he was still snarling profanities and fighting his restraints. We did a quick trauma eval and FAST exam (partly for his benefit, partly for my education; I can now find the kidneys fairly reliably, but not the liver or spleen – without which the kidneys aren’t much good), and then left him be while another couple doses of haldol, ativan, and benadryl kicked in. (By the time I left he was still growling.)

At this point another squad brought in an elderly lady who was very visibly and obviously trying to die on us. Even I could see that. She was grey, sitting up in bed and puffing away with a respiratory rate of 50-something, on 100% oxygen. As soon as the nurse got the cardiac monitor hooked up, we got even more worried. Her heart rate was ~170, and looked uncomfortably like V-tach. The nursing student and I were delegated to run an EKG, as two nurses were struggling to get ivs started. I’m sure the young man and I are both capable of tacking on EKG leads neatly, if given five minutes to do it in. As it was, we were tripping over each other and misconnecting the wires, in what would have been a pretty comic Keystone Kops style, if there hadn’t been a palpable chance of the patient actually coding before we got the EKG done.

At length the machine condescended to acknowledge her horrible rhythm, and printed out. The attending considered it, and ordered an amiodarone drip. Now it was the nurse’s turn to wrestle with lengths of tubing and wire, as though there was a magnetic force field that was preventing any useful lines from being connected to the patient, who all this while was huffing away, virtually undressed in a crowd of staff, staring at the wall, oblivious to our commotion.

After the amiodarone was finally connected, it took only a few minutes for her rhythm to improve dramatically, slowing down to the 120s, and demonstrating itself to be merely atrial fibrillation with RVR (rapid ventricular return). (All this while, whenever the attending or the ICU resident who showed up to assist asked me about the EKG, I kept calling it Vtach, primarily because that’s the only part of ACLS that I know yet – and also because I’m not good at reading EKGs; once the rate gets beyond 150, I can only say sinus tachycardia, or Vtach. Finally the resident took pity on me, and took me in a corner to show me all the characteristics which made it clear that this was atrial fibrillation, not Vtach: irregular rate; some things which could be called P waves; a few narrow complexes; and of course the fact that the amiodarone was converting the whole thing to narrow complexes.)

So for a good twenty minutes this lady was on the verge of dying, and we were all crowding around her, doing things. But we hardly said anything to her. The nurses, of course, told her a couple of times, “You’re going to be fine. We’re taking good care of you.” And, “Try to breathe slowly.” (Much more easily said than done!) She could have died right there, and have had no final human contact, other than a bunch of us spinning in circles and messing with electrical arrangements. She didn’t die. But if she had. . . And what do you say to someone whose whole energy and concentration is devoted to getting one more breath of air? Maybe “try to breathe slowly” was the most useful thing that could be said. . . The attending asked her at one point if it would be ok if he put a tube to help her breathe in case she needed it, and she said no. He thought she was expressing a desire not to be intubated. I doubted that; but with the level of adrenaline in the room, unless a family member arrived to confirm her statement, she was going to get intubated anyway. (It’s always easier to fix being too aggressive than to fix being too laissez faire.) Later, after she improved, he asked her again, and she was able to say, only if absolutely necessary. Which is of course exactly the opposite of what he thought she’d said earlier. So clearly we were unable to communicate on matters of vital importance while she was in extremis.

(Note to non-medical folks out there: DNR does not mean, I don’t want to live on machines for months on end. It means, I don’t want any rescue measures done, even if they would help me over a short crisis, and I might recover fine in a few days. Be careful what you sign, and be careful what you tell your doctor. I’m afraid that a great many elderly Americans are signing DNR forms, and thus giving up the chance at drugs or defibrillators or brief intubations which might extend their lives for months or years, to their satisfaction. You probably don’t want to sign a real DNR unless you have a terminal condition. Otherwise, you want a living will or a power of attorney for a reliable family member.)

Advertisements