A call-night story:
Sometime after the third unsuccessful code, and after walking the intern through a line in the ICU while we were both being paged by four or five separate nurses for patients with increasing abdominal pain/no urine output/difficult to arouse/heart rate of 150, we were admitting another patient in the ER, when the ER radios started chattering, and then people started walking up to me (the charge nurse, some ER residents, the tech who’s best at getting ivs on hypotensive patients): “Alice, did you hear yet? We’re getting a ruptured AAA. It was exciting the last time we did this together, huh? We’ll make sure to give you a heads up when the helicopter gets closer.”
The intern was also excited at the prospect. I used to be excited. By now, though, ruptured AAAs are no longer new and thrilling, they’re old and stressful. I would be just as happy not to be the point person for coordinating the response, and finding out if I can move things fast enough to save a person’s life. (I am still looking forward to actually being the lead resident on my first open AAA; probably that won’t be as great as I expect, either.) Called the OR, called the ICU, made sure that the ER had already told my attending what was happening. Then I ran upstairs to swing through the ICUs quickly, check on my hypoxic vent patients (solved by turning everyone’s PEEP up), and warn the nurses to ask quickly if they needed anything, because we would be unavailable for a while.
Back in the ER, five minutes ahead of the helicopter; the charge nurse came up to me again. She’s not usually very cheerful, but I think there was a lot of adrenaline going around, and she was almost smiling. “Alice, I just want to let you know, we brought a patient back with a cold leg. The ER staff haven’t seen her yet, but I thought you would like to know. She’s in room 10.” I had time for one quick look at the cold leg, which wasn’t too impressive. The patient was a frequent flier on the medical services, and vascular surgery had often been consulted for her legs, but never felt moved to intervene. I decided it wasn’t worth spending time on right then.
The AAA patient arrived: intubated, unresponsive, pale, unable to get a pressure, everyone in the room frantically feeling for pulses, unable to decide if we actually felt them or not. No time to waste. “Don’t worry about monitors or blood draws or better access – let’s get up to the OR and sort it out there.” We ran (as fast as you can when you have to wait for an elevator), and soon arrived in the OR. Anesthesia was not completely thrilled with our plan, which was to move the patient on to the table, scrub while they started inhalational agents, and then let them figure out iv access (only one or two peripheral ivs so far) and blood pressure monitoring (none so far) while the attending and chief resident started cutting. The anesthesia staff were good, though; by the time the surgeons were down to fascia, the patient had a central line and an a-line started.
I left an intern to scrub in and help retract (remembering how thrilled I’d been to have that job once), added his pager to my collection, and went back to look at the cold leg. Now 45 minutes later, it was clearly cold and pale. But given the patient’s complicated medical history, and the number of times I’d been consulted for a cold leg (on this particular patient) which turned out to be a non-issue, and given what was happening in the OR, I couldn’t recommend immediate surgery. So I called the radiology resident: “This patient has a cold leg. You could probably do thrombolytics, and in any case you could give us a definite diagnosis of where the obstruction is. Get your attending to come in, right now. My attending wants this done. He’s scrubbed in a ruptured AAA, don’t make me interrupt him to tell your attending to come in.” (Radiology and vascular surgery have a semi-complimentary, semi-adversarial relationship at my hospital. Friendly during daylight, but if you want a procedure at night, you have to dig in your heels and scream bloody murder. Sometimes it does come down to the vascular attending calling radiology and throwing his weight around.)
They came in, and it was a good thing they did, as the angiogram showed a lesion I hadn’t entirely expected. It still required surgery, but by then the AAA was stabilized, and the attending could pay attention, and started a second room.
Not a big deal, really, but I took great pleasure in treating that cold leg all on my own, without talking to the chief or attending till it was all settled; and a little perverse pleasure in taking my attending’s name in vain to get the necessary procedures done.
At the end of the day, all the patients and all their legs were still alive, which was a little astonishing. The only people who seemed to be in danger of collapsing were the vascular attending and chief resident, who had been operating for nearly 24 hours straight, and still had no end of their duties in sight. I don’t know whether to be excited or scared that I’m little more than a year away from that role.