Code Captain!

It happened again, I was the first one to the code, and for a long time, the only physician. I ran through the bradycardia algorithm, paced him, did brief CPR until someone held up his post anesthesia orders in front of me. Narcotics overdose. Narcan deficiency 😉 2 milligrams of naloxone woke him right up. This time, they even had me sign the code sheet! (I guess they could tell who the code captain was). If there’s one thing I’ve learned this month is that at a chaotic code, the most assertive person is in charge so I had to make that me!

Rapid Reduction

Can’t hardly a day go by without learning something new! As long as your patient’s are sick, that is. Tonight I was on call and admitted a patient with an aortic disection to the service. Aortic disection is a scary, scary word. Many don’t survive to make it to the hospital. Of those that do, many never leave the hospital, and many more have neurologic impairment due to damage to the arteries that supply the brain or spinal cord. From what I read in the news, John Ritter died of an aortic disection. The consequences can be devastating as the blood vessle wall tears in half and allows blood to track into a “false passage”. (Imagine mice in the walls of your house, creating a “false” living space.) If the tear in the vessel crosses over the origins of the larger arteries that supply your arms, your brain, or even the heart itself…disaster, stroke, limb loss, paralysis and death can result.

The more I learn, the more I realize that now (residency) is the time to jump in to every situation possible. Even though this patient was sick, sick, sick, I had right at my side (well, down the hall in the radiology viewing room) a cardiologist, a cardio-thoracic surgeon, and the cardiology fellow, not to mention the ED nursing staff, attending and resident who had seen the patient. I was agressive with my blood pressure management, and eventually made the call to start an arterial line and a second IV drug to continue lowering blood pressure, knowing that I had two attendings to bail me out if disaster occured. I felt totally comfortable, well, a little bit squirmy, in how I was treating the patient in regard to administering powerful intravenous cardiovascular medicines.

WE got up to the CCU and I continued aggressive management until his goal blood pressure was met. The intern was unfortunately finishing a previous admission and missed out on most of the acute management. I felt bad about that, but there was nothing I could do about it. He lamented, “I’ll never get the patient alone,” in order to finish his History because the patient had constant nursing care while we worked on his pressures. Meanwhile, I realized how far I’d come in a year’s time. Last year, as the intern on cardiology, I would have been terrified to try and manage this type of my patient without the help of someone else making decisions and going over every single order I wrote. But today, once I understood the plan, I just continued on the right course of action. I felt good, I consulted all my resources including pharmacy and online reference material. The nurses understood my main goal and helped him get rapid and aggressive treatment. When patients are really, really sick, it’s great to see all the team members come together.

Follow your instinct

While doing mid-morning rounds on the floor, the operator paged anesthesia emergenty overhead to the coronary unit. My intern and I locked eyes and wondered aloud who it was. Our attending glibly said, “It’s just for anesthesia, someone needs to be intubated. You don’t have to go.” Which really meant, “Don’t go, moron.” The intern and I locked eyes again…we had 5 of the 18 patients in the CCU. I took off running down the hall.

Sure enough, it was one of OUR patients whose endotracheal tube had begun to leak. There were about 3 or four nurses around the bed, the intubation box was open, and one of our nurse anesthetists was pulling equipment out of the box. In the 5 minutes since our team had left his bedside, the patient began to cough, pushing the tube out. His tidal volume on the vent dropped to about 1 ounce of air moving in and out. (instead of the usual 1/2 liter or more) I could understand the nurse’s urgency in calling anesthesia to bedside, but was a little irked that they hadn’t paged one of us instead.

I politely asked the anesthetist, whom I’ve worked with before, if he wouldn’t mind if I took a look first. After all, he’s finished his training, and the whole reason I’m in residency is to learn how to deal with emergent scenarios and procedures…if all cases were easy, I’d be in practice right now! I gave him extra sedation and I gently looked down his throat with the laryngiscope blade and nudged the tube in a little further past his vocal cords. His oxygenation improved as did his volume of air he was moving.

When I returned to rounds, the interns and fellow were curious about the incident, but the attending tried to quickly refocus rounds on the current patient. She just shrugged a bit when I told her it was one of ours. I think there are some alpha female issues at work on service this week, but thankfully, only five more days to go, with turkey day off!

D is also for Duck

Great gains were made this weekend on the birding database. I have reverted back to just one list, the American Ornithological Union’s latest revision of about 2100 birds in the America’s. Kookaburu’s will just have to wait.

I’ve finally got the birdlists being pulled into HTML via an SQL statement in PHP. Now I just have to refine the selections of birds, but the first display of the whole lot has been successful. I predict a site preview by the end of the week!