Today just sucked. It was the worst day so far in the ICU. It started out slowly, but then layers of chaos simply built upon one another. And there’s only so long you can shield yourself from the sadness of sick and dying patients around you.
Mid morning, I floated down to the west end of the ICU pretending to work. Why? The Amish family of a young, dying father was singing hymns in his room. It was eerily beautiful, with full harmonies and many, many versus of the same simple melody and lyrics of a humble faith. I wished they would sing forever.
While the 2 other upper level residents were at lunch, we recieved a new patient…a young girl who was paralyzed in an auto accident. Broken neck with ascending paralysis due to the bruising and swelling still taking place in her spinal cord. How quickly things can change. She probably wasn’t wearing a seatbelt, but there are plenty of jerks who get tossed out of cars with minimal injuries. Why did she have to be my first complete spinal patient?
Later, an intern and resident put in a central line together. I gave the resident the procedure (it was my patient) because he’s only done about 6 lines, and I’ve done about 60. Then I checked the x-ray only to see the catheter was sitting right in the patient’s ventricle…the most dangerous place for it to be. I hurriedly rushed the intern over to show him how to withdraw and told him how far in he ought to put the catheter next time.
While this was going on, one of my favorite patients, who I wrote about last June, arrived back in the unit in respiratory distress. She had already been assessed by the 3rd upper level who was pulled away to show another intern how to pull back a central line in the car crash girl. This really irked me because the intern is doing his 2nd month in the Unit, and has had to have supervision for simple procedures that I was doing alone as a medical student. It’s not a competency issue, it’s a confidence issue. He has no confidence and it’s very frustrating.
SO now the attending is upset because an unsupervised intern is admitting the sick lady with respiratory distress. So I went over to check things out. The first thing I notice is her blood pressure (low). I asked the nurse to give a fluid bolus. “She doesn’t have any IV access.” was their reply. “Well what’s that large double lumen catheter in her right subclavian vein?” I asked. “Oh, well, that’s the only access she has,” they answered. “Well, can we use it? Or is it reserved for plasmapheresis?” “No, we can use it, I guess.” “Good, she need a fluid bolus, then hang a liter of saline.”
Well, I guess I wasn’t directive enough, because the nurse was literally having a nervious breakdown, swearing at clotted blood tubes, swearing at his colleagues, because no one was helping him with his patient. Understandable from his piont of view. But in the meantime, she’s crashing. Really crashing. I have no idea where the fluids are kept. I have no idea how to access her plasmapheresis catheter that has to be aspirated (not flushed) prior to using. She’s choking and sputtering, mouthing “Help Me.”
Crap. What else can I do? Chaos is beginning to bubble to the surface. Nurse working alone having a personal war with the lab draws. Patient hypotensive. Intern clueless. Me asking someone, anyone, can we please get her some saline?? (OK, I know what you nurses are thinking…why didn’t I do it myself? I wish I could have but even when I know what types of syringes and supplise I’m looking for, I can’t find them.) We really needed additional personnel to chip in, and it seemed everyone was concentrating on getting out by 4pm.
Meanwhile, did I mention the guy in the next room having worsening abdominal pain, tachycardia and a firm distended abdomen? Where was surgery? We paged them twice in the midst of the Amish man dying, the hypotensive lady staying hypotensive and interns scattered about withdrawing central catheters by 2 cm and sewing them back in.
Finally, stuff started happening with the hypotensive lady. A liter of saline was run in full bore. Her pressure came up. The other resident was busy trying to futily suction from around her trach…but the fluid and pus was deep, deep in her lungs. The attending finally stepped in to help manage his staff and perform a bronchoscopy, sucking out loads of pus in the process, and giving her 3 more liters of fluid.
Tired of reading yet? There’s more….
THe attending for signout was 45 minutes late, holding up 5 residents and 2 attendings on a Friday afternoon. I was really anxious to get home since I’m on call this weekend, and I’ll be back all too soon. 2 residents and two PAs were unable to get central access on the guy with abdominal pain. Finally we were ready to sign out when we heard a code called overhead…in the ICU! No joke… there were now 20-25 people gathered around one room, where CPR and cardiac drugs were being pushed. I felt helpless but there were already too many people around her bed. CPR was not being performed in it’s textbook fashion. I felt like yelling at the resident performing it, but I could see he was tired. Someone else stepped in to take over. She had a pulse back. She had a blood pressure. I squirted betadine on her groin so someone else could get a central line in. Cardiology showed up to echo her heart.
There were 3 staff attendings, 2 physician assistants, 1 trauma attending, 7 residents standing around, with just as many nurses, assistants, techs and code nurses. My favorite patient of my career was dying. The guy in the next room still needed central access and the underconfident, oversupervised intern asked me if I want to chip in to help the on call team, and help him put in the catheter.
“No.” was my simple reply.
He was not dying. He was not urgent. He had access. His new access could wait. All I could think about was the phrase “resident well being.” I hated that place right then. I despised it. I was not on call. I was not staying to do a semi-elective procedure with an intern who has enough experience that he could be supervising the several of the upper levels. If I could do anything to help save my favorite patient I would have. But I could not even push my way to the bedside at this point.
I quietly surveyed the other half of the ICU. “Is anyone crashing or dying over here?” I asked the charge nurse. She laughed at me and said “No, why, do you want someone to?” “No, I want to go home,” I said. I gathered my jacket, ran home, changed into gym clothes and lifted weights for about 30 minutes at maximum effort. I went to a coffee shop, had homemade soup, listened to local guitarists play. I liked hiding from reality there.