Reflections From Call

Being on call is terribly overwhelming.  I feel overwhelmed not from inability to do the work, instead the physical, mental, and emotional demands give me little room to gain perspective or reflect and come to terms with the amazing and horrible things that happen during a 24 hr call.  I was on call from Sunday 6am to Monday 6am, so Monday morning all I could focus on was finding my bed.  Today is when the reality of the call begins to hit.

The recap:  Two patients coded.  One of them died.  There was one trauma code.  I took a patient to the OR and did several bedside procedures.  I saw seven or eight (I can’t remember) patients in the ER and half of them went home – the rest were admitted.  If you asked me to order those cases chronologically, I couldn’t do it.  It remains a blurred composite of twenty four hours with sharp details at critical moments.  The background is filled with miscellaneous interventions on SICU patients; taking phone calls from patients at home with questions; answering nurse questions, requests, and concerns; and the ever-critical search for food or elusive cat nap.  That is the aseptic, clinical view of “getting the job done”.

The “trench warfare” version starts with a Code being called overhead.  The Medicine residents run to the codes.  Surgery walks.  Medicine carries out the ACLS protocol while Surgery offers advice and provides procedural expertise, if needed.

I walk into the room with CPR in progress.  The patient is blue and huge – probably over 300 lbs.  End-stage COPD in PEA (pulseless electrical activity).  A nurse says they have been expecting him to code all day and, despite his poor prognosis, the patient and his wife want “everything done”.  We go about our sad ritual of a full code on a lost cause.  I want to yell at the guy, wherever he is,

“Do you want THIS???!!!  Are you happy, because we’re doing everything?”

I ask the medicine resident how long we shall persist and if they need vascular access.  She shrugs her shoulders to the first question, but the second question is easier to answer.  They want a line.

During a procedure I become so focused on the task that everything around me disappears and time stands still.  Now I’m jabbing a 6″ needle into the patient’s groin trying to stab his femoral vein.  I get in and get dark red blood back, but I can’t thread the wire because I keep loosing access from movement – the chest compressions add a degree of difficulty.  I repeat this several times with the same result while the medicine intern retracts the abdominal fat away from his thigh so I can see.  No success.  The chief takes over and gets the line in.

After the procedure, I “come up for air” – mentally check back into the big picture.  CPR is still in progress and now he’s intubated.  No change except the patient’s abdomen is bigger and there’s no condensation in the ETT (endotracheal tube)  Somehow, only the chief and I notice this.  I can’t hear much for breath sounds due to the patient’s obesity and lung disease.  I think the ETT is in his esophagus.  There’s bleeding from his lips – no doubt a difficult intubation on a good day.  I’m so focused on airway that it takes me about 30 seconds to notice nobody is doing chest compressions.  I pull my stethoscope out of my ears – back to the loud world.

“What’s going on?  Did you get a pulse?”

They called it.  Time of death….  We did everything  No time for reflection.  The ER is calling and they think some little kid has appendicitis.

Later in the night, or is it early morning, a young girl comes in mauled by her pet.  The dog latched onto her arm and wouldn’t let go even when a man began hitting it on the head with a hammer.  The girl sufferred 10 minutes of this torture.  Finally, several adults were able to pry the dog’s jaws open.  I want to kill the dog and slap the adults.  I picture a dog grabbing my daughter and me shooting it with my gun before 60 seconds have elapsed.  I could have sawn the dog’s head off with a hacksaw before 5 minutes were up.  10 minutes?  I could have wrapped plastic trash bags around the dog’s snout and suffocated it sooner than that.  For doctors, the knowledge to save life is also the knowledge to efficiently end it.  I wish they had the knowledge to quickly dispatch the dog for this girl’s sake.

Her arm is a mess and she is hysterical.  Pieces of SQ fat and muscle are hanging out of a dozen holes in her arm.  The dog got into the flexors and the extensors of her forearm, but the worst damage is to her extensors – she can’t extend her fingers.  At least she has circulation and sensory intact.  I knocked her out with morphine and Ativan and loosely re-approximated the wounds until Hand Surgery could evaluate her in the morning.  Her mom watched me suture, told me more details, and cried.  A two year old was at the scene watching the attack – thank God the dog didn’t grab her.  I hope she never remembers what she saw.

Another Code is called overhead.  This one is in my ICU.  I walk over.  It’s not my patient – some Medicine disaster quit breathing.  The nurses are placing an oxygen mask over his face and watching the pulse ox.  His breathing is agonal.  I suggest bag-valving him since he’s not moving air.  His sat comes up and he starts breathing again.  Medicine doesn’t want any lines.

I head off to the call room for an attempt at sleep.   This is my third attempt in 24 hrs.  On the previous two, the ED called as I entered the room.  All is quiet this time.  It’s 4:30am, so if I’m lucky I’ll get about an hour before the teams call for morning report.

Pager wakes me up from some bizarre dream.  4:45am.  Medicine is calling.

“The guy that Coded?”….”Yeah, OK I’ll be right over”

The respiratory Code from earlier is now intubated and in cardiogenic shock.  They can’t get a BP on the cuff, can’t get an ABG, and need central venous access for pressors.  Only palpable pulse is his carotids and his wrists are bloody and brusied from a dozen or more radial artery attempts.  The Medicine resident is trying another radial art line.

It’s procedure time and I hate art lines!  I decide to try to place a femoral artery line in a groin with no palpable pulse, but I don’t have much else for options.  I get a weak Doppler signal, so I triangulate my mind on where I imagine the source.  A few dry sticks and then I get dark blood back – probably femoral vein, but on a guy this sick it could be arterial blood.  I decide he isn’t THAT blue and go lateral.  Bright red pulsing blood!!  The wire goes about 15 cm and then comes to a grinding stop.  I pull it out and get pulsatile flow.  I try re-threading the wire, but it still gets stuck.  I reason it’s probably stuck due to atherosclerosis since the artery is only about 2-4 cm deep.  Given the patent’s medical problems, his arteries are probably fossilized and have stalactites hanging from the ceiling.  I go for it.  I pull the needle, thread the catheter over the wire, pull the wire out – the moment of truth!

Bright red pulsatile flow through the catheter!  I draw a gas, the nurse hooks up the pressure transducer, and there is an excellent waveform.  BP is 50/30, but I am elated.  Now, the Medicine resident can quantify how badly he wants that central line.  Triple lumen in the IJV (internal jugular vein) coming up!  Would you like fries with that?  On the heels of my success and given the patient’s critical condition, I consider going for a blind IJ.  I figure his CVP is sky high and he has the JVD (jugulovenous distension) to prove it.  Plus, I have palpable carotids.

Nah!  I go conservative and grab the ultrasound.  The line is a breeze – you could drive a truck down his jugular vein.  The Medicine resident is appreciative of the ultrasound-guided demonstration becasue they don’t get much experience with lines.  I take the opportunity to do some line teaching.  It’s 5:45am and the teams will be calling any second.  My last duty on call is to review the CXR on my line.  I stop by radiology on my way out the door to my motorcycle.  The central line is in perfect position.