The second week of EM. As soon as I put my bags down for the second shift (2:00 PM to 10:00 PM) at the physician/nurses station, a code blue is called over the loudspeaker – “Code Blue, Triage.” My PYG3 resident, a 30-year-old mountain biking enthusiast yearning for his upcoming Montana life after graduation in a few short months, waves for me to join as several residents, nurses, and attendings briskly walk over to triage.
A 70-year-old obese female is lying on the floor surrounded by six people. Two are taking turns performing chest compressions. A resident is attempting to ventilate the patient with an Ambu Bag manual resuscitator. We get the patient onto a stretcher, and cart her off to one of our rooms. The ED is divided into a trauma section, triage, a sick section, an observation unit, and a healthier section. Once she is on a bed in the sick section, an attending and her resident prepare to intubate.
The attending hands a GlideScope, a video-assisted laryngoscope to the resident. Unlike a traditional direct laryngoscope that allows only the intubator to see what is happening, with the GlideScope both the attending and resident can see what’s in front of the scope, The resident then inserts the blade and visualizes the cords, but struggles to get the ETT (endotracheal tube) through the vocal cords. They are tight. He asks for a “boogie,” a long thin bright blue bendable plastic tube that he is able to pass through the vocal cords. He takes the laryngoscope out, threads the ETT over the boogie, and pushes the ETT forward aggressively. The attending asks, “Are you in?” He responds, “Yes, I feel the tube gliding over the [tracheal] rings.” The attending agrees, “I feel you too,” as she removes her hands from the neck.
The respiratory therapist (RT) hands us the tubing connected to the ventilator. Every tube at initial intubation is hooked in series with an end-tidal CO2 colorimeter. If the ETT is correctly in the trachea (i.e., not in the esophagus) carbon dioxide on exhalation will change the color confirming correct placement. While this is going on, another attending and resident are “dropping lines” including a central venous catheter and arterial line.
We learn that a granddaughter brought the patient after she had trouble breathing with wheezing. The daughter said, “She was just in the hospital for a COPD exacerbation two months ago.” The patient was coding for 20 minutes. My attending asks if the family would like to come in during the code to watch. (Afterwards, she says there is evidence that the family seeing the end-of-life code is helpful for the grieving process.) The granddaughter, daughter, and son-in-law take one step into the room and begin sobbing. They step out after a few minutes. On the next pulse check, the patient is still in asystole. My attending asks if anyone has any other thoughts. “We’ve ruled out other reversible causes of arrest.” After a short pause with silence, she announces, “Time of death – 15:25.” There is a quick debrief afterwards, and then everyone scatters. I help the two nurses get the patient presentable for the family to come into the room for one last farewell. The charge nurse can tell this is my first code. “Oh sweetie, thanks. We cannot forget to clean their bottom.” The other nurse chuckles, “Post-mortem shits. Nothing quite like it.”
Immediately after this a mother brings in her 20-year-old daughter, a bone-thin IV drug user with uncontrolled type 1 diabetes who presents for weakness and confusion. She is found to be in diabetic ketoacidosis (DKA) and is septic from likely bacteremia. She is tachypnic (breathing fast) and becoming more lethargic. The attending states, “We need to intubate her now.” The attending and resident let me intubate the patient. The resident instructs the charge nurse to grab an induction agent and paralytic. We first pre-oxygenate the patient by placing a non rebreather (breathing mask) over her mouth. After two minutes, the attending tells the nurse to push the sedation followed by the paralytic.
The resident hands me the GlideScope. “Watch the teeth! It’s not a rotation motion, it’s a lift up to the crease between the wall and ceiling.” I struggle with the motion, being too timid. The attending pulls my hands to the sky, supporting the entire weight of her head and neck off the table, pulling into view the vocal cords (pretty much a perfect view… she is an easy intubation). I guide the ETT through the vocal cords. Once through, the RT blows up the balloon. Once intubated, the RT connects her to the mechanical ventilator.
After a few minutes, the nurse comes out to the station saying the patient is now hypotensive (low blood pressure). The attending asks, “How much fluid has she gotten?” The resident says, “She’s gotten two liters, and she is a tiny skinny lady.” My resident turns to me, “Would you like to place a central line?” I exclaim, “Yes.”. “If you can grab all the right stuff, it’s yours.” I speed off towards “Walmart”, the ED stockroom. I grab a central line kit, sterile ultrasound probe cover, enough suture to weave a sweater, and several pairs of sterile gloves. The resident jokes, “Not bad.” While I was off, he had already grabbed everything we needed. “Let’s get started, the hardest part is positioning everything.”
After we place the patient in Trendelenburg, we open up the kit on a stand. I put a sterile gown on with my resident’s help, and then my gloves. He does it all by himself. We prep the patient. The nurse hands us the ultrasound and we are ready. Okay, show me the internal jugular. I grab the ultrasound and scan up and down the neck. “It’s the plump vessel, next to the pulsing carotid.” I push down with the ultrasound probe, thereby compressing the internal jugular (IJ) vein. “Notice how the IJ nearly compresses on inhalation. She is quite hypovolemic.” The resident hands me all the tools in the right order. I insert the access needle into the IJ under ultrasound-guidance. “Don’t freak out when blood squirts back at you. Hold steady. I’ll hand you everything. We both will freak out if it is pulsatile (indicating we hit the carotid and not the IJ)” Once I get blood return, he hands me the guidewire that I thread through the needle. “Look at the ectopy on tele!” (when the guidewire knocks around in the atrium it can cause aberrant heart beats.) I communicate, “It’s threading easily.” I take the needle out, and he hands me the dilator followed by the flushed catheter. The catheter goes in smoothly, I suture it in place. I struggle placing a sterile covering, a fancy plastic lining that goes over to try to prevent infections. “I’ll do that, this is our signature for nurses.”
As we walk out, the resident shares, “One of my best friends has type 1 diabetes. I’ve noticed that type 1 diabetics are either extremely health conscious and disciplined, or are complete wrecks and die of massive heart attacks in the 40s.”
I leave exhausted, but am too excited to fall asleep. Type-A Anita has been active on Facebook. She writes about a New York City article citing the rise in divorce rates: “I’m glad the divorce rate is higher. You want to know why the divorce rate was so low back in the Day? It’s because your grandmother did not feel safe to leave the relationship. It means women feel empowered now to leave their shitty husbands because they are not dependent on any man. #StandUp”
[Editor: Type-A Anita is on track to make $400,000 per year in ob-gyn and her fiancé (now husband) is in a much less lucrative career. If she is unwise enough to settle in one of the states that awards alimony, in about 15 years we might find that her opinion on this topic changes…]
Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Beers and burgers with Sarcastic Samantha. Mischievous Mary unexpectedly joins midway. She recounts walking away from her Tinder date without introducing herself to the young man because he showed up to the restaurant in an undisclosed wheelchair.
[Editor: It would appear that the medical school’s heavy investment in diversity and inclusion education is not reaching everyone.]
The rest of the book: http://fifthchance.com/MedicalSchool2020