July or Breathing II

Most people think the new year starts in January. Confirmed academics believe the new year starts in September. Anybody who has ever worked in a hospital KNOWS for a fact that the new year starts in July. July is when the newly minted physicians, ink still wet on the diplomas arrive in the hospital to actually figure out how to take care of sick people. They are young young young. The smart one's are petrified. If they don't look like they've worn a quarter inch off their teeth in the last 24 hours you should watch them like a hawk. During my residency I worked on the in-patient service each July. July first of my internship year I turned up for "Morning Report" and was assigned my first patient. She had been admitted the night before. She had pancreatitis. I had enough sense to recognize this as a "bad" thing. The rather scary senior resident (later to be widely known as "General Rao") who had worked the night had done her history and physical exam and then over the course of the night had transferred her to the ICU where she was subsequently intubated. There I found her sedated and intubated with a central line going into her neck and a tube coming out of her bladder. Later she would get another line inserted in the artery of her arm and a bag attached to her rectum. I would ultimately care for her for the entire month. I would go to the ICU in the morning and review the night's events. I would always talk to her even though most of the time she couldn't respond and it was questionable whether she was aware of anyone speaking. In my mind pancreatitis went from being a "bad thing" to an absolute nightmare. She developed adult respiratory distress syndrome which makes it hard for oxygen to get into the blood stream even when there is a machine delivering it to the lungs. Next her kidneys failed. Her blood pressure was so low we couldn't do conventional dialysis. Instead she got a special kind I'd never heard of before. While on dialysis her blood sugar went dangerously up and up. I sat at the nurses station near her room and questioned each specialist in turn. Why is X happening and what can be done about it? Why? Why? Why? I understood my role to be that of a large and annoying three year old and I refused to let anyone caring for this patient do so on auto-pilot. I was there to make them stop and think. "What am I doing for this patient and why? If it isn't working then why? What else can be done?" Ultimately I convinced the renal fellow to check what was in the dialysate fluid and we found it was full of sugar. Sugar that was crossing into my patient's blood stream. I pestered him to concoct a custom dialysate to correct this problem until he did so.

One weekend night I was on call. I had taken enough call that I could actually put myself to sleep basically praying: All I have to do is get everyone to morning alive. I was asleep when my pager went off. I recognized the number to the ICU and dialed it. Respiratory had changed the tube in my patient's throat and while taping it in place had accidentally cut the balloon through which air is introduced to keep a cuff around the tube inflated. The cuff is deep down by the larynx with out it the ventilator cannot generate enough pressure to inflate the lungs. The tube had been switched again but now despite all the equipment working the lungs could not inflate. They needed me. Me! I told them to call a code hospital wide so that anesthesia and others would report to the scene. I pulled on my scrubs ran down the stairs and across the hospital and sprinted up two more flights arriving unable to speak. They were having some success using an old fashioned bag mask to keep her oxygen up. There were no breath sounds on the right side of her chest. Keep bagging. I called my second year. "I've never deflated a pneumothorax." That night I watched him stick a needle between my patient's ribs but no satisfying gush of air came out. The air outside the lung was still keeping the lung from inflating. We both knew the next step was to insert another needle in the front of the chest under the second rib. We also knew this was highly dangerous because of the major blood vessels passing under there. Next a senior anesthesiologist appeared and without discussing it proceeded to do just what we had feared to do. He took a deep breath and plunged the needle in. The trapped air gushed out and the lung could re-inflate. I could have cried. (Years later I ran into him and thanked him. He still remembered the case.)

Suddenly the crisis was over and we were back to the previous mere train wreck. At the end of July my patient had a tracheostomy. Her kidneys and lungs resumed working. She left the ICU and went home from the hospital in mid-August while I was on who knows what rotation. To this day I feel badly about a stupid sort of thing. While she was in the ICU I neglected to get splints but on her feet until about the second week. As I learned you cannot bend your ankles anymore after laying there without moving for a month. My patient had to have painful physical therapy for weeks and could only walk with splints after that.

Did I mention she was only 24?

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