“She keeps trying to die on us …”

I spent two weeks of my surgery clerkship on the nights team. At our hospital, one team (3-5 surgical residents) covers the entire surgical service of the hospital and sees all the consults and traumas that come in. There are usually about 50 surgical inpatients, so this doesn’t sound too bad, except: one of the juniors or interns is in the ED the entire time, and usually the senior and chief are either in the ED or operating. That leaves a single lonely intern to cover “the house” at night – one of the toughest jobs in all of medicine. Especially when things go wrong.

We had a patient in the surgical ICU who I had been following for the first week I was there. She was a lady who had had a major trauma, was transferred to our (Level 1) Trauma Center from a regional center for definitive managment of her extensive internal injuries. She had actually been turning a corner over the past week, and I got to know her husband a little during our brief interactions on rounds. It was a joy and a privilege to be able to see her start responding to his voice, opening her eyes, and moving each of her extremities. I looked forward each night to sign out when we would hea about her small progress, and to pre-rounding on her and checking out her notes from the prior day.We backed off on her sedation while still controlling her pain, and her transfusions decreased in frequency.

If you’ve ever managed an ICU patient, I think you can see where this is going.

I was with my senior in the ED seeing a consult when his pager went off – “Code Blue, White 17, Room 11.”

I’ve written before about knowing that the overhead page was for your patient. This was a bit different – since ICU codes are so common, and since the codes are run by the ICU staff, they don’t announce them overhead in the hospital. So the page was our first notification that something had gone wrong – we took off at a brisk power walk (you never run unless there’s a fire, and she was being coded by the ICU staff).

It took us 2 minutes to get to the surgical ICU – by which time she had regained a rhythm and a blood pressure, but barely. 40/20, measurable by arterial monitoring. SVT. No cuff pressure. Fluids flying in, O neg ordered stat, adenosine 6, adenosine 12, adenosine 12, gotta break this rhythm to give her heart time to fill. Nurses working, in various degrees of control, to get more access and more fluids. She’s on contact precautions for a minor UTI/pneumonia, no one pays attention to that. I help put in a cordis in her femoral vein for the rapid infuser. ABG’s are bad: she’s severely acidotic, hematocrit approaching single digits, and her belly is distended. She is actively trying to die. Bicarb is given for her low pH. Whenever you give bicarb you know you’re at a bad bad scene.

I think you learn a lot about people during a code. Some nurses become snappy, and criticise you for being in their way while you are trying to place a lifesaving central line and they’re trying to untangle a BP cuff. Unsuprisingly, those nurses also tend to be the ornery and mean ones no one likes. The cool calm and collected nurses are literally saving this lady’s life – the doctors are just sitting back after the access is in, thinking and ordering meds, but the nurses are the ones actually in the arena doing the work.

At this point we have about a dozen people working on her in a more or less coordinated effort to get her stabilized so that we have more options. If we don’t get her BP back, we can’t think about moving her. She will code and die in the elevator to the OR. But she may very well need to go to the OR if we are to have any chance of saving her life. I started this discussion with my senior – “So, her crit sucks, her BP sucks, and her belly is triple in size …” – and while the ICU attending and the senior help run the resuscitation, the chief calls in our attending and pulls up a CT scan.

As a medical student in this situation, your job is first and foremost to stay out of the way. Secondly, you’re an extra set of eyes. You know what the priorities are, and since you’re not as involved in executing tasks, you can keep track of the big picture. Thirdly, you are there to learn, so you have to learn aggressively. This conflicts with priority #1 (don’t screw things up), but you learn to negotiate the boundaries of your knowledge safely.

The resuscitation proceeds (for certain reasons I won’t go into more details), and we take her to the operating room. Some notables:

1) 15 minutes into the case, I look down at my hands and realize I tore my glove. Great. I immediately stop, point it out to the scrub nurse, make sure I’m not the one who is bleeding (I’m not), and re-scrub. That’s what I get for sizing down and single gloving. Stupid.

2) Medical students can occasionally be useful. Since one of my hands is often not occupied during our exploratory laparotomy, I usually have at least one hand resting on the patient. I soon start to feel cold. I am *NEVER* cold in the OR. I realize that if I am cold, our lady with her belly wide open is going to quickly become coagulopathic. If she can’t clot, she will die, no matter what we do. I turn to the attending when there is a brief break in the case, and speak up. “She’s getting cold. We should consider warming her.” There is no thermometer at this point. One is placed. 89˚F. Fuck. We try to close after tamponading most of the bleeding. She’s still oozing. We open again, for what we know has to be the last time. We’re transfusing her intra-op, giving her FFP, cryoprecipitate, factor VII (at $2000/vial), platelets, everything that we can. We’ve replaced her blood volume once and will replace it again, and again, before the night is over. If we’re lucky.We get better control, close and put her on the stretcher. She’s as stable as she’s gonna get, BP’s acceptable with tons of medical support, but she is cold and oozing. We cannot stay in the OR.

We have to run the gauntlet from the OR back to the SICU. This is the most dangerous time in her post-operative course. We send an OR tech to call the emergency elevator. For about two minutes, we will be without most of our tools for resuscitation. Of course we have our defibrillator and our code meds, but we’re going to be moving at top speed or in a tiny elevator. Two minutes is long enough for her to die.

As we leave the OR hallways and approach the elevator, she starts frothing at the mouth. Foamy pink sputum. Every second year medical student in the world knows – this is pulmonary edema. She’s third spacing like crazy. Her blood vessels are unable to hold fluid inside them due to the combined insults she has just suffered and our necessary efforts to resuscitate her, and are leaking, gushing really, into every potential space in her body. Her hands and fingers are puffy, her legs and face and neck, everything filled with fluid. Her oxygenation starts to beep ominously – from a normal 95% down to low 90%, then dips dangerously into the high 80’s – and now we are literally racing against the fluid that is filling her lungs. The anaesthesiologists are working as hard as they can, but it is clear that we have to make it to the ICU or she will drown in her own blood. Sat’s down to 78% – 9th floor – 72% – god how low is this thing going to go – 12th floor – just pray that the elevator doesn’t break, nothing else to do – 68% – 16th floor, thank god, the tech runs ahead to open the doors for us and we sail into the room.

Now the real work begins. We have to get blood, clotting factors and fluid into her faster than she can ooze out of her belly or out of her vascular spaces into the rest of her body. Rapid warm infusers, warm blankets, slowly we get her temp up and her pressure up. Everything we can do to raise her blood pressure. We have to keep getting blood to her brain, her kidneys, if we want to keep her alive. She was already in renal failure before.

The tempo slows. We’ve reached a steady state. We can wean her down from some of the “pressors” – last ditch blood pressure raising medications that are keeping her alive but at a high price – her husband can come in and see her. I prayed three times that night – not really sure for what or to whom. We move on – she is in good hands with the nurses, there are other patients to see. Always, there are other patients to see.


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