Day 5: The Good, the Bad, and the Ugly

Let me first start of by saying, that what I have just been through in the last 4 days cannot truly be described in words, but I will try. Needless to say, the last 48 hours, have been some of the most stressful I've ever felt.

Let me just give you a brief background. My first rotation is CCU/ICU- it’s a combined rotation- cardiac critical care, and Intensive care, put together. Not the ideal rotation to start, but no complaints. On top of that, the senior residents assigned to us (me and 2 other 1^st years) are 4 days from graduating. So your lucky that you can even see them for 5 minutes sometimes. So a good majority of the time, you are left alone, depending on your senior. In my case, I got real “lucky”. I was put with another second year resident, who is about to graduate to 3^rd year. At first I thought it was a blessing. But not really. The guy is like a superstar resident. When he is given a patient, he quickly goes to the computer reviews basically the entire medical history of the patient (including ct’s, xray, cultures, ultrasound, surgery history, the labs and how the correlate for possible the last 3-4 days. And etc..) and writes it down on 1 sheet, which is filled with any lab you can think of. After he writes it down (Oh yeah and the 15 meds the patient is on) and 5 minute later he throws it away. And when the attending ask him questions about the patient, he talk like he’s given a lecture. He knows every single detail about the patient. And by that time he has consulted with like 3 doctors on the case, all this within a really short time. When we do rounds me and the other 1^st years and another 2^nd year are all carrying notes and patient binders, and this guy just has his hands folded behind his back, and knows the patients, like the back of his hand. I was just amazed. It’s a mixed blessing because I was like “damn, I want to be just like this guy!” But damn I think I need to read a little more…lol….

It was on Thursday that I practically saw him rescue a guy that was given to him by another 2^nd year resident. I will call this superresident clark or superman. the patient was called into him and afterwards, I then saw him go to action. First of, I was able to follow him a bit, because I came in at 6am and tried to do my notes, because I wanted to see what this super resident was doing. Once the patient was giving to him, he went directly to the computer and started bringing up his labs. He saw the current days labs, wrote them down. Then he saw wbc were down and went and retrieved the last 3 days of wbc. Then he also followed the patients last 4 labs (the pt. has HIV,hep c, liver failure, not compliance with meds, history of toxo,CABG )and the ABG’s. When he looked at the ABG, he noticed a mixed syndrome. He had respiratory alkalosis with metabolic acidosis, he was hyponatremic 119, and his T4 count was 2!!!!! Can you believe that ! 2 cell count!!! His co2 was like 60, and he turn to me and said “this patient is about to code and crash, we need to get him to the ICU now!” And now for the ugly. When he called downstairs to the medical floor “nobody” seemed to care. The nurses says they had no order to bring the patient to ICU, and that they had to run it through their floor manager. He didn’t get much from them, so he told the ICU staff about his patient and they were like “what? Your bringing who here? We haven’t heard about this. Were not gonna get him” basically this guy was going down and this nurses were just interested in fighting which room he would go into. They were not able to get any lab work today because his veins had collapse and without a PT, PTT levels nobody in the ICU will put in a central. (I learned this from superman). Basically he told the nurses that why bring him here , because he couldn’t put in the central. So basically superman, thought for one second before calling the cardiovascular interventional radiologist personally (who was just about to leave for the day) and asked him if he could put in the central line with ultrasound guidance. But even before he could do this, the patient had to be brought to the radio unit. And finally a caring nurse said “ok, I’ll get him, if nobody wants to go “ So she told her supervisor, they started moving and she went down to get the patient as a favor for superman. While I’ll this was going on, I was just in amazement. One, because nobody really cared about a patient who is probably moments from dying and who is chronically ill, and secondly because this superman was fighting for this guy, who he had never even met. He was fighting with 2 floors of nursing staff and calling 4 doctors and TELLING them what to do. He called them so that they would give him the ok. He was very confident, stern, but remained human at least. He was stern with the nurses and was determined to get the patient to ICU to do something about it. He didn’t take no for an answer, when asked what was wrong with the patient, he recited all the labs and his defense of what he was doing. After about 30 minutes the patient was brought to ICU, superman calculated the ventilator settings and put the patient on the respirator. He was thinking it was pcp pneumonia and MAI but he was going to check with infectious disease first. He was also thinking legionella because of the hyponatremia. He started a sepsis working up and the patient was ok for now.

Now comes the bad. The following day he signs of duty after being on call, and leaves the patient to me!!! I was like what? He left me “alone” with the patient . I wasn’t completely alone, but might as well have been because, the other seniors had no clue of his history. And that’s what has cause my stress in the last 48 hours. Yesterday , the head of the infectious department (whose patient this happens to be) asked my about the patient, and I was fumbling my notes of the patient in front of him, and couldn’t answer his questions. You should have seen his face, I think he wanted to stab me if he could. If he had any non-earthly power, I think he would have banned me to mars !! Man I was nervous… That’s not even the start of it. He was not their today and I had the patient all the myself again TODAY !!! In the entire ICU CCU it was one 3^nd year senior and 3 first years . She was like “whatda hell? I’m alone with these guys!!” I figured this was happened so I went early at 6am to the hospital to try to learn all the history of the patient and try to find out what the heck was going on. When I was in the unit. I put my face down and prayed “God help me with this”. I told myself “ok, lets think this through you can do this” So this was around 7 am. By 11am they guy was almost crashing !!! His ABG were horrible. I was looking at his labs and there were 2 attendings standing outside. I told myself “you’re the doctor, do something about this” I went and checked his levels. I noticed in the cxray he had bi lateral effusions, he was not breathing to good. He was getting dehydrated. When I told this to the cardiologist, he was like just stop the IV normal saline because your fluid overloading him. I was like (respectfully) “If I take him off liquids I think that might exacerbate his pre-renal state” He paused and look at me. I told him “He is pre-renal, his bun is 63 and creatine is 24.” He then kinda studdred and was like “ok, talk to nephrology” I then spoke to the pulmonary specialist who agreed with me. He said call the renal and get the ok to stop the iv saline and will go 20 mg lasix 1 time. I got on the phone with renal (after I spent 10 minutes looking for the number) and spoke to renal over the phone. We were able to get the ok. And we gave him the lasix. I though this would take care of the problem. Until suddenly I walked into his room 1 hour later and his respiration was at 40!!! I was like whatdahell !!! I looked outside the room and nobody was their!! I didn’t know what to do. I said to myself "I think this guy probably need to be intubated again" (he had been token of the respirator a few hours ago.) I went and spoke to the 2^nd year senior and she was like “what? Who are you talking about?” I paced back and forth for about a minute, and guess what happen. Just at that moment. My beeper buzzed. I looked at the number I called it back, and guess who it was? SUPERMAN !!! He was like “get a vital capacity on that guy. Call respiratory they will do it.” I also went and told him about the last ABG’s. He then told me “check his vital capacity, and if its ok, then continue with the oxygen” I paged respiratory. They came and checked his vital capacity which was 0.07 !!! (that’s bad) and his nif was -15 (that’s really bad) I didn’t panic much because superman had told me to call the pulmonary attending who had left 2 hours ago. I called him and he said to put him on BPAP . I went to the respiratory guys (who were giving me dirty looks) and I told him were going to do BPAP. 1 hour later he was on BIPAP and stable and I was on my way home thanking God and my lucky stars. I wanted to kill superman !!!! I couldn’t believe he left me alone with this guy. I didn’t even do my note, I was to busy trying to figure out what the heck was going on. I wrote my notes at the end and left around 1pm.

Man what a relief, when the patient was put back on bipap. I was already thinking of the next match or maybe another career, but I prayed told myself “you’re the doctor do something!!" and luckily everything turned out "ok.”

Geesh man, they don’t teach this stuff in the books!!! Man I thought I knew medicine. But one thing is reading and another is having people you can rely on. I guess that would be the good-Having individuals who are willing to help and sacrifice for others. Individuals fighting for the sick and those in need.

God Bless friends. Pray for me.

Dr.Mike