Day 346 My battle with Superman

It happened when we were on-call a few nights ago. It was the first time I have worked with him in about 7 months, since I first had my Unit rotation with him (you can read about it here: http://thankyougodforresidency.blogspot.com/2008/06/day-5-good-bad-and-ugly.html). It's kind of strange but he is probably one of the only residents that I actually have NOT talked much with him the last few months. I have spend a lot of times with the other residents and have built a good relationships, but he has to be the one that I'm least closest to. He is a nice guy. A bit serious on most occasions. I get the sense he wants to maintain a slight distance amongst himself and the interns. A sense that he is the teacher and we are the students. Its the same odd feeling you feel when your hanging out with a teacher or attending. You don't really feel like letting your "hair down". You conversation is reserved and you are not as open. I personally like joking around and having laugh with most of the residents, and some attendings, but with some people you just feel like you have to be reserved. Anyways, so thats how I act sometimes when I'm around superman. He is the "teacher" and I'm a "student"..lol. But its still a good relationship. I have no ill will towards him. He is very knowledgeable and helpful. He is always ready to review something with the interns.

So I was on-call with him. He was covering the floor and He called me for an admission. I went to the ER to do the admission, and in the middle of the admission a code blue was called in the ct scan room. I have to say that I really was looking forward to doing the code with him. I wanted to see how his approach to running a code was. At the sound of the code blue alarm we ran to the ct scan room. It was a female patient that was getting a ct scan, they were working her up for PE. There was a controlled mayhem that followed. Nursing screaming, radiologist tech screaming and anesthesiologist trying to in-tubate while everyone was screaming around him. The code had started in the ct scan room to the dismay of the CT tech who was like "can you guys take this outside?" It must have been less than 2 minutes, when the anesthesiologist said "Ok we got it, lets take an xray and move her out." Superman agreed and told everyone to take it outside. The respiratory tech started bagging the patient and we slowly worked ourselves out of the ct scan room and headed towards another empty room about 1 minute away. When we arrive at the second room the code was still continuing , and it was my turn to do the chest compressions (its usually about the only thing the interns are allowed to do) I started the chest compression. When I place my hands over the sternum and started compressing, it felt as though her ribs or sternum were a bit cracked. I remember feeling a chest similar to that a few months ago when I was running one of my first codes. The chest wall was very frail. I tried not to compress too hard while I did the compression. Superman saw how I was doing the compressions and yelled loudly "Hey do those compressions harder." I started to do it it a little deeper and faster. About 15 seconds of trying and superman was like "look that's not how you do it" and he came over and tried to show me how to do the compressions. Its not that I didn't mind him showing me how he did compressions, but it was the way he did it. And yelled in front of all the other nurses and techs. (by the way this was not my first,second,third or fifth or tenth time doing chest compressions....) He then told one of the critical care techs to take over the chest compressions. Less than 1 minute into doing the chest compressions superman yells "good chest compressions. Very good." He kind of said it really while I was next to him. It was really irritating. It felt as if he was trying to rub it in my face. Maybe he wasn't doing it on purpose, but it made me really upset. This was probably not the time to try to "teach me" how to do chest compressions.

Anyways I didn't say anything and the code kept on running. About 6 minutes into the code. He asked for a pulse. I tried to feel for it but didn't feel one. Superman came over and "felt" one in the carotids. He said we had a pulse and proceeded to cal of the code. "Her rhythm was sinus tach. (no afib or flutter). The code was over for now and I went to look for a phone, because an attending was waiting to get in contact with me. I went back to the E.R. to call the attending. And the female that we had coded was brought back to the E.r. While I was in the E.R about 8 minutes. Another code blue was called again. (Codes in the E.R are run by the E.R doctors and not the residents. I went to find the room in the E.R that the code was being run, because I figured it was superman running the code. I found the bed number and sure enough superman was their running the code. All in all it must have been at least 40 minutes all together that this female was being coded. While he was running the code and one of the techs was doing compressions, superman again said while he was next to me "keep those compressions going. " He then turn to me again and said "you see that's how you do it." I turned to him and said "no, that's not how you do it. He is doing the compression way to hard (this guy must have weighed about 260 lbs and the female was about 140lbs.) He is doing the compressions too hard and she probably has cracked ribs and is going to lose all the negative intrathoracic pressure your trying to preserve." I didn't say it too loudly. But he kind of stayed quiet when I responded the way I did. Anyway, another 20 minutes passed and he decided to call of the code. Even after trying to rule out tamponade (which he had the Head of E.R do a bed side sonogram). Cold was called, and the team was dispersed. I have to be honest with you. I was extremely pissed. I thought it was really inappropriate for superman to start giving me lectures on cpr in front of the entire code team.

I waited for some time to pass by and when I saw him sitting down at a desk I told him. "You know, that's not how you do chest compressions. You are gonna crack ribs and cause lose of pressure. DO you remember ICU bed 13? The guy with hydronephrosis? We coded him 1 hour and a half. (me and another resident doing the chest compressions), and we brought him back. You don't need to do he-man compressions on someone. Thats not the standard." (later when I got home I even read more on the AHA guidelines about chest compression which need to be 1 1/2 -2 inches. I also remembered one of the lectures of critical care telling us in a lecture to make sure you try and not break the ribs and you lose pressure and air. When I first heard this few months ago, because I felt that I had broken some ribs on a patient I had done cpr on. If you read on the net and some specialist they will say that breaking ribs is better than not doing any at all. But ideally you want to make sure you try no to break the ribs.) Anyways superman said "i know. I know." and didn't say anything again. I didn't want to keep on, because it wasn't the place for it, but I was just so upset at the way he was acting or by his approach.

Anyways fast forward a week later, and I saw superman approach me at the resident lounge. He said "guess what?" I said "what?" he said "its your turn to do an M+M (morbidity +mortality) conference." I said "on whom." He said "remember that lady we coded? come here sit down, and check out this xray?" I sat down and he opened the xray from the computer system. I looked at the xray and coudnt really see anything. He pointed to the trachea, and said "you see the Et tube that was placed, looked at it? You see, its in the ESOPHAGUS!!!" I was like "wow.. your telling me the anesthiologist put the tube in wrong place? and nobody caught that? Wasn't the xray read by someone in the E.R? " He was like "yup, one of the experienced staff E.r Docs read it during the code, and it was wrong!!" I was a bit in shock. Looking back her stomach was a bit distended. But because of the chaos, no one bother to check the breath sounds from the Et tube placement.

Looking back, it really was a chaotic night. Seemed that everything went wrong, and sometimes goes wrong. Looking back I'm sure there was a lot of things that could have been done, that was not. Overall one of the toughest nights I've seen in a while. Me and superman are still friends though his approach might not be ideal, but he tries to do the best he can for his patients.

Gd Bless

Dr.Mike