Day 530 : ZZZZZzzzzzz.....

Well I just had the busiest night in almost 2 years in the hospital, and I think we broke the record for the most unit/ccu admissions in one night. IT was about 8 unit admissions. I have started the night float, and my night began around 7pm. It usually starts around 8pm, but a friend of mines called and asked if I could go in early. I got there at 7pm and right away a friend of mines called me to do a unit admission. He was originally suppose to do it, but since it was close to 715 and they usually take around 2 hours, I did him the favor. Anyways, so I head out to go do the admission, and it was for multiple drug overdose. Apparently, this 19 year old girl had take 4 full bottles of medication wellbutrin, propronalol, and 2 other pschy meds. IT seemed like she had a long history of mental disorders. I spoke with the e.r physician and the nurse, and she was found in the room lying on her bed very lethargic. When she came into the E.R. she had a generalized tonic clonic seizure and she had been intubated. It seemed like a pretty straight forward unit admission that we get in the E.R. As I was approaching the bed of the patient the nurse hands me the paper work and he also says, oh yeah and by the way she is the daughter of one the members of the senate or governors office of the state. I was like "huh?" I got a little bit nervous. I try to play it off like it wasn't a big thing. "Ok...no problem." I proceeded to the bed side and when I arrived there, the pt was intubated, and I didn't see any of her parents. I went back to the nurse and asked if he knew where the parents were. HE went outside to get them so I could speak to them. Geesh, I don't know why I was so nervous. I was breathing a little heavy, I guess because its someone who is "famous". Most of the people and including the e.r. attending seemed paranoid too. Anyways I met with the "member of congress or senate" No noe knew if it was for sure. They seemed very pleasant and concerned about what had been going on. I told this individual that poison control had been called and she was receiving all the appropriate medications. Her vitals were stable and her oxygenation had been wnl. She was on fiO2 of about 40percent and her saturation was about 95%. She seemed comfortable. According to poison control because of the propranolol overdose, they had place a lipid infusion. It was a very rare recommendation. The director of poison control had to be called because he had not seen it in 20 years. The fact that she was also on this lipid infusion also meant that it was binding to her propofol and versed, so she was very arousable. I had to discuss with pharmacy for another agents that we could use. In the end we dscided to give her boluses of ativan and fentanyl as the last resort. After speaking with the parents, I went over to the internet, because I didn't recognize this supposed member of congress. I checked the states website and It WASN't the senator or governor who I had spoken too. (later on the following 2 days I found out that it was an official from one of the "local districts" or possible state "assembly".) Anyways, regardless of who it was, I was a bit scared I guess. Whenever you are around a person of "power", I guess you think twice about what you did, and you want to do a good job. They even labeled her a vip, and gave her the best available room. Well after I finished this admission, I went over to try to get the sign out from the ccu resident. I called his cell phone and he said that I better come sign out to him in ccu. I didn't like the sound of that, but I went anyways..lol. When I got there, everything "seemed" in order except for the patient in bed 8 whose heart rate was in the 180-190's. She was also in the middle of dialysis when it was going on. It was probably only my second time having to personally deal with it my self. (We see it a lot on the floors but the cardiologist always handles it.) It seemed like svt on the monitor we got a 12 lead ekg that showed svy at 160. We had given her multiple bolus doses of lopressor and cardizem, but she was still running 160. So we decided to give her adenosine 6mg IVx1 which didn't break it. We were looking at the moinitor to see if we can see the underlying rythym. We gave her 12mg adenosine push and at first we didnt see any change, but then in about 2o seconds we saw the underlying a.fib or a.flutter. Me and the other resident were so happy !! We then decided to call cardiology to let them know what we had done. The suggested cardizem drip. So we started it, and no heparin drip. Anyways so I got the sign out of all the ccu patients. As soon as I got back to the lounge the other senior resident on the floor told me he had a unit sign out. I told him about the one I had done. He also gave me a floor admission with the intern. As I was going down to do the unit admission, I get a call from the ccu "hey doctor, you know the lady in bed 8 she is still tachy at around 170" I then hung up the phone and went to the bedside. She was still in svt. I really didn't want to call the cardiologist, but I had no choice to wake them up, it was not too late. He recommended to use digoxin 250IVx1 and then digoxin 125mcg uvx1 after that and also place her on lopressor 2 mg IV q4h. AND, he also added "you know you can cardiovert her if her bp drops." I answered "sure...I will do it" SO I hang up the phone and told the nurse the plan. One of the head nurses asked me about the cardioversion. And I told her "he said we can cardiovert if we have to." She looked at me puzzeled "don't the cardiologist have to be at the bedside to do this?" I told her "off course, but I guess if they trust you, they might allow you to do it, lets hope that we don't have to do it." (I have seen it done in a more controlled environment in minor or, and not normally at the bed side)

Right around this time, I got another call for another unit admission. I went down to the E.r and it was for chf exacerbation for a patient on bipap. I went to see her and she seemed more or less comfortable. On the bipap she was saturating 94%. Right around the time I was examining her, the patient in the next bed started having a seizure (she was the other unit admission my friend had just done.) She was also in the middle of dialysis. I told them to give her ativan IVx1 and repeated it twice, and to call anesthesiology for possible intubation. I called my friend on the cellphone "hey, you know that pt you just admitted? she is having a seizure, you might have to come and intubate her." Sure enough he came down in a few minuted and they intubated her. Right around this time, the E.r attending tells my friend "by the way, there are 5 floor admissions." My friend looks at me and says "can you believe this guy? I think he is going home and just wants to clear all his work?"

Anyways, we grab charts and distribute the admission between us three (me, him and the intern) About 2hours into the last admission, my friend calls me and tells me "sorry mike, there is another unit admission." I try to finish up the last admission, and head over to the other unit admission. It was a female patient going to the unit for STEMI, she had st elevations on v2-v6 and she wanted to signout AMA. I get to the bedside and she tells me "I'm not staying, I'm going home. I don't have anything." I told her "you don't have anything besides a possible heart attack." AT this time her son. who is sitting next to her says "she ain't got nothing !" I look at him a bit confused and say "I'm telling her exactly how I would say to my mother. If you were my mother I wouldn't let you go home." So I convince her to stay till the morning-which it was. Just when I was finishing this admission, the intern calls me on the cell phone "hey I just wanted to let you know that I'm not letting a patient go AMA. He is not fully oriented, and I told the nurses." I said fine and hung-up the phone. A few minutes go by and I heard an alarm go off in the hospital speakers "ALERT CODE GREY, ALERT CODE GREY." I don't think twice about it, I told myself that it was probably the alcoholic patient he had just called me about. So I finish with the stemi admission, and head back to the lounge to see if I could get a break, when the intern calls me and says "hey, do you think you can take a look at this guy. he seems to be oriented but i'm not sure." just around this time the other senior resident meets me on my way to the floor. When we arrive, this patient is on 4 point lock restraints and a body net. I turn to the intern and say "this guy is in full blown DT's and needs to be upgraded to the unit and started on IV benzo's. I almost intubated the guy, but we decided to give him a chance. We started boluses of vallium and made the upgrade to the unit.

It must have been around 5am in the morning when I called the cardiologist for the STEMI admission. He sounded half asleep and said "did you check the last ekg?" I fumbled my words and said something strange, and he said "those are not new, she has thos from previous ekg's." I proceeded to apologize and also told him about ccu bed 8 "by the way she is still in the 160's. Her bp is stable, so we havent cardioverted yet." He muffled ok and went back to sleep. At around this time I got a call from the other senior who had been called to another unit admission, and he wanted my help to do it faster. So i went down with him so we can finish it up. I don't remember exactly what it was, I was half asleep, but we finished it anyways.

Overall we had about 7-8 unit admissions (including upgrades) 15 floor admissions, one code grey, one intubation, one seizure,one SVT, one hour sign out to am team and one half angry cardiologist. All in all, not too bad.

Off to sleep.....

God bless
Dr.Mike

p.s the svt was cardioverted in the am with anesthesiology and after TEE to rule out thrombus.