Work finally calms down…
Exhausted, I sit in our office, and finally get a chance to open my book and get a small amount of studying done.
And of course… as soon as I open up my book there’s a code blue in the ICU.

ARE YOU KIDDING ME?!

The other night we had a patient who was flown into our ER from a much smaller and rural hospital after going into cardiac arrest. The other hospital didn’t have the facilities to care for him after he was resuscitated. He was already intubated and sedated. He wasn’t my patient so I didn’t know much about him and he went up to the ICU fairly quickly.

Several hours later after the physician who saw him had already gone home, they called a code upstairs in the ICU. As we began our rush to the ICU, the hospitalist practically sprinted past us, telling us that we didn’t need to go because he wasn’t busy. 

About 30 minutes later one of the nurses decided to pull up the telemetry monitor of that patient to see if he was was doing alright. He wasn’t. His vitals were absolute crap. He was hypotensive, hypoxic, and bradycardic. We called the doc over to look at it, and we just watched. Watched as his HR slowly become more and more brady: 50s to 40s….40s to 30s. We watched as his BP fell from 90s/50s to 80s/50s to 60/40. Watched as he somehow became more and more hypoxic. We watched as his 12 lead slowly evolved from sinus bradycardia to what looked like an evolving idioventricular rhythm. We watched and waited. Slowly he dropped into the 20s. Eventually he jumped into this fantastically extravagant polymorphic wide complex tachycardia. Finally a code was called and once again we ran to the ICU.

It’s hard to realize that on the other end of that telemetry monitor, past all those lines and numbers, lies a person. 

So I was talking to one of the physicians about the patient that was resuscitated in my last post and right after I finished talking about him they called a code up in the ICU.

We go upstairs and it was the same patient who was in cardiac arrest (again).

And of course he didn’t make it.

Does someone want to take my black cloud for a few weeks? I’m sure the patients here would appreciate it.

So yesterday my second patient of the day was a EMS Code Blue, presented in Aystole x10m of CPR. EMS gave x2 of vasopressin (Don’t ask my why because I was always taught that you only replace the first or second round of Epi with one dose of vasopressin) and that was it. We ended up reviving him with an amp of D50 ( bedside glucose was 22, EMS didn’t do a d-stick). Then, right when we’re doing some post-resuscitation care like hanging a dopamine drip and starting a central line, a perfectly stable patient that the previous physician signed out to us coded two rooms down.

My black cloud seriously hates me, y’all. I was told that the day was perfectly fine and normal until I walked in, which is what usually happens.
(But we resuscitated both!!)

So here’s the story, and it might be long

Two days ago a middle aged woman presented to the ER with c/o knee pain after a syncopal episode. She was a frequent flier at out ER and was usually seen for anxiety or chronic pain issues. On this visit, she denied any Chest pain, SOB, Dyspnea, or even anxiety. The ER physician wanted to admit her but the hospitalist thought she was crazy and didn’t believe that she had passed out. To his defense, she was  ”being dramatic” and started to refuse lab draws that the hospitalist wanted to order. So the hospitalist personally discharged her from the ER. 

Yesterday, the same patient presented to the ER again, this time with c/o SOB and anxiety. At this point her vitals were stable except for slight tachycardia at around 105-106. She said that her anxiety had started up again and that she was feeling short of breath. The same ER physician from the day before saw her on this visit as well.She wasn’t hypoxic at this point either.  She denied a Hx or recent surgery, taking birth control pills, long trips/car rides, any previous blood clots, and she was not overweight. The only significant history was a 2-3pack per day smoking habit. So, we do a cardiac workup with a D-Dimer. Surprise Surprise her D-Dimer comes back in the 3200s. (A D-Dimer is a lab test that can help indicate the presence of a Pulmonary Embolism). So, off to CT she went for a CTA of her chest.

The next sequence of events happens in about 10 minutes:

The CTA images came back and I took a quick peek at the images and saw obvious and HUGE  PEs bilaterally. We have a nighthawk radiologist (A radiologist who reads images after the house radiologist has gone home) and it was too soon to get a report from them. I showed the physician and he agreed so he began to call the hospitalist and order a Heparin drip. I went to go check on her vitals and noticed that she was slightly more tachycardic in the 115s, but was started to go hypoxic on 2L (O2 sats were dropping into the low 80s). I went and made sure it was okay to turn up her O2 and cranked it up, which seemed to help slightly, with her sats going back up into the low to mid 90s. At this point the nighthawk radiologist called to confirm that she had bilateral PEs that were fairly large. 

So we walk in the room with the nurse to give her and the family the diagnosis. She looked fine, just a little hypoxic, but in no obvious distress. The physician was only able to say “Well, it looks like you have what’s called a Pulmonary Em-” before she suddenly started gasping for air and fell back into her bed, her skin quickly turning cyanotic. The physician yells for the airway cart and I pressed the code button and started to open up the BVM for the nurse who went to go grab the airway cart (it basically has all of the intubation supplies).

She gets intubated and hooked up to the crash cart monitor, after which she immediately loses her pulse and goes into PEA. We pushed Epi/Atropine several times but weren’t getting anywhere and she was slowly becoming more bradycardic even with compressions and ACLS meds. We hung the heparin drip and that wasn’t helping either (I don’t think anyone thought it would). Eventually we got to the point where we pushed tPA (a thrombolytic “clot busting” drug normally used for ischemic strokes). The tPA was probably already too late as well. After about 1.5 hours the physician called the code off, and she was pronounced. 

Overall it was definitely a pretty dramatic night

I had another patient die today.

This one for some reason really struck home, and definitely humbled me to how prepared I thought I was to deal with death. 

It was a patient I had seen several times in the ER. She was very morbidly obese and had a trach along with a plethora of issues one expects from morbid obesity in a 70 something year old female chain smoker(CHF, HTN, DM, CAD, CABG, PEs, ect..).

She was asystole x15m prior to arrival in the ED and was completely unresponsive to Atropine and Epi, even in the ED. 

It was called probably 10 minutes after she rolled into the ER. 

I don’t know why her death struck a nerve. 

I’ve seen death several times throughout the few months I’ve had my job, but this is the first one that I couldn’t get off my mind.

Interesting things to ponder into the night.

New nurse: “I’ve never seen a code blue here before”

5 seconds later….
Overhead PA System: “CODE BLUE TO THE ER”

Yesterday I attended my first Code Blue in which we were unable to resuscitate the patient. 

This specific patient came into the ER the day before with complaints of hypertension (above usual) and pedal edema. He had ESRF (End stage renal failure) and got dialysis twice a week. The ER physician wanted to admit him but his nephrologist decided he didn’t need to be admitted to the hospital (I’m not sure why)

Apparently, the next day when he came for dialysis, they chose to admit him (I didn’t manage to hear what his admitting diagnosis was during the chaos of the code)

Before he coded he stood up and went to the bathroom walked around the unit, and as he was sitting back down in his bed, he essentially died.

By the time the ER physician and I made it up to the floor, he was in PEA (pulseless electrical activity) 

We did CPR for a while, pushed some x4 epi and x4 atropine and x1 of bicarb (not in that order). Nothing seemed to be working so we were about to call it after 30 minutes, but then his nephrologist showed up. At this point the ER physician and I decided to leave since the patient’s primary physician was there and there didn’t seem like there was much more we could do.

We got a call about an hour later that they decided to call it.

It was a pretty crazy night to say the least. 

The reasons for why he could have died are extensive, I think. The most likely I would think would be hyperkalemia or acidosis. Maybe even pulmonary edema but I doubt it.