What's it like to have a patient die?

[nuvaira.butt]

As dr said patients are subject for us n their. Is no sympthy but empthy
But i must say as doctor its really feel bad when sm1 die infront of us

---

Members don't see this ad.

 

[TooMuchResearch]

You did CPR for 2+ hours? I mean frick, I could have had them on ECMO by then.

You couldn't if you a) didn't have ecmo capability or b) your ecmo capability was already at full capacity.

 

[ridethecliche]

Also like this:

Scrubs is by far the most realistic medical tv show I've ever seen.

While yes they use narrative convenience like this (Dr. Cox and Kelso appear to be the only attendings JD ever has), they capture the spirit and pathos of residency like no other show.

Thanks for reminding me that the show used to be really awesome at one point of time. I think they did a really good job of capturing the frustration of situations beyond one's control...

The biggest mistake I have made is to let myself imagine a patient as my wife. I had a lady over the summer when I was on trauma...34 y/o female out running WITH her husband and 2 young children when some gomer who had no business still driving nails her with his car. Ends up tubed in the unit with the most ridiculous looking CT I have ever seen, not even recognizable as a brain. Brain dead. Kept her optimized for gift of life....the next AM i go into the room and her kids had drawn her all these pictures with crayons "mommy we cant wait until you wake up we want to play with you." FML And I let myself pretend that was my wife for a second. I ******* cried for a minute in the bathroom after that, grown man here.
So if some premed is going to claim they will never form any sort of emotional connection to a patient they are full of $hit.

Ugh. So many feels :/

 

[Shinobiz11]

Come to the south side of Chicago and you will find out.

Coincidentally I will be in Chicago next weekend, but no thanks. I go to school in Flint and volunteered in the ED near downtown, that's good enough for me. I just wanted to know if there was more to the story like the sibling playing with a loaded gun.

 

[mimelim]

Thanks for reminding me that the show used to be really awesome at one point of time. I think they did a really good job of capturing the frustration of situations beyond one's control...



Ugh. So many feels :/

Had this weekend off and have been marathoning Scrubs since I was reminded in this thread. I haven't seen a lot of these since I started residency. Well worth the re-watch.

 

[ridethecliche]

Had this weekend off and have been marathoning Scrubs since I was reminded in this thread. I haven't seen a lot of these since I started residency. Well worth the re-watch.

Scrubs destroyed my first semester frosh gpa. Whoops.

 

[Hospitalized]

As dr said patients are subject for us n their. Is no sympthy but empthy
But i must say as doctor its really feel bad when sm1 die infront of us

Oh no...

 

[Tawantinsuyu]

I think it really depends

The first patient that died under my care did so under the best circumstances and was a relief for everyone involved. He went peacefully in good company and I was glad to have been a part of it

There is a crack in my computer screen, and I read this as "The first patient that died under my car did so..." hahaha

 

[FutureOncologist]

3rd year here. I had to help with a suicide via GSW to the head. We tried but there is only so much you can do. This affected me profoundly because I used to have depression and saw myself on that table. I almost left the hospital if it weren't for the great residents and attendings that helped me through that experience. Something I wouldn't take away.

 

[Perrotfish]

Had this weekend off and have been marathoning Scrubs since I was reminded in this thread. I haven't seen a lot of these since I started residency. Well worth the re-watch.

I woke up early watched the pilot episode about JD's first day the morning before I started MS3 clinicals, and again the morning before I started my first Intern year rotation. I felt like a huge nerd each time, but I left for work feeling a lot better than when I woke up.

 

[Perrotfish]

One story about death to share: The first death I ever saw in the hospital was a DOA heart attack brought in on my MS3 ED rotation. The EMTs had been doing compressions for 45 minutes and probably should have called it before they started. Since it was a slow night, the ED doctor looks at the body, looks at me, and says 'medical student, please take over the chest compressions'.

They made me do multiple round of compressions on that corpse while the residents smirked and critiqued my form. The ED doctor meanwhile explained that this was a great opportunity to practice CPR. I will always remember that as one the most morbidly dickish things ever done to me.

 

[UImom]

Being in this moment. It's one of the gifts of medicine as well as one of the downsides.
To be able to help ease suffering, let someone or their loved ones know that all possible was done, and to offer organ donation to those applicable is a comfort on a visceral level that is an intrinsic part of medicine. You will be with people in some of their most important moments and they will always remember your input. These difficult situations will become less difficult for you with experience but will always make you feel you are doing the work that really matters.

 

[mehc012]

One story about death to share: The first death I ever saw in the hospital was a DOA heart attack brought in on my MS3 ED rotation. The EMTs had been doing compressions for 45 minutes and probably should have called it before they started. Since it was a slow night, the ED doctor looks at the body, looks at me, and says 'medical student, please take over the chest compressions'.

They made me do multiple round of compressions on that corpse while the residents smirked and critiqued my form. The ED doctor meanwhile explained that this was a great opportunity to practice CPR. I will always remember that as one the most morbidly dickish things ever done to me.

And yet I'd be shocked if any of the attendings can even remember the last time that they actually performed chest compressions.

 

[TooMuchResearch]

And yet I'd be shocked if any of the attendings can even remember the last time that they actually performed chest compressions.

Doctors are paid to manage, not compress. If anyone else is available, they push on the chest.

Besides, with devices like LUCAS and Auto-Pulse, there might be young attendings who have never done compressions.

 

[mehc012]

Doctors are paid to manage, not compress. If anyone else is available, they push on the chest.

Besides, with devices like LUCAS and Auto-Pulse, there might be young attendings who have never done compressions.

...yes, that was my point.
Not only was it a rather cruel exercise by the supervising docs, it was a pointless one as well, since it's not like chest compressions are a skill commonly used by attending physicians.

 

[cidem2065]

...yes, that was my point.
Not only was it a rather cruel exercise by the supervising docs, it was a pointless one as well, since it's not like chest compressions are a skill commonly used by attending physicians.

Definitely something worth knowing. I don't see physicians starting IVs very often either but it's a skill worth learning and understanding and is taught in medical school.

 

[mehc012]

Definitely something worth knowing. I don't see physicians starting IVs very often either but it's a skill worth learning and understanding and is taught in medical school.

I get that, but then, you don't usually spend 4omin starting an IV on a dead person. It's one of those 'yeah, I see where you are going, but maybe you took it a bit far' things.

I have to say, working with ER attendings (who are required to run every code in our hospital), I have seen multiple IVs started, even a few Foleys, but never once, even remotely, was there a question of them performing compressions. Codes don't work unless there are a bunch of people - and every single person in that room will be called on for compressions before the doc. Always. The doc is usually doing something that only they can do, like starting a central line or intubating...it would be an utter waste for them to be doing compressions even if they weren't responsible for running the show.

 

[cidem2065]

I get that, but then, you don't usually spend 4omin starting an IV on a dead person. It's one of those 'yeah, I see where you are going, but maybe you took it a bit far' things.

I have to say, working with ER attendings (who are required to run every code in our hospital), I have seen multiple IVs started, even a few Foleys, but never once, even remotely, was there a question of them performing compressions. Codes don't work unless there are a bunch of people - and every single person in that room will be called on for compressions before the doc. Always. The doc is usually doing something that only they can do, like starting a central line or intubating...it would be an utter waste for them to be doing compressions even if they weren't responsible for running the show.

True - I haven't done compressions in the field for years for the same reason - but it's good for a medical student to know the how to and what compressions are like so they can effectively manage the code and correct potential mistakes.

 

[Perrotfish]

Definitely something worth knowing. I don't see physicians starting IVs very often either but it's a skill worth learning and understanding and is taught in medical school.

I would argue that starting IVs is actually a more useless skill than chest compressions. Theoretically you could be the first one into a code, or find someone down in a remote location, and need to do compressions as a physician. One of my attendings actually just saved a drowning victim when he was at the beach, using nothing but BLS. I do think its a skill physicians need to practice regularly. On the other hand I can't imagine a scenario in a modern US hospital where a non-anesthesiologist physician is asked to start an IV.

The problem was more how the ED doc had me practice

 

[cidem2065]

I would argue that IV starts is actually a more useless skill than chest compressions. Theoretically you could be the first one into a code, or find someone down in a remote location, and need to do compressions as a physician. One of my attendings actually just saved a drowning victim when he was at the beach with BLS. I can't imagine a scenario in a modern US hospital where a non-anesthesiologist physician is asked to start an IV.

Yeah you won't see a physician with IV start materials or first-line drugs out of the hospital.

On that note I have seen some ER docs starting IVs but only twice, and in both cases they were really just assisting the physician taking primary care of the patient and bouncing treatment ideas back and forth.

 

[group_theory]

Had this weekend off and have been marathoning Scrubs since I was reminded in this thread. I haven't seen a lot of these since I started residency. Well worth the re-watch.

Re-watching the show after having some clinical experience behind my belt reminded me just how funny (and true) that show is (and a lot of inside jokes that only those who have undergone medical training will understand)

 

[Ismet]

Re-watching the show after having some clinical experience behind my belt reminded me just how funny (and true) that show is (and a lot of inside jokes that only those who have undergone medical training will understand)

I thought med students were good at scoping out/taking free and "free" stuff. Then I met interns.

 

[mimelim]

Re-watching the show after having some clinical experience behind my belt reminded me just how funny (and true) that show is (and a lot of inside jokes that only those who have undergone medical training will understand)

Thank you for that XD.

And that is soooo true. Every last bit of that clip.

 

[Gurby]

Yeah you won't see a physician with IV start materials or first-line drugs out of the hospital.

On that note I have seen some ER docs starting IVs but only twice, and in both cases they were really just assisting the physician taking primary care of the patient and bouncing treatment ideas back and forth.

Don't anesthesia docs need to be good at IV starts?

 

[TooMuchResearch]

I would argue that starting IVs is actually a more useless skill than chest compressions. Theoretically you could be the first one into a code, or find someone down in a remote location, and need to do compressions as a physician. One of my attendings actually just saved a drowning victim when he was at the beach, using nothing but BLS. I do think its a skill physicians need to practice regularly. On the other hand I can't imagine a scenario in a modern US hospital where a non-anesthesiologist physician is asked to start an IV.

The problem was more how the ED doc had me practice

Yeah, what they had you do was awful for you and the patient.

I throw in EJ PIVs if our nurses can't hit something else with ultrasound or they aren't good with ultrasound. I will occasionally do an US guided PIV if the nurse can't get it and I need it for an CT angio.

 

[Doctor Bob]

I don't know the data on thoracotomy for traumatic arrest secondary to penetrating trauma in infants, but it is actually relatively successful in adults.

Do you mean relatively successful compared to doing it for infants? I would guess the number of emergent thoracotomies on infants nationwide in the past 50 years can be counted on two hands. So sure, there's no data.
Plus trying to get your hand through the rib interspace to do anything meaningful... EDs just aren't equipped for this.

You did CPR for 2+ hours? I mean frick, I could have had them on ECMO by then.

Depends on the center.
Even if you're an ECMO center... not sure why you'd do CPR that long. A good neurologic outcome after that much downtime is going to be pretty unlikely.

And yet I'd be shocked if any of the attendings can even remember the last time that they actually performed chest compressions.

~3 weeks ago. I like to go to the codes on the floor and watch the residents try to manage the clusterf*** that occurs. I'll usually stand in the back and mutter suggestions to the resident who is running the code. And then once it gets into the repetitive part of the code, I'll take my turn in the CPR line. It gives me something to do.

 

[Doctor Bob]

I would argue that starting IVs is actually a more useless skill than chest compressions. Theoretically you could be the first one into a code, or find someone down in a remote location, and need to do compressions as a physician. One of my attendings actually just saved a drowning victim when he was at the beach, using nothing but BLS. I do think its a skill physicians need to practice regularly. On the other hand I can't imagine a scenario in a modern US hospital where a non-anesthesiologist physician is asked to start an IV.

I agree that good quality CPR is more useful for an out-of-hospital physician than being good at starting an IV. And that's because, as you mention, the situations where CPR is needed are more likely to occur.
But, I think it's also good (not necessary, but good) for doctors to be proficient at all of the various skills that we have the nurses do. Because there will be many times when the nurses can't do some simple procedure (starting an IV, inserting a foley) and your options will be give it a try yourself or escalate to a higher level procedure. Often the patient's condition doesn't warrant the risks of a higher-level procedure (eg: nurse can't place a foley so you go to a suprapubic tap).

As for scenarios where non-anesthesiologists are asked to start IVs in a hospital? That's nearly a daily occurrence for me in the ED and maybe a weekly occurrence in the ICU. Sometimes it's patient's ill-conceived preference ("I don't want the nurse starting my IV, I'd rather have the doctor do it"), sometimes it's patient condition (dehydrated neonate that the nurse has tried a few times to get a line on and can't), sometimes it's need for IV access but central lines aren't warranted (profoundly edematous patient on hospital day 30, pulled out his line by accident, and the PICC team is out for the weekend).

When I was deployed it was a pretty common thing for me to do as well... but that's a different practice environment.

 

[SouthernSurgeon]

Had this weekend off and have been marathoning Scrubs since I was reminded in this thread. I haven't seen a lot of these since I started residency. Well worth the re-watch.

It's kind of like House of God - it's always good to revisit at different stages of your training to see how much your appreciation of it evolves

 

[SouthernSurgeon]

On the other hand I can't imagine a scenario in a modern US hospital where a non-anesthesiologist physician is asked to start an IV.

Lol. You need a better imagination. Happens pretty often and I'm at a quaternary hospital with an IV access team and great ICU nurses.

 

[TooMuchResearch]

Do you mean relatively successful compared to doing it for infants? I would guess the number of emergent thoracotomies on infants nationwide in the past 50 years can be counted on two hands. So sure, there's no data.
Plus trying to get your hand through the rib interspace to do anything meaningful... EDs just aren't equipped for this.



Depends on the center.
Even if you're an ECMO center... not sure why you'd do CPR that long. A good neurologic outcome after that much downtime is going to be pretty unlikely.



~3 weeks ago. I like to go to the codes on the floor and watch the residents try to manage the clusterf*** that occurs. I'll usually stand in the back and mutter suggestions to the resident who is running the code. And then once it gets into the repetitive part of the code, I'll take my turn in the CPR line. It gives me something to do.

No, I mean thoracotomy on adults adults with penetrating trauma has a high success rate, up to 70% in isolated stab wounds to the chest.


In the right patient with good, immediate bystander CPR, 2 hours with good outcome is doable.

 

[mimelim]

Our ED thoracotomy survival rate is less than 10% and I am at the busiest trauma hospitals in the country. I did 4 on my trauma rotation last year. Absolutely indicated in penetrating thoracic trauma and crashing patient. But 70% is just laughable.

 

[Mad Jack]

Closed chest cpr for traumatic arrest is essentially never adequate. What blood volume are you circulating? I don't know the data on thoracotomy for traumatic arrest secondary to penetrating trauma in infants, but it is actually relatively successful in adults. This wasn't your call to make, though, and the outcome wasn't your fault.

Relatively successful? Last I saw, survival rates of emergency thoracotomy for penetrating trauma where just barely in the double digits, something like 12-13% chance of survival. Oh, here's the study actually: http://www.ncbi.nlm.nih.gov/pubmed/1613839

It's actually about 22% for penetrating, 2% for blunt, overall 13%. 34% for stab wounds isn't all that bad, but 8% for gunshots is kind of bordering on futile.

 

[SouthernSurgeon]

Sigh why did this thread turn into an e-peen measuring contest over resuscitation strategies?

 

[Awaiter]

CPRA = Chronically Pointless Repetitive Assault

That's usually what it amounts to.

 

[ridethecliche]

Sigh why did this thread turn into an e-peen measuring contest over resuscitation strategies?

Because surgeons

 

[TooMuchResearch]

Our ED thoracotomy survival rate is less than 10% and I am at the busiest trauma hospitals in the country. I did 4 on my trauma rotation last year. Absolutely indicated in penetrating thoracic trauma and crashing patient. But 70% is just laughable.

If you do too many (non-indicated) procedures, the success rate will be low...

The 70% for isolated stab wounds causing tamponade is straight from trauma.org.

 

[TooMuchResearch]

Relatively successful? Last I saw, survival rates of emergency thoracotomy for penetrating trauma where just barely in the double digits, something like 12-13% chance of survival. Oh, here's the study actually: http://www.ncbi.nlm.nih.gov/pubmed/1613839

It's actually about 22% for penetrating, 2% for blunt, overall 13%. 34% for stab wounds isn't all that bad, but 8% for gunshots is kind of bordering on futile.

Thanks for the one institution, 22 year old study. :sarcasm:

 

[TooMuchResearch]

CPRA = Chronically Pointless Repetitive Assault

That's usually what it amounts to.

Look at survival rates in places with good ems systems. V-fib outcomes are decent in good systems.

 

[Mad Jack]

Thanks for the one institution, 22 year old study. :sarcasm:

Thanks for your zero institution, nonexistent study.

http://www.ncbi.nlm.nih.gov/pubmed/10703853

Here's a meta analysis that combines 24 studies from 2000. If you believe thoracotomy procedures have changed drastically since then, please, do share.

http://www.ncbi.nlm.nih.gov/pubmed/18224370

Here's a more recent study in which 23 out of 180 patients survived neurologically intact from 2008. It's only one institution, but it's a level 1 trauma center and likely represents peak survival.

 

[SouthernSurgeon]

If you do too many (non-indicated) procedures, the success rate will be low...

The 70% for isolated stab wounds causing tamponade is straight from trauma.org.

How many more qualifiers can you add?

First it was "penetrating trauma"

Then it was "isolated stab wounds"

Now it is "isolated stab wounds causing tamponade."

...

Yes, obviously if you have a low velocity mechanism with a correctable injury, your success rate is going to be much higher. But that's not what you originally said and what people responded to. In the original post you were criticizing, it was a one year old who was shot in the chest with the bullet going through all the mediastinal structures - so that is a high velocity mechanism with a devastating injury. Completely incomparable situations.

...

And I also find it humorous that in your attempts at backpedaling and being overly defensive, you're ignorantly throwing shade at one of the better trauma hospitals in the country, a department whose vice-chair is a legend in the trauma community. @mimelim knows what he's talking about.

 

[TooMuchResearch]

How many more qualifiers can you add?

First it was "penetrating trauma"

Then it was "isolated stab wounds"

Now it is "isolated stab wounds causing tamponade."

...

Yes, obviously if you have a low velocity mechanism with a correctable injury, your success rate is going to be much higher. But that's not what you originally said and what people responded to. In the original post you were criticizing, it was a one year old who was shot in the chest with the bullet going through all the mediastinal structures - so that is a high velocity mechanism with a devastating injury. Completely incomparable situations.

...

And I also find it humorous that in your attempts at backpedaling and being overly defensive, you're ignorantly throwing shade at one of the better trauma hospitals in the country, a department whose vice-chair is a legend in the trauma community. @mimelim knows what he's talking about.

In the original post I responded to, the poster needed to know their cpr had absolutely nothing to do with the kid's death. Closed chest cpr doesn't work in trauma. Thoracotomy usually doesn't work. For some things, it works better than others. The institution down the road from mine does many more thoracotomies than we do, and they (anecdotally) do not have more survivors. They do more pointless thoracotomies.

 

[SouthernSurgeon]

In the original post I responded to, the poster needed to know their cpr had absolutely nothing to do with the kid's death. Closed chest cpr doesn't work in trauma. Thoracotomy usually doesn't work. For some things, it works better than others. The institution down the road from mine does many more thoracotomies than we do, and they (anecdotally) do not have more survivors. They do more pointless thoracotomies.

And in quality institutions that do an appropriate number of thoracotomies, the success rate is not 70%. That number is, as was said above, laughable.

 

[CircadianRhythm]

To the pre-meds who have never been in a clinical environment you have absolutely no idea how you will react because you haven't been there. Clinicians don't choose to have emotional reactions to patient outcomes, it happens involuntarily. I'm not a physician by any means, just a green EMT, and I've already experienced feelings I never would have anticipated.

I don't want to talk about patients dying, but I'll tell you my first "save" was equally disturbing. Found a girl around my age in her car having OD'ed on heroin. I gave her naloxone, bagged her and yelled for my partner to call ALS. She regained consciousness pretty quickly and started sobbing hysterically about being an addict for three years, how she was kicked out of her parents house, her only friends were junkies, how she didnt know where she was going to sleep. The thing I didn't anticipate is how normal she looked, I could imagine one of my buddies showing up to a party with a girl like her. I still randomly think about her.

One of my lay friends asked me how it felt like to "save a life", I wanted to laugh in his face.

 

[Doctor Bob]

Thoracotomy usually doesn't work. For some things, it works better than others. The institution down the road from mine does many more thoracotomies than we do, and they (anecdotally) do not have more survivors. They do more pointless thoracotomies.

Herein lies one of the problems with an ED thoracotomy (and I'm a big fan of doing them).
You don't know before you go in whether or not there's going to be something fixable. I've opened people with little holes in the chest wall and found massive devastation inside from cavitation or tumbling or fragmentation or whatever. And I've had the opposite; opening someone who looks unsalvageable from the outside, but then I find something to whipstitch and then I'm able to get the heart to refill.
So a thoracotomy isn't pointless until you get into the chest at which point you may realize that it was a road to nowhere. But it's tough to make that call beforehand. And as your denominator increases your numerator (of saved people) isn't going to keep pace.

One of my lay friends asked me how it felt like to "save a life", I wanted to laugh in his face.

There are good saves, bad saves, righteous saves, and many more flavors.
Getting ROSC back on the demented 95 yr old quadraplegic nursing home patient who is trach/PEG dependent? Well... it's a save, but so what.
Recovering a 4yr old who drowned in the pool makes you feel great at first until you find out they languished in the PICU for a week before the neurologists declared them brain dead and the family withdrew care. Then you feel sad.
Promply using lytics and restarting the heart of a 40yr old mother who had a big saddle PE in front of her kids at the mall, then taking over care in the ICU and seeing her wake up, get extubated, and talk with her family... well that's a good save.
And the list goes on and on and on.

I thought the field of pathology was pretty immune to this. Then I did a forensic path rotation. We did the post on a young kid who reportedly died after aspirating while eating. When we opened her up there were bruises under the scalp and blood filling the cranium. Turns out her older brother beat her with a baseball bat because she wouldn't stop crying. That day (week) was a pretty low point.

 

[Perrotfish]

I agree that good quality CPR is more useful for an out-of-hospital physician than being good at starting an IV. And that's because, as you mention, the situations where CPR is needed are more likely to occur.
But, I think it's also good (not necessary, but good) for doctors to be proficient at all of the various skills that we have the nurses do. Because there will be many times when the nurses can't do some simple procedure (starting an IV, inserting a foley) and your options will be give it a try yourself or escalate to a higher level procedure. Often the patient's condition doesn't warrant the risks of a higher-level procedure (eg: nurse can't place a foley so you go to a suprapubic tap).

As for scenarios where non-anesthesiologists are asked to start IVs in a hospital? That's nearly a daily occurrence for me in the ED and maybe a weekly occurrence in the ICU. Sometimes it's patient's ill-conceived preference ("I don't want the nurse starting my IV, I'd rather have the doctor do it"), sometimes it's patient condition (dehydrated neonate that the nurse has tried a few times to get a line on and can't), sometimes it's need for IV access but central lines aren't warranted (profoundly edematous patient on hospital day 30, pulled out his line by accident, and the PICC team is out for the weekend).

When I was deployed it was a pretty common thing for me to do as well... but that's a different practice environment.

I'm sorry but I just don't see it. If someone fails to do a procedure you call someone more experienced. If a nurse fails an IV then that's not me. Going to me because after the nurse failed an IV is like calling in a medical student when the surgery resident fails to stop a bleed. When you go to a new provider you go to someone who is better: an ICU nurse, a NCIU nurse, or an anesthesiologist. If they're not available you change the procedure, which in the case of IVs means an IO and isn't that much of an elevation.

 

[SouthernSurgeon]

I'm sorry but I just don't see it. If someone fails to do a procedure you call someone more experienced. If a nurse fails an IV then that's not me. Going to me because after the nurse failed an IV is like calling in a medical student when the surgery resident fails to stop a bleed. When you go to a new provider you go to someone who is better: an ICU nurse, a NCIU nurse, or an anesthesiologist. If they're not available you change the procedure, which in the case of IVs means an IO and isn't that much of an elevation.

I think you devalue your own role/expertise.

I haven't started as many IVs as a PICC or ICU nurse.

But I have other procedural skills which come into play that they don't have, and comfort doing things that they won't.

Sometimes it's something as simple as using the right arm in a patient who had a right mastectomy 30 years ago. The nurse won't touch their right arm because it's "against protocol", whereas you know the risk of lymph edema is absurdly low.

Other times it is being comfortable going somewhere they won't (midline, EJ)

Most of the time actually it is just sheer stick-with-it-ness which unfortunately a lot of nurses lack.

But anyways there are a lot of times as a resident, even in a "modern" hospital where you are called on to start IVs and it is not practical not available to call on someone else to do it for you

 

[TooMuchResearch]

Herein lies one of the problems with an ED thoracotomy (and I'm a big fan of doing them).
You don't know before you go in whether or not there's going to be something fixable. I've opened people with little holes in the chest wall and found massive devastation inside from cavitation or tumbling or fragmentation or whatever. And I've had the opposite; opening someone who looks unsalvageable from the outside, but then I find something to whipstitch and then I'm able to get the heart to refill.
So a thoracotomy isn't pointless until you get into the chest at which point you may realize that it was a road to nowhere. But it's tough to make that call beforehand. And as your denominator increases your numerator (of saved people) isn't going to keep pace.



There are good saves, bad saves, righteous saves, and many more flavors.
Getting ROSC back on the demented 95 yr old quadraplegic nursing home patient who is trach/PEG dependent? Well... it's a save, but so what.
Recovering a 4yr old who drowned in the pool makes you feel great at first until you find out they languished in the PICU for a week before the neurologists declared them brain dead and the family withdrew care. Then you feel sad.
Promply using lytics and restarting the heart of a 40yr old mother who had a big saddle PE in front of her kids at the mall, then taking over care in the ICU and seeing her wake up, get extubated, and talk with her family... well that's a good save.
And the list goes on and on and on.

I thought the field of pathology was pretty immune to this. Then I did a forensic path rotation. We did the post on a young kid who reportedly died after aspirating while eating. When we opened her up there were bruises under the scalp and blood filling the cranium. Turns out her older brother beat her with a baseball bat because she wouldn't stop crying. That day (week) was a pretty low point.

That's a good point. Our last one had a tiny hole on the outside that made meat of the LV, hilum, and spine. We still played the game, but the outcome on that one had already been decided. We probably wouldn't have done it on a 90 year old. Do you do them routinely for blunt trauma arrests? It's an ongoing conversation at our institution.

 

[TooMuchResearch]

I'm sorry but I just don't see it. If someone fails to do a procedure you call someone more experienced. If a nurse fails an IV then that's not me. Going to me because after the nurse failed an IV is like calling in a medical student when the surgery resident fails to stop a bleed. When you go to a new provider you go to someone who is better: an ICU nurse, a NCIU nurse, or an anesthesiologist. If they're not available you change the procedure, which in the case of IVs means an IO and isn't that much of an elevation.

Our nurses won't shoot for the EJ, and I don't know if most of them know IJ PIVs are a thing. Even if they did, they wouldn't do them. But I can.

 

[mehc012]

I think you devalue your own role/expertise.

I haven't started as many IVs as a PICC or ICU nurse.

But I have other procedural skills which come into play that they don't have, and comfort doing things that they won't.

Sometimes it's something as simple as using the right arm in a patient who had a right mastectomy 30 years ago. The nurse won't touch their right arm because it's "against protocol", whereas you know the risk of lymph edema is absurdly low.

Other times it is being comfortable going somewhere they won't (midline, EJ)

Most of the time actually it is just sheer stick-with-it-ness which unfortunately a lot of nurses lack.

But anyways there are a lot of times as a resident, even in a "modern" hospital where you are called on to start IVs and it is not practical not available to call on someone else to do it for you

Most of the MD IV sticks I see are EJ sticks - nurses won't touch them, usually.

 

[Doctor Bob]

Do you do them routinely for blunt trauma arrests? It's an ongoing conversation at our institution.

After the review in the Western Journal of Trauma, yes, we do them for blunt trauma arrests. But with a shorter allowable pre-hospital arrest time.