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- Jan 7, 2004
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Definitely a fun call night (all this except MRI guy occurred between 11pm and 2 am), makes me wonder what else is in store for me.
1. Hypotensive to 76 sbp, tachycardic to 130s, sitting 90 degrees up with ONLY a nasal canula at 4L and a RR of 33 (satting 96%). Nurse called my team, but no one seemed concerned except me. Pt is young, in ARDS, AIDS, and ESRD on HD.
On exam - fully edematous, anasarca up to UE b/l, crackles in the lungs.
Looking at him I knew it was probably the calm before the storm, if he was 60, he'd probably have coded by now.
Can't push any nitro drip on the guy, he's hypotensive and not the typical hypertensive pulmonary edema patient in the ED. Lasix and butamide didn't work because UO was 0. Only 2 things left, bipap or intubate.
Well I didn't want to push for intubation on my first night as a 3rd year so I decided we needed to push fluid out by bipap. I also placed in an art line and placed the pt on a levophed drip.
Pt fell asleep, decreased his RR, BP normalized and tachycardia diminished.
2. Pt with hgb 5.4, plat 23K. Has hx of BM mets, TTP suspected. Bleeding from nose, likely posterior. Copious amounts of blood with clots on vomit, even positive melena stools. Only line by primary team was a 20g. No blood could be drawn for morning labs/vbg. Nurse calls me.
PGY2 medicine tries to stick hand, RN tries medial tibia. No blood return. Pt is dry as a bone. I knew this lady needed blood and we needed to know how much she has dropped to call ENT and alert the fellow.
I wasn't going to poke in the femorals, I wasn't going to do a SC on her. I knew even with the US nearby, I wouldn't be able to go into either IJ because if I trendelenburg her long enough, she'll suffocate on her blood.
Checked her neck, possibly an EJ.
Tilted her back, forced her head to the left as she was telling me "I can't hold the blood in, Doc.... I can't breathe, the blood is filling my head!"
Popped in the 18g EJ in 8 seconds, placed her back in mild reverse trendelenberg, got maybe 10cc of blood out for labs. She dropped 2u in 10 hours, ordered prbc, ffp, and placed platelets on hold just in case.
Called ENT and they had the gall to tell me the lady wasn't actively bleeding over the phone.
3. Hypertensive guy who wasn't making any sense to me (partly because I was not the pt's primary) and had just hit 230 systolic. Pt on multiple po antihypertensives. "Nothing to do" according to primary team on sign-out, but seems like this guy needed something.
ESRD pt.
Decided to go slow at first, nurse says he's a little loopy normally. Lowered my suspicion of hypertensive enceph.
Hydralazine 10 iv, nothing. Another 10 iv nothing. Another 10 iv, nothing. Maybe because he's on clonidine, lets try 200. Nothing. Let's try 100, nothing.
Can't use nitroprusside, can't use labetatol (HR 67).
Placed on nicardipine drip. Responded.
4. Pt is ESRD and presents AMS. MRI of brain yesterday failed 2/2 movement in machine. MRI attending breathing down my neck, telling me that the previous team of incompetent doctors (the previous on call team) did not sedate the guy appropriately and now they had to call their tech in for "overtime" because I had reordered the MRI and somehow gotten approval from the senior radio resident in the hospital (a friend I have gotten to know from all my ER reads).
He told me that I had 1 shot, if he moves or twitches, the MRI is cancelled and that I better not try any funny business of bringing him back unless he was intubated.
My attending didn't want any more sedation on the guy, he was already altered and we didn't want to blur out the guy's mentation any more.
I had a leeway of 2mg ativan.
Well she didn't mention morphine.
So I gave 2 of ativan and 4 of morphine (figured I could reverse morphine faster).
Guy was on the MRI table prior to the scan. He twitched.
So I taped his head to the bed. Again and again.
MRI went without a hitch.
5. Had a young guy, AIDS with pcp pna and mrsa pna with ARDS. On a vent. Had a chest tube on Lt from a ptx a week ago. Primary signed out to me that the patient had began to desat a little while on fi02 of 50%. They pushed him to 70%. Told me to check a little later and see if I could wean him back to 50%.
Ok.
Took a look at the CXR from am. Hmm... is that a Rt pneumothorax?
Reordered pCXR. Yup, a Rt ptx.
Called CT surg (I'm not putting a tube in this guy and having MICU attending yell at me for complications). CT surg comes by. Places pigtail while I watch.
Guy desats to 79% while they were stitching the pigtail in place. This guy begins bucking against the vent.
Uh oh.
I increased the versed and morphine drips. Guy calms down but the sats are in low 80s. I pushed to 100 fiO2, increased the rate, dropped the TV.
Still in the 80s. pCXR was taken. I pulled the US over. No fluid noted anywhere in the chest. pCXR pulled on GEpacs.
50% pneumo on Rt s/p pigtail instead of the 5% we had earlier.
CT surg senior freaks out as it was 1st call as a 3rd year. Grabs another surgical senior on another service. We get the real chest tube out and insert.
Pt still satting in the 80s.
Finally we figured out a small leak in the pigtail connectors. It was causing a near tension pneumothorax by sucking in air when the ventilator inspires for him.
Clamped the malfunctioning pigtail, sats go up to 90s. pCXR s/p chest tube shows reinflated lungs.
6. And there were several more fires that had to be put out.
I wonder what's in store for me in 2 days.
1. Hypotensive to 76 sbp, tachycardic to 130s, sitting 90 degrees up with ONLY a nasal canula at 4L and a RR of 33 (satting 96%). Nurse called my team, but no one seemed concerned except me. Pt is young, in ARDS, AIDS, and ESRD on HD.
On exam - fully edematous, anasarca up to UE b/l, crackles in the lungs.
Looking at him I knew it was probably the calm before the storm, if he was 60, he'd probably have coded by now.
Can't push any nitro drip on the guy, he's hypotensive and not the typical hypertensive pulmonary edema patient in the ED. Lasix and butamide didn't work because UO was 0. Only 2 things left, bipap or intubate.
Well I didn't want to push for intubation on my first night as a 3rd year so I decided we needed to push fluid out by bipap. I also placed in an art line and placed the pt on a levophed drip.
Pt fell asleep, decreased his RR, BP normalized and tachycardia diminished.
2. Pt with hgb 5.4, plat 23K. Has hx of BM mets, TTP suspected. Bleeding from nose, likely posterior. Copious amounts of blood with clots on vomit, even positive melena stools. Only line by primary team was a 20g. No blood could be drawn for morning labs/vbg. Nurse calls me.
PGY2 medicine tries to stick hand, RN tries medial tibia. No blood return. Pt is dry as a bone. I knew this lady needed blood and we needed to know how much she has dropped to call ENT and alert the fellow.
I wasn't going to poke in the femorals, I wasn't going to do a SC on her. I knew even with the US nearby, I wouldn't be able to go into either IJ because if I trendelenburg her long enough, she'll suffocate on her blood.
Checked her neck, possibly an EJ.
Tilted her back, forced her head to the left as she was telling me "I can't hold the blood in, Doc.... I can't breathe, the blood is filling my head!"
Popped in the 18g EJ in 8 seconds, placed her back in mild reverse trendelenberg, got maybe 10cc of blood out for labs. She dropped 2u in 10 hours, ordered prbc, ffp, and placed platelets on hold just in case.
Called ENT and they had the gall to tell me the lady wasn't actively bleeding over the phone.
3. Hypertensive guy who wasn't making any sense to me (partly because I was not the pt's primary) and had just hit 230 systolic. Pt on multiple po antihypertensives. "Nothing to do" according to primary team on sign-out, but seems like this guy needed something.
ESRD pt.
Decided to go slow at first, nurse says he's a little loopy normally. Lowered my suspicion of hypertensive enceph.
Hydralazine 10 iv, nothing. Another 10 iv nothing. Another 10 iv, nothing. Maybe because he's on clonidine, lets try 200. Nothing. Let's try 100, nothing.
Can't use nitroprusside, can't use labetatol (HR 67).
Placed on nicardipine drip. Responded.
4. Pt is ESRD and presents AMS. MRI of brain yesterday failed 2/2 movement in machine. MRI attending breathing down my neck, telling me that the previous team of incompetent doctors (the previous on call team) did not sedate the guy appropriately and now they had to call their tech in for "overtime" because I had reordered the MRI and somehow gotten approval from the senior radio resident in the hospital (a friend I have gotten to know from all my ER reads).
He told me that I had 1 shot, if he moves or twitches, the MRI is cancelled and that I better not try any funny business of bringing him back unless he was intubated.
My attending didn't want any more sedation on the guy, he was already altered and we didn't want to blur out the guy's mentation any more.
I had a leeway of 2mg ativan.
Well she didn't mention morphine.
So I gave 2 of ativan and 4 of morphine (figured I could reverse morphine faster).
Guy was on the MRI table prior to the scan. He twitched.
So I taped his head to the bed. Again and again.
MRI went without a hitch.
5. Had a young guy, AIDS with pcp pna and mrsa pna with ARDS. On a vent. Had a chest tube on Lt from a ptx a week ago. Primary signed out to me that the patient had began to desat a little while on fi02 of 50%. They pushed him to 70%. Told me to check a little later and see if I could wean him back to 50%.
Ok.
Took a look at the CXR from am. Hmm... is that a Rt pneumothorax?
Reordered pCXR. Yup, a Rt ptx.
Called CT surg (I'm not putting a tube in this guy and having MICU attending yell at me for complications). CT surg comes by. Places pigtail while I watch.
Guy desats to 79% while they were stitching the pigtail in place. This guy begins bucking against the vent.
Uh oh.
I increased the versed and morphine drips. Guy calms down but the sats are in low 80s. I pushed to 100 fiO2, increased the rate, dropped the TV.
Still in the 80s. pCXR was taken. I pulled the US over. No fluid noted anywhere in the chest. pCXR pulled on GEpacs.
50% pneumo on Rt s/p pigtail instead of the 5% we had earlier.
CT surg senior freaks out as it was 1st call as a 3rd year. Grabs another surgical senior on another service. We get the real chest tube out and insert.
Pt still satting in the 80s.
Finally we figured out a small leak in the pigtail connectors. It was causing a near tension pneumothorax by sucking in air when the ventilator inspires for him.
Clamped the malfunctioning pigtail, sats go up to 90s. pCXR s/p chest tube shows reinflated lungs.
6. And there were several more fires that had to be put out.
I wonder what's in store for me in 2 days.
