Back from a little trip to phoenix. The night before I flew out was my last shift working nights. Of course, I should have known something would go wrong. I had my first solo code like situation. Throughout training I think it's the thing you dread most. Unlike most situations in medicine, your processes are catapulted into mach speed. There is no time to dwindle, pondering the effects of your decision. It's now or never.
The situation was a young sickle cell guy. I'd been the one to admit him 5 days earlier when his Hemoglobin was down to 3.9 (recall normal is 13-15). I hadn't heard much about him on my night time calls. The call came at 12:07 from someone on the floor "the nurse needs you up here quickly, something is wrong with Mr. R -he's just not acting right" I noted vitals and rushed up. What could be wrong- the guy is 27 - surely not a heart attack. Blood clot? Too much pain meds? Stroke? Seizure? I was silently pleading for God to grant me wisdom.
It always produces anxiety when there are groups of people around your patient's bed- the room was full already with nurses and respiratory therapists- I felt their tension lift as I entered. AS if, 'whew the doctor's here we can relax.' BUT my tension had hit the roof. Okay, start with information and assessment. He was obtunded, breathing hard, but if you squeezed his hand he'd respond. GOOD. Glance to the tele' monitor with the vitals- BP 250/120 UH, not good. Pulse 130's, not good. Oxygen 99% on the 2 liters they had strapped on his nose. That was good. Now I realize they( being everyone in the room) are looking at me -directly into my eyes. Can they see my fear? Can they see I am child, that I'm just dressed up in my dad's doctor coat and stethoscope, not really a doctor?
I push out my calm in control voice- "let's order some things- CBC, CHem 12, mag, phos, d-dimer, Abg, Chest xray" next "Let's do something about that blood pressure" And I order some quick IV meds. All this is intermixed with questions "what happened today?, anything new? what meds did he last have? Any changes? What were this morning's labs?" All the nurse knew was that he was okay when she came to work at 7pm- he was alert, not in pain, even refused his pain meds. All was okay until his alarm went off that monitors heart rate and blood pressure. He was FINE- and now all had changed. I was encouraged that he was awake enough to move all hands and legs- but something was definitely wrong.
Although things were serious, they were stable enough to keep gathering info - the nurses were helping sit him up a bit when one of them let out a loud shock like gasp. I glanced over. She was carrying something she'd found by his neck. There in her hand were about 3 teeth from a set of dentures- obviously broken, chomped right a part. Light bulb goes off in my head- "He had a seizure" I shout- "let's get some ativan on board." As the nurse went to get it- it happened- another seizure. His whole body started to convulse, as saliva and froth spewed from his mouth- she gave the push of ativan as his body, a minute later relaxed. During the seizure I was watching his oxygen rate- they suctioned, he seized and his 02 dropped to 50% - His seizure over, I stood saying out loud "go up, go up" The numbers crept -55, 60, 65, 70, 80" Then stopped- 80%. Not good enough- he wasn't maintaining his airway.
Game up. That's what I thought- no more playing for me -time for help. I gave the order that everyone had been waiting for, wondering when I'd say it - "let's call rapid response, get him up to the ICU" The ICU team swept in, didn't need to intubate, or put a tube in, but wanted to watch him upstairs in the ICU. In minutes he was gone. Now the empty room, and all the extra nurses and people who had stepped in to help. Suddenly it really did feel like some sporting game- nurses coming up patting me "great job" "way to go" "that was good" And i doing the same "you all were wonderful". "Good thing you found those teeth!"
So, another first. Not too many big 1st's left in medicine. But the "first crashing patient in the middle of the night" can be crossed off the list.
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