9:40am. Thus concludes the final night of four ER shift! Wow, I feel great knowing I can sleep, and don't have to wake up at 5pm to go back to work. My last night I was on the "West Side" of the ER, which is the acute care side, meaning there are fewer but much sicker patients--the heart attacks, the GI bleeders, the septic patients etc. My one real sick guy of the night was this 32 year old patient with Downs syndrome and mental retardation who came in from a group home with vomiting and fevers. When we saw him he looked shitty--coughing up a storm, agitated, and had a fever of 103, a pulse of 110, and a blood pressure of 65/35 (really low). He was super dehydrated from his infection. We got two good IV's in him and started flooding him with fluids. The initial chest x-ray showed a possible area of haziness in the left lower lobe, combined with the cough, it made us think he probably has a develping pneumonia. We hit him with antibitoics (Zosyn if your wondering), and kept the normal saline IV running. He got about 6 liters of fluid, but the highest we could get his pressure was in the low 80s, and he was making very poor urine. He continued to cough up a storm, and was flailing around violently in agitation (remember, it did not help that he was severely mentally retarded). I asked the nurse to put in a foley catheter (a bladder catheter), and you could hear the screams and wails in the next building. But I would have my own challenge yet to come, since now that his blood pressure wasn't responding to the fluids, we had to put in a central line to give him vasopressors (medications to get his blood pressure up, which clamp down and constrict his arteries--which in sepsis, are very dialated). This won't be fun. I opted to go for the femoral line since with his level of cooperation, a neck line would be virtually impossible (basically a central line is a large IV that goes into one of the larger, more central veins of the body, in this case, the femoral vein). Meanwhile, as I contemplated my plan of attack, another patient, thoroughly demented and also quite sick, was writhing in pain a few beds over. This particular patient didn't formulate words, but made you feel like you were trapped in the middle of Jurassic Park. I shit you not, if I could ever come face to face with a Teradactyl, it would sound like this man. Everytime he screamed, I ducked for cover and looked to make sure I didn't get swooped upon. "Kwwwaaaaaa!!" Anyways, I digress....
So now I am at the bedside, I have managed to tie down the patient's hands, I gown up, and I prep the groin with iodine. He is already not happy. I see a period of calmness, and I glance at his BP which is now 67/30, and decide I better do this soon. I get the lidocaine and stick the needle where I want to go, and then realize (the hard way) his legs are still free. He kicks them up like Pele in overtime, and somehow I managed not to stick myself with the needle. Fuck! That was dumb. I get the nurse to tie down his legs this time, and proceed. The stick was pretty easy, and with a little difficulty, I get the line in, and we start vasopressin for his hypotension. But then, he became progressively hypoxic despite oxygen therapy. A repeat x-ray shows horrible diffuse infiltrates in both lungs, part of it is likely the developing pneumonia, but most is probably all that fluid we gave him. At that point we knew he was headed for intubation, so we made the call to do it. Now I have attempted 2 intubations as an MD, and almost succeeded in one. Now I am dealing with a crashing patient, with crappy oxygenation; nonetheless, I said I wanted to do it. We got everythin ready, we hit him with a paralytic agent, and I made my first attempt. Of course while we were bagging him to get his oxygenation up, he vomited, and when I looked in his mouth, all I saw was yellow, frothy vomit and phlegm everywhere. I suctioned, manipulated the blade, but saw nothing. Damn. We come out and rebag him. I go in for my second look, still vomit everywhere, his BP now is in the 70s, and his oxygenation is 80%--meaning I better act fast. I suction his mouth, and I stick in the blade and give it a big lift, and then I saw them--the vocal cords! I grabbed my endotracheal tube, and I got it in. Phew! My first ever successful intubation, in a crashing patient at that. That felt good! We finally had to add levophed to maintain his pressure, and he eventually got sent to the MICU. I have a feeling though, that he won't make it.
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