Chasing Heartbeats and Waterfalls

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Today I am chasing waterfalls. Two nights ago, I was chasing heartbeats. Here is the story.

It was a particularly busy night call for me. The moment I walked in the hospital at 5 o’clock that afternoon, I was told by my partner who I was relieving for the night, was that we had a few unstable patients in the ICU that needed my attention. She told me to see ICU bed 32 right away as he may need to be intubated and placed on mechanical ventilator.

When I went to see the patient, my medical resident was already in the room assessing the situation. The patient is a young man in his 20’s, but already had his share of medical issues. First of all he had achondroplasia. What is that? That is a genetic bone disorder that causes dwarfism, like the actor Peter Dinklage of the Game of Thrones. Our patient had end stage renal disease also and was a recipient of a kidney transplant a year ago. But now, that transplanted kidney was failing and he was in need of acute dialysis.

Intubating him was a challenge given his anatomy of having a short neck. But we were able to do it without much difficulty. Placing a dialysis catheter presents another challenge, again because of his particular anatomy. We have to place the dialysis catheter in his groin instead of his neck, as the adult catheter was too long for him with his short torso, and the pediatric catheter has a very small lumen for his adult need.

By around 9 PM, after some delay, we hooked him to a machine for continuous dialysis.

In the meantime we also admitted two new sick ones in the ICU. The first one was a transfer from the floor who was in septic shock. She really crashed and burned. We worked on her almost continuously for two hours, but we cannot stabilize her. It was not that we gave up on her, but I told my resident that the patient was beyond saving and we should focus our efforts on the other patients that we could save. That patient died less than 3 hours after coming to the ICU.

Then there was another patient that was transferred from another hospital to our ICU who was not doing well too. I told the family that she might not survive the night given her severe illness, her advanced age, and all her co-morbidities. Placing her on life support would only prolong the inevitable. Thankfully the family saw my point and they decided to transition to full comfort cares. The patient died before the night was through.

We also admitted from the Emergency Department two drug overdoses that just needed to sleep off whatever medication they overdosed on, and another lady with diabetic keto acidosis that required insulin drip. There’s another man who had an acute stroke and was given thrombolytics so he needed to be monitored in the ICU. All of them were rather stable.

Back to the 20-something-year old patient. The continuous dialysis would not go through smoothly. We were able to do only an hour or so of run at a time and the dialysis machine or the catheter would clot off, interrupting our treatment. This happened throughout the night. By 5 AM our patient was really acidotic and fluid overloaded. Then it happened. His heart, though young as it may, stopped beating.

What followed was furious CPR, and rounds after rounds of epinephrine. This ran for about 20 minutes before we can get a semi-secure heart rhythm. I called the patient’s parents and they wanted to continue our efforts until they come to the hospital to see their son. They lived 45 minutes away.

While we are doing the CPR on that patient, another patient in our ICU had another medical emergency. Just our luck, two Code Blues running simultaneously! I sent my resident to that other Code Blue, while I continue on the other. Fortunately the other medical emergency was short and the patient was stabilized quickly and my resident came back to assist me about 15 minutes later.

When the parents came, I updated them of the dire situation. After realizing that their boy was probably not coming home in a normal condition, they made the difficult decision to let him go, given his very poor prognosis.

Before I left at 8 in the morning, I relayed to my partner who was relieving me for the day, that death was imminent in our patient in ICU room 32 as he was transitioned to comfort cares.

I needed a break to recharge. It’s not only defibrillator machine that needs recharging. But I know I would be chasing heartbeats and breaths again when I come back to work.

In the meantime, let me chase my own breath as I rest from my hike.

(*room number and some minor details were altered for privacy; photos taken near Jenny Lake at Grand Teton)

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