so i forgot that i was overnight and just assumed i was on regular long call, so i started off my day by showing up at 6am for no reason. awesome. the morning was uneventful and i left and returned by 9pm. i had 2 admissions already waiting for me, and those got worked up at a fairly sluggish pace (as an intern, you are only as fast as your resident, and the night admitting resident that night was SO s-l-o-w). by 2am we had only finished 2 admissions. i received admission #3 shortly thereafter, and this was quickly followed by #4 and #5, around 3:30am. so the idea is to get all the admissions done by 7am so you can again see all your old patients and be ready to round with the team by 8am. having 3 admissions left to do around 3:30am is a bit of a crunch, so i was a bit anxious and really pushing my resident to pick up the pace a bit.
4:00am i get a call that one of my old patients is not doing well, i'm needed on the floor.
***
this is a guy who's my age, only medical problem being wildly uncontrolled type 1 diabetes, who came in with a pretty bad pneumonia. his pneumonia got worse despite IV antibiotics and he continued to spike fevers through it all. for a while we thought he might have had TB but all of his tests came back negative for it. he then developed a large loculated pleural effusion (basically, pockets filled with fluid in the space surrounding the lung, which essentially pushes on the lung and collapses it). we expected it to be full of pus (an empyema) and thus be the source of his infection - except that when we drained one of the pockets, there was no bacteria in the fluid and no pus. we then decided that a drain would need to be put in to take out this fluid, since it MUST be the source of his infection, even though all the cultures and gram stains were negative. so we put in a pigtail catheter and he drains a few 100cc's (which is not really all that much) overnight.
the next day the pulmonary fellow comes by and infuses tPA (tissue plasminogen activator, used during heart attacks to break up clots) through the pigtail, the idea being that the tPA will break up the loculations and allow more fluid to drain without having to place a second pigtail. so we do that and it works, he drains about 500cc's overnight. the following day, pulmonary decides to repeat the procedure, which he does and this time it only drains about 25cc's overnight.
so we either have run out of fluid to drain, or something else is wrong. clinically the patient seems to be feeling better, he says his breathing is easier, his cough is better, his chest hurts a bit less. but he still continues to spike fevers, really high fevers up to 104 degrees F. he's still on 3 different IV antibiotics that should cover just about any bug that could be causing this.
we call and ask the cardiothoracic surgeons to come and evaluate him as we think he may require surgery to decorticate (strip the loculations) the lung and help it reexpand. they say they will come by, and they left a note, but for the "plan" section of their note (the most important part) they leave it blank. which is of no help whatsoever.
the next day we call CT surgery again and ask them again to come see the patient and remind them that we need a plan from them otherwise their consultation is useless. later they come by and write "discuss with attending" in the plan section. that's it. nothing else. the patient continues to be clinically stable, the pain in his side hurts a little more, but otherwise breathing is okay. his oxygen saturation continues to be about 97-98% on room air, which is fine.
that night was when i got paged to come to the floor.
***
so i arrive and the overnight team is already at the bedside, a 100% non-rebreather oxygen mask is over my patient's face, and he looks delirious and woozy and doesn't recognize me when i first show up. i find out that the nurse came in to do a routine vital signs check overnight and found that his oxygen saturation was 74%. she called the overnight team to assist, they placed him on 100% oxygen and rechecked, and his saturation went up to about 85% (still not good). critical care medicine was called, CT surgery was again called, and pulmonary was called. critical care recommended a BiPAP machine, which is basically the last step before you intubate someone. it forces oxygen into the lungs and is this hugely uncomfortable mask that you have to strap on to your face. we tried that for a few minutes, got him up to 95%, but then he dropped back to the 80s because you have to be awake and cooperative for BiPAP to work, and he wasn't either one. the respiratory therapists were forced to ambu-bag him to keep his saturations up as they prepared for intubation.
to intubate someone you need to sedate them, or at the very least relax them. you're placing a tube into their throat and down the trachea, past the vocal cords. as you may imagine it is a very unpleasant experience to be awake for. but this guy just would not calm down. we push nearly 50mg of sedative (4mg at a time) trying to get him to calm down. after the third attempt, he was finally intubated, and coughing up pink frothy foam, which is a sign of pulmonary edema - fluid and blood in the lungs. chest X-rays showed signs of fluid all over both lung fields - he was in ARDS, acute respiratory distress syndrome. yes, this is bad.
after the initial incident and intubation, all the services write event notes for the chart - medicine, pulmonary, critical care, nursing. CT surgery does not write a note. the resident was present during the event but did not contribute anything. she had left to go look at chest X-rays and never came back.
i proceeded to spend the next 15 hours more or less at his bedside, managing his sedation and ventilation, suctioning him as he needed it, pushing more sedative as he needed it, speaking to family on the phone, talking to all the consult services, speaking to my attending, etc. by 7:30pm that evening he finally was transported to the PCU (pulmonary care unit).
***
it was only then that i was able to finish my next 2 admissions (#4 and #5, which i had to put on hold because of all of the aforementioned events). i left that evening around 9pm. 24 hours straight, no sleep, no food, no water. i pissed orange that night.
since that horrible day was technically my "post-call" day, i was due for an admission the next day. that meant coming home at 9pm, showering, passing out, and waking up to be at work at 6am the next day to get my short-call admission.
***
but my karma has come back around. yesterday i was on long call again, this time not overnight. eligible for 4 admissions between 7am and 7pm. i received zero. i don't know if that's ever happened before, to be on long call and receive no admissions. but it was great. i watched a lot of football (though i missed the end of the bears game) and ate a lot of food.
***
my patient is still in the PCU, still intubated, still on sedation. he looks a little bit better. i can tell he recognizes me again. he makes a bit of a smile when he sees me. but otherwise they still haven't fully drained the loculations and they still don't have a source for the fevers. he continues to spike through the antibiotics. more than likely he will eventually need surgery and this will probably become a chronic problem for the rest of his life. CT surgery now sees him and writes notes daily.
this educational lesson brought to you by dr. j around 10:21 AM | 
