The Slow Code

All patient identifiers in this story have been changed. One afternoon, I was scuttling about the hospital checking off my to-do list when I get an urgent page from my attending: "We are in the OR. Please see rapid response team called for room D303, it is one of our chronic pain patients." I dropped everything and ran over where I met the patient for the first time. I had heard of her on rounds and recognized her as a young woman with chronic neuropathic pain that had failed treatment with opioids, anti-inflammatories, anti-neuropathic agents, anti-depressants, and a host of other medications. She was getting an infusion of a newer drug that only a few attendings had intimate knowledge of. The rapid response team had been called because of altered mental status. A few minutes after the infusion had started, she became unresponsive, but 30 seconds later, regained consciousness. Her vital signs remained stable. I quickly evaluated her, and she appeared to be close to her baseline except for a mild headache and some myalgias. The ICU fellow showed up and we conferred. We obtained an EKG, some basic labs, and stopped the infusion. The attending arrived in scrubs from the operating room (he's the kind of attending that on the floor always wears a suit and tie), and we all felt comfortable with keeping the new medication off and observing.

Over the next few hours, I continued to do my floor work, but I overheard the fellow talking to the nurses because the patient was slowly getting worse. Her headache became more and more severe to the "worst headache of her life" (her chronic pain was in her extremities), and she began having nausea and vomiting. I started worrying about increased intracranial pressure so I went to go see her. The first thing I noted was that she had the strangest arrhythmia. Her heart rate would flip back and forth from bradycardia at 40 (regular) to tachycardia to the 120s (also regular). Her oxygen saturation was pretty poor; she was already on a 6L facemask and I bumped her first to a Venturi mask, then a non-rebreather. Something was going on, and I did not know what.

Part of the problem with this situation was that there was no leadership. The fellow was constantly pulled away for other matters, and I didn't know this patient very well. We flip-flopped on a medicine consult versus a cardiology consult, but finally I called the ICU fellow. With increasing oxygen requirements and an unclear arrhythmia, I felt she needed a higher level of care. Eventually, an ABG came back with hypercarbia and the patient was intubated in the ICU. She was extubated the following day with a stable heart rhythm and discharged the day after that. It was felt that her headache, oxygen requirement, and arrhythmia were all associated with this new medication infusion. Only one case report had been published in the literature of a similar circumstance.

The truth is, recounting the story makes it sound easier than it was. All last year as an intern, I had backup, but in this case, I felt that I was running the show - the fellow didn't provide the support I needed. I could feel myself walking through the differential diagnosis in my head, deciding on the labs to order, figuring out which consultants to call, and coordinating the care. The whole incident played out over hours, and it was stressful being in that situation as I didn't know the patient or the medication well. Afterwards, I debriefed with the medical student and we discussed all the things that didn't seem to work. It was a very good lesson on crisis management for me.