Saturday, August 13, 2016

Five Days in ICU


A young man is picked up by emergency medical services unresponsive and hypotensive. He is intubated but despite liters of fluid, his blood pressure remains barely measurable. On exam, his belly is rock hard; I think it's filled with blood. After we start a massive transfusion, we're able to get him to the CT scan, and we find a massive retroperitoneal bleed. He is whisked off to the operating room. On return, his drains pour out liters and liters of blood. The color of the blood coming from the drains is the same as blood drawn from the arterial line. Of course, he returns the operating room and then to interventional radiology for an emergency TIPSS because he has severe cirrhosis. All in all, over a 12 hour period, he gets 25 units of blood, 25 units of plasma, 4 six-packs of platelets, and 2 units of cryoglobulin. Over the week, he goes into acute respiratory distress syndrome with impressive oxygenation requirements (FiO2 100%, PEEP 18), cardiovascular collapse needing pressors, renal failure requiring continuous renal replacement therapy, alcohol withdrawal, continued transfusions, and a return trip to the operating room.


I sign out to the night-time intensivist at 6PM. I finish my notes over the next two hours, clean up pending items, and get ready to go home. On my way out, the nurses flag me down because a surgical patient who was doing fine and planning to leave the ICU had an acute aspiration. After intubating and stabilizing the patient, I sit down to finish those notes as well. I get home well past 9.


I am called by the emergency department to help with an intubation for a cardiac arrest. When I rush down, I see the nurses doing compressions on a child. A three year old previously healthy girl presented with ventricular fibrillation and seizure. Other than accidental overdose of medications, I'm not even sure what causes cardiac arrest in a child. I intubate her, but an hour later when I am admitting a separate patient from the ER, I see that they call time of death. The family is in hysterics. I go home to wrestle with family crises of my own.


I see twenty two patients today. We only have 21 beds, but we started with 17 patients and despite sending a bunch to the floor, I get 5 new admits. I'm not even sure if clinic physicians see 21 patients in a day. I make myself a spreadsheet to keep track of notes, orders, and to-do items. The most interesting patient is a person who comes in with torasdes de pointes (shown below). We all learn about torsades in medical school, but this may be the first time I've actually seen a case. It is caused by medications she takes. That first afternoon, she kept having scary episodes of polymorphic ventricular tachycardia, but they finally subside as the medications metabolize off her system.


I get my most interesting patient on my last day on service. A young woman is intubated in the emergency department because of "bizarre behavior." When I get the call, I wonder how bizarre her behavior was to necessitate intubation and sedation. Apparently, she hasn't been herself for two months. She works at a cafe in the daytime, but according to her boyfriend, she started going out every night to four or five in the morning. She'd sleep for three hours, then go back to work. He wasn't sure what she did at night, but wonders if she was smoking, drinking, and doing drugs. The day before admission, she parked her car on the shoulder of a freeway and ran across the highway. Fortunately, she was picked up before getting hurt and brought to our emergency department. Initially she was admitted to psychiatry, but over the course of the day, she became more combative, even hitting a nurse and harassing another patient. She got 25mg of haldol, an impressive amount, as well as atypical antipsychotics and benzodiazpines. Finally, the ER decided she simply needed to be sedated so they intubated her to get a lumbar puncture and head imaging. She was negative for meningitis, encephalitis, or structural abnormalities. Her toxicology showed benzos and marijuana. I really don't know what was happening with her, but I suspect either intoxication or withdrawal of drugs or a new psychiatric diagnosis with a manic or psychotic episode.

I haven't worked this many hours since fellowship. Along with these cases, I also had the usual old person presenting with sepsis from a nursing home, cirrhotics with low blood pressure, slow ventilator weans, chronically ill patients who had been hospitalized for over a month, gastrointestinal bleeds, and postoperative patients. What a week.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

No comments: