Bad Call Day
I just got up a little while ago after sleeping for fifteen and a half hours. Sometimes that happens after my 30 hour call shifts when I don’t get to sleep. And even after the fifteen or so hours of sleep I still feel tired. Thursday to Friday afternoon was my call shift. It was crazy. At about 2pm on Thursday the computer system went down for the VA hospitals. The regional system went down at the main frame….. what ever that means other than BAD, VERY BAD. Since EVERYTHING is on computers for the VA it makes it very hard to take care of people when the system is down. It was especially hard to admit people and get them the right medications and the right tests. The system came back up at about 10pm and then went down again at about 3am. It was a very frustrating call shift.
And one of my cute little patients died. He was a 59 year old guy who had terrible heart failure from ischemic cardiomyopathy (very enlarged heart because of lack of oxygen to the heart muscle—usually from a heart attack or something). His ejection fraction was about 18% (how much blood is pumped out of the left side of the heart with every heart beat, normal is about 65%). Because of his very poor heart function, several months ago they had put in a pace maker/defibrillator. He was actually doing pretty good at home. Very functional, up and about. He lived with his daughter and granddaughter. Went shopping, went for walks. Doing well.
He came in to the ER on Thursday morning because he was sitting on his recliner at home about to get dressed when he passed out. Then later during the morning it happened two more times. Other than that, he was feeling great. Good energy, happy.
In the ER they evaluated his pace maker. His heart had been going into a rhythm called V-tach (very bad rhythm where your heart doesn’t pump like it’s supposed to). His pacemaker was kicking in and trying to pace him out of it, but instead he was going into V-fib (even worse rhythm where you don’t really pump blood around at all and will die if you don’t come out of it with in a couple minutes) at which point he was passing out. Then the pacemaker would shock him and put him back in a normal rhythm. Normally we want the pacer to shock before someone goes into vfib and passes out. But it is a little nicer if someone isn’t awake when they get shocked. It hurts. But it’s safer than letting them pass out all the time.
So in the ER they adjusted his pacer settings and then decided that even though he was doing really well that they wanted to admit him to the hospital to put him on a new medication that would help prevent these funny rhythms. He was on a med for this called Mexelitine but it obviously wasn’t working.
When I saw him in the ER he was awake, alert and happy sitting on the end of his gurney, swinging his feet back and forth. He was in a talkative mood and I couldn’t stop him from telling me stories. He told me all about what had happened this morning and also all about his neighbors and his ‘adopted’ son who he could always count on. And about the guys down the street who were growing meth in the house and how he told his detective friend that there was something weird going on there—and they were arrested a couple days later. When I asked if he had noticed any fevers lately he told me about how his 5 year old granddaughter would bring him drinks and leave them on his night stand, but wouldn’t get too close because she had a cough right now. And he told me all about how he usually watched ‘Touched by an Angel’ and sometimes the show was good, but sometimes it wasn’t so good. But he liked it anyway.
So the arrhythmia guys decided to try Sotalol to help his heart. We gave him a dose of it in the ER before he came up to the floor. But then they called back and said they wanted to use Amiodarone instead of the Sotalol. We told them that he had already gotten the Sotalol and they said it was fine, just give him the Amio a little later.
A couple of hours later, the system still down, as I was trying to admit another patient and wishing I could rip out someone elses’ chest hair (not mine because I don’t have chest hair and if I did have chest hair I think it would hurt if it got ripped out) one of the nurses called me to tell me that my little guy had a low blood pressure and was feeling really dizzy and sick to his stomach. I gave him some IV fluids to help with his blood pressure. Just a little though, because of his heart. His blood pressure came up a little so we decided to start the Amio. Amio is usually given through the IV at first. First with a loading bolus and then then at a certain rate for 24 hours. Then we give it in the oral pill form. So we started the bolus. But his blood pressure dropped again. And he started feeling very sick to his stomach and like he couldn’t breath. Then he started feeling a lot of chest pressure. We stopped the bolus and the IV fluids and then called the ICU to have them come take a look at him.
Ten minutes later we moved him into the ICU because he looked so bad. And about twenty minutes after that he stopped breathing and lost his pulse. While one doctor did chest compressions and another put in central IV lines, I intubated him. We coded him for about two hours off and on. We’d get a heart beat back, but then lose it again. His family came in, and after a few discussions decided that this was not what he would want and so we let him go.
The hard part for me about him dying, was how good he was doing earlier. He wasn’t feeling sick at all. He was happy and didn’t really think he needed to come into the hospital. I couldn’t stop him from telling me all his stories. And then ten hours later he was dead.
We’re not sure why he crashed. But we have a couple of theories. His heart was obviously getting worse because he was having those bad rhythms. He may have had another massive heart attack while he was in the hospital. We also gave him new medication meant to prevent arrhythmias. But maybe his heart function was so bad that any more blocking medication was too much for his heart to work against.
We will never know exactly what caused his death. But I hope it was the first theory. I hope he had the heart attack and that he didn’t die because we gave him a new medication.
They tell me that someday I will directly cause the death of one of my patients. I already hate that day.
And one of my cute little patients died. He was a 59 year old guy who had terrible heart failure from ischemic cardiomyopathy (very enlarged heart because of lack of oxygen to the heart muscle—usually from a heart attack or something). His ejection fraction was about 18% (how much blood is pumped out of the left side of the heart with every heart beat, normal is about 65%). Because of his very poor heart function, several months ago they had put in a pace maker/defibrillator. He was actually doing pretty good at home. Very functional, up and about. He lived with his daughter and granddaughter. Went shopping, went for walks. Doing well.
He came in to the ER on Thursday morning because he was sitting on his recliner at home about to get dressed when he passed out. Then later during the morning it happened two more times. Other than that, he was feeling great. Good energy, happy.
In the ER they evaluated his pace maker. His heart had been going into a rhythm called V-tach (very bad rhythm where your heart doesn’t pump like it’s supposed to). His pacemaker was kicking in and trying to pace him out of it, but instead he was going into V-fib (even worse rhythm where you don’t really pump blood around at all and will die if you don’t come out of it with in a couple minutes) at which point he was passing out. Then the pacemaker would shock him and put him back in a normal rhythm. Normally we want the pacer to shock before someone goes into vfib and passes out. But it is a little nicer if someone isn’t awake when they get shocked. It hurts. But it’s safer than letting them pass out all the time.
So in the ER they adjusted his pacer settings and then decided that even though he was doing really well that they wanted to admit him to the hospital to put him on a new medication that would help prevent these funny rhythms. He was on a med for this called Mexelitine but it obviously wasn’t working.
When I saw him in the ER he was awake, alert and happy sitting on the end of his gurney, swinging his feet back and forth. He was in a talkative mood and I couldn’t stop him from telling me stories. He told me all about what had happened this morning and also all about his neighbors and his ‘adopted’ son who he could always count on. And about the guys down the street who were growing meth in the house and how he told his detective friend that there was something weird going on there—and they were arrested a couple days later. When I asked if he had noticed any fevers lately he told me about how his 5 year old granddaughter would bring him drinks and leave them on his night stand, but wouldn’t get too close because she had a cough right now. And he told me all about how he usually watched ‘Touched by an Angel’ and sometimes the show was good, but sometimes it wasn’t so good. But he liked it anyway.
So the arrhythmia guys decided to try Sotalol to help his heart. We gave him a dose of it in the ER before he came up to the floor. But then they called back and said they wanted to use Amiodarone instead of the Sotalol. We told them that he had already gotten the Sotalol and they said it was fine, just give him the Amio a little later.
A couple of hours later, the system still down, as I was trying to admit another patient and wishing I could rip out someone elses’ chest hair (not mine because I don’t have chest hair and if I did have chest hair I think it would hurt if it got ripped out) one of the nurses called me to tell me that my little guy had a low blood pressure and was feeling really dizzy and sick to his stomach. I gave him some IV fluids to help with his blood pressure. Just a little though, because of his heart. His blood pressure came up a little so we decided to start the Amio. Amio is usually given through the IV at first. First with a loading bolus and then then at a certain rate for 24 hours. Then we give it in the oral pill form. So we started the bolus. But his blood pressure dropped again. And he started feeling very sick to his stomach and like he couldn’t breath. Then he started feeling a lot of chest pressure. We stopped the bolus and the IV fluids and then called the ICU to have them come take a look at him.
Ten minutes later we moved him into the ICU because he looked so bad. And about twenty minutes after that he stopped breathing and lost his pulse. While one doctor did chest compressions and another put in central IV lines, I intubated him. We coded him for about two hours off and on. We’d get a heart beat back, but then lose it again. His family came in, and after a few discussions decided that this was not what he would want and so we let him go.
The hard part for me about him dying, was how good he was doing earlier. He wasn’t feeling sick at all. He was happy and didn’t really think he needed to come into the hospital. I couldn’t stop him from telling me all his stories. And then ten hours later he was dead.
We’re not sure why he crashed. But we have a couple of theories. His heart was obviously getting worse because he was having those bad rhythms. He may have had another massive heart attack while he was in the hospital. We also gave him new medication meant to prevent arrhythmias. But maybe his heart function was so bad that any more blocking medication was too much for his heart to work against.
We will never know exactly what caused his death. But I hope it was the first theory. I hope he had the heart attack and that he didn’t die because we gave him a new medication.
They tell me that someday I will directly cause the death of one of my patients. I already hate that day.
posted by M @ 11:10 AM
1 Comments:
At 1:14 PM,
Holly said…
This was an interesting and sad story, but I didn't cry until I read your last sentence. Well stated.
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