Today was a day I will not forget for a long time. It was one of those days when you really want to go into a storage room at work and cry alone but cannot afford the luxury because you just don’t have the time.
It began like any other call day. I woke up with a jolt at 4 am realizing I had completely forgotten to finish my clinic notes from yesterday – was supposed to do them after the gym last night but had a long hot shower and crashed instead – it had completely skipped my mind! Well, good thing I had my laptop near my bed from last night’s The Office binge. I stayed under the covers and finished all three notes within the next hour and a half. My mind was surprisingly fresh. I remembered all the details from the previous day – I gave Ms A her Flu shot but Mr B refused to get his Shingles vaccine. Ms C was due for her colonoscopy – but she wanted to think about it. I put in a little reminder note for when she comes in next. It was great. I finished by around 5:40 am, and then snuggled back under the covers for twenty more minutes. Then it was the hustle of the morning – a blur of eggs over easy, coffee, trying to use concealer on my bruised upper lip in vain (don’t even ask) and searching for my ID in frustration while Alexa played Honest by The Chainsmokers in the background. Ahh, my life was so hot and perfect.
Walking into the ICU sign-out room at 6:55 am with my usual ‘hey guys’ I plopped myself down, a little giddy. This had been my favorite rotation in my entire residency. I find myself actually looking forward to the uncertainity of my days in the ICU. Soon, the night team walked in, a little too solemn for having just finished their shift. Before we could ask, J said, ” I have bad news… Bed 12 passed away last night”. I was briefly disoriented. For a moment I wondered if he was talking about someone else. Wait, what?! Bed 12, who had just last evening laughed and joked with me? Bed 12, with the amazing girlfriend of 20 years I had bonded with – ‘I’m gonna marry him now, she had said..I had cold feet the last time he asked me..but now I know for sure..I have to marry him the minute he gets discharged’. I had been delighted at their story – they had met in Kindergarten and reconnected many years later (yes, like V and I). I remember thinking she was so lucky – he had coded twice in the cath lab, and had been succesfully resuscitated, and had improved so much in two days that he was sitting up in a chair and joking around, eager to go home. Only he never got to. And she never got to marry him. He possibly had another clot in his LAD, they said. I couldn’t believe how fucked up this was. I sat through sign-out trying to focus, but my mind was already numb.
Well, I couldn’t afford to stay that way much longer – it was barely 8 am and my pager was going off incessantly. The ER attending was calling ICU consults with a vengeance. I wasn’t rattled though. I shrugged and got to work. I downgraded the less sick patients to a regular floor/Telemetry, and worked in earnest stabilizing the others. As I went through my day I marveled at how much my efficiency and confidence in my clinical decisions had improved over the last three years. I could almost do this in my sleep now.
Around 1 pm, I had finally almost caught up. The anion gap had closed and sugars were under control for the young newly diagnosed Diabetic patient with Ketoacidosis. The 91 year old with COPD exacerbation was now off BIPAP, saturating well on nasal cannula at 5 L. Labs were cooking for my post op patient in Room 13. He had had a hernia surgery, with small bowel resection, developed a post op anastomotic leak, had that repaired, and then developed a retroperitoneal bleed , with wound dehiscence, and was taken to the OR again today. I had started him on some sedation and pain management as my attending had advised. He was hemodynamically stable. Maybe I have a minute to finally start working on my consult notes, I thought, ignoring my pangs of hunger. I had barely sat down when my pager went off again. CODE BLUE IN 32 SOUTH, the overhead announcement repeated. I ran, 32 South was the ICU. I burst in through the doors when R directed me to the back of the unit. ‘It’s 13′, he said. Fuck.
We coded him for 20 minutes, and then finally got a pulse. Barely. He had become hypotensive and acidotic once he got on the unit while I was down in the ED, and my attending had been working on keeping him afloat, putting him on three pressors and pushing bicarb. His systolic blood pressure was still in the 70s. He was bound to code again. We called the family, asking them to come in as soon as they can. They wished for us to try all we can until they got there. We obliged. He coded again. We resuscitated him again. He held on until the family got there. My intern had his first go at the difficult conversation. Would they want us to continue to try and resuscitate him, when that may just prolong his suffering? I did not expect them to know the answer. And they did not. We decided to give them time. Meanwhile, we called the Chaplain for them so he could get his last rites.
But time is elusive. It slips by before you know it. CODE BLUE IN 32 SOUTH was called again. We ran over, to find 13’s lovely nurse N waving her arms indicating NO. They did NOT want us to pound his chest anymore. He was DNR now – Do Not Resuscitate. We let him go.
N was hugging everyone in the family tight. Tears were rolling down all of their faces. I blinked back mine. He was a good man, the wife said. We got them a bereavement tray – I truly do not know what that entails – some food and other things to provide comfort, I was told. I hope it helped.”I have to get the fuck out of here’, the son said in anguish before walking out of the room where his father lay cold. I called my intern over. ‘Have you ever done a death exam before? Come, let’s do it together’ I told her the steps. He was not responding to verbal or tactile stimuli. His pupils were dilated and fixed. We each listened to his heart and lungs and checked his pulses. We flashed a light in his eyes. We checked his reflexes. Time of death: 16:30.
ER paged again. My second COPD patient who had his blood CO2 level so high it was unmeasurable, was having second thoughts about his code status. He wanted a tube now. The Catholic in me secretly rejoiced – it has been a constant struggle for me to be the one who has these conversations with patients – I wanted them all to want to live! ‘Protect life from conception till death – my Catholic medical school had taught me. This whole DNR business was new for me. I explained his options to him again. I am always careful to start these conversations reiterating that this is something I am required to ask every patient in the hospital – asking them their code status does not imply that they are going to die the next minute. But in this case it could go either way. He was alert and awake at that CO2 level. COPD patients sometimes live at these higher levels of CO2. I truly could not predict his prognosis in the next 24 hours. But naturally, that is what the family wanted to know. What do you think his chances are? I tried to explain the facts while trying to not make the decision for them. The daughter tried to get her father with mild dementia understand the question again. She began to repeat my explanation to him, and then broke down unable to continue. I got her a tissue and rubbed her back pathetically.
The rest of the day was a blur of similar emotions. I know I did good today. I actually played doctor. I helped some people through their worst nightmares. I was efficient, effective. I got the job done. “You guys were terrific today’, the ICU ACLS coordinator said to my intern and I. ‘Thanks’, I smiled feebly.
It is 8:30 pm. I opened the door to my apartment, switched the lights on, took my coat off. Then I crumbled to the floor, sobbing.