FROWN UPSIDE DOWN
As an attending physician (i.e. finished with my formal medical training) I don't get to go to many CPRs in the hospital anymore (a.k.a. "Code Blues" on TV).
There's a designated CPR team of residents each month, who oftimes because of crowding, will kick out whomever is not on the team during a CODE in progress.
They usually won't kick you out if:
1.) It's your patient that's CODING (not HTML coding, but CODING as in CPR), or
2.) You're actually there when the patient's pulse or breathing stops (i.e. when the patient CODES).
Or, like in this instance, both.
[Three hours prior to CPR....]
"Miss Prettay is ready to go to the nursing home," I tell the discharge planner in glee.
"I haven't heard back from them yet, so we'll see," she answers back rather testily.
Eighty-five years old, demented and smiling, Miss Prettay still had that glint in her eye that was rather beguiling.
Admitted for a urinary tract infection. She'd be discharged with full nursing home attention.
The UTI went away. The nursing home would be ready today. She even had her hair done up in doll-like braids, although admittedly rather gray.
Up to that point, things were going well.
But shortly afterwards, things went to hell.
[Ten minutes prior to CPR.... I can't keep this rhyming shit up, by the way.]
"ThisIsDr.ScottIWasPaged," I rattle into the cafeteria phone.
"Dr. Scott, Miss Prettay doesn't look so good. I think you had better come up here," the nurse on the other line replies.
"Be up in a minute. *CLICK* Fuck."
These calls always happen when I'm in the cafeteria, and I only spend like fifteen minutes there a day.
I swallow the rest of the hopefully biodegradable cafeteria food down, and head out.
[Nine minutes prior to CPR ....]
Me. Standing by the elevators. Leaning against the wall with my finger glued to the button. Trying to swallow a bolus of what I know believe is NON-biodegradable cafeteria sludge. From yesterday.
Insert annoying muzak from the infamous Blues Brothers elevator scene here.
(And yes, actually keeping your finger on the elevator button DOES help at my hospital. Otherwise the button goes out just before the elevator passes your floor by. Five years it took me to realize this.)
[Eight minutes prior to CPR....]
In Miss Prettay's room.
"Still got a pressure, in the 100s. Heart rate is 47 now," the nurse answers me.
She's breathing but not as responsive as this morning.
"Did she get any sedation? Get me 0.4 of Narcan and 0.5 of Atropine," I order and then start yelling at Miss Prettay's sagging frown. Her breathing has slowed down noticeably.
At this point I realize that I really didn't miss going to CPRs that much anymore.
"Call anesthesia STAT! We're gonna 'tube her (i.e. intubate). Is the Atropine in yet? How do you drop the head of the bed here?"
The nurses roll the cherry red crash cart into the room and break the little taped seal over the drawers. I squeeze behind her bed and lift/push it three feet from the wall. The bed is heavy and the wheels are locked, but it's not the sort of thing you notice when you've already got a crash cart's worth of epinephrine (adrenaline) pumping through your own veins.
Frankly, the exertion keeps my hands from trembling.
From behind her headboard, her unresponsive frown is upside down. She's virtually smiling like she was two days ago. We lower the end so more blood can get to her brain.
"So what's going on here?" the anesthesiologist says as the nurses bag the patient with oxygen preparing for intubation."She was fine this morning and then she went unresponsive. I want to 'tube her for airway protection," I say.
No detectable pulse now, although the monitor has a heart rate of 40. Her breathing stops too.
"No pulse! Call a CPR now! I need a milligram of epi. I'm starting compressions. Get the central line kit out too."
I don't press overly hard on the compressions but there's still a little too much give to her chest. Another 85 year old with osteoporotic rib fractures now.
Just like old times.
The compressions look pretty effective judging from the surges on the EKG monitor.
When I stop for a moment, the monitor shows a heart rhythm but no pulse. This is called PEA or Pulseless Electrical Activity. The heart is moving but for practical purposes the blood isn't. The cause varies from low blood volume, to drugs, to heart attack, to mechanical causes like fluid squeezing the heart, or a massive blood clot.
The treatment is basically the same as what I've been doing. Epi and atropine. No shocks. If you need a mnemonic for PEA, you could go with Phuck! Epi! Atropine! But it's not that hard to remember without it.
The CPR team arrives quickly enough, and they take over. I suppose attendings are supposed to have better things to do. I tell the CPR Captain, a dear resident I had on my team just a couple months back, what has happened so far. They check her labs, put a line in her femoral vein (must be a new surgical intern - I've done it quicker), alternate the epi and atropine, and check an ultrasound of her heart to look at other possible causes.
After about twenty-five minutes, it doesn't look like Miss Prettay's smile will ever be right-side up again. I call the grandson (the only contact), and say, "she doesn't look so good right now."
"Doctor, I'm her only family, and I have to know now -- Is. She. Dead?"
It's a tough call. She's not dead until we say she is. Until we stop. The concept of doing CPR on a dead person is incongruous and ridiculous. That's why she's not dead until the CPR is ended. And we haven't ended it yet.
"They're still working on her.... But it's been nearly 30 minutes, and I don't think she's going to make it," I tell him flat out. It's hospital or nursing policy to not give bad news out like that over the phone. But fuck that, I think he can take it, and not knowing is worse than knowing. Then I add,
"Are you alright? Listen, you'd better not drive. Get someone else to bring you here and take your time."
She sure isn't going anywhere.
"I'm okay doc, but I'm an orphan ... and she's my only family, you know? She had a good life," the grandson on the other end says.
[Five minutes after CPR ends....]
The CPR Captain is one of the most sympathetic residents I've met. She has this slightly sad, worried, but always pretty look to her in the hospital. Like a concerned guardian angel. She interrupts her chart writing and tells me,
"Thank you for staying. You know, sometimes, these old people, they just die like that. There's nothing you could have done."
I smile, not just because it's nice of her to reassure me like that …
But because I told her the exact same thing just two months ago.
[Two days prior to CPR ….]
"Okay Mrs. Prettay, I'll see you later okay?" I say after I've examined and interviewed her enough for the day.
No answer, she just stares dementedly. And smiles at me contentedly.
"Okay, bye," I say on my way out.
"My, you're so prettay!" she practically does shout.
Alzheimer's or not, she makes me laugh and even now, I can hardly stop grinning.
Thus proving the best endings often occur at the middle or in the beginning.
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ONE PERSON'S NIGHTMARE IS ANOTHER PERSON'S ....
Amy's been having bad dreams with this pregnancy thing.
Last night, she had a weird one. She dreamt we found a house that had nothing but video games inside. We went in to investigate, and the place was filled with "blonde and light-haired girls that all loved to play video games," per Amy's description.
And they all wanted to talk to ME in her dream AND play video games with me, haha!! (Reminder: this was her dream, not mine.)
At that point, all these girls were talking to me, and my poor Amy got upset and said, "Next time you can come here by yourself."
And THEN this huge bouncer guy grabs her by the shirt and holds her out the window and says,
"If you don't let Scott come back here, we're going to kill you."
And then she wakes up.
That's one fucked up dream.
I mean, first off, what's with all the "blonde and light-haired girls"? Like some sort of Swedish bikini video gamers team? (Okay, so she didn't mention bikinis but that's how I visualize it.)
And more importantly, if all these girls actually wanted to talk to me AND play video games with me, I wouldn't be standing there talking to them ... I'd be playing video games with them!!
Jeez, after all this time you'd think your partner would know you by now.
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LIKE POPEYE
Amy and me at the gym today:
ME (sitting on bench and exercising with weights).
AMY (sitting on other bench and doing the same exercise, with less weight).
ME (looking at her funny).
AMY: "So what does this exercise do anyways?"
ME: "It makes your forearms big and manly."
AMY: "What?! Pshaww!" (Drops weight.)
ME: "Hahahaha!"
Q: Why does this physician carry around a ChocoCat toothbrush to work?
A: Because the bristles on his Badtz Maru toothbrush were too harsh.
