Wednesday, August 26, 2009

The Tale of A3

I've been working night for almost a week now. I like working nights -- I prefer the patient population and the structure (starts out busy, tapers off) and by about 2am, whoever is coming in is genuinely sick. That being said, there can be nights like last night (I slept!) or there can be nights like what is now being called "A3 night" among the residents.

I walked into shift. The ER was packed, the rack had 3 or 4 charts in it, the signout was clean (fortunately!) and I picked up the first chart -- 50 year old guy with syncope. groan.
(translation of above for my non-medical friends: there were 3 or 4 patients to be seen, signout is patient handoff from one doc to another at the end of shift so that care continues and being "clean" means that there isn't much to do on the patients who are being transferred.)

Syncope (fainting) is the presenting complaint for 1-3% of annual ER visits nationwide. There are over 112 million ER visits per year according to the CDC, making syncope account for up to 3.3 million ER visist per year. As a comparison, "chest pain" accounts for approximately 6 million visits per year. So yeah, syncope is common. Of pateints complaining of syncope, only 34% get admitted to the hospital and, of those only about half actually get diagnosed with a cause for their syncope -- this doesn't take into account the patients who complain of syncope and then upon further questioning turn out to have had "near-syncope", aka- lightheadedness. I couldn't find a number for how many patients fall into that category, but I promise you it is a LOT.

Back to the "Tale of A3"... I'm looking at my guy, who is sitting up, awake, alert, telling me he feels kindof silly for being in the ER. I haven't laid hands on him yet-- we're still in the talking phase -- his monitor looks good, EKG normal, normal heart rate, normal blood pressure, normal oxygen content, but first thing I notice is, "wow, this guy's story sounds like he really did loose consciousness!" He doesn't have any medical problems, no medications, no allergies, no ciagaretts, no alcohol, no drugs, nada. I ask if he felt anything funny before passing out and he looks at me and says "You know doc, I'm kindof feeling it right now. A headrush thing..." aaaaand he's unconsicous. I look at the monitor and he is asystolic!!!! Heart NOT beating. Well fuck.

I call for help, sternal rub him to wake him up, I'm about to lay him out and start chest compressions when he wakes back up! He was out for about 5 seconds -- by the time the rest of the ER staff arrives they're looking at me like I'm crazy because his heart is beating and the patient is like, "I can't believe I passed out again!!" This episode made number 3 for the day.

He does it a fourth time about 20 minutes later, this time while the nurse is with me. Everyone sees that one. We need cardiology and we need them 5 minutes ago. I go directly to the top and page the SENIOR fellow (this is kindof ballsy for an intern) "ED STAT"... I didn't even leave a phone number. (later he told me he thought that the page was hillarious) But he appeared in about 2 minutes, so it had the desired effect.

Recap: I have a patient who is going periodically flatline on me, crash cart is OPEN at beside, code meds are already drawn up into syringes, the senior cards fellow has no clue what is causing this becuase the guy's EKG looks like it could be in a textbook under "normal," and the patient is looking at all of us like we're crazy 'cause he feels fine.

He can't be moved from the ER becuase what if he goes asystolic and this time doesn't spontaneously recover. It's too dangerous for him to be being wheeled down a hospital hallway when that happens. But he NEEDS to be in the cardiology intensive care unit.

The decision is made that we need to put in a pacemaker in the emergency room to take over triggering heartbeats when he heart pauses. It's simple -- we thread electrical wires through a vein in the patient's neck into their heart. However, before we can do that... the patient's heartrate starts to slow to the 20's. We're all thinking, "here he goes again!" Nope. This time, he has a seizure! (actually, "seizure-like activity"... medical technicality) and afterwards he is vomiting, confused and has zero short term memory. We went from conversing with and intelligent, cognizant guy to: "wha? who're you?" "I've been passing out? NO WAY! SERIOUSLY? duuuuude." "Why is my wife here?" "Wha? who're you?" ... repeat. He couldn't follow commands any more because he couldn't remember them and he was vomiting on top of that. The decision was made to intubate the patient to protect him from inhaling vomit in his confusion.

After that, things went much more smoothly. He had another episode of asystole while I was placing the pacemaker (I got to put in a transvenous pacemaker!!!! SO COOL!), but otherwise, things were ok. He went up to the Cardiac Internsive Care Unit where he got a multi-million dollar workup, a permanent pacemaker was surgically placed and he was discharged after 4 days -- the cardiologists still had no clue why his heart was stopping.

That was the first 4 hours of my shift. Cleanup takes an hour (the room looks like a hurricaine hit it). Next up in A3 was a ruptured ectopic pregnancy who got rushed to the Operating Room in about 20 minutes flat. We were able to diagnose her rapidly with a life-threatening condition and get her to help. Later, the Ob/Gyn came down and told us that she had over 3 liters of blood in her belly and they were able to successfully stop the hemorrhage. Yowzer.

Clean the room again (antoher hour becuase it looks like another hurricaine hit it after the ecotpic -- running around to get IVs, blood, fluids, ultraosound, yada yada.) and a little old lady comes in. Another syncope. Moderate language barrier and no one around who speaks Mandarin, so the story is fuzzy, but it sounds like she's having seizures. However, she's sitting in bed looking all cute and normal. Ok, chill out, we'll get Neurology. Neuro's evaluation gets interrupted becuase a stroke rolls in, whatever, she's fine.

All the docs are chilling back in the doctor's room, we're tired, it's been crazy, things are finally settled, the stroke is in the MRI and it's 6am. The overhead comes, "doctor needed in A3." again!?!?! Yep, little old chinese lady is having a seizure. Well, at least that's confirmed. She's gonna be admitted to Neurology. However, her seizure isn't breaking despite medications. Takes about 20 minutes, but we finally get the seizure to break and once again, the room looks like a tornado hit it. The nurse is begging us not to put any more patients in her room and just let her finish the last hour of her shift in peace!

Fortunately, that is exactly what happened. =)

I leave in the morning, sun is up, it's a hot August day and I look around -- it's weird to be outside. Every once in a while we get a gift. A reminder of why we spend our days and nights inside with beeping machines, no windows, drunks, crazies, the smattering of rediculous complains, disgruntled people and admitting residents who resent that you are making more work for them. The story above is why. This is what I do. And this is why I do it. Damn straight.

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