Sugar: Day 2

Again the disorientation of being pulled from a deep sleep. Again grabbing the wrong device. Pressing the button on the beeper does nothing to the grating noise and I eventually realize it's the alarm. I so wanted to sleep. Just sleep.
The rule post-call is "Keep moving".

Brush teeth, keep moving. Shower, keep moving. Any pause, just sitting for a minute with a cup of coffee, can cause a resurgence in the barely suppressed need for sleep. I drive in to the doctor's lot and shut down the car. For a moment the battle is lost and I go out in the driver's seat. A door slamming across the lot brings me around and I head for the hospital.

Up the stairs to the third floor and into the unit. I greet the HUC (stands for unit coordinator or some such) with the standard "Good morning! Who died?". '
"None of yours, Doc."
I slide into the chair before a computer and log in to the clinical information site. While my list opens with impossible slowness I glance into Room 355. The young diabetic is still there, restraints on the arms, endotracheal tube (ETT) in place, vent sighing and alarming, monitor traces blinking and alarming.

The labs have gone from incompatible with life to just grossly abnormal. That's a start. I go to the room and begin my exam. Still unresponsive but the pupils are reactive and C, the nurse, tells me he's been agitated at times. Actually a good sign in this case as it suggests he hasn't totally cooked his brain. I check the drips and their respective pumps, and review the flow sheets. Things look pretty good in fact and I can feel the weight of the Angel fade. Always that low, non-human chuckle and the feeling of shadow passing. It talks to me sometimes, but not today. I smile as I write my progress note and new orders. "Get over it Angel! This one is not dying, not on my watch."

The family files in. Today they seem less hostile, even sympathetic; perhaps in recognition of my being here again bright and early this morning despite an obviously sleepless night. Perhaps also in recognition that things are better and their boy will live. The mother is smiling a little, her questions more gentle. I sense the father wants to hug me and so begin sliding from the room.

The scene as I leave is orderly. The boy is still critically ill but the Angel of Death has given up. Orderly.

I have often felt that practicing critical care medicine is about creating order out of chaos. The ICU doc is compulsive and repetitive, checking again and again, not because he's neurotic, but because it holds back the darkness, holds back the Angel of death, creates order where once chaos ruled.

Sugar Sugar

He was young, 26 years old. In the ICU that's young and it ups the ante. It's one thing to lose an ancient patient whose time has come. Quite another to lose a young man who should have a full life ahead of him. If you don't screw up that is.
The beeper woke me up from the deepest levels of REM sleep and I was momentarily disoriented. I picked up the alarm first, pressing the snooze control to no effect. Finally, wakefullness intervened and I lit the beeper up. The ER number flashed and I groaned, knowing that my night's sleep was done.

ER speak: 26 yo, type I diabetic. Last heard from 2 days ago. Found down by concerned girlfriend. EMS transported. Intubated in the ER and placed on a mechanical ventilator. Labs barely compatible with life. Blood sugar 1657 (a personal record in my experience), blood pH 6.8. Acute renal failure, coma, hypotension. Blah, blah, blah. I was already tuning it out, planning my counter-attack.

What it all meant was that my night was screwed. Diabetes has many manifestations, but one of the worst is diabetic ketoacidosis or DKA. An absolute lack of insulin sets off a cascade of metabolic disarray that if not diagnosed early and managed carefully resuilts in death. This boy was a late presentation to say the least. Down for two days with blood sugar levels so high I'm suprised his blood didn't crystalize. His blood was dangerously acidotic, his brain wasn't working and his blood pressure was failing. The Angel was definitely in the room, if not sitting on the bed laughing at me.

When I arrived at the Unit, a crowd of family members were wringing their hands in the room. I chased them away with my doctor-on-a-mission mode and got to work: physical exam, check the labs, attempt to decipher the illegible notes of the ER doc, place lines (arterial line, central venous line), adjust the vent, order iv insulin, iv fluids, lab monitoring.

Two hours later I was heading home. The sky was lightening and the birds were beginning to sing. For the now the Angel had been chased out of the room, but it would be several days before the battle was decided. The most difficult part was dealing with the family members after seeing the patient. It was the usual cast of characters: mother who was a nurse with some medical knowledge asking detailed questions, belligerent sister who wasn't going to let any goddam lazy doctor not give her loved one the best of care, silent and distraught father looking on in disbelief as his little boy, the one he taught to throw a baseball just the other day, lay near death, tubes in his lungs, veins, arteries, bladder. Eventually I managed to convince them that I knew what I was doing and that they were going to have to trust me.

Home, bed, wait for the next call.