The Angel Wins One

I returned to the ICU at around 7 am that morning. The patient was back from the OR minus his entire colon. The operative findings suggested a toxic megacolon and the initial path was consistent with C. Dif. colitis. C. Dif. is a bacteria that overgrows the colon when other beneficial bacteria are killed by antibiotics. The C. Dif. flourishes causing illness that ranges from mild diarrhea, to bad, persistent diarrhea, to what this patient had: toxic megacolon with septic shock and multisystem organ failure. That explained the super high white count. The colon had been transformed into a dilated sac, leaking toxins and bacteria into the bloodstream. The surgeon had whacked out the whole thing and transported the patient back to the ICU, back in my court.

I first called up the labs and saw that the metabolic disaster was worse than I anticipated. He had severe acidosis and the potassium was life-threateningly high. I would need to get him on dialysis like right now. I went into the room and did a brief exam, while letting the day nurses, G. and N., know what I would need to put in a dialysis catheter. I also dialed up the extension of the dialysis room and told the dialysis nurse to clear the schedule and set up for an acute run in the ICU.

And then he arrested.

The heart rate slowed, the alarms went off, and then the heart stopped. I yelled something intelligent like "Jesus, Fuck!" and then told the nurse to do what she was already doing, call a code.

We started CPR, took him off the ventilator and started bagging him by hand. The code team arrived and we started trying to flail his heart back to life. What could only look like a circus where the clowns were dead drunk was actually a carefully choreographed procedure. An RT bagged the patient, three different nurses administered the drugs that I and the house officer called out, two beefy orderlies alternated vigorous CPR, and a charge nurse carefully recorded everything we did on a code sheet.

At first things seemed hopeless. Flat-line is the worst thing you can see on a monitor during a code. Remembering the acidosis and hyperkalemia I gave him bicarb, calcium, epinephrine, more bicarb, more epi, atropine.....

Time went by and we were getting nowhere. I could sense the desperation in the nurses, waiting for me to call it. I kept thinking "28 fucking years old, the Angel is not getting this child...". But still the monitor was flat.

"OK, another dose of epi and atropine,,,,"

The nurse looked at me but gave the meds. "Epi and atropine in."

"Stop CPR." They stopped. The room was silent as we stared at the monitor. I looked at the House doc who looked back at me and nodded. The flat line was now a rough squiggle.

"Yes! VFib. Shock him, 300 joules."

The nurses set up the defibrillator. "Clear." We all stepped back and the body arched up. The monitor swerved erratically and then settled back into a coarser vfib.

"Shock him again."

"Clear!" Again he arched. The monitor came back to a smooth line and then a slow rhythm appeared.

"Jesus!"

The nurse looked up at me. "Perfusing. I've got a femoral pulse."

I looked at her. "Thank the fucking Lord. Get me the dialysis catheter." I turned to the dialysis nurse B., "You ready to go?"

He nodded, lines in hand. I harpooned the femoral vein without bothering with the niceties of scrubbing and draping. the line was in and we hooked him up. "How long was the code?" I asked the charge nurse.

"Two hours, 35 minutes."

My mouth hung open. "What?"

She nodded. "We thought we were gonna have to call Security to haul you away from the bed. We've never coded anyone that long."

I turned from her and looked at the ventilator sighing, the monitor beeping out the struggling rhythm and alarming away, the dialysis machine spinning and bucking. "This boy is alive." I turned to the crowd in the room. "Thank you everyone. This boy is still alive."

I left the room and sat with the chart to try and write a progress note. To reduce what had just happened to medical jargon and lab values seemed ridiculous. I felt like writing: "We met the Angel of Death in the field of battle, and remained locked in mortal combat for 2 hours and 35 minutes. The boy is still alive. Do you hear that, Angel? He will not die. Not on my watch you son of a bitch." Of course, writing that might raise eyebrows. In the end I wrote a clinical code note. I signed the patient out to my partner who was coming on service and left the hospital for the office.

That young man died that afternoon.