The Battle Is On
I got to the ICU around 1 am and went straight to the young man's room. C was the night nurse, and I nodded hello, not interrupting her as she continued organizing the patient's care. I checked the monitor, noting the low blood pressure, and then went over the IV drips. He was on high doses of pressors (drugs given iv to maintain blood pressure) and some iv fluid.
"What's he gotten so far for fluids?" I asked.
"The house doc gave him some saline boluses, 250 cc times 2 so far." C replied.
I checked the pressure monitor once more. "Give him a liter of saline over the next hour and chase it with 6% Hetastarch, 500 cc." C nodded and went on about her business. "Let's set up for a central line and A-line as well." I checked the ventilator settings and, satisfied, started washing my hands for the procedure.
A central line is a three-lumen catheter that goes into the subclavian vein, useful in critical cases for giving fluids and meds, as well as monitoring pressures in the right side of the heart. An A-line, or arterial line, is a catheter in the femoral artery that allows continuous blood pressure monitoring and blood sampling. Every doctor does his procedures in quirky and idiosyncratic ways, but C and I had worked for many years together and she knew the particular equipment I needed for these procedures. We worked efficiently, with little needing to be said, and, luckily, all the lines went in quickly and with no complications. Once the lines were in I began to examine the man. His eyes were dilated, but that could be due to the pressor drugs, rather than brain damage. Heart and lungs were clear. I pulled back the sheets to see a distended belly. No bowel sounds could be heard. The belly was ominously quiet. It was also rigid. Ok so now we knew he had an acute abdomen.
"We need surgery to see this guy, like right now!"
"Who do you want?" C asked.
"Probably start with colorectal."
Getting a surgeon to come in in the middle of the night can be tricky. I figured the on call doc for colorectal surgery was more likely to come in than the general surgeon on call that night.
I sat down at the desk and pulled up the labs on the computer. Grim. He had acidosis and renal failure. No surprise there. His white count was astoundingly high at about 60 thousand, evidence of a catastrophic event, most likely in the belly. While I was writing orders and dictating a note the surgeon arrived. Fortunately, he agreed to operate and in minutes the OR techs were wheeling the patient away. I say fortunately, as surgeons come in several types. The best type are the ones who love to operate, night or day. They seem to only truly come alive when they are in the OR cutting someone open. This type of surgeon is like a sophisticated weapon that, when deployed and quided properly, can kick the angel's ass.
The other type of surgeon will start ordering diagnostic tests, consulting other specialties, suggesting medical management, anything they can think of to avoid taking the patient to the OR. When a surgeon starts suggesting medical management you know you're in trouble. A surgeon who doesn't like to operate is about as useless as an unloaded gun.
Well, tonight's surgeon was ready to rock and roll. He agreed that the patient had an acute abdomen and an exploratory laparotomy was in order. I finished up the paperwork and headed for home, knowing I had several hours before the patient would be back to the ICU.
Home, bed, sleep.
"What's he gotten so far for fluids?" I asked.
"The house doc gave him some saline boluses, 250 cc times 2 so far." C replied.
I checked the pressure monitor once more. "Give him a liter of saline over the next hour and chase it with 6% Hetastarch, 500 cc." C nodded and went on about her business. "Let's set up for a central line and A-line as well." I checked the ventilator settings and, satisfied, started washing my hands for the procedure.
A central line is a three-lumen catheter that goes into the subclavian vein, useful in critical cases for giving fluids and meds, as well as monitoring pressures in the right side of the heart. An A-line, or arterial line, is a catheter in the femoral artery that allows continuous blood pressure monitoring and blood sampling. Every doctor does his procedures in quirky and idiosyncratic ways, but C and I had worked for many years together and she knew the particular equipment I needed for these procedures. We worked efficiently, with little needing to be said, and, luckily, all the lines went in quickly and with no complications. Once the lines were in I began to examine the man. His eyes were dilated, but that could be due to the pressor drugs, rather than brain damage. Heart and lungs were clear. I pulled back the sheets to see a distended belly. No bowel sounds could be heard. The belly was ominously quiet. It was also rigid. Ok so now we knew he had an acute abdomen.
"We need surgery to see this guy, like right now!"
"Who do you want?" C asked.
"Probably start with colorectal."
Getting a surgeon to come in in the middle of the night can be tricky. I figured the on call doc for colorectal surgery was more likely to come in than the general surgeon on call that night.
I sat down at the desk and pulled up the labs on the computer. Grim. He had acidosis and renal failure. No surprise there. His white count was astoundingly high at about 60 thousand, evidence of a catastrophic event, most likely in the belly. While I was writing orders and dictating a note the surgeon arrived. Fortunately, he agreed to operate and in minutes the OR techs were wheeling the patient away. I say fortunately, as surgeons come in several types. The best type are the ones who love to operate, night or day. They seem to only truly come alive when they are in the OR cutting someone open. This type of surgeon is like a sophisticated weapon that, when deployed and quided properly, can kick the angel's ass.
The other type of surgeon will start ordering diagnostic tests, consulting other specialties, suggesting medical management, anything they can think of to avoid taking the patient to the OR. When a surgeon starts suggesting medical management you know you're in trouble. A surgeon who doesn't like to operate is about as useless as an unloaded gun.
Well, tonight's surgeon was ready to rock and roll. He agreed that the patient had an acute abdomen and an exploratory laparotomy was in order. I finished up the paperwork and headed for home, knowing I had several hours before the patient would be back to the ICU.
Home, bed, sleep.
posted by ICUDOC at 8:31 PM
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