The Bleeding Whale
The patient was admitted to the Hospitalist service, but by late afternoon on Sunday they were well over their heads. What is a Hospitalist? This is a new practice of Internal Medicine that basically involves a group of Internists who manage patients in the hospital. This way the primary care doctors (other Internists and Family Practioners who see patients in clinics) don't have to bother with inconvenient things like sick patients in the middle of the night. It is a division of Internal Medicine into clinic based practice and hospital based practice, and I am wholly unconvinced it is a good idea.
I moonlighted for the Hospitalist service at our hospital when I was young and hungry and the service had just begun. Basically, I covered for the weekend, admitting general medicine patients, dictating H & P's, discharging patients, dictating discharge summaries. By the end of the weekend I was bored to death. I concluded that I would rather drive a truck than be a hospitalist.
At any rate, the patient was in his sixties and had come in with shock and respiratory failure. In the ER someone put down an NG tube (a flexible tube that goes from the nose, N, to the stomach, G for gastric) and got back a lot of fresh and digested blood. His hemoglobin was down to 6 (normal around 14) and he was getting lots of transfusions. The GI doc had called in the endoscopy team and was preparing to pass a scope down his gullet, but they wanted the patient to be more stable first. Having a patient arrest during endoscopy can be such a bummer.
The Hopsitalist decided to call in the Cavalry and there I was... better late afternoon than three in the morning. The first order of business was a central line. When someone is critically ill you want a big tube going into either the subclavian or internal jugular veins so that if they go south quick you can give them meds, fluids, blood. Usually you just find the landmarks on the neck and get a needle into the vein so that you can pass a wire through the needle into the central veins near the heart. Then you slide the actual IV catheter over the wire and pull the wire out. Sounds complicated but it gets easier after the first thousand or so.
The problem was this guy was a whale. I'm talking 200 kilograms (2.2 pounds per kilogram, you do the math). Locating a neck was tough, and finding any landmarks hopeless.This scenario is becoming more and more common in the hospital. While obesity certainly causes lots of morbidity, it also makes the patient very difficult to care for. Just to turn this guy over in bed took four nurses. He needed a "Big Boy Bed" with extra weight capacity and controls to maneuver his mass.
Well, what to do? The Endoscopy nurses were looking at their watches, thinking about Sunday dinners going down the tubes, while I poked and prodded. Solution? Bring out the Site-Rite. This is a little ultrasound machine mounted on an IV pole. You cover the probe with a sterile condom-like sheath and use it to guide the needle stick. It was amazing, I could see the round pulsatile carotid artery and flat compressible internal jugular vein clear as day. I could watch the needle dive through the neck and enter the vein, all the time watching a little screen on the pole rather than the patient. Blood return, thread the wire, done.
Next we needed an arterial line. This is a catheter threaded up the femoral artery and hooked up to a transducer that allows continuous measurement of blood pressure, and sampling of arterial blood to do blood gases on and help manage the patient's ventilator. Normally, the femoral artery can be felt in the groin area, but in this case two nurses had to retract the patient's massive gut and hold it back just to see the groin. Every time I pressed in to try and feel a pulse, mounds of fat pushed back at me. Occasionally I convinced myself that I felt a pulse, but the flab would shift and I would lose it. In the end I used the Site-Rite again, saw the pulsing, round femoral artery on the screen and plunged a large needle into his groin. Fortunately I was soon rewarded with a geyser of bright red arterial blood spurting across the sterile drapes. Thread the wire, pass the catheter, done.
Once the lines were in I could manage his fluids and drips, and we had his blood pressure stabilized in short order. In fact, they started the endoscopy while I was still in the room so I stuck around to watch. They have a big video screen on a cart and you can see the whole thing. His blood filled stomach was actually pretty gross to see, and I couldn't tell what was what, but the GI specialist confidently located a bleeding ulcer and injected an artery with epinephrine to close it off.
I sat to review the chart, pull up the labs on the computer, write my consult and dictate. About half an hour later I walked back into the room for a last check. What had been bloody chaos was now a scene of neatness and tranquility. The patient was clean, sedated and laying still in bed. The tubes and lines snaked off to their pumps and monitors and no alarms were sounding. The blood pressure was steady and, if not normal, at least at an acceptable level.
Home, bed, sleep
I moonlighted for the Hospitalist service at our hospital when I was young and hungry and the service had just begun. Basically, I covered for the weekend, admitting general medicine patients, dictating H & P's, discharging patients, dictating discharge summaries. By the end of the weekend I was bored to death. I concluded that I would rather drive a truck than be a hospitalist.
At any rate, the patient was in his sixties and had come in with shock and respiratory failure. In the ER someone put down an NG tube (a flexible tube that goes from the nose, N, to the stomach, G for gastric) and got back a lot of fresh and digested blood. His hemoglobin was down to 6 (normal around 14) and he was getting lots of transfusions. The GI doc had called in the endoscopy team and was preparing to pass a scope down his gullet, but they wanted the patient to be more stable first. Having a patient arrest during endoscopy can be such a bummer.
The Hopsitalist decided to call in the Cavalry and there I was... better late afternoon than three in the morning. The first order of business was a central line. When someone is critically ill you want a big tube going into either the subclavian or internal jugular veins so that if they go south quick you can give them meds, fluids, blood. Usually you just find the landmarks on the neck and get a needle into the vein so that you can pass a wire through the needle into the central veins near the heart. Then you slide the actual IV catheter over the wire and pull the wire out. Sounds complicated but it gets easier after the first thousand or so.
The problem was this guy was a whale. I'm talking 200 kilograms (2.2 pounds per kilogram, you do the math). Locating a neck was tough, and finding any landmarks hopeless.This scenario is becoming more and more common in the hospital. While obesity certainly causes lots of morbidity, it also makes the patient very difficult to care for. Just to turn this guy over in bed took four nurses. He needed a "Big Boy Bed" with extra weight capacity and controls to maneuver his mass.
Well, what to do? The Endoscopy nurses were looking at their watches, thinking about Sunday dinners going down the tubes, while I poked and prodded. Solution? Bring out the Site-Rite. This is a little ultrasound machine mounted on an IV pole. You cover the probe with a sterile condom-like sheath and use it to guide the needle stick. It was amazing, I could see the round pulsatile carotid artery and flat compressible internal jugular vein clear as day. I could watch the needle dive through the neck and enter the vein, all the time watching a little screen on the pole rather than the patient. Blood return, thread the wire, done.
Next we needed an arterial line. This is a catheter threaded up the femoral artery and hooked up to a transducer that allows continuous measurement of blood pressure, and sampling of arterial blood to do blood gases on and help manage the patient's ventilator. Normally, the femoral artery can be felt in the groin area, but in this case two nurses had to retract the patient's massive gut and hold it back just to see the groin. Every time I pressed in to try and feel a pulse, mounds of fat pushed back at me. Occasionally I convinced myself that I felt a pulse, but the flab would shift and I would lose it. In the end I used the Site-Rite again, saw the pulsing, round femoral artery on the screen and plunged a large needle into his groin. Fortunately I was soon rewarded with a geyser of bright red arterial blood spurting across the sterile drapes. Thread the wire, pass the catheter, done.
Once the lines were in I could manage his fluids and drips, and we had his blood pressure stabilized in short order. In fact, they started the endoscopy while I was still in the room so I stuck around to watch. They have a big video screen on a cart and you can see the whole thing. His blood filled stomach was actually pretty gross to see, and I couldn't tell what was what, but the GI specialist confidently located a bleeding ulcer and injected an artery with epinephrine to close it off.
I sat to review the chart, pull up the labs on the computer, write my consult and dictate. About half an hour later I walked back into the room for a last check. What had been bloody chaos was now a scene of neatness and tranquility. The patient was clean, sedated and laying still in bed. The tubes and lines snaked off to their pumps and monitors and no alarms were sounding. The blood pressure was steady and, if not normal, at least at an acceptable level.
Home, bed, sleep
posted by ICUDOC at 8:03 PM
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