Valve Job
People don't get sick at convenient times of the day. This is the hardest lesson for young doctors to learn. The transformation of a medical student to a doctor has something to do with knowledge and experience, but in the end comes down to an acceptance of the need to care for patients at night, on holidays, on Christmas Day or Thanksgiving. For the Angel, a holiday is just another day. For the ICU doc, there is no let up, ever.
I had fielded some calls during the early evening and, optimism triumphing over experience, gone to bed at around eleven pm. At 1:15 am the beeper went off and I pushed the backlight button. I scrolled down to the message, and moving the screen in and out to find a place where my middle-aged eyes can actually focus, finally saw the number. "5141". Fuck.
The ER doc was nervous. An 80 year old, previously healthy, never hospitalized before except for childbirth. She had gone to bed, but subsequently gotten up and walked to the den. She then called her husband to help her. He found her drenched in sweat, unable to get her breath, complaining of chest pain. The ER doc figured it for a run of the mill MI, but it didn't fit. First set of enzymes negative, EKG unremarkable. Then her lungs began to fill up with fluid, despite a lack of evidence of total body fluid overload. Her chest xray was whiteing out, and by the time I got in to the ICU she had been tubed and was on the vent.
I talked to the husband, checked the xrays, reviewed the labs and what little medical records this octogenarian had generated over her lifespan so far. Then I went to examine her. The legs were not swollen, the heart sounds from the front of the chest were pretty bland, but when I listened to the left chest from behind she had a loud, harsh, systolic mumur. Hmmm.
An echo tech was summoned and did her magic with the echo machine: severe mitral regurgitation. The mitral valve, which usually directed blood from the left atrium to the left ventricle was bad. Putting it all together, she had acutely blown a mitral valve tether and blood was not moving forward through the chambers of the heart. Her lungs filled up with fluid and her blood pressure was plummeting. We started dopamine to raise the blood pressure and I bit the bullet and gave her some iv fluids to pretty good result. Then I called in the A team.
I'm an Internist, a nephrologist and an intensivist, but to give this patient a chance of survival I was going to need a cardiologist and a CV surgeon. I asked the HUC to get me the cards guy on the phone and began the process of mobilizing doctors in the middle of the night. By now it was about 3 am and none of them were too excited about coming in, but that's life. As I once told a complaining resident, who was upset about working all day after having been up all night: If you don't want to take care of sick people find another profession.
Patients don't get sick at convenient times. When you say the Hippocratic oath you commit yourself to battle with the Angel of Death. You give up the quaint notions of sleeping at night and sitting with your family on holidays that civilians take for granted..
The next morning the cavalry was in full charge: trans-esophageal echo confirming a flail valve, cardiac cath with placement of an intra-aortic balloon pump, trundled off to the OR for mitral valve replacement. The whole nine yards. Our role as intensivists was to sit back and watch it all unfold, making sure someone was keeping the overall picture in view.
She made it back to the ICU, but when I went back into the room I felt the air pressure shift, heard the rustling of robes. A shadow lingered at the edge of the ceiling light and then vanished. "Yeh, yeh, I get the picture." I grumbled to the departing Angel. I checked the monitors, looked at the screen for the balloon pump, reviewed the iv drips and then went to the desk to sit at the computer and see what the labs were showing. Satisfied that we were doing everything we could I went back to my rounds and eventually back home.
Sometime in the night she faded out and died. She had had eighty years of good health and then died within 48 hours of falling ill. We had done what we could, and now she walked with the Angel.
I had fielded some calls during the early evening and, optimism triumphing over experience, gone to bed at around eleven pm. At 1:15 am the beeper went off and I pushed the backlight button. I scrolled down to the message, and moving the screen in and out to find a place where my middle-aged eyes can actually focus, finally saw the number. "5141". Fuck.
The ER doc was nervous. An 80 year old, previously healthy, never hospitalized before except for childbirth. She had gone to bed, but subsequently gotten up and walked to the den. She then called her husband to help her. He found her drenched in sweat, unable to get her breath, complaining of chest pain. The ER doc figured it for a run of the mill MI, but it didn't fit. First set of enzymes negative, EKG unremarkable. Then her lungs began to fill up with fluid, despite a lack of evidence of total body fluid overload. Her chest xray was whiteing out, and by the time I got in to the ICU she had been tubed and was on the vent.
I talked to the husband, checked the xrays, reviewed the labs and what little medical records this octogenarian had generated over her lifespan so far. Then I went to examine her. The legs were not swollen, the heart sounds from the front of the chest were pretty bland, but when I listened to the left chest from behind she had a loud, harsh, systolic mumur. Hmmm.
An echo tech was summoned and did her magic with the echo machine: severe mitral regurgitation. The mitral valve, which usually directed blood from the left atrium to the left ventricle was bad. Putting it all together, she had acutely blown a mitral valve tether and blood was not moving forward through the chambers of the heart. Her lungs filled up with fluid and her blood pressure was plummeting. We started dopamine to raise the blood pressure and I bit the bullet and gave her some iv fluids to pretty good result. Then I called in the A team.
I'm an Internist, a nephrologist and an intensivist, but to give this patient a chance of survival I was going to need a cardiologist and a CV surgeon. I asked the HUC to get me the cards guy on the phone and began the process of mobilizing doctors in the middle of the night. By now it was about 3 am and none of them were too excited about coming in, but that's life. As I once told a complaining resident, who was upset about working all day after having been up all night: If you don't want to take care of sick people find another profession.
Patients don't get sick at convenient times. When you say the Hippocratic oath you commit yourself to battle with the Angel of Death. You give up the quaint notions of sleeping at night and sitting with your family on holidays that civilians take for granted..
The next morning the cavalry was in full charge: trans-esophageal echo confirming a flail valve, cardiac cath with placement of an intra-aortic balloon pump, trundled off to the OR for mitral valve replacement. The whole nine yards. Our role as intensivists was to sit back and watch it all unfold, making sure someone was keeping the overall picture in view.
She made it back to the ICU, but when I went back into the room I felt the air pressure shift, heard the rustling of robes. A shadow lingered at the edge of the ceiling light and then vanished. "Yeh, yeh, I get the picture." I grumbled to the departing Angel. I checked the monitors, looked at the screen for the balloon pump, reviewed the iv drips and then went to the desk to sit at the computer and see what the labs were showing. Satisfied that we were doing everything we could I went back to my rounds and eventually back home.
Sometime in the night she faded out and died. She had had eighty years of good health and then died within 48 hours of falling ill. We had done what we could, and now she walked with the Angel.
posted by ICUDOC at 8:20 PM
1 Comments:
Good stuff doc, keep it up.
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