Rat Poison 2
I went about my rounds, eventually leaving the ICU and doing ward follow-ups. In truth, I almost forgot about the case until about 4 in the afternoon when it kind of struck me that I hadn't heard anything about her lately. I wandered down to the ICU and sure enough there was a lot of commotion in her room. The Flying Squad was back and they were getting the patient organized, giving report to the ICU nurses, getting her hooked up to the ventilator and monitors.
I walked in and caught the flutter of a shadow in my peripheral vision, the rustle of robes of heavy cloth. No one else seemed to notice. Not a good sign if the Angel was taking interest. "What happened in IR (Interventional Radiology)?" I asked, as soon as I caught a nurse's eye.
"They found a bleeder, in the splenic artery. They coiled it with a good result and she seemed to stabilize. For a while at least."
I looked at the monitors first. The A-line was reading about 75 systolic with a pulse of 130. Not good. "Labs?"
"Just drawn. Nothing back yet."
I set her up for two more units of blood and some FFP as well on spec and started examining her. Her extremities were cool and she had a purplish mottling of the skin that is called livido reticularis. It's seen in patients with shock from various causes. Her abdomen was still rigid and she was obtunded (doctor speak for totally out of it). The labs began to trickle in: her INR was now 1.25 and her platelets were ok. The hemoglobin was low but not terrible and would improve with transfusion, but her blood pH was markedly decreased implying severe acidosis. I heard the rasping, huffing laugh and turned around only to see a shadow disappear. The Angel would get this one. We had waited to long to intervene.
Maybe it wouldn't have mattered anyway but I felt that we had had a window of opportunity and missed it. Medicine is a team sport. I need the surgeons and the radiologists, and they need me. They each have to make their own decisions and we all live, or die with them. I reluctantly went out to talk to the family. This would be a tough one: relatively young, abrupt onset of a lethal event.
About an hour later we had an order for DNR/DNI, and later in the evening they agreed to withdraw support. She died in the early morning hours the next day without ever waking up.
I walked in and caught the flutter of a shadow in my peripheral vision, the rustle of robes of heavy cloth. No one else seemed to notice. Not a good sign if the Angel was taking interest. "What happened in IR (Interventional Radiology)?" I asked, as soon as I caught a nurse's eye.
"They found a bleeder, in the splenic artery. They coiled it with a good result and she seemed to stabilize. For a while at least."
I looked at the monitors first. The A-line was reading about 75 systolic with a pulse of 130. Not good. "Labs?"
"Just drawn. Nothing back yet."
I set her up for two more units of blood and some FFP as well on spec and started examining her. Her extremities were cool and she had a purplish mottling of the skin that is called livido reticularis. It's seen in patients with shock from various causes. Her abdomen was still rigid and she was obtunded (doctor speak for totally out of it). The labs began to trickle in: her INR was now 1.25 and her platelets were ok. The hemoglobin was low but not terrible and would improve with transfusion, but her blood pH was markedly decreased implying severe acidosis. I heard the rasping, huffing laugh and turned around only to see a shadow disappear. The Angel would get this one. We had waited to long to intervene.
Maybe it wouldn't have mattered anyway but I felt that we had had a window of opportunity and missed it. Medicine is a team sport. I need the surgeons and the radiologists, and they need me. They each have to make their own decisions and we all live, or die with them. I reluctantly went out to talk to the family. This would be a tough one: relatively young, abrupt onset of a lethal event.
About an hour later we had an order for DNR/DNI, and later in the evening they agreed to withdraw support. She died in the early morning hours the next day without ever waking up.
posted by ICUDOC at 11:34 AM
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