RCA

Remember this guy?  Dr. Slapstick?

Well, a couple months ago Dr. Slapstick reverted back to his old habit of doing 3 cases in a day.

He's been explicitly asked told not to do this.  But, since he is the medical director, there is little oversight regarding his practices.  Essentially the top echelon of administration has to get involved if there's any issue with him or his practices.  And we all know how fast administration moves--like I've seen glaciers move faster...especially in this day and age of global warming.

Anyway, Dr. Slapstick's 3rd case of the day comes out on night shift, about 8 pm. 

The patient is a 47 y/o female patient getting a valve repair.  It's her 5th valve surgery.  She had congenital valve problems--two surgeries as a child performed by some other obviously competent surgeon.

The next three surgeries were performed by our very own Dr. Slapstick.  In fact, the reason for the 5th surgery is because Dr. Slapstick damaged a leaflet of her aortic valve during her 4th valve surgery.

Oops.

Now, because of all these previous surgeries, Dr. Slapstick decided that the sternal/mediastinal scar tissue would be so bad he needed to take a different approach--like between the posterolateral ribs, much like a thoracotomy.  The anesthesiologist/perfusionist decide to cannulate the femoral artery and vein.

This is an excellent piece of clinical decision making.  CT surgery is moving towards the minimally invasive route as a whole, and scar tissue on sternotomy reentries can be a real problem.

Except I have never seen Dr. Slapstick do this particular surgery from this particular approach. 

Ever.

And this case ends up with an 8 hour pump time.

Regardless, the patient comes out with rock steady vitals, on very few vasoactive drips, and minimal bleeding (especially for Dr. Slapstick).  Orders are to sleep the patient for 2 hours, then wake her up and extubate.

Well, along comes 2 am, and the patient has been off propofol for 4 hours and is still not responding.  The night nurse is concerned (rightfully so) but the night charge nurse advises against calling the physician.  You see, Dr. Slapstick has three cases scheduled the next day.

Night nurse, (God bless her, she's awesome!) decides she's going to call anyway.

Dr. Slapstick yells at her, "I can't believe you are calling me about this!!  I mean really?!?  I have a 6 am case!!  Just turn the propofol back on and we'll deal with it in the morning."  Which she documents in real time, word for word, with quotation marks.

Next morning this patient is half of my assignment, and the night nurse relays all this to me in report.  I immediately start weaning down the propofol, and perform a thorough shift assessment.  Pupils are a 2 and sluggish, and all the primitive reflexes I test are present.

By 8 am, I'm off propofol completely.  The patient is unresponsive.  Dr. Slapstick comes by shortly after.  He's still miffed about being woken up the night before, assesses the patient, and tells me to continue what I'm doing.

At 10 am, the patient is still unresponsive, and isn't over-breathing the vent.  I'm getting concerned, and my nursing spidey sense is going off like a klaxon horn on the bridge of a WWII warship.  I do another full neuro assessment.

Oh crap.

Right pupil 3 and veeeerry sluggish.  Left pupil 8 and fixed.  No gag, no corneal.  Potential toe flare on babinski.  I can barely hide my concern from the patient family as I dash for the phone to call Dr. Slapstick.

Dr. Slapstick is in the OR.  I relay the message through the circulating nurse, and the reply, incredibly, is to turn the propofol back on, and he'll be out to assess the patient when he's through in about an hour.

I ask for a neurologist consult, but do not receive one.  I ask for a head CT, but do not receive one.

Completely dissatisfied, I call the anesthesiologist who worked the case, trying to get a back door order.  The anesthesiologist is unwilling to countermand Dr. Slapstick.  The charge nurse calls the house supervisor, who calls administration.  Nobody is willing to go out on a limb.

The hours creep by.  Calls to Dr. Slapstick's OR reveal his current case is not going well.  Complications abound.  I've updated the family, because that's what I do.  I don't lie to families, and I keep them informed.  They are besides themselves, and I am too.

Dr. Slapstick finally shows up at the bedside 4, (FOUR!!) hours later.  Does a quick 5 minute exam and has me consult a neurologist.  The neurologist is at the bedside within 10 minutes, does his exam and we are in the CT scanner in another 10 minutes.   The neurologist stays in the control room with us and reads the CT slice by slice as it comes up.

Massive diffuse global anoxic injury.  Oh and she's partially herniated, and it's progressing.

After meeting with the neurologist the patient's husband tells me he's preparing himself for the hardest conversation of his life.  He's headed home to tell his 5 year old daughter that her mother isn't coming home.

---------------------

Two weeks later I get summoned to a Root Cause Analysis (RCA) for this patient's "unexpected negative outcome."  Dr. Slapstick proceeds to attempt to blame the entire debacle on nursing, stating that we "failed to communicate the seriousness of the situation to him."

All I can say is thank goodness for thorough charting and for my less than shy mouth.  And my healthy belief that doctors put their pants on just like everyone else.

One leg at a time.

Two days later, there's a note up in the break room on the unit from Dr. Slapstick.  It seems he's leaving to pursue other opportunities in an outlying community where he has the privilege to develop a CT surgery program.  He trips all over himself thanking us for the excellent care we always gave his patients.

Sometimes administration finally does get it right.

I'm sure the patient's 5 year old daughter really appreciates that.

Nightmare Shift

Just another morning in the ICU (or so I think) as I walk up to the front nurses station to get my assignment.

I see my name next to a pair of patients, but then I notice it's also next to another pair of patients, but on the other side of the unit. 

"Hey Tracy," I call to the night charge nurse, "I think you've got me double assigned here."

"Weeeelll," she hedges, "Not really.  These two will be your assignment, but I need you to take these two also.  But just until their rooms are clean."

She can tell by my face, I'm sure, that I'm much less than thrilled.

"Don't worry, It will just be for a few minutes and you just have to wheel them upstairs, the night nurse already called report."

It occurs to me that the charge nurse, or the night nurse, seem quite capable of "just wheeling them upstairs".  I mean, I've heard of being tripled, but quadrupled?!  In the end though, I grudgingly accept the assignment.

By the time I get report on my two "real" patients, the unit secretary lets me know that the room is ready for one of my "fake" patients.  I glance in on my other patients to make sure they are breathing, load him up in a wheelchair and head for the elevators.

Once I return from settling him, the unit secretary tells me the other room is ready as well.  Maybe this is going to work out just like the charge nurse intended.  But that scares me almost as much as the stupid assignment, because if it does work, they'll be inclined to do it again.

When I go into the other room, the first thing I notice is that the chest tube atrium is almost full.  Knowing full well the floor nurses will bitch and moan about having to change it (and also a high likelihood they'll refuse to accept the patient until it's changed) I head to clean supply for a fresh atrium. 

I fill the atrium with the blue water (same color as the water in porta-johns, think about THAT for moment), clamp off the chest tubes, and make the new connections.  It's only when I slide the old, full one over that I notice the TWO other old, full atriums hiding under the end of the bed. 

Now realize, I haven't gotten any kind of report on this patient.  I really have no clue what's going on with him, even really what surgery he's had.  I assume he's had some sort of CT surgery, given the fact he has chest tubes in.  I pause, contemplating the significance of THREE full atriums.  I mean surely the physician knows, right?  Surely he wouldn't have written floor orders if it wasn't a resolved issue, right? 

Right?

I turn around and happen to look at the fresh new atrium.

The first chamber is already full.

As in 200 mls of fresh, frank blood.  And as I watch, the level is steadily rising. 

Ah crap.

I grab the chart to find out which physician I need to call.

Great.  Dr. Ballantine.  I have NO clue who he is, not one of our regular surgeons.  I fumble around, and find a cell phone number in the progress notes. 

Ring.  Ring.  Ring.

Finally a very tired doc answers the phone,  "....Hullo?"

"Dr. Ballantine?"

"...yeah?"

"Your patient Mr. Soandso is bleeding quite badly into his chest tubes."

"......"

"Um, I have 3 full atriums here, and he's put out 200, no, 400 mls now, in the last 10 minutes."

"......"

"Uh, sir?"

"What do you want me to do about it?" he slurs.

Dumbfounded, I stand there for a moment, only to be shaken from my reverie by the monitor alarming.  Guess whose pressure is now in the 60s.  He's also gone unresponsive.  I set the phone down on the counter to check a pulse.

Of course there is none.

I immediately leap up on the bed and start compressions.

"I need some help in here!!"  I yell.

But nobody seems to be coming.  I yell a second time.

Nobody.

Finally, I lean to the head of bed and while continuing compressions one handed, I mash the code button.  Now, normally we don't use the code button--we run our own codes.  Pushing the code button results in a room crowded too full of overeager, yet usually semi-clueless residents and interns.

Today is no exception.

My knight in shining armor turns out to be a first year resident.  I'm immediately reminded of the 4F's of a gallbladder differential diagnosis--Fat, Female, Forty, Fertile.  With huge boobs.  I wonder abstractly if her stethoscope is long enough to reach past her boobs?

She immediately decides my patient needs to be intubated--which is the most ridiculous thing to be concerned about at this particular moment.  No pulse, no pressure, probably no blood because the damn atrium is full again and the chest tubes look like red garden hoses.  And, since the patient was headed to the floor, no central access.  I tell the resident so.  She is clearly very pissed, but stops the intubation charade.

The room is filling up now, and someone FINALLY brings in the crash cart.

And of course, here comes RT trundling in with a vent.  The vent alarm is continuously going off, "Circuit Disconnect, Not Ventilating!!"

Only then I realize, it's my cell phone alarming.  And I'm home in bed.

Dreaming.

Awfully tiring working a shift in your dreams at night between two day shifts.

Report

Night nurse: (Flopping chart down on desk, and sighing dramatically.) "The shit really hit the fan with this patient last night!"

Me: "Oh really!? What happened?"

Night nurse: "Well one minute I was looking at the monitor and her heart rate was in the 90s, and then the next minute she was in the 130s! All I did was turn her! She totally went into a-fib with RVR!!!!"

Me: "Uh huh, then what happened?"

Night nurse: "Nothing. It was really BAD!"

Me: "....oh."

(76 y/o female patient in the ICU for COPD exacerbation, on 5mcg/kg/min of dobutamine for her heart failure.)