Doing the CCUing Out the Door Dance

1100 (T - 0) My patients are all signed out and my shift is over.  I am heading home for some rest after doing a few errands.  The next time you see me I will be starting my rotation (not until Tuesday!!!) at one of the local community hospitals, and I will be back in the E.D.  So for now, good night, and good luck!
0700 (T - 4h) 24 hours later and I am pre-rounding for my patients again.  Getting their information.  A little behind due to the admission.. oh, I should get back to it!
0600 (T - 5h) My resident paged me.  The perfect night is ruined.  Got an admission in the E.D.  I can't complain.  I wonder what number my colleague is on.
0515 (T-5.45h) I got a page from the same nurse for the "I need a sleeping pill patient" for some lab orders and a Foley (urine catheter.)  I mumbled "yes" in my sleep and rolled over again.
0200 (T - 9h) I just came back from another Code Blue.  This time, a patient that had coded on the floor during the prior code had been transferred down to the MICU.  He had just come down and within about 1/2 hour he was bradying down (heart rate was slowing: bradycardia = heart beat less than 50.)  I went upstairs to find them doing CPR and he had just been intubated.  He was the 6th admission for my fellow EM resident, and, when the patient was pronounced, she came out to tell me she was expecting her 7th admission.  I keep waiting for the pager to go off.  (It did once but only to ask if a patient could have a sleeping pill.  Sure, why not?)  For now, it's back to dreaming about city streets and neighborhood layouts.  Maybe, I've been playing SimCity too much.  Hmm.
23:15 (T - 11.75h) So, for the last 4 hours since my last entry, I have been watching television in our resident room.  I saw all of a CSI episode, followed by most of the movie "Working Girl," and then I channel surfed for a while.  I was just about to get extra comfortable in the recliner when I heard a Code called overhead.  A Code Blue is cardiac or respiratory arrest, meaning the patient's heart isn't beating or they're not breathing, or both.  Although, they called a Code Blue this afternoon only to find the patient was actually just sleeping.  Must have been a young nurse or aide.  Anyway, I went upstairs to find one of my fellow EM residents there and a crowd in the room.  Initially, the story was that the patient was found down on the floor in their bathroom.  Then we noticed the makeshift noose made out of a hospital gown hanging from the shower rod.  Apparently a nurse's aide went in to check on the patient and found him hanging.  He'd been taken off the telemetry monitor just a minute or so earlier, so he hadn't been there long.  We stabilized his neck and moved him to the bed where he was intubated.  He became more responsive and had started to breath on his own prior to having the tube put in, but for his own safety he was intubated.  We have to worry about neck fractures and any damage he might have done to his trachea.  Also, how much brain he might have damaged, although little if the timing is correct.  He'll be going to the MICU (Medical Intensive Care Unit) tonight.  The EM resident working there will probably be able to tell us what happens with him in the morning.  She's on her 5th admission of the night.  I, myself, am planning to settle in my comfy recliner and hope the white cloud keeps blocking out the admissions.
1900 (T - 16h) We had dinner.  It was a nice beef souvlaki salad for me.  Currently on the low-carb/no-carb diet for the next 6 weeks until the wedding.  My patient who's now re-intubated seems to be doing well.  By my read, CT scan looks negative for anything scary.  His heart, lungs, kidneys and liver still have a ways to go.  We got a new patient.  Another 4 - 5 beer a day, plus I smoke and sometimes do drugs, kinda guy.  He's going to be a pain just because, as I've stated before, chronic drug users (ie: heroin, cocaine, etc.) tend to fry out their pain receptors and then usually need more medication to help them with something you or I might take an ibuprofen for.  I am getting ready to relax for a bit and pray my white cloud keeps me covered over night. (Residents, especially surgeons, believe you're either a white cloud - nothing happens when you're on call or it's a light call, or black clouds - chaos rules and you get many admissions.)  I had a friend who I used to call a black cloud with thunderstorm warnings because whenever he took call it seemed the service was suddenly three times as busy.  Here's to praying for blue skies all around me...
1545 (T - 19.25h) Just got back from running downstairs because a patient had self-extubated (pulled out their own breathing tube.)  I admitted this gentleman yesterday.  (Getting on the soapbox)  Everyone should learn CPR.  My patient was at home and told his wife that he felt like he was having heartburn.  Then he suddenly shuddered and collapsed.  She called to him and then called EMS.  Their response time was about 5 - 6 minutes, but meanwhile nothing was done for this patient.  When they arrived, he was in v-fib arrest (let me just say this is bad) and needed to be shocked twice.  They got his heart going again, and when he came to he suddenly became very agitated and combatative.  So much so that they needed to put a breathing tube in when he arrived to the E.D.  We pulled the tube out yesterday because he was responding to voice and following commands.  He was again very combatative and not breathing properly so he needed to be put back on the ventilator.  Today, we had sent him downstairs for a CT scan to check out his brain, and he somehow managed to reach up and pull out his breathing tube despite being in restraints.  When I was a medical student at the VA, this meant the patient was ready to be extubated (have the breathing tube removed) but in this case, not so much.  So, now he's reintubated, and I am going to go see what his CT scan shows.
We got another admission which means the evening resident will be leaving, and I will be responsible for all admissions until morning.  We're in the process of ordering dinner.  Yes, it's early, but you never know when you're going to eat on-call, so it's better to have cold food than no food at 11 p.m. if you're suddenly busy.  The day continues...
1230 (T - 22.5h)  At lunch.  Admitted a patient this morning:  needs by-pass surgery for bad coronary artery disease, but oh, by the way, is a Jehovah's Witness so no blood products, and on peritoneal dialysis for bad kidneys, AND had a severe allergic reaction to anesthesia.  Oh yeah, if you know you have clogged coronaries don't wait several hours for your son to come home before going to the hospital, go when you're having the chest pain.  Every minute is another 1000 heart cells lost.  And, to add to the on-going drama in the CCU (more on that at some other point), the I'm-having-a-heart-attack-again-yet-continue-to-smoke-and-hate-waiting-in-ED's decided he didn't like the No Smoking policy and left.  I think I talked about signing out AMA (against medical advice) once before.  He did.  He was warned he could drop dead.  He didn't care.  He was warned not to drive because he's driven off the road once already.  He didn't care.  Probably was lighting up as he was walking across the lobby and out the door...
0915 (T - 25.75h) - So, rounds just ended, and they weren't too bad.  What's bad is the story of one of the patients admitted overnight.  They started to have chest pain two days ago around 8 p.m., so instead of going to the hospital, they thought it was more important to drive to get kerosene to heat their house.  On the way, they became dizzy and light-headed and drove their car off the road.  Around midnight, they were found by local PD and thought to be inebriated because they were confused.  So, they were arrested and taken to the local jail.  When the breathalizer was negative and a friend who was an officer recognized them, they were released.  By the way, they continued to have chest pain.  So, their fiancee came and picked them up and took them home.  The next morning they went to see their primary doctor who did an EKG and told the patient to go straight to the emergency department.  (Me, I would have called EMS, but that's just me.)  According to the patient, they were ignored for 30 minutes despite complaining of chest pain, shortness of breath and diaphoresis (sweating.)  So, they left.  And came to BGH yesterday evening where they were admitted and are now on our service.  Yep, they've had a heart attack.  Don't feel too bad for them.  They continue to smoke 3, yes 3, packs a day of cigarettes like they have for the last 30 years despite having had 9 heart attacks, a 4 vessel by-pass, and a very strong family history of heart attacks before the age of 40 including deaths on both sides of the family.  Natural selection, folks.  More to come I am sure...
0730 (T-27.5h) - I got to the hospital about 1/2 hour ago.  I brought coffee and donut holes (Dunkin, ooh gourmet compared to the "Timmy's" everyone here seems to like).  I like to show my appreciation to the staff.  I've done it since I splurged as an intern and bought pizzas for 2 shifts at Cook County for the floor 8 nurses.  They REALLY helped me get used to new environs and work around the system.  Anyway, I've collected all the data from last night (vitals, labs, medications) and now I am off to physically examine my patients before rounds...

Tags: CCU, BGH, by-pass surgery, leaving AMA, hypoxic brain injury, suicide, MICU, Code Blue, SimCity, STEMI, NSTEMI

Tomorrow's a Big Day

Well, tomorrow is it.  The end of the CCU rotation.  My goal is to do a play by play during call.  We'll see how that works out.  As for today, we did a little cleaning house.  Moved most of our patients out of the unit and onto the floors upstairs.  And, most of my patients went to private services... meaning off my service, and I don't have to do the discharge dictation...!

So, until tomorrow for a Friday night on call...

CCU Countdown:Days until the end of the rotation:  3
Actual number of days I will be working during that time: 2
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off:  2 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0
Number of long call shifts remaining: 1 - TOMORROW!!!
Number of patients: 2 - I picked up a new one from yesterday
Number of evil nurses in the unit: 4 - evil nursing aide actually made #4, she just had too much attitude for one small person
Number of evil Internal Medicine residents: 2

Tags: CCU, BGH

Last CCU Short Call

So this is my first official entry of 2008.  I didn't write on New Year's Day because after an exceptionally long morning of rounds for a non-workday, I decided to take a nap.  After waking up just long enough to have dinner, feed the cats and get things organized for another day of work, I just decided to go to bed.
One interesting thing that happened yesterday is that the patient who was brain dead died.  I spent another hour with the son the day prior and had finally gotten him to the point of thinking in terms of finding a funeral home and thinking about his parent's last wishes.  Then, he suddenly changed his mind again and said that something else could probably be done for his parent, and that as long as they were on the breathing tube, he could still come and see them.
I then told him that if his parent's heart stopped, it was no longer a matter of choice.  They would be removed from the ventilator, and he would have to tell the hospital where to send his parent for burial.  Again, I am usually very kind and understanding when it comes to talking to families about their loved ones, their conditions, and in talking to families about witholding or removing care.  But, this situation called for me to be more brusk and candid than I usually am.  I felt bad about this.  I really like to be as understanding and patient with families as I can be, but that wasn't going to be the case in this situation.
When I came in yesterday morning for rounds, the patient's temperature had dropped to the low 90's, and the nurses were having a hard time getting a blood pressure.  When the patient's heart rate dropped to the 30's, we knew we were close.  When the patient went asystole (flat-lined), we ran the code, gently, and then pronounced the patient.
I called the son to let him know his parent had died, and he would now need to make arrangements.  At that point, he finally seemed to have an acceptance of what had happened and came to the hospital to say good-bye.  The social worker promised to help him out with whatever he needed.  So that was the start of his New Year, and too, I guess, of mine.
CCU Countdown:Days until the end of the rotation:  4
Actual number of days I will be working during that time: 3
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off:  3 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0 - I finish tonight!
Number of long call shifts remaining: 1
Number of patients: 2
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 2

Tags: CCU, code blue, end of life, health care proxy

Wait a Minute, Mr. Postman!

Today was a very dull day.  Which is good for a Wednesday.  We didn't have grand rounds, so I had to sit through rounds.  Luckily, rounds were over quickly, and there were no radiology rounds - meaning sitting in front of the computer and looking at angios and echos.

The most exciting thing for me today is that I mailed out my wedding invitations.  That kinda makes it just that much more real.  Real scary.  Eeek!!  That means I just have 8 more weeks to get ready.  I feel like there's so much still to do.  Luckily, my Maid of Honor Nicole seems to have a more level head and is keeping me reined in.

So, for now, the countdown continues:
CCU Countdown:
Days until the end of the rotation:  11
Actual number of days I will be working during that time: 10
Days left until the painful attending returns:  4
Number of days until my next 24 hours off:  10 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 1
Number of long call shifts remaining: 1
Number of patients: 2, I think, sometimes it's hard to keep track of the patients that go to private service.
Number of super nurses in the unit:  4
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 3 1/2 (1/2 because I like the one I took call with the other day, but he stole one of my procedures)

Tags: wedding invitations, CCU

Silent Night

I spent the day at the hospital.  I took a call day so that everyone else could leave and enjoy their Christmas Day.  I called my mom mid-morning and got the report from the night before.  She enjoyed the gifts I had sent, and the extra special basket of sugar-free goodies from my fiance.

All in all it was a nice, dare I say, quiet day in the CCU.  I had one admission, and one sort of excitement toward the end of the day.  For the most part, I had about five hours of watching a CSI marathon and almost all of "Goldeneye" uninterrupted.  Mmmm, Pierce Brosnan as James Bond.  I could just watch him all day long.  For me, there is no more perfect Bond.  But, I digress.

If you've followed my prior posts, I think by now we've established some of the rules to follow when it comes to drinking.  Something I don't think has come up to this point, mostly because I see people in the ED once and not for several days in a row, is the discussion about what happens to people when they drink excessively for days and weeks and months on end and then come to the hospital where they're not allowed to drink:  a little something known as the DT's.

You're ok for the first couple of days.  Normal for the most part.  Then around day 3 you start to get a little anxious.  Maybe, a little more irritable.  Your heart rate starts going up and your blood pressure might go up as well.  Then the fun starts.  You start imagining things that aren't there.  You get confused.  You might even get physically argumentative.  If your medical team is unaware of your alcohol intake (and granted most patients lie when it comes to alcohol consumption which is why as a general rule since med school we've been taught to double anything the patient states is the amount of alcohol they admit to consuming), you might get placed on thiamine and folate and some Ativan (Lorazepam) to help you avoid the mental confusion aspect part.  When you start having seizures, that's a bad thing, and you could actually die (so admit to drinking alcohol and how much.  Please.)

If they don't, and you lied (of course you did) about the amount of alcohol you consume, you can go into full blown DT's (delirium tremens) which includes shakiness, severe mental status changes, lethargy, etc. and end up like my patient who is now on a ventilator after he became somnulent to the point he couldn't remember to breathe.  He would barely breathe when we shook him or called his name, but then he would go off into a stupor.  So, now he's got a breathing tube.  His girlfriend called later, and I had to tell her that he was on a breathing tube.  I couldn't tell her why though, there's this thing called HIPPA which is basically a patient rights document that states your medical information can't be shared with anyone not directly involved in your care.  I am sure she would tell me how much he actually drinks... if only I could ask her...

Some shots of downtown Buffalo.  I love the city, especially at night.  Merry Christmas to all!


CCU Countdown:
Days until the end of the rotation:  12
Actual number of days I will be working during that time: 11
Days left until the painful attending returns:  5
Number of days until my next 24 hours off:  11 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 1
Number of long call shifts remaining: 1
Number of patients: 4
Number of super nurses in the unit:  4
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 3 1/2 (1/2 because I like the one I took call with the other day, but he stole one of my procedures)

Tags: CCU, delirium tremens, Pierce Brosnan, James Bond