Code Blue
Code Blue
It’s 0650 hours. Everyone comes piling into my patient’s room. I’m doing compressions.
…10..11..12…
In between compressions I’m glaring up at my Fellow. He could read it in my eyes… “This is all your fault…”
Twelve hours earlier
1900 hours I clock in and get report on my second patient of the night. A 22 year old obese, Caucasian male with a ‘holy hell’ list of comorbidities. Top of the list: aortic stenosis. He was born with some congenital heart defects and was a frequent flyer in the cardiac units. This time, he ended up in Cardiovascular Intensive Care with me. He was relatively stable, but with his ever decreasing blood pressure the team decided to admit him to the ICU.
He was a man, but he sounded much like a boy. His mother was apprehensive about leaving him, and who could blame her. Her son had been in and out of the hospital since the day he was born- and here he was again- but she was tired. I convinced her it would be okay for her to go home and get some rest and return in the morning. The unit was cramped anyways. In the basement of the hospital, surrounded by concrete walls, no windows, beds separated by curtains, and not a couch in site.
She agreed. She would come back in the morning.
About midnight, his MAP was dipping just below 65. I notified the Fellow; Dr. Avil. No interventions at this time. I decided to increase his cuff intervals to go off every 10 minutes. What I needed was an a-line, but this boy would have to get worse before Dr. Avil decided to put one in. But that’s the game sometimes isn’t it? How far can we push the limit?
Throughout the night, I had gone back to the Fellow countless times. Frustrated and more irritated every time I knocked on his door.
We had started phenylephrine, but it wasn’t doing much good. He had an increased heart rate and he was now wearing 2L O2- not a lot, but enough for my antennas to go up. My guy was in cardiogenic shock. We should have started dobutamine hours ago… Not knowing how hard to push my Fellow, I aired on the side of caution and acted as a sort of nuisance with a slight attitude. There should be 20 people around this man’s bedside right now, but instead I have a slightly concerned Resident and a Fellow who is okay with a dropping cuff MAP of 58. Document. Document. Document. That’s what I was taught. So that is what I did.
By 0400 hours his body was colder than it had been. I retrieved some blankets from the warmer, but he wasn’t cold because he didn’t have enough covers. Labs came back and confirmed what I suspected to be cardiogenic shock: increased lactate, troponin, and ABG was indicative of metabolic acidosis.
NOW dobutamine is ordered and started, among other things. It’s too late.
I stayed over my shift an hour while the team and I performed advanced cardiac live support. He lived, but to what end? When I left he was hooked up to a ventilator and preparing to be transported to the cardiothoracic intensive care unit.
My patient fought hard. He lived another month in the hospital going back and forth between the two cardiac units and having every possible procedure performed.
In the end, it was all for not- and I always think back to him and think: “If I had pushed the doctors a little harder.” Would he have made it? “If my doctors had listened to me the first ten times I tried to voice my concerns.” Would he still be alive?
In the end, there is no sense in playing the “what if” game with yourself; however, there are always lessons to be learned.
Be Bold.
Be Brave.
Advocate For Your Patient.
Even when the doctor makes you feel stupid and small:
Listen to your gut.
Because at the end of the day, you’re the one who has to live with the care that you delivered.
And when you look back and ask yourself, “Did I do everything I could?”
You want to be able to answer…
YES!
