Saturday, September 13, 2014

Lineman For The County

I walk over to the ICU to pick up my next patient coming to the operating room. She is having severe GI bleeding and the doctors had been calling all day to the OR asking when we are going to bring her. When I walk into the room, the young patient looked relatively healthy, awake and alert and breathing room air. That's a pleasant surprise for an ICU patient.

Then I look at her monitors. She is in sinus tach going in the 140's with the last measured systolic blood pressure of about 100. I ask the nurse in the room who is getting the patient ready for the transfer about the heart rate. "Oh, it's been that way all day," she answers. What have they been doing to treat the tachycardia and hypotension? She replies, "the patient was given a 500 cc NS bolus and one unit of blood. The heart rate is now down from the 160's earlier." I see. The nurse also kindly volunteers that the ICU team gave her a small bolus of esmolol to try to bring down the rate but unfortunately the blood pressure bottomed into the 70's so they didn't try that again. The team's opinion is that the patient is very sensitive to beta blockers. I force myself from rolling my eyes.

I then ask her what kind of IV access the patient has. The nurse isn't quite sure since she had just started her shift. We look under the patient's blankets and find her lone IV, a delicate little 22 gauge catheter dangling on the back of her hand. Is this the only IV she's had all day? The only one that they're using to give fluid boluses and transfusions? "Yes," she says. "They were planning on putting in a central line later tonight." I couldn't help letting out a deep sigh of frustration.

What's her urine output been? "Oh, she doesn't have a foley catheter. But she is making urine. She just went on the bedpan." Does the patient have any more blood available in the blood bank? "Yes she has four more units ready and the team wanted to send one with the patient to the OR." Well at least they got something right though it would have been infinitely more helpful if the blood was given prior to the patient's procedure.

We quickly wheel the patient to the operating room. This mismanagement of a critically ill patient is going to take some work on my part to get her through the procedure. I proceeded by placing in her the appropriate monitors for somebody who is on the verge of hypovolemic shock. While I was getting the patient lined up, the OR phone rings. The circulating nurse picks it up and calls to me, saying the ICU resident needs to talk to me. Feeling no desire to talk to these incompetent boobs, I tell her that I'm busy resuscitating the patient and I can't come to the phone. She relays the message then hangs up. "The ICU resident is just asking if you could put in an arterial line and central line while you have her in the operating room." I gritted my teeth and tried to ignore that request while Glen Campbell plays in my head.

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