Over My Head

When I'm on call, 5am seems to be the bewitching hour of every disaster I encounter. Like that old saying, "the hour is darkest just before dawn". This morning, I'm trying to put out a minor disaster when I got paged by a nurse who works in the physical rehab unit about a patient who'd had heart bypass surgery a week or so ago and is now diaphoretic and out of breath. I tell the nurse to put 100% oxygen on her and I'll be right there. I get down there and the poor lady was absolutely drenched in sweat, complaining of chest pain radiating to her neck, is severely out of breath, and her blood pressure is 70/30. Worried she's got a PE, I order stat labs: a chest xray, cardiac enzymes, blood gas, an ekg, and morphine. I'm seriously contemplating intubating her at this point, but she seemed to be maintaining her oxygenation okay.

While this was going on, I called the on-call pulmonologist and told her what was going on. While we're talking, the lady's blood gas comes back normal and her labs showed she was adequately anticoagulated. The pulmonologist told me she likely was not having a PE but she needs to be transferred to ICU and I need to call her cardiologist (who had already ben called but was slow in calling back). I get word that one of the nurses calls him and he is on his way. We started getting the lady ready to transfer. She was scared and really hurting. By this time I'm thinking she's having an MI. Her cardiologist walks in, looks at her, and I start telling him the labs I drew. He was pretty rude. First of all, he asks the patient if she's been participating in rehab or if she's just been lying in bed. She's so out of breath she can't answer very well. He then starts chewing on me, telling me that you can't have an MI after heart bypass therefore the cardiac enzymes I ordered are pointless. "Did it ever occur to you she might be having a PE?" he asks me accusatory. I told him it did but her blood gas is normal and her INR is 2.8. He's pretty pissed off. I tell him we have an ICU bed for her and he said she didn't need one, just transfer her to intermediate care (sort of in between a regular hospital bed and ICU). He then asked me if I'd bothered to order a chest xray and I told him one was just taken but I hadn't had time to see if was in the computer yet to look at it. He stomps off and I didn't see him again. The nurses helping me were angry that he was so awful to me. We got the lady transferred to the new room, on the cardiac floor. Her new nurses (experienced cardiac nurses) were clearly alarmed at her condition and didn't understand why the cardiologist was so flippant about it. I stay another 10 minutes and then realize there's nothing more I can do, she is the cardiologist's patient now and he needs to write her admission orders. 15 minutes after I left, she went asystolic and quit breathing. Finally, the cardiologist realized how sick she was. I mean, who am I, a mere intern 6 months out of medical school, to tell him when a patient is sick or not? I felt a bit of redemption, but it was at the unfortunate expense of the patient. She's still alive, but now she's on a ventilator and when I left, they were performing a ton of tests to try and figure out what happened to her. As I walked out of the room, he patted my back and said, "good job". I guess he knew he was wrong.

I got back to the call room and realized what a close call that was. This was my first experience with a patient who has heart failure and is decompensating right in front of me. If we delayed her transfer just 10 minutes, she would have either died in her rehab room or worse, died in the elevator on the way to the cardiac floor. Both locations don't offer much hope of survival. It still scares me when I think about it. I don't want to be on call anymore-ever.