A Pulse of 288

The ICU attendings talk in code.

I’d been on my medical ICU (intensive care unit) rotation for a week, and I was still having trouble wrapping my head around some of the patients who had been there for over a month. This one man had been intubated and on a ventilator for a month and a half after having a heart attack, and had gone through so many different antibiotics for fever – “Stop the ceftriaxone, start meropenem,” then, “Let’s add inhaled tobramycin and stop the ceftriaxone” – that I wasn’t sure what we were even treating anymore. The patient also wasn’t waking up, and the running diagnosis was “toxic-metabolic encephalopathy.” Finally, while working nights, I had the chance to query the attending, Dr. P. “What does that even mean?”

“Oh, it mostly means we don’t know.” He joked. Then why can’t we just say that??? In reality, he said, he probably was not waking due to his critical illness, but sometimes we just aren’t sure.

This poor guy’s wife had been showing up to the ICU every morning, faithfully sitting in a hard green chair between the ICU bed and the partially shaded window. She wasn’t the easiest to work with, frequently rebuffing our attempts to discuss his case with her and demanding to speak only to the real doctor – a.k.a. the attending – about her husband’s condition. It’s hard not to be offended by someone who thinks a resident spending 70 hours a week steeped in a warm bath of critically ill patients after jamming their brain cells full of medical facts for the 4 years prior would be somehow unqualified to update you on daily events. But at the same time, we haven’t fully developed yet the confident linguistic dance of simultaneously saying “I don’t know what’s going on” while still giving the family the idea that we do, in fact, at least know what we’re doing. But moving past the injured pride, I do find myself respecting this woman who lovingly sits there, watching over a man who has aged 20 years in a month and lies in bed, connected via a tube coming out of his gaping mouth to a machine that’s doing all the breathing for him.

Anyway, I hadn’t seen her that day because I was switching to the night shift. The night had been fairly quiet – no admissions to the ICU. The only thing that had happened so far was that one of the nurses had flagged me down to look at some poo. (Glamorous, I know.) “Does this look like melena to you?” She asked. (Melena is a beautiful term for poo that looks like digested blood.) I stare down at this watery, tarry mess between the patient’s legs emerging in a spring behind his scrotum, and agree. Sure enough, the patient’s blood counts had been steadily dropping for 2 days, slowly enough that no one really thought anything of it. We gave him a blood transfusion, stopped his blood thinners, started him on acid suppressing medications since the bleeding was probably from an ulcer, and then called the gastroenterologist so they could put him on the schedule to scope him in the morning. In the ER I’d be corralling drunks, sedating people on synthetic marijuana, and treating a guy with chest pain while also dealing with this bloody poo. So, like I was saying, just a slow night in the ICU.

Slow that is, until a different nurse comes over to the resident room – our room with computers and non-ergonomic chairs where we can get away with eating snacks at night but not during the day – and informs me that our intubated man who has been there for over a month suddenly has a heart rate in the 170s. I walk into the room and he looks exactly the same as always: mouth gaping, eyes half open, only his heart is in this crazy rhythm we call Afib with RVR. It’s definitely too fast and too much work for a heart that’s already been through a couple months of the wringer. We give him some meds to slow it down, while I text Dr. P to let him know. The attendings at night hide in a call room. I imagine the attendings’ room has a luxurious bed with actual sheets, a sofa with throw pillows, and maybe even a framed painting on the wall. We usually just text them for minor happenings and tell them what we are going to do. Three years into residency, we’re months away from being bosses ourselves, so they tend to give us a lot of free rein.

Unfortunately, the man’s heart rate wasn’t really budging, so I texted my next plan to Dr. P. I watch the little dot-dot-dot quivering on my iPhone screen until he finishes typing his response. “I’m coming.” And that’s the moment we crossed over into major events.

Within minutes, I hear the mechanical sound of the automatic doors to the ICU groan open as Dr. P arrives. He suggests a different course of action and asks the nurse to give a a few rounds of metoprolol while we sit at the bank of computers outside his room having a rather intellectual conversation for 3 am about treatment options for Afib with RVR (the crazy rhythm), until my intern calmly walks over, “His heart rate is 288.”

Dr. P doesn’t look up, not registering the number. “Okay, good.” I’m already out of my chair, rather alarmed. I have to forgive him for not reacting though, because my intern, while still only in her first year has a low, honey-coated voice that never sounds insecure, scared, or otherwise excitable. Dr. P heard an intern sounding measured, and registered only the reassuring tone. But being used to working with her, I heard “You should come now.”

The number 288 blinks rapidly on the monitor as it screeches. He’s in VTach. (We’ve skidded past crazy rhythm squarely into deadly.) I reach for his carotid, knowing I probably won’t feel a thing and I don’t, and in a moment rehearsed to the point of not requiring active thought, I start compressing his chest and tell the nurse to call a code. Dr. P walks in, “What did you do?” insinuating that I broke him. I laugh, “Sure, blame it on the resident.” And yes, I laugh. What else can you do up to your eyeballs in disease and death but find humor when you can? We cared for this man, we respected his family’s wishes to just keep him alive, we spent hours putting our heads together trying to squeeze out of our vast cumulative knowledge of medicine a drop of hope. A little laughter goes a long way to keeping us sane, and allowing us to, in these critical moments, focus on what we can do for a patient, and not how badly we feel that with all of our resources and knowledge we still can’t keep this person above ground.

The rest of the nights major events involve a flurry of CPR, return of pulses, the patient’s oxygen plummeting and him turning blue before we had to start CPR again, return of pulses, starting 3 different medications to maintain a livable blood pressure, the wife running into the room after what must have been a nail-biting drive, a discussion with the family to not do CPR again, and finally the family slowly coming to the decision at 7 am to just stop the meds and disconnect the ventilator. A letting go that was months in the works, we finally allowed this man to ease into death, surrounded by his family and his ever-present wife. In the morning after rounds, I walked down to the chipper people in the admitting office only an hour into their day to sign the death certificate with my electronic fingerprint. And in having to lay out cause of death, I felt like I finally understood this man’s whole hospital course.

A man died, but I learned something, worked with talented and amiable people, and gave a family peace. It was a good night. I said a prayer for him as I brushed my teeth before slipping into bed.

“Protect us Lord as we stay awake. Watch over us as we sleep. That awake we may keep watch with Christ, and asleep rest in his peace.” It’s from a night prayer, and likening death to a long sleep, I pray this for all my patient’s that die, hoping that they may finally have some rest.

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