Today I was working in the medical ICU again in the urban hospital, the Inner City Urban Hospital. I arrived there about 4:30 in the morning and the on-call senior resident was slammed. The whole unit looked like it was hit by a tornado; and so right as I got there, plenty early to help out, I received a bonus in the form of a very sick patient who had been transferred over from another unit without any information about her. So this was an inter hospital and inter department transfer. A dying, crashing patient.
Normally when I am not on call, I get there at 4:30 or so; 4:00, sometimes 5:00, whatever, and my job is to take current patients that we are already managing from days before. I am not responsible for new admissions when I am not on call. I start to see these patients in the morning and work on their current problems and treatments. Generally the person who was on call, particularly at 4:30 in the morning, is responsible for admitting those patients and later in the day we will help with new admissions. This was above and beyond my duties, but they had had a rough night, so the senior resident said, "Aw please take this patient in Room XYZ and she's very sick". And I said, "Well, what can you tell me about the patient". She said, "Aw nothing. They just dumped her here. I'm not sure who it is." That is how my day began. I went into the room to see a elderly lady, probably 91 years old, with extremely low blood pressure, you know, 50/palpable, meaning I couldn't get the diastolic. You know, normally 120/80 is normal. This lady was 50/who knows what. So diagnosis, or differential diagnosis in that kind of a scenario often includes sepsis or cardiogenic shock and there's a couple of other things that can cause that kind of presentation. Often with elderly patients, particularly who had come from a nursing home, sepsis is high up on my list for diagnosis. I looked at some of the medications that were running and from the department that had transferred her over to me, it became apparent that they thought this patient must be septic because of the treatments they were using.
However, this patient didn't look like a typical septic patient. It seemed like something else was going on. So I immediately began to assess the patient and examine the patient and found some notes about the patient and tried to sort out what was going on, but in the meantime, the patient was awake and her gag reflex was protected, meaning she wasn't about to lose her airway. So my first and foremost priority was covered and I did not need to intubate her to protect her airwaiy; but she was sick nonetheless and I needed to get her blood pressure up. I noticed she also had congestive heart failure. I did not want to slam her with IV fluids because you can essentially drown a patient who has congestive heart failure if you give them too much fluid.
My options were to give her pressors, which are medications that help your heart and vascular system move blood. I did an EKG, a chest X-ray, started some fluids very carefully and started her on medications, which brought her blood pressure up. That bought me some time. I started some antibiotics, in case there was some sepsis going on, and then I started to look at the patient's care to kind of see what was going on and basically the story was this was a "semi healthy" patient, but we weren't sure if she had dementia or not, who was transferred to our hospital from another hospital a few days ago; I think on Sunday, where she had presented to their emergency department for something we call altered mental status, confusion, and they admitted her and then realized the scope of her treatment that was required was beyond their hospital abilities and so they transferred her over to our hospital.
Initially she was on a general medical floor and then as she progressed to get sicker and sicker, at 3:00 in the morning, they decided to transfer her over to the ICU, and shortly thereafter I came into her life.
It's kind of like detective work to a certain degree. I just started reading her charts and notes and found some family members' numbers. I ordered a bunch of labs. As some of her labs are came back my suspicions were confirmed that this was not sepsis nor was it necessarily cardiogenic shock. I noted she had coronary artery disease and congestive heart failure and that was bout it. So I ultimately got a hold of some of her family members and had to talk to them about do not resuscitate, do not intubate and update them on their mother's situation, and I was able to find out that on Saturday night they were with her and she was fine, not confused at all. Then Sunday she started to get kind of tired and confused and that's when they decided to bring her to the other hospital. This information shed some light on what was going on and I was able to ask them about some of her past medical history.
As the day went on, her hold on life was tenuous at best. She was hanging on by a thread and I kept having to manage her medications to kind of keep her from crashing and ultimately, by late afternoon of balancing her medication, we never had to intubate her, but by giving her some forced oxygen, she was able to start turning around. Finally I did a 2-D echocardiogram, which is like an ultrasound of the heart, and was able to determine that she has pulmonary hypertension and basically a pretty bad heart, and so that gave us an idea of what was going on. It turned out it was a multifactorial combination of things that was causing her, to be sick and she's not out of the woods, but she is much more stable tonight than she was this morning when I inherited her. It will be interesting to see how she does over the next few days. In talking to her family, she is full code, meaning they want us to resuscitate, they want us to intubate if necessary.
This patient was one of the five patients that I was in charge of taking care of today. She took a lot of time because she was very sick. These are the kind of patients you take care of in the ICU. Another exciting day in the medical ICU.
No comments:
Post a Comment