I had needed to vent. Needed to ever since seeing my very first patient early this morning. It upset me, can not explain just how much it upset me. However, I couldn't wait until arriving home this evening, it steamed out of me at the slightest of invitation that someone would join me in my outflow of words. And now, I don't need to vent any longer.
But I am still distressed. I am saddened and distressed.
As the 2nd year resident on the team my job in the morning is to round on the "outlyers" Meaning I must run around from ICU to ICU and between all the floors seeing all patient's not on our surgical floor. Once done I then join the rest of my team on the surgical floor with the goal that I have done so prior to them finishing their own rounds and then we run the complete list of patients together.
My first stop, the MICU (Medical Intensive Care Unit). Last week we had emptied a patient's belly of over 5L of bloody ascites and old blood clot. Since then we've been waiting for a liver to come available for transplant. The patient was very sick, hence why a critical level of care was required. As per ritual I check the morning labs prior to rounding and and noticed this patient's to be completely out of whack, which was kind of normal as per the patient, but these were a little more out of whack than usual.
Let me set the scene for you that I found this morning. The MICU was quiet, lights dimmed. My patient's nurse was sitting calmly outside the room on her computer. The medicine residents sitting over by their own computers. No alarms sounding at all. I start conversation with the nurse to find out about the night's events. She informs me that the patient is probably going to be taken off the transplant list. Surprised I ask why, to which she shrugs and says the patient isn't doing well. I whirl around and enter the room to try and figure out what's going on.
- Patient's vital signs were in the tank, covered-with-mud bottom of the tank. The last blood pressure showing on the monitor was 47/14, taken by a cuff set on cycle every 15 minutes, so who knows when that blood pressure was. I clicked for a STAT measurement and it came up ??/??. I feel for a pulse at the neck, nothing. I move to the groin and find a thin, but strong pulse. Reassured that the patient wasn't already dead, I moved on.
- What was being done for the patient's nonexistent blood pressure? One measly liter of fluid was being bolused via a TLC. And not one, not two but three pressors were flowing in at max rates.
- By this time one of the residents had wandered over to observe what I was making a big deal about. I ask him about why an arterial line wasn't in this patient. Anyone on one pressor should have an arterial line, let alone three. In addition, the cuff BP had ceased to be reliable. To what end are you attempting resuscitation if you don't have a mean arterial pressure?!?!?!?! I asked in a quick pondering way in hopes the resident would take a hint and not offense at the suggestion.
- And as for "attempting resuscitation", one liter was going to do as much for this patient as a drop would make a difference in the ocean. Blood was needed. I also hinted at massive transfusion protocol, in a way hoping to light some sort of urgency in this resident, a spark, a flicker, really just any kind of reaction out of him. He responded, that they were waiting for repeat labs to be sent and resulted!?!?!? (haha, oh ok I see, you're waiting for labs. and in the meantime, THE PATIENT DIES!!!!!!!!!!!!!!!!!!!!!!!!)
- Thankfully a fellow had shown up at that time who seconded my opinion. He had come to scope that patient as admist all of this the patient had started bleeding from orifices. I was surprised that he was going to scope, and told him so. At that time, without proper resuscitation, if scoped the patient was sure to Code.
- I turned to the resident again and reiterated the need for an arterial line. To which he muttered more under his breath than either to me or the fellow that was there, "why? the patient's been like this for the past 3 hours." 3 HOURS!!!!!!!!!!!
I am just a junior resident, and have just as much to learn as the next idiot out there, but even I could tell that this was wrong. This was so wrong. No matter what direction you looked at it. Wrong. I had to leave, I could not stand by and watch such poor mismanagement in action. The quick explanation above is only half of what I had encountered from the time I entered the MICU this morning to the time I left it again.
A couple of hour laters I come across my Attending who had been present at the time the fellow had attempted scoping the patient. The patient had indeed coded, for which no one in the MICU had responded. My attending was livid, even moreso than I had been. To the point he was threatening to have the MICU closed down!
I just don't understand. It is distressing me how I just don't understand how badly that situation had been allowed to become. How anyone could have been sitting outside of a room when your responsibility is inside the room of an actively dying patient.
And one last question, where was the MICU Attending in all of this. Had it been TICU, and I the resident, I would have called for help immediately.
I am still so steaming mad that it makes me sad to the point of tears. It makes my heart hurt.
Much Love.
