The patient was admitted to me from the ER around midnight. I remembered him from a previous MICU stay. He was very sick with a terminal condition and he had not been taking his medications. When he came to me he was wide awake, talking, asking to get out of bed. I felt as if he looked sick but it remained to be seen just how sick he was. We couldn’t pick up anything from his pulse ox because of his poor peripheral perfusion. He was tachycardic. He asked me to use the urinal twice but was unable to make any urine. When an ABG was obtained, we were able to see the full story. He had worsening metabolic acidosis. He was breathing very rapidly in order to compensate. The resident came in and attempted to consent him for intubation. The patient refused to answer the question. He kept asking for ice chips and water, which are like the controlled substances of the MICU. The narcotics flows freely but the ice chips and water are carefully guarded, especially for the patient who is on the brink of being intubated.

So back and forth they went. The resident simply could not get a straight answer out of this guy.

“Sir, will you agree to have this breathing tube placed?”

“All’s I want is some ice chips!”

And all of a sudden, he stopped talking, his limbs started shaking violently, he looked up at me scared and confused, I grabbed his hand, and then he just went limp. His heart beat stopped, his ceased to breath. In a sense, he died.
But of course being in the MICU, death was not necessarily the end for him. We immediately began resuscitating. The code alarm was pulled and within seconds there was twenty people surrounding my room, eager to participate. This was not my first code but it was certainly the first one that completely took me off guard. I was just telling someone the other day that I had yet to do chest compressions and I felt as though I had better jump in and do it the next time the opportunity presented itself. To me it was the most intimidating part of the code. You need to really have muscle behind it. You pound someone’s chest until the ribs crack. I just didn’t know if I had it in me. But I was standing there, right at his chest. Another nurse had begun bagging him. So I started pounding away. I don’t know how long I managed to do it but I eventually became winded. And the charge nurse (who was one of the few people I had confided in about my early pregnancy) screamed, “Someone take over compressions for her! SHE’S PREGNANT!”

So I guess that was the official announcement to my workplace that I was pregnant.

And I so I started pushing the drugs, which is what you’re supposed to do if the coding patient is yours, because it is assumed that you know which lines are available to use.

And then he was alive again. Not alive, alive, mind you. But he had a blood pressure and a heart beat so he wasn’t dead. And now he was intubated. Later the resident came up to me and asked, “I did the right thing, right? He wouldn’t answer me so I had no choice.” And it’s true. You must do everything to sustain life unless the patient has told you he wanted otherwise. I completely agreed with his decision.

It was his next decision that I did not agree with. The resident, after consulting with the on-call fellow, decided to put him on high frequency oscillatory ventillation, or HFOV. In other words, we were going to switch him from the regular ventillator to the oscillator. I didn’t understand why. I mean, I understood the obvious answer, which is that he wanted to correct his acidosis and he didn’t think the ventilator was going to cut it. I do understand that logic. But by that time his pH was 6.73. and his CO2 was in the 90’s. What I wondered was how was he going to FIX the acidosis. Sure you can temporarily CORRECT it, or at least get it up to maybe 7.15 (which still really sucks).

But at that point you are simply chasing your tail. Antibiotics do not work fast enough. I am finally starting to learn these things from my own direct observations. When the pH goes that low, the blood sugar will also start to drop, precipitously. So it seems like all you are doing is pushing Dextrose-50 and Sodium bicarbonate, and waiting for the patient to die. So far I have not seen anyone bounce back from that scenario. If and when I do, it will make a believer out of me. Heck, if anyone out there has a story about someone bouncing back, please share it with me, it also may make a believer out of me.

But the oscillator? I really got this sense that they were just “playing around”, that it was more for research and experimentation than for actually curing the patient. Did I mention that his ‘terminal condition’ was end stage AIDS?
He coded once more during my shift and again we brought him back to life. At 7 AM I gave report to the day nurse. I left thinking that when I returned that night there would be a 50/50 chance my patient would still be alive. I would not be surprised by either outcome.

As it turns out, he didn’t even make it until noon.

I asked the charge nurse how it all ended.

“Well, he coded three more times before 11 AM. The third time I went in and said, ‘Does anyone have a problem if we call this?’ ” The fellow (who had OK’d the use of the oscillator) agreed that it was time to call the code.

I am finding that the more experience I get, the less things surprise me. But this one really left me astounded. Did the physicians really think they were going to turn things around for this guy? How many times can you code a person and still have a chance for a successful outcome? And as far as the oscillator is concerned, has anyone else out there seen it used to reverse severe septic shock? (And I mean for an adult patient, not a nenate or a peds patient, when I know it used more frequently). I would really like to have a physician’s perspective. What goes through your mind? Do you simply have this singular vision of saving the patient’s life at any price, and with any tool at your disposal? Does it sometimes take an outsider to step in and give you a different perspective?

To be fair, this did take place on the weekend, and the MD team that was taking care of that patient did not have the benefit of having an attending to advise them. Most of our attendings are quite good at taking control of the situation and deciding when ‘enough is enough’.

But I work at a teaching hospital, where our three-fold mission is “patient care, teaching, and research.” Sometimes it doesn’t seem to fall in that order. As it turned out, the fellow who approved the use of the oscillator had actually been focusing his research on HFOV. It makes you wonder. What if he had been focusing his research on Xigress? Would there have been a different outcome? I guess the other side of it is that this teaching must take place in order to produce competent practitioners. Our wonderful attendings, they aren’t born that way. They also had to go through the process of trial and error, and learning by observation.