The patient in front of me is trying to die. Elderly and frail, he is lying in bed. His ribs are outlined under skin that should be smooth. His temples are concave where they should be flat. Both are an outward display of internal damage from his lung cancer. More striking than his cachexia are the strained muscles in his neck and his pursed-lip breathing.
He is working hard for each breath, drowning in the air around him, from his cancer or pneumonia or more likely both. It is my first night on call as a senior resident in the ICU.
It’s early in my second year of residency at the University of Chicago, where I am splitting my time between internal medicine and pediatrics. The ICU is outside my comfort zone, with its rapid pace, large volume of data to process, and the complexities of multiple failing organ systems to manage. I am both intimidated and inspired by those who seem to recognize patterns, synthesize information and anticipate problems with ease.
I want to be like them. I want to face my fears head on. I have chosen to be here, to prove to myself that I can do this. I am capable of caring for the sickest of the sick. And now, in the middle of the night, without a supporting daytime cast of residents and attendings, I am anxious for my first test. And it happens to be the man in front of me struggling to breathe.
I want to be here. I want to be a critical care physician. I know what to do.
ABC. Airway, Breathing, Circulation. He has “A” (an airway). He needs “B” (breathing). His “C” (circulation) is fine, his blood pressure for the moment is good. The team, two interns and I, prepare to intubate — place a tube into his lungs to help him breathe. I have been reading for months about managing patients on a ventilator. The perils and the pitfalls. I have reviewed chapters in books written by my attendings, whom I will report to in the morning. I am ready.
Anesthesia comes and places the tube. I run fluids to prevent low blood pressure. I start medicine to sedate and calm my patient. I call out ventilator settings to help breathe for and give oxygen to my patient.
It all goes wrong.
His blood pressure drops dangerously low. He is thrashing around in bed, working even harder than before. Alarms on the ventilator are beeping. His oxygen levels are now critically low. He needs more sedation to calm him, but that will make his already low blood pressure worse. He needs medicine to help support his failing circulation, but it requires a special IV, a central line in his neck or groin. I have placed a few, but not in critical situations, much less in a patient moving all over the bed.
I try different settings on the ventilator: Settings for pneumonia, with high oxygen and more pressure and settings for COPD, with quicker but smaller breaths — all to no avail. He is not following the books I have read nor any pattern I recognize. He has gone from bad to worse and is now close to death.
I breathe. All eyes are on me. The nurses, the respiratory therapist, the interns are all looking to me, the senior resident, to take charge and help this patient. But the puzzle of my patient’s physiology is beyond my recognition.
“Call a code.”
The nurses look puzzled, “But he is not coding. His heart hasn’t arrested!”
“He’s about to. Call it. I need more people here. I need help.” (go to page 2 to continue reading) [lz_pagination]