When I was a brand-spanking-new intern, I took an ICU call that was so scary it nearly gave me PTSD. This fearless senior resident was supervising me—and thank God she was, because the way people were coding all over the place felt exactly like stepping on landmines. My upper level was an Army Ranger of a resident; she had already secured a spot in a Pulmonary/Critical Care fellowship, and was basically like a mini-ICU attending. To that, all I could say was hallelujah.
The ICU scared me. Every single page that came through was about something really, really serious. No “Can you write for a stool softener, please?” or “Can I get a verbal for some pain medicine?” calls. Nope. Every beep was for the hell that was breaking loose in some part of the unit—and let me tell you, hell was breaking all the way loose. I was so glad I was being covered by someone who knew what to do.
Now, ICU nurses are, by definition, tough as nails, and generally don't go bothering folks with simple things. These nurses were not only knowledgeable, but excellent teachers for new interns. So, between the unit nurses and my hard-core resident, I had great support.
It was a rough evening but the hell that was breaking loose for most of the night eventually did slow down. At that point, the unit was full, and my resident told me this “was a good thing because now we couldn't get anyone new.” I decided to believe her, relaxing my new-kid-in-school expression and even laughing at a few jokes.
I guess I got a little too relaxed.
Holding down the fort
All that easygoing laughter must have made me look more confident than I was. That's the only explanation for what could have possibly given my resident the unwarranted faith in me to nonchalantly shrug her shoulders and say to me, “I'm gonna go and get me a few winks since I have clinic tomorrow. I'll be back in two hours and then you can go get a couple of hours before rounds. You hold down the fort, okay?”
Dude. It was 2 a.m.! That meant I had at least five hours of potential hell-breaking-looseness remaining!
This resident was responsible and hard-working, and I know she would have never left me if she didn't think I'd be able to manage things. But the thing is, I didn't agree with her. I was NOT ready for prime time. And being alone in the ICU at 2 a.m. was definitely prime time. I offered her a sick smile but tried my hardest to look easy-breezy. Behind the cool expression was somebody screaming and waving her hands like Prissy in Gone with the Wind, “MAMA! DON’T LEAVE ME MAMA! I DON’T KNOW NOTHIN’ ‘BOUT BIRTHIN’ NO BABIES!!”
She didn't catch on. “Call if you need me, okay?” And before I could say a single word, she had disappeared through the automatic doors. Just like that.
I remember standing in one place, kind of like some city dweller plopped in the middle of the Amazonian rainforest at night. I was scared to move, speak or breathe. All I did was pray in my head, “Please let nothing happen, please let nothing happen.” I felt my stomach rumbling and my pulse quickening. I repeated my pleading prayer. “Lord, please let nothing happen. Please let me not hurt anybody. Please let nothing happen.”
And for about ten minutes, nothing happened.
I sat in the nearest chair gripping my sign-out cards. I jumped every time I heard a beep or an alarm on one of the vents. For a little while, I even held my breath. And eventually, I decided to put my head down on the nurses' station. Exactly one second after I laid my head down, my pager went off. Before I could even dial the number, I overheard Ida, one of the ICU nurses, yelling for me to come.
“Doc! Doc! Are any of you guys still over there?”
The urgency in her voice made me feel sick. I knew this was going to be something and not nothing. I wanted so bad for it to be nothing. So bad.
I scuttled over to Ida and, in my most confident voice, asked what was going on. To answer me, she handed me a strip of paper with an EKG tracing on it. It showed intermittent runs of ventricular tachycardia—the kind of heart rhythm that precedes a cardiac arrest. I sifted through my brain for a logical approach to what was surely about to be a problem.
Mr. Jones was the 71-year-old patient in question, and had just turned the corner after a near-death experience with multilobar pneumonia. He'd been intubated for nearly a week, and had just been extubated earlier that day. According to my sign-out notes, he was now in a step-down bed and was “doing just fine with nothing to do.” Nobody said anything about v-tach.
My brand-spanking-new intern brain wasn't on autopilot yet. I took a deep breath and thought for a second. Electrolyte abnormalities? Was his potassium high or his calcium low or his magnesium low? Was he hypoxic? Were his medications somehow screwed up?
Ida must have read my mind. She'd been an ICU nurse for much longer than I'd been an anything, so before I could say a word, she rattled off answers to my short list of thoughts.
“Lytes are all normal—potassium is 4.1, calcium and mag are stone-cold normal. Tolerating the 40% ventimask just fine and oxygenating at 95%. Renal function is also fine.”
I swallowed hard as I listened to all of that. Crap! Now what? Ida went on. “We were going to transfer him to the floor earlier today, but the attending decided to just watch him overnight to be safe since he'd had such a tenuous course. That was a pretty nasty pneumonia he had, you know?”
I nodded while staring at Mr. Jones. He didn't look good. His face had a grayish cast over it and his brow was covered with sweat. The whites of his eyes looked unusually white, enhancing what I am sure was an expression of fear. A sinking feeling rooted in my stomach and suddenly I recognized something that my senior had been trying to teach me for the past few weeks—the sense of impending doom.
Impending doom. That gut feeling that tells you that things are not right. It's how you know who is sick and who is sick-sick. This man was sick-sick.
“Mr. Jones? Sir, are you okay?” I asked. A dumb thing to ask because he obviously wasn't okay at all.
His response was a widening of his eyes and an anxious pant. I looked at Ida.
“Come on, buddy. We're okay.” She tried to prop him up with some pillows and readjusted the pulse oximeter on his finger. She pushed a button to recycle his blood pressure. “Doc, I sent off some cardiac enzymes and checked a twelve-lead EKG on him already. Other than a few premature beats, it looked okay.”
From bad to worse
The cuff slowly deflated and eventually displayed an error sign across the LED screen. Ida grabbed a manual blood pressure cuff before I could register what that meant and began attempting to check his blood pressure. All of a sudden, she pulled her stethoscope out of her ears and growled, “Dammit! We don't have a pulse!”
Famous last words. We. Don't. Have. A. Pulse.
No. “We” don't have a pulse, nor do we have a spine. I am 100% sure that, had I had time to eat dinner that evening, I would have evacuated my bowels right then and there. This wasn't supposed to happen. I wasn't supposed to be the one leading a code on Mr. Jones. He was supposed to wait until my resident was awake to have his v-tach and his no pulse.
“We need some help in here!” Ida bellowed to her fellow nurses. They quickly ran to her side.
Things started moving fast all around me. Ida quickly let down the head of his bed so that his feet were elevated. This position, called the Trendelenburg, assured blood flow to the brain when patients became hypotensive. Before I knew it, the room was filled with ICU nurses, industriously positioning themselves to save Mr. Jones' life.
But the problem was, there were no other doctors.
See, here's the thing. The ICU nurses already knew what to do. They had paddles nearby and were assessing his cardiac rhythm. They were doing chest compressions. They were drawing up meds and handing me gloves. The respiratory therapist pushed a mask over the now somnolent patient's face and began bagging in oxygen. And me? I just stood there with my gloves on. Paralyzed with fear. Terrified to say or do the wrong thing.
Ida saw the terror in my eyes and whispered in my ear, “Come on, baby. You can do this. We got you, baby. Just think it through. We got you.”
And you know what? They did have me. They really did. I carefully walked through the stepwise interventions in the Advanced Cardiac Life Support protocols as experienced nurses helped me through it. They gave me gentle suggestions and firm “uh-uh, baby”s when things weren't going in the right direction. It was like walking a tight rope with pillows all around you.
Finally, we regained a rhythm for Mr. Jones and the anesthesia team reintubated him. Shortly after, my resident came in and helped with the rest of his stabilization. We confirmed his ventilator settings with the respiratory therapists and reviewed the stat lab results that had just come back. After a few more tweaks, he had turned the corner. “Strong work, Kim!” my resident said while suturing down an arterial line in Mr. Jones' wrist. “You saved Mr. Jones' life.”
I saved Mr. Jones' life? Uh, I don't think so.
I glanced over at Ida who was now across the room giving report to the nurse on the next shift. She smiled and gave me a thumbs-up. I tried to profusely thank her before she left that morning, but she disappeared before I could.
And so, Mr. Jones lived. The sun came up a few hours later. I gathered information on my patients for that upcoming morning. And rounds happened at 7 a.m.
On rounds, my resident told our attending, “Kim saved Mr. Jones' life last night!”
To which I responded, “The nurses were amazing. Especially Ida.”
No, I can't exactly say I saved Mr. Jones' life. We did it together. And the way I see it, that night it was an RN who saved my life.