On Call: Code Blue

Headed up to the ER at around 6:45 or 7, after dinner and before Miricups went to bed. She had a patient there, vaginal bleeding, possible miscarriage. Got the ultrasound out and took a look - nothing but debris in the uterus - and by her scalebook she'd had a 7w ultrasound 6 weeks ago that showed no fetal heart tones. Cervical check was closed and bloody; she wanted to go home and come back for a D&C in the morning.
Dear Dr. Stiver: Thank you for taking me in on the molar pregnancy D&C. We just did one here and Becky was glad I knew something about what to expect. There was a startling amount of tissue, just like you told me there would be. You will be interested to know that we can only monitor her HCG status here by doing serial dilutions of urine pregnancy tests.

And then after that there was an infected foot to review and then there was the three month old with the fever of 39.7 (103.4 F) to get a lumbar puncture on (with an 18ga standard needle), admit to ward A, bed floor-I (peds is full; they're lining them up on the floor in the middle of the room) with some of our precious Rocephin for his cloudy blood-tinged CSF, and then I got a call from C-ward about this woman with abdominal pain. So I headed over there and I called Becky-my-backup and I put my hands on her belly and we ultrasounded her ginormous liver and there was nothing else abnormal about her exam. Belly was soft, very tender, bowel sounds faint but present, visible peristalsis on ultrasound. We wrote for IV antibiotics and IM morphine and some labs to be done in the morning and weren't sure what else to do.
And then I got calls every 30 minutes, it seemed, about this woman. "Dr. Nicole, we made a mistake and gave this woman 5mg of IV morphine. Her pain is better, respirations are 24." Call me if they go down to less than 10. "Dr. Nicole, her pain is back, it's been an hour since we gave her the morphine IV by accident. She's doing okay." All right, you could maybe try some IM now. I think I told the same nurse four times that it would be ok to give the patient pain medicine, and maybe that should have been my clue, but there is this curious quality to talking with nurses here: we both speak English, except we don't. And I was busy with learning how to reduce a dislocated shoulder and I went home at 10:15 or so, and then the phone wouldn't stop ringing. "Her pain." It's still alright to give the IM morphine you haven't given yet. "She hasn't eaten, she's shivering, can we feed her?" Put some D50 in her IV fluids (we don't have any D5 currently, so it's 1 liter NS plus 1 amp D50 to make D5NS, good as we have). And my thoughts were somewhat less than charitable at the point I got the call "She's having vaginal bleeding." Is it her period? "I'll go check." Five minutes later, phone ringing again. "She hasn't had a period for 8 months before now." Well, I know she's not pregnant. Ten minutes after that: "It's just a spot of bleeding really. But she looks very pale, and blood pressures all day were 60-70's-" (first I'd heard that) "- so we got a CBC, stat. Hemoglobin 11.2, WBC 8, platelets 14." And I called Becky, who suggested maybe I should get back in the Tracker (please imagine me driving a gigantic 4WD diesel truck thingy) and drive back up and see what was going on. The whole thing was just weird. And - reluctantly, because nobody on call likes getting out of the bed they've just gotten into at last - and with a whole lot of bad-natured grumbling - I got my skirt back on and started to head for the door. Ring! Nurse 1: "She's sort of almost coding now." I'm coming! "OK." Ring! Nurse 2: "How fast should I hang the IV fluids." I'm coming, just wait.

And I got there and she really was sort of almost coding; they were bag-ventilating her, and she was sort of maybe responding to my questions, and her extremities were the cool-pale of a code. And the ultrasound didn't look any different than before, and she still winced a little when I pushed on her belly, and then she stopped wincing and stopped responding and stopped breathing and then she stopped.
They have a code cart here, and I'll freely admit that I coded her blindly - no EKG's, no IV pumps, my only fluids were D5NS. She had a heartbeat, but no pulse, so we did compressions and ran D5 wide open in case her sugar was low and I found some Narcan that was only 8 years out of date and pushed it, and some epinephrine that was only 5 years out of date, and some atropine similarly. And sometimes she had a pulse and sometimes she didn't, but she didn't breathe on her own, and eventually after a few rounds of code drugs and some on-the-fly teaching about how deep to do compressions (I felt one rib crack, oops) and how to adequately bag-ventilate an adult (pointy end of the mask over the nose, oxygen tubing attached to the bag or mask) and how to check for a pulse properly (carotids or femorals, not brachial, and that's your own pulse you're feeling) I looked at the medicines I had available to me: dopamine, epinephrine, ephedrine, atropine, all the things that go in a code cart, and some of them might even be in date - and I thought about how codes were run where I came from, and about hanging dopamine or something like that, and about how there wasn't an ICU or a ventilator, and I told them to continue compressions and I called Becky.

Becky told me I'd probably done more than anyone else on station would have, and that it was all right to stop. So I went back, and in my absence the thready thud-thud of her heartbeat had at some point ceased. I had them hold compressions. I listened. They listened. I didn't argue with the nursing student who wanted to try one more round because he thought he felt a pulse - I remember that kind of desperation - but after that, I told him he was feeling his own. Don't check at the brachial artery.
Her family was quietly dignified about their grief; I wrote a code note and they sobbed but did not wail. One of the other patients - apparently a relative; remember, this all took place in a ward of beds only a few feet apart - came over to cry with them. And I prayed, and I took my bag, and walked out into the night feeling painfully inadequate.

I don't know what happened; I think if I knew then it might make things a little better. I have my suspicions - overwhelming sepsis (platelets 40 this morning, 14 now, but you can't always rely on the lab accuracy), fulminant hepatitis, some kind of non-visualized abdominal process - but I'm going to have to put this one on the list of things to know at the end of things. And that's hard for me, so very hard. And part of me wonders - if I'd had a CT scan, all the labs I wanted, if at 7:45 I could have gone looking for that elusive something - would it have made a difference? I want to believe it wouldn't have, so very badly, but I can't make myself know that.

And I feel so guilty for thinking badly of the nurses; I can't help but wonder if they had been trying to tell me something, and I was too tired or arrogant or not-listening to hear it. I find that the hardest piece in all of this to let go of, somehow. If I had listened differently, instead of with my frustration at repeating the same things over and over, would it have changed things? Probably not, not if she was septic. Not if her liver was failing. We don't have anything more than we did for things like that, here. But I'm finding it hard to forgive myself for it, right now, which is why I'm up, writing, at 1 AM - and not sleeping like I probably should.

Lord, let me listen with an open heart, and hear what is really being said.