Thursday, March 17, 2005

Another sick one

Had another one today. New admission, young-ish male in his 40's, admitted for what appeared to be pneumonia. Cough, left-sided chest pain, some consolidation on chest X-ray. Already on anticoagulation for something else, so pulmonary embolism was much lower on the differential. Admitted to my junior on the floor.
I got involved when she came up to me to ask what I thought of this arterial blood gas pH of 7.1! Asked her how he looked, and she said he looked short of breath but otherwise fine. Thought the numbers didn't make sense, so I thought I should see how he looked.
Checked him out, and immediately knew he was in trouble. Tachypneic at 40 breaths a minute, tachycardia 140's, pulse ox 80's and very diaphoretic. Spoke briefly to him, then scooted out of the room to call the ICU to make tranfer arrangements. Because he looked like he was going to crum any time, asked him about his code status: Full Code.
Rushed him to the medical ICU. In fact, room's right beside my other MICU patient from yesterday, and signed out care to the MICU team (we're Gen Med). Within minutes, they intubated him.
Now, at 122am, he's hypotensive, on 2 pressors. Probably in septic shock despite the antibiotics. My colleagues gave me an update; basically, he's coded once every hour. Keeps going into PEA (pulseless electrical activity). His last ABG showed his pH to be 6.8 with pCO2 greater than 100.
I just spoke to him this afternoon. He looked sick, but was able to talk. But now, he's not going to live to see tomorrow. And he has no family around.
Life can be so fragile.
This brings back some haunting memories. Things I still see in my nightmares after a bad day:
  • That young male patient with advanced myeloma, who developed a tension pneumothorax after he had a central subclavian line place. I saw his pressures drop to zero. Despite the surgical resident's heroic efforts to put in a chest tube.
  • That dialysis patient who coded when I was an intern and 2nd in line on the code team. I did the chest compressions, and I remember exactly how it was, me straddling his chest and pushing, feeling the ribs crack. Crack, crack. I still feel it.
  • That middle-aged gentleman with a mitral St. Jude's valve who developed a huge right arm hematoma while on coumadin. We had to stop the anticoagulation; we had no choice, knowing the risk of clot formation. I was at clinic when the oncall resident paged me: Your patient is coding. By the time I rushed over, he was gone.
  • That elderly patient I had in the cardiac intensive care, who kept going into pulseless ventricular tachycardia. We coded him many times that night. Shock shock shock, 300 joules. Until his wife said, enough, let him go. I still hear the cardiac alarms in my dreams.


Blogger PaulOS said...

How'd he get so sick? The general classification of this sickness is Pneumonia or what?

Do pray for him..

3:09 AM  
Anonymous Vagus said...

He passed on shortly after I blogged.
Still not sure what's going on, my suspicions: pulmonary embolism (clot in lungs) or a really bad bacterial pneumonia.
He was supposed to be on anticoagulation, but his bloodwork showed he wasn't so a clot is still a possibility.

6:43 AM  
Blogger vagus said...

Autopsy: staph aureus bronchopneumonia with sepsis.

10:00 PM  
Anonymous musical said...

huh???? can elaborate more?

1:13 AM  
Anonymous Vagus said...

he had a lung infection with a bad bacteria called staphylococcus aureus. this also infected his blood causing him to be septic.

6:51 PM  

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