So strange.
After parting with my team today, only saying a proper goodbye to the attending because I'll see the fellow again tomorrow to pick up a letter she's writing for me I went to get the signed confirmation that I'll need for my medschool and turn in my pager. After that, I went up to Brainy's office to say goodbye to her, arriving at the same time as the heart failure team that wanted to round. But Brainy was on the phone anyway and they let me trade goodbyes with her before they started.
It was only after I left her office that I started feeling sad. Like they always say .. you never know what you have until you lose it. Working here was fun. I've pretty much decided not to come to the United States permanently - but that certainly wasn't for the work environment.
Walking down those halls in my terribly ugly short white coat towards the exit for the very last time even choked a heartless person like me up a little. And as if in agreement, a hot summer rain had started just around this time.
Thursday, May 31, 2007
Wednesday, May 30, 2007
Excitement
The day started out as usual, went up to A700 to get breakfast after getting up to speed with my patients from the past days. I hung out with some Germans and listened to morning report, which was about an interesting case of a 28-year-old pregnant patient that presented to two different ERs with a cough, one of those ERs being ours, both of those ERs making a chest x-ray (yes, on a pregnant patient!) and sending the patient home, both ERs calling the patient back into the ER after having taken a second look at the x-ray. After they did a CT at the U of Chicago (yes, patient still pregnant .. at least pre-CT ..) they found her to have sarcoidosis.
But that was not the exciting part. Neither was my stroll afterwards, at around 11am to the cardiology fellows' room to check in with Missy. She said that she hadn't gotten a consult yet and with a smile on her face offered that if there wasn't a consult by noon, I should go home (the weather today is what other people would call gorgeous .. I actually liked the mostly air-conditioned interior of the hospital at that point). Even when she said that though, I knew that wasn't going to help her karma. It's those days where the morning seems like nothing's going to happen that come back to bite you in the ass. Which was good. I wanted to do consults. That's what I'm here for.
So I left the fellows' room thoroughly expecting the page that came half an hour later about a patient in one of the surgical ICUs. She had received a left lung transplant yesterday. Somehow I still have a high level of respect for lung transplants. But the way they have simply extubated the patient this morning, just about 12 hours after surgery and the way Missy would just send a foreign med student that's still coughing once in a while to see this highly immunosuppressed patient breathing with someone else's lung for a few hours now started wearing down this respect.
Anyway, I went up to that ICU and spent the rest of the time until noon getting started with the consult, jotting down her history and deciphering some of the surgical (i.e. minimal and cryptic) notes of the past days. The reason we were called was that the anesthesiologist who did the intraoperative transesophageal echo found severe mitral regurgitation. I looked at the pre-transplant workup and found a right heart catheter from just a few months ago numbering her pulmonary capillary wedge pressure at 1 mmHg which all but rules out any mitral regurgitation back then. That means if she had MR now, it would have to be rather acute. So I did check in on the patient - who was doing remarkably well, obviously having pain in her chest on day one post surgery but was very lucid and pleasant to talk to - before going back to A700 for lunch and an interesting infectious disease conference on endocarditis.
I had meant to go back to finish the consult about half an hour into the conference, after having enjoyed the excellent free Potbelly lunch. But the presenter from ID did such a great job presenting that I stayed until the end at about 1pm. So that's when I went back to the ICU.
After settling down again with the patient's charts (because they have two on ICU) I happily scribbled away at my consult sheet when the surgical resident from the primary team asked me whether I was from cardiology.
Sure.
- Oh good. Cardiac enzymes just came back positive. Did you see the EKGs?
There were EKGs? You drew enzymes? What's going on?
- Oh the EKGs are not in the charts, huh. Let me see if I can track down the nurse to find them.
And off she went after the nurse to get the EKGs. While she did that, I brought up the patient's labs on oacis and sure enough, she had had cardiac enzymes drawn this morning at 2am and again around noon. The latter ones had just come back positive with a troponin of 0.26 - with the 2am ones already at 0.16. CK-MB ratio was also mildly positive on both.
Just about after I had found this out, the nurse came around with two EKG's from the patient. They had almost identical time stamps to the two sets of cardiac enzymes, 2am and noon. The 2am EKG looked normal enough. The noon one had pretty impressive ST elevations in the inferior and lateral leads, yet not in the anterior ones. With scaredly-widened eyes I looked up to the nurse (the surgical resident had apparently taken off again) and asked her if the patient had chest pain with this.
Of course the patient had chest pain.
Duh. She had had her left lung replaced yesterday.
So this patient had chest pain, positive cardiac enzymes, a new onset of localized ST-elevations on a day after major surgery and I seemed the only one freaking out about this. That couldn't stay that way, so I paged Missy with a text page saying just that - something along the lines of "pt has cp (confounded by surgery), + enzymes and ST-elev. I think you". Apparently, as I later learned, I must have sent the page before I was done writing it because it ended in the middle of a sentence and before I gave a call-back number or my own pager number to identify who sent the page. This may have happened because I was showing Jen, who happened to be there, the EKGs and running to the patient's cubicle to look at the vitals on the monitor while writing parts of the page. Which was why Missy never called back.
Jen was seeing another patient and had come over to chat so I showed her those EKGs. Being a nephrologist, she said she hadn't been reading EKGs in a while but agreed this together with positive enzymes was likely to be either pericarditis or an acute myocardial infarction.
I knew this had to happen on a day that Missy wants to send me home at noon. With Missy not answering her page (which she couldn't as I only found out later) I went to the most extreme measures, came into the patient's cubicle and talked to her. And when asked about it specifically, she'd say that she had no pain in her chest - unless she moved.
Phew.
Her vitals were stable, on two pressors admittedly. But stable, and the patient had no chest pain at rest. Then again, she had a high epidural. I still didn't quite understand why I was the only one worrying there. I was about to send another page to Missy, when she came into the ICU around 2pm. She showed me the botched-up page that I apparently had sent and said that she had checked up on the other patients on the service that were a little more likely to be having acute MIs than mine not knowing where or who the page came from.
Oops.
So I gave her a quick run down on the patient's story and came to the enzyme and EKG part rather quickly. She was similarly relieved by the fact that the patient had no chest pain and a decent blood pressure of 100/60 and also pointed out the PQ depression hinted at in some leads that would make pericarditis more likely. But she asked for another EKG nonetheless, since the one we had was already two and a half hours old by then.
That's when the attending called to go start rounding in ten minutes. Missy had gotten another consult in the meantime (karma's a bitch), so we went down to that other ICU to at least grab that person's EKGs before meeting the attending in the workroom.
We relayed the most pertinent information about our patients to him upfront but he'd of course as always want to look at a maximum amount of "pictures" (read: imaging studies) on all the patients we were going to see. So that took a while and afterwards, when deciding which patient to see first, we went to see Missy's patient. She wasn't as critical as the patient in ICU but geographically closer. Guess that's what you get for being on a regular floor.
Afterwards, we finally went to see the freshly transplanted lady at around 3:45pm but we were apparently just in time, the tech was in the process of writing my patient's third EKG for the day. While we were kind of aimlessly standing around waiting for her to get done, I saw the first Dr. Cart being initiated in front of my eyes.
No, it wasn't on my patient.
I was leaning on the ICU's coordinating clerk's desk which was just a few steps outside of another patient's cubicle. Anyone who's ever been on an ICU knows they are noisy places with ubiquitous and incessant beeping coming from somewhere or other around the clock. There's so much of it you get used to it and you don't even consciously perceive it anymore.
Except for a few kinds of beeping - those ones where the monitor actually means business.
And this was one of them.
When I looked up from the desk into the cubicle right across from me, the blue and red lights on top of the actual screen of the monitor flashed alternatingly, while the screen read multiple wide-complex QRS's in rapid succession - this was ventricular tachycardia. Inside the room were a nurse and a relative - the nurse poked her head out of the cubicle and yelled for the crash cart, while the relative gave a yelp and started to cry, before storming out of the cubicle, seemingly to make way for the influx of the ICU staff that was about to happen. While the nurse that was originally there opened the hinged glass walls on the front of the cubicle another nurse flattened the patient's bed before the rest of the ICU people including my consult team had the patient's bed surrounded and all I could see from the desk was the monitor.
That didn't look good though. The VT had apparently subsided and reverted into some kind of slow narrow-complex rhythm, maybe sinus brady, maybe junctional, couldn't tell from where I was standing. I did see the blood pressure from the arterial line around 60/40 and occasionally dropping further though. I knew nothing of the patient's history but her future seemed increasingly in jeopardy. At this point someone yelled to "call a Dr. Cart", which the ICU clerk right next to me did. Just moments later, the overhead public announcement system made another all-too-familiar overhead page to "Dr. Cart", this time calling to the bed I was standing at.
They started compressions right around that time and since there wasn't going to be much I'd be doing with the code, I grabbed the new EKG of my patient from the tech and compared it to the two other ones of that day. And I must have had that wide-eyed look of fear again - not only did her ST-elevations get worse in the lateral leads, I hadn't before noticed that she had had a solid 1mV R in lead III at 2am, that had become isoelectric at noon. Already then there wouldn't have been much blaming this on lead placement, since these are limb leads and the P axis did not change. But now, on this EKG close to four hours later, this lady did not have an R in III anymore, it was a 1mV Q.
I showed the EKGs to my team who were now more on the outer rim of the Dr. Cart crowd and the attending had an interesting way of putting it .. "oh no. She is losing voltage." Finally, things became more hectic with this patient and the attending told the patient that he'd say her odds were about 60% of having a heart attack and 40% of just having pericarditis and that he'd suggest they do a cath right away.
Outside the room, Missy voiced her concerns about this patient. She wasn't as sure about this patient having an acute MI as the attending and she was making a good point. The patient just wasn't symptomatic enough. Blood pressure was stable on the pressors and she just didn't have any pain. She didn't quite convince the attending though. He agreed that the clinical picture was underwhelming for this amount of EKG changes and that pericarditis was a more likely explanation - so the odds were maybe 40 to 60 or even 20 to 80. But even with only a 20% chance of this person having a huge infarction - can you afford not to cath her?
While the attending was talking to the primary team I followed Missy to the cath lab, where she was about to inform their people about the patient and show them the EKGs. On the way, she made another good point, being that the patient was severely medically immunocompromised and about to be wheeled through the hospital to the cath lab where someone would be poking wires around her freshly operated-on mediastinum. The cath wasn't a benign procedure.
This was a really tough decision to make.
Missy said that she was "only a fellow" and was afraid to be "too cavalier" in her opinion to rather "ride this one out" rather than sending the patient to cath. I disagreed in so far as I didn't find it cavalier to be seeing the whole picture and to be afraid the patient could die of overwhelming infection with totally clean coronary arteries just a week from now if we do wheel her to the cath lab.
When we returned to the ICU, though, the decision was basically taken off our hands. The attending cardiothoracic surgeon of the primary team answered his page and talked to our attending. Two new pieces of information prevented the cath - for one thing no one among all those people involved in this so far had been privy to the fact that during her transplant surgery, not only the pericardium but also the left atrium had been cut open for the anastomosis of the pulmonary veins. That was a good explanation of the cardiac enzymes and pericarditis on EKG and made them even more likely, still didn't quite rule out infarction though. However, the other piece of information was that the surgical attending expressly forbid us to use aspirin, clopidogrel or heparin even if we did find something on cath. The only thing he would let us put her on among the usual MI medication was a beta-blocker, which she got. With all those meds out of the picture and stents therefore not being an option there wouldn't be much point in a cath anyway, with angioplasty being unlikely to change much.
So unless a third set of enzymes would come back exceedingly high, there'd be no cath on her today. This will be something interesting to follow up on tomorrow.
After getting home this afternoon I met the sociologist again and he took me to one of the two places in Hyde Park to go out in, as I learned from him there. And apparently, he now also is a reader of this blog so I cannot say any more evil things about him. Rats.
During the several hours we talked I learned among many other things that the University, owning a significant portion of Hyde Park, actually and actively prevented more leisurely (read: alcohol-dispensing) places to open up around campus.
Shame on them!
Look, it's half an hour into Thursday already - my very final day in the U of C hospital. Time to finally write that summary report I've been promising, isn't it.
Well if you're waiting for that, just hope that no more exciting days come in the way.
And tomorrow afternoon the entire Chicago gang is invited to barbecue at CS's place.
I may just end up blogging the retrospective report from Germany - or maybe the plane. Some sky-high-blogging for the perfect circle. See! It did pay off to have read this whole thing for that beautiful sense of closure, right? RIGHT?
OK never mind, I should sleep.
Blog to you later.
But that was not the exciting part. Neither was my stroll afterwards, at around 11am to the cardiology fellows' room to check in with Missy. She said that she hadn't gotten a consult yet and with a smile on her face offered that if there wasn't a consult by noon, I should go home (the weather today is what other people would call gorgeous .. I actually liked the mostly air-conditioned interior of the hospital at that point). Even when she said that though, I knew that wasn't going to help her karma. It's those days where the morning seems like nothing's going to happen that come back to bite you in the ass. Which was good. I wanted to do consults. That's what I'm here for.
So I left the fellows' room thoroughly expecting the page that came half an hour later about a patient in one of the surgical ICUs. She had received a left lung transplant yesterday. Somehow I still have a high level of respect for lung transplants. But the way they have simply extubated the patient this morning, just about 12 hours after surgery and the way Missy would just send a foreign med student that's still coughing once in a while to see this highly immunosuppressed patient breathing with someone else's lung for a few hours now started wearing down this respect.
Anyway, I went up to that ICU and spent the rest of the time until noon getting started with the consult, jotting down her history and deciphering some of the surgical (i.e. minimal and cryptic) notes of the past days. The reason we were called was that the anesthesiologist who did the intraoperative transesophageal echo found severe mitral regurgitation. I looked at the pre-transplant workup and found a right heart catheter from just a few months ago numbering her pulmonary capillary wedge pressure at 1 mmHg which all but rules out any mitral regurgitation back then. That means if she had MR now, it would have to be rather acute. So I did check in on the patient - who was doing remarkably well, obviously having pain in her chest on day one post surgery but was very lucid and pleasant to talk to - before going back to A700 for lunch and an interesting infectious disease conference on endocarditis.
I had meant to go back to finish the consult about half an hour into the conference, after having enjoyed the excellent free Potbelly lunch. But the presenter from ID did such a great job presenting that I stayed until the end at about 1pm. So that's when I went back to the ICU.
After settling down again with the patient's charts (because they have two on ICU) I happily scribbled away at my consult sheet when the surgical resident from the primary team asked me whether I was from cardiology.
Sure.
- Oh good. Cardiac enzymes just came back positive. Did you see the EKGs?
There were EKGs? You drew enzymes? What's going on?
- Oh the EKGs are not in the charts, huh. Let me see if I can track down the nurse to find them.
And off she went after the nurse to get the EKGs. While she did that, I brought up the patient's labs on oacis and sure enough, she had had cardiac enzymes drawn this morning at 2am and again around noon. The latter ones had just come back positive with a troponin of 0.26 - with the 2am ones already at 0.16. CK-MB ratio was also mildly positive on both.
Just about after I had found this out, the nurse came around with two EKG's from the patient. They had almost identical time stamps to the two sets of cardiac enzymes, 2am and noon. The 2am EKG looked normal enough. The noon one had pretty impressive ST elevations in the inferior and lateral leads, yet not in the anterior ones. With scaredly-widened eyes I looked up to the nurse (the surgical resident had apparently taken off again) and asked her if the patient had chest pain with this.
Of course the patient had chest pain.
Duh. She had had her left lung replaced yesterday.
So this patient had chest pain, positive cardiac enzymes, a new onset of localized ST-elevations on a day after major surgery and I seemed the only one freaking out about this. That couldn't stay that way, so I paged Missy with a text page saying just that - something along the lines of "pt has cp (confounded by surgery), + enzymes and ST-elev. I think you". Apparently, as I later learned, I must have sent the page before I was done writing it because it ended in the middle of a sentence and before I gave a call-back number or my own pager number to identify who sent the page. This may have happened because I was showing Jen, who happened to be there, the EKGs and running to the patient's cubicle to look at the vitals on the monitor while writing parts of the page. Which was why Missy never called back.
Jen was seeing another patient and had come over to chat so I showed her those EKGs. Being a nephrologist, she said she hadn't been reading EKGs in a while but agreed this together with positive enzymes was likely to be either pericarditis or an acute myocardial infarction.
I knew this had to happen on a day that Missy wants to send me home at noon. With Missy not answering her page (which she couldn't as I only found out later) I went to the most extreme measures, came into the patient's cubicle and talked to her. And when asked about it specifically, she'd say that she had no pain in her chest - unless she moved.
Phew.
Her vitals were stable, on two pressors admittedly. But stable, and the patient had no chest pain at rest. Then again, she had a high epidural. I still didn't quite understand why I was the only one worrying there. I was about to send another page to Missy, when she came into the ICU around 2pm. She showed me the botched-up page that I apparently had sent and said that she had checked up on the other patients on the service that were a little more likely to be having acute MIs than mine not knowing where or who the page came from.
Oops.
So I gave her a quick run down on the patient's story and came to the enzyme and EKG part rather quickly. She was similarly relieved by the fact that the patient had no chest pain and a decent blood pressure of 100/60 and also pointed out the PQ depression hinted at in some leads that would make pericarditis more likely. But she asked for another EKG nonetheless, since the one we had was already two and a half hours old by then.
That's when the attending called to go start rounding in ten minutes. Missy had gotten another consult in the meantime (karma's a bitch), so we went down to that other ICU to at least grab that person's EKGs before meeting the attending in the workroom.
We relayed the most pertinent information about our patients to him upfront but he'd of course as always want to look at a maximum amount of "pictures" (read: imaging studies) on all the patients we were going to see. So that took a while and afterwards, when deciding which patient to see first, we went to see Missy's patient. She wasn't as critical as the patient in ICU but geographically closer. Guess that's what you get for being on a regular floor.
Afterwards, we finally went to see the freshly transplanted lady at around 3:45pm but we were apparently just in time, the tech was in the process of writing my patient's third EKG for the day. While we were kind of aimlessly standing around waiting for her to get done, I saw the first Dr. Cart being initiated in front of my eyes.
No, it wasn't on my patient.
I was leaning on the ICU's coordinating clerk's desk which was just a few steps outside of another patient's cubicle. Anyone who's ever been on an ICU knows they are noisy places with ubiquitous and incessant beeping coming from somewhere or other around the clock. There's so much of it you get used to it and you don't even consciously perceive it anymore.
Except for a few kinds of beeping - those ones where the monitor actually means business.
And this was one of them.
When I looked up from the desk into the cubicle right across from me, the blue and red lights on top of the actual screen of the monitor flashed alternatingly, while the screen read multiple wide-complex QRS's in rapid succession - this was ventricular tachycardia. Inside the room were a nurse and a relative - the nurse poked her head out of the cubicle and yelled for the crash cart, while the relative gave a yelp and started to cry, before storming out of the cubicle, seemingly to make way for the influx of the ICU staff that was about to happen. While the nurse that was originally there opened the hinged glass walls on the front of the cubicle another nurse flattened the patient's bed before the rest of the ICU people including my consult team had the patient's bed surrounded and all I could see from the desk was the monitor.
That didn't look good though. The VT had apparently subsided and reverted into some kind of slow narrow-complex rhythm, maybe sinus brady, maybe junctional, couldn't tell from where I was standing. I did see the blood pressure from the arterial line around 60/40 and occasionally dropping further though. I knew nothing of the patient's history but her future seemed increasingly in jeopardy. At this point someone yelled to "call a Dr. Cart", which the ICU clerk right next to me did. Just moments later, the overhead public announcement system made another all-too-familiar overhead page to "Dr. Cart", this time calling to the bed I was standing at.
They started compressions right around that time and since there wasn't going to be much I'd be doing with the code, I grabbed the new EKG of my patient from the tech and compared it to the two other ones of that day. And I must have had that wide-eyed look of fear again - not only did her ST-elevations get worse in the lateral leads, I hadn't before noticed that she had had a solid 1mV R in lead III at 2am, that had become isoelectric at noon. Already then there wouldn't have been much blaming this on lead placement, since these are limb leads and the P axis did not change. But now, on this EKG close to four hours later, this lady did not have an R in III anymore, it was a 1mV Q.
I showed the EKGs to my team who were now more on the outer rim of the Dr. Cart crowd and the attending had an interesting way of putting it .. "oh no. She is losing voltage." Finally, things became more hectic with this patient and the attending told the patient that he'd say her odds were about 60% of having a heart attack and 40% of just having pericarditis and that he'd suggest they do a cath right away.
Outside the room, Missy voiced her concerns about this patient. She wasn't as sure about this patient having an acute MI as the attending and she was making a good point. The patient just wasn't symptomatic enough. Blood pressure was stable on the pressors and she just didn't have any pain. She didn't quite convince the attending though. He agreed that the clinical picture was underwhelming for this amount of EKG changes and that pericarditis was a more likely explanation - so the odds were maybe 40 to 60 or even 20 to 80. But even with only a 20% chance of this person having a huge infarction - can you afford not to cath her?
While the attending was talking to the primary team I followed Missy to the cath lab, where she was about to inform their people about the patient and show them the EKGs. On the way, she made another good point, being that the patient was severely medically immunocompromised and about to be wheeled through the hospital to the cath lab where someone would be poking wires around her freshly operated-on mediastinum. The cath wasn't a benign procedure.
This was a really tough decision to make.
Missy said that she was "only a fellow" and was afraid to be "too cavalier" in her opinion to rather "ride this one out" rather than sending the patient to cath. I disagreed in so far as I didn't find it cavalier to be seeing the whole picture and to be afraid the patient could die of overwhelming infection with totally clean coronary arteries just a week from now if we do wheel her to the cath lab.
When we returned to the ICU, though, the decision was basically taken off our hands. The attending cardiothoracic surgeon of the primary team answered his page and talked to our attending. Two new pieces of information prevented the cath - for one thing no one among all those people involved in this so far had been privy to the fact that during her transplant surgery, not only the pericardium but also the left atrium had been cut open for the anastomosis of the pulmonary veins. That was a good explanation of the cardiac enzymes and pericarditis on EKG and made them even more likely, still didn't quite rule out infarction though. However, the other piece of information was that the surgical attending expressly forbid us to use aspirin, clopidogrel or heparin even if we did find something on cath. The only thing he would let us put her on among the usual MI medication was a beta-blocker, which she got. With all those meds out of the picture and stents therefore not being an option there wouldn't be much point in a cath anyway, with angioplasty being unlikely to change much.
So unless a third set of enzymes would come back exceedingly high, there'd be no cath on her today. This will be something interesting to follow up on tomorrow.
After getting home this afternoon I met the sociologist again and he took me to one of the two places in Hyde Park to go out in, as I learned from him there. And apparently, he now also is a reader of this blog so I cannot say any more evil things about him. Rats.
During the several hours we talked I learned among many other things that the University, owning a significant portion of Hyde Park, actually and actively prevented more leisurely (read: alcohol-dispensing) places to open up around campus.
Shame on them!
Look, it's half an hour into Thursday already - my very final day in the U of C hospital. Time to finally write that summary report I've been promising, isn't it.
Well if you're waiting for that, just hope that no more exciting days come in the way.
And tomorrow afternoon the entire Chicago gang is invited to barbecue at CS's place.
I may just end up blogging the retrospective report from Germany - or maybe the plane. Some sky-high-blogging for the perfect circle. See! It did pay off to have read this whole thing for that beautiful sense of closure, right? RIGHT?
OK never mind, I should sleep.
Blog to you later.
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