What Have I Done?

I had my supercharged latte in one hand, papers/graphs/lab results/ekg's crumpled in the other. It was 6 a.m., and I was making my morning pre-rounds in the ICU before the attending arrived, so that when he did come to work, I could tell him what had happened overnight to everyone and how they were doing. For the most part, everyone was stable. Sick, but stable.

I walked into room 3. "Good morning Mr. Smith," I said. "How do you feel this morning?" I had already reviewed the night's events: his night nurse said he slept through the night peacefully, his foley catheter had put out lots of urine (I myself should try that before going to bed so that I don't wake up to walk to the bathroom 12 times a night), and he didn't spike a fever. All good news. His laboratory work showed normal blood counts, electrolytes, liver function, coagulation profile and cardiac enzymes. He was a 70-year old man who had been through a lot: open heart surgery not too long ago, vascular surgery, severe pulmonary hypertension (he has to sleep sitting up), and two heart attacks. Diabetes and chronic obstructive pulmonary disease had ravaged his microvasculature over the years, and the surgeons were doing their best do alleviate that damage by creating new vessel routes throughout his body.

"I feel alright," he said. "So-so."

"Yesterday you said you were feeling great. Why only so-so this morning? Are you having any pain or problems breathing?"

"No, not that."

"Then what's the matter?"

"It sounds weird, but I, um.....I....." It looked like he was fishing for the right words to say. "I feel like I'm doing a bit worse, and well, I feel like I'm going to....well....I feel like I'm going to, um, die today or something. Does that sound weird to you?"

Every doctor knows -- from intern to resident to attending -- that if a very sick patient verbalizes that they're going to die, you'd damn well better listen. It is inexplicable -- not everyone says that or knows that, but some do. And whether it's through evolution or intelligent design, nature is full of examples of sentient and non-sentient beings who have an innate proximate sense that their time on this Earth is up: fish go their place of birth and die, dolphins will do the same, and most of us have probably had a pet dog or cat who just kind of knew that they needed to lie down next to you one last time.

I thought about Mr. Smith's comment only very briefly and shrugged it off. Every objective marker said he was doing better. "Oh Mr. Smith," I sighed, "you'll be fine. You're doing very well and we're all proud of you."

"Okay," he replied. He seemed reassured, as if I was giving him the answer to a question he didn't necessarily ask.

I finished my pre-rounding in time to get some "real" food from the cafeteria -- mass-produced eggs with sausage made from grade D beef, one step up from bovine cannibalistic bone-meal that's been linked to mad-cow disease. I wondered if those cows from which the sausage I was eating knew that they were going to die on their slaughter date.

A brief while later, I made rounds with the attending. "How's Mr. Smith?" he queried.

"He did well overnight. He was afebrile, urine output was roughly 60 to 100 cc's an hour with only 20mg of lasix q 12 hours; he has no elevated white blood cell count and no bandemia, his hematocrit is low-normal but stable, his cardiac enzymes are negative, and his creatinine is normal. His vital signs were within a normal range all night, and his systolic blood pressure ranged from 110 to 140."

"Good. His exam?"

"Same. Alert and oriented, communicative. Pupils reactive, breath sounds a little coarse, be we know he has bilateral, small effusions on chest x-ray. His heart has a regular rate and rhythm to it, and I don't hear any murmurs. His abdomen is soft, non-tender, and bowel sounds are present, and he has 2+ pulses in all extremities."

"Fine. So what would you like to do for him today?"

"Well, he's now seven days out from surgery. For the past two or three days, all we've been doing is monitoring him and watching him get better. He still has some small pleural effusions that are diuresing nicely with lasix, but he doesn't need to be in the ICU for that. I think we can send him to the regular floor now."

"I agree. Tell you what -- take out his arterial line, change his central line over a wire and send him to the regular post-op unit."

"No problem."

We finished making rounds, then we chatted for awhile. The attending does bedside teaching, but he also is great about having at least one topic a day for teaching and discussion over a cup of coffee -- today it was about ventilatory settings. But my attending is also a very interesting man with a lot of opinions on many subjects. We've had spirited debates about Supreme Court nominees, iPods as examples of unfair market practices of monopoly, and whether Israel should engage in pre-emptive air strikes of Iran's fledgling nuclear facilities. Today's brief non-medical foray was whether ABBA was true musical genius or simply transient pop phenomenon of the 1970s. (Transient? Are you kidding? Their influence is still felt the world over, and if you listen, really listen to the music, the interplay of instruments and their talent is non-debatable. Obviously, I took the pro-ABBA-is-genius side of the debate.)

So we wrapped up our morning session (I promised to email him some mp3's that he promised to really listen to), and I went to work. I put in some orders, ran some lab work, dispensed some medications, and checked over some x-rays. When it came time for Mr. Smith, my list was easy: remove the arterial line, change his triple-lumen central line over a wire, and send him to the regular post-op unit. I had already told the ICU nurses to give report to the post-op unit that Mr. Smith was coming in an hour or so.

I removed his arterial line and gathered up the materials for a new central line. For those of you unfamiliar, a central line is a giant IV that goes directly to the heart for rapid infusion of medications or more invasive hemodynamic monitoring. These aren't your garden-variety IV's that nurses put in: these are large devices that MD's have to put in because there is a not-too-insignificant amount of morbidity and mortality associated with these things. And think about it -- why wouldn't there be? You're puncturing one of six large vessels (two in either side of the neck -- the internal jugulars; two in either shoulder -- the subclavians; or two in either side of the groin -- the femorals), and you're feeding a large tube that actually sometimes touches the heart. The list of complications is legion: you can introduce an infection if you don't do it under sterile conditions; you can puncture a large artery instead of a vein; you can dissect the vein itself and cause internal hemorrhage; you can puncture a lung and cause an iatrogenic pneumothorax; you can slice an important nerve running parallel to the vein you're trying to hit; you can accidentally introduce air into the vessesl and cause an air embolism; you can even accidentally puncture the heart itself with the wire over which you thread this giant IV and cause a heart attack or even worse -- a pericardial tamponade where there's bleeding in the sac in which the heart sits -- so much so that the pressure on the heart from the blood surrounding it is too great for it to pump anymore. Thus, this procedure should not be taken lightly.

I got all the central line materials together and explained to Mr. Smith what I was going to do. "Mr. Smith," I told him, "you're coming along so well, we're going to move you to a regular floor. I'm going to change that big IV sitting in your neck first though, okay? To do that, I'm going to lay you flat for about five minutes and cover your face and the rest of the bed with a sterile drape. It's important for you to stay very still during this and not move around after I clean off the area and set it up. Understood?"

"Yep. Do whatcha gotta do, doc."

"Great, thanks." I laid the bed flat, cleaned off the area with antiseptic, and put a large sterile drape over the bed. His monitor was in sight so I could see his vital signs while doing this, and I changed into a sterile gown with sterile gloves, mask and cap. This will be easy, five minutes tops. I've done this a hundred times now.

It was going smoothly. I put a wire into the old central line at the proper mark (not too deep, not too shallow), pulled out the IV, held onto the wire, there was very little blood leaking out, flushed the new one with fluid, and inserted it over the wire to the 16-cm mark. I tested each of the three separate ports that coalesced into the large-bore IV going straight to his heart, and each one returned blood when I aspirated with a syringe, and each one flushed nicely with normal saline.

"How are you doing, Mr. Smith?" I asked as I was doing the procedure. I could see his heart rate, blood pressure and oxygen saturation were all fine. I just couldn't see his face under that sterile drape.

"I'm fine," he said, voice slightly muffled. In fact, I kept asking him so much how he was doing during the procedure that he told me to shutup and stop asking.

I noticed the whole time that he was slightly shifting his legs during the line change. I had asked him to be perfectly still, and he was doing a pretty good job of it. The legs weren't really interfering with what I had to do, so I didn't mind that he was trying to get more comfortable. But I was sewing the line onto the skin, and I asked again:

"How's it going, Mr. Smith?"

Muffled noise. And he was no longer shifting his legs.

I looked at the monitor. Everything was still normal. I finished sewing one of the two locks down onto the skin.

"Mr. Smith, how are you doing?"

No answer.

"Mr. Smith? Mr. Smith?"

He didn't answer me, but the monitor did: beeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeep. I looked up at the monitor with gooseflesh:

Flatline. No heart rate.

HO.

LY.

SHIT.

I whipped back the drape. His eyes were open, staring, non-focused.

"MR. SMITH! MR. SMITH!" I smacked his face. "MR. SMITH, ANSWER ME! CAN YOU BREATHE???"

No answer. Oxygen saturation on the monitor was dropping.

What the fuck just happened?

"NURSE!!!" I screamed, "CALL A CODE RIGHT NOW IN BED 3!!!!"

I know I have a 31-year old heart, but what was going on right now whipped it into an 80-year old heart that kept skipping beats. In a test of quantum mechanics, one millisecond had morphed into ten minutes. The room was spinning, I had no idea what the fuck was going on, everything had been going so well, and I had done this same procedure for the umpteenth time. My heart sank well below my stomach and I myself was lightheaded. But it's my job to function at a time like this, so there's little to think about during a code.

But my first thought was this: Primum non nocere -- first do no harm. I just gave this guy an air embolism.

Thus, the first thing you do is drop the head of the bead and turn the patient to their right to trap an air bubble -- if there is one there -- from going to the lungs or brain. After that, it's all ABC's: airway, breathing, circulation.

Within one minute, a horde of whitecoats rushed into the room and the nurse had already wheeled a crash cart in. I whipped out an airway kit and intubated him to secure his airway and started bagging him. I also noticed this right-sided neck IV only halfway stitched in. My attending ran in there and provided focus to the throng of doctors and nurses that flooded the room: he ran to the head of the bed, kept bagging, and ran the code.

"Is there pulse?" he called out.

"NO," shouted someone trying to feel his femoral pulse.

"Start chest compressions!" he yelled.

Someone stepped up and started rhythmically compressing this man's chest. During these compressions, one has to compress very hard and very deep in order to externally approximate the heart's intrinsic contractility. And with the compressions, we all heard crack, crack, crack. Those were his ribs -- this man is 70 years old and has osteoporosis. But that's the least of your concerns during a code, and everyone who's been involved in one knows that rib fractures happen if you're doing the compressions correctly.

Mr. Smith vomited. He shit his pants. I think I did too.

On the monitor, there WAS electrical activity of the heart -- there was just no pulse. Called a P.E.A. arrest (pulseless electrical activity), there is, as in all medical codes, a certain algorithm to follow.

"Push one amp of epinephrine!" my attending shouted.

I was also at the head of the bed, holding this IV in place with my finger so it didn't slip out while his body was violently shaking during chest compressions. This is also the only IV access he has, so it CANNOT be lost. In a contortionist feat, I held onto the IV and unlocked one of the ports with one hand, and injected epi with the other.

Nothing.

"Resume compressions!"

POUND POUND POUND.

"Push one amp of atropine!"

Again, I injected and held onto that IV for dear life -- his AND mine.

Nothing.

"One amp of bicarb!"

Still nothing.

POUND POUND POUND

Thank God I wasn't trying to run the code, because I could only think one thing:

He's gonna die
He's gonna die
He's gonna die
He's gonna die
He's gonna die

-- and it's all your fault.

"Another epi!"

In it went. Still electrical activity on the monitor, but still no pulse.

"Another atropine!"

After each round of a drug, everyone -- the world, it seems -- stops to look at the monitor. There's an eery two-second pause where no one speaks, no one shouts, no one moves, no one does chest compressions, no one even breathes while we wait to either see something on the monitor or to feel a pulse.

Please, Mr. Smith, please please please please please please please please please please please.

Nothing.

"Another bicarb!"

In it went.

POUND POUND POUND.

"STOP COMPRESSIONS!" shouted someone. "I think I feel a pulse."

Huh?

Someone did feel a pulse. And someone else felt it. Someone on another limb said, "I feel it here too." And another person did too. As if we all had one mind, we all simultaneously looked at the monitor: indeed, there was a heartbeat. There was also a low, but present, blood pressure. Everyone slowly put their hands up and backed away from Mr. Smith, as if disturbing the air around him would cause him to re-code. Me? I whip-stitched the rest of that central line so fast that I'm not sure anyone saw me do it.

I know that there were at least two angels in that room: one sitting on Mr. Smith's shoulder, and one sitting on mine.

----------------------------

We all slowly filed out of the room.

"WHAT THE FUCK DID YOU DO???" screamed the senior resident at me.

My scrubs were already see-through, soaked with sweat.

What could I say? I told him what I did: changed his original central line.

"YOU KILLED HIM YOU FUCKING MORON!!! I CAN'T BELIEVE HE MADE IT THROUGH THAT CODE! HE WILL STILL PROBABLY DIE IN THE NEXT TWENTY-FOUR HOURS AND YOU WILL HAVE DONE IT!"

A group of about twenty people were watching this interchange.

How do you respond to that? I just let myself be his whipping boy because I thought he was right.

"YOU PROBABLY GAVE HIM AN AIR EMBOLUS AND KILLED HIM! WHAT THE FUCK ELSE COULD IT BE??? IT'S NOT JUST CONVENIENT COINCIDENCE THAT HE DIED WHILE YOU WERE CHANGING HIS LINE!" He was gesticulating wildly.

A stat bedside echocardiogram was being done as he was yelling at me. If there's an air embolism, on this cardiac ultrasound, one would see an air bubble in the heart.

Thus a jury of twenty doctors and nurses once again flooded the room to look at the echo as the cardiologist was sliding the probe over Mr. Smith's chest. His heart was still beating, his blood pressure was still there, and his oxygenation was still good. The cardiologist kept running this probe over different areas of the heart, taking snapshots, making printouts, and using Doppler color-flow technology to see red and blue perfusion areas. It took less than five minutes, but to me, standing there by the echo machine (in the witness stand), and the twenty people behind me boring into my soul with their accusatory eyes, it seemed like forever. We were all looking at that echo, but to almost all of us, since we're not cardiologists, it just looks like a loud, snowy screen, similar to those UHF channels you had on your TV as a kid in the 1980s. We were waiting with baited breath for the expert witness and judge -- the cardiologist -- to render his verdict. He finished up his echo and turned around to face all of us. I kept my back turned to everyone. I couldn't bear to hear it.

"There's no air embolism," he factually stated.

I slowly turned around and saw everyone looking at him, then at me, in disbelief.

As if the cardiologist could sense that disbelief, he repeated it: "There is no air embolism." And then as if he were my personal savior, he also followed that up by saying, "In fact, his heart is functioning as well as it was on his previous echo from days ago. The valves are fine, there's no effusion, and his ejection fraction is unchanged."

Like I said, Mr. Smith AND myself each had an angel on our shoulders.

Everyone filed out of the room and shrugged their shoulders. The air embolism theory was the only explanation for his initial code that anyone could think of. If not that, then what?

And though I was exonerated from one crime, I was still guilty of something in the senior resident's eyes.

"YOU STILL FUCKED IT UP. I DON'T KNOW WHAT THE FUCK HAPPENED, BUT LIKE I SAID, IT'S NO FUCKING COINCIDENCE HE DIED WHILE YOU WERE CHANGING HIS FUCKING LINE. YOU BETTER THE FUCK FIGURE OUT WHAT THE FUCK IT WAS, YOU FUCK. AND HE'D BETTER NOT FUCKING DIE AGAIN, OR YOU'RE REALLY FUCKED."

And then he stormed off.

Alright, I get it. You kiss your mother with that mouth?

Now, this is true: I never drink to relieve stress after a stressful day; it's a personal rule I have. But all rules have exceptions, so after I left that day, I called my ER compatriot Jay, and we went straight to the bar over which my apartment sits.

"Sean," I said, "I'll have a ketel one martini straight up, extra dry."

"Rough day today?" he asked.

"I killed someone," I replied.

"In that case," he said, "this one's on the house."

So Jay, God bless him, listened to me vent, was a great friend and really dissected down the day's events. I actually didn't kill Mr. Smith, and my technique in doing the procedure was fine. No one knows what exactly happened, and no one may ever know, but Mr. Smith, if you'll recall, knew that something was going to happen to him that day.

A little while later, I stumbled upstairs to my apartment and prayed and prayed and prayed. And despite three martinis and an ambien, I slept about 90 minutes that night total. I was not even buzzed or woozy or sleepy in the least. I kept waking up and calling the ICU to check on Mr. Smith. The nurse finally told me to quit calling or to come in in the middle of the night and check for myself.

So that's what I did.

-------------------------

THEN the rumors and politics started, and boy, does the story twist from person to person. The next day, I kept overhearing people talk about "that amazing code where the guy actually lived through it."

"Did you hear???" some resident said to another. "There was this total fuck-up intern, some foreign medical graduate from Guatemala or something, and he totally killed this guy, but he lived through the code."

And another: "This stupid second-year MED STUDENT did a CENTRAL LINE without telling anyone and the guy died."

I kept hearing it all day:

"This bonehead actually pierced his heart and they did emergency heart surgery and saved him."

"Some foreign anesthesia visiting student gave him a pericardial tamponade."

"This idiot intern dissected his AORTA."

Intern? Foreign student? Aorta? I chose to ignore it. If they were talking about me in my presence, then they didn't know it was me, and I preferred to lay low and keep it that way.

I just kept my eye on Mr. Smith -- and he's doing fine.