My Worst Week

I am still in shock over this past month. I think I have PTSD. For the past three weeks I haven't been able to sleep and have been crying a lot and I'm only now just starting to feel some bits of normalcy coming back. Medicine is such a beast sometimes. It rips your heart out and there's no way to prepare your brain for the types of things you are exposed to. I can't imagine being a doctor in the military or in a third world country and seeing death all the time...but then, maybe that's what these experiences are preparing me for someday.
I started the first two weeks of last month out on night float with Erica. She's awesome, and we had some good times and laughed a lot. It was the best night float experience I've ever had. I was getting to teach a lot, and show her the ropes, and I feel like I made a really good friend. The other good part of it was that OB was ridiculously quiet. Yeah, that's right, I just said the "Q" word...but I can because it's already over.
We then started days the second half of the month, and all hell broke loose. Monday was admit day, and by the end of the day we had 14 equivs. Nuts. Tuesday, we thought we'd get caught up, but ended up admitting again. Wednesday, I couldn't even get my rounds done in the AM because I got called to help Patrick on nursery who had a patient in preterm labor at 32 weeks. I then had clinic at 9:30 am, so I had to ditch everyone and head over there. I did my clinic, was late for lunch, and then came back just in time for Erica to check out to me. I had brought a book with me that day, thinking that I might actually have a nice afternoon on service where I'd have time to read. I couldn't have been more wrong. I got 2 admissions and a ton of calls in the first couple of hours after lunch. And then at 4:30, right when I thought things were calming down, I heard the overhead code chimes for patieint on tele. I ran up there alone, since I had sent the sub-i home early, and found that it was one of our patients that was coding. He was an elderly guy that had come in about 2 weeks before with a syncopal episode. We ended up doing a full workup and discovered colon cancer. He had a colon resection, and was still recovering from it. Just that morning we had seen him and he had finally been improving and feeling better- in fact we were planning to send him to SNF the next day and surg had signed off. The most heartbreaking part of the whole situation was that he had been all alone in the hospital during the entire ordeal because his daughter had refused to come see him because she was pregnant and "worried he's infected and will get me sick". We had tried to help him through the whole depressing situation, but it was really getting to all of us. When I got to his room during the code, I discovered he had vomited old blood for some reason, and had aspirated and went into respiratory and then cardiac arrest. It was a horrible sight, and I worked on him for over 45 minutes but just couldn't get him back. Poor Erica was in clinic and didn't even know any of it had happened, and she was affected the most because she had really gotten close to the guy. Wendy and I then had to call the daughter, who came in, and tell her what happened. She didn't even know he had surgery because she had never called. I know in the back of my head that there must've been more to the situation than met the eye- they must've had a strained relationship and a lot of history that we didn't know about...but it was still so hard to sit down and tell her about everything that happened and not feel some remnants of anger towards her for not being there for her dad in the end. So I finally made it to checkout, and later that night Erica called to see how the afternoon went, and I didn't want to lie to her so I told her what happened, and ended up talking to her until after midnight because she was so upset.
The next morning I was hoping for a better day but it only got worse. It was Thursday, so we took a couple admits in the morning. Things seemed to be going alright. And then right after lunch, we found out we were getting an FMCer transferred to our service who had accidentally been admitted to the hopsitalist group. I sent Erica to go start seeing the patient, and the med student and I went over to clinic to pull the patient's chart. Almost as soon as we got there, we heard the hospital code chimes going off overhead "Rapid Response, Labor and Delivery". I grabbed the med student and we literally ran from clinic back across the entire hospital to OB. The whole way over, my poor confused med student was looking at me like "what the heck is going on". I yelled that Rapid Response and Codes in OB are never EVER a good thing. We arrived at the room in L&D about 5 minutes later to a scene of complete chaos. There were about 20 people swarming in a patient's room. Firemen and EMS workers were standing outside the door looking in, and about 10 respiratory students were also there getting in the way. I shoved through everyone to make it into the room and saw Patrick trying to hold down a 200+ pound lady with the look of the fear of God in her eyes, who was flailing like crazy on the bed, still in street clothes. Wendy was there, and was yelling out orders and nurses were running around the room like chickens with their heads cut off. I saw the lady sit up suddenly, fighting against everyone, with this blank look on her face. She suddenly stopped moving, fell back onto the bed, and lost consciousness, and was foaming at the mouth. I saw the nurse finally get the patient on the monitor, as I was yelling for vitals, and her blood pressure was 240/180. I heard Wendy yelling to start a Magnesium bolus, and I was calling for labetalol, but the lady had ripped out her IV before passing out. Wendy finally realized I had come in and yelled "Nicole, go get an OB here NOW. We need a crash c-section NOW. Make it happen!". I ran out of the room to the L&D desk, and a few nurses were out there looking dazed. I told the HUC to call the OB on call, and call Harris or Rau or Martin and to tell them all it was an emergency and we needed someone there ASAP for a crash section. She kinda fumbled with the phone, so I grabbed another phone and called over to clinic. I had just been up there and saw Le up there seeing patients. I told Vanessa to page him overhead and get him on the phone now. He picked up about 30 seconds later and I told him I needed him now for a crash section and he said he was coming and hung up. As I ran back to the room I was yelling for someone to get me some labetalol and hydralazine stat, and when I got back in the room, I heard the nurses getting dopplers and saying fetal heart tones were in the 70s. I told Wendy that I'd gotten Le for section, and to get the patient in the OR. I then ran to the OR to tell anesthes the patient was coming in and I started scrubbing to first assist. They rolled the patient past me into the OR, and the anesthesiologist immediately started trying to intubate, but huge amounts of secretions were coming up out of the patients lungs and she was obviously in flash pulmonary edema. He finally got the tube in, and Wendy ran by and they got the patient hooked up to the monitor and we all watched as she coded. We lost pulses, and as we threw iodine on her belly, Wendy and Patrick started compressions and they called a code overhead. We all knew we literally had a couple minutes to get that baby out since mom was technically dead. I looked at the tray with the scalpel on it, and looked at Wendy, and I know we were both thinking that we hoped Le or another OB would show up so we wouldn't have to cut ourselves. I seriously thought about doing it for a few seconds when Le suddenly blew through the OR doors, scrubbed and ready, and we started. While Patrick and the ER doc and team, including Rad, who had showed up when we called the code continued pushing meds on mom and doing chest compressions, Le and I cut and got the baby out. It was extremely surreal to be cutting on a belly that was moving all over the place from the force of the chest compressions. She wasn't even really bleeding because her heart wasn't beating. We pulled that baby out in less than 3 minutes, and handed a blue, limp, lifeless child to Wendy who was ready and waiting (neo wasn't there yet, either). She immediately started the code on baby, who had no heart beat at all.. The ER team immediately started adding shocks after baby was out, so every couple of minutes, Le and I would have to step back and clear the patient while she got shocked, and stop sewing her up for a few seconds. I just remember feeling like I was in a daze. I saw Wendy over in the corner at the baby warmer, with about 4 nurses surrounding her, working as hard as they could to get the baby intubated, IV access placed and pushing meds while they did compressions. I watched out of the other corner of my eye as the ER team and Rad and Patrick coded mom on that side of the curtain, doing chest compressions and shocking, and pushing meds into her. I could see the monitor over their heads, watching all of the abnormal rhythms mom's heart went into- V-tach...V-fib...V-tach...V-fib...PEA...V-fib...PEA. I looked in front of me as I stepped back from the table while they shocked mom, with her uterus sitting on her belly, just kind of flopped over and hanging there, waiting to be sewed up, but not bleeding because there was nothing to pump blood to it. I looked to the other corner of the room where poor Erica and my med student were standing, watching with their wide eyes above their masks looking on in horror. I remember feeling mad at that moment that this was one of their first introductions to OB, thinking that it shouldn't be this way. OB is usually such a happy, amazing place of miracles and life, and yet they were getting the exact opposite impression that would probably warp their view of it forever. I stepped back up to the table after the shocks each time and Le and I went right back to where we had left off. We had just gotten all of the deep layers closed, and were just starting to close the skin with staples, when Plimpton finally got there. I remember thinking that if Le hadn't happened to be in clinic that day, that the mom would've still been sitting in the L&D room, dead with her baby still inside of her. In fact, our program was 100% there for this lady who had no doctor. We were playing ER doc, OB, surgeon, neonatologist, and much more. It was pretty sweet seeing us work together as a team to manage a freakin horrible situation.I heard the baby's code team yell that they had a pulse. We finished closing mom, pulled off the drapes, and I took my turn doing chest compressions on mom. The ER doc and I took turns, and we also took turns feeling femorals and brachials and radials and carotids, praying we'd feel a pulse. We'd pushed over 20 sets of meds, bolused, diuresed, shocked and compressed, but mom was gone. After about an hour long code, we called it. I stepped back, shaking inside and looked down at myself, covered in blood. I pulled off my gown and went directly into the nursery where they had transported the baby who was on a ventilator. I looked down, and the first thing that came out of my mouth to the nurses in there was "My new shoes are ruined. They have blood all over them". I think that shook me out of my stupor because I realized how heartless and ridiculous I was being, complaining over stupid shoes. I looked in to where Wendy and the neonatologist who had just made it in, were working on the baby still. I then felt in my pocket for my wedding rings, where I always put them when I scrub in the OR, and realized they weren't there. I ran back to the OR and dumped out the garbage and started rummaging through it, and thankfully found my rings at the bottom, while tears streamed down my face. I wiped them away quickly and grabbed Le, and we, along with Wendy, Erica, Patrick, the med student, and Rosie, went to do the hardest job yet- talking to the patient's family. At that point we were finally putting together the whole situation. The mom had eclampsia and also had a history of preeclampsia with her last pregnancy and had a crash c-section at that time, and was in so much denial and so frightened by the past experience that she refused to go to a doctor this pregnancy and refused to come in for the past three weeks, although she was having symptoms and her sister was begging her to go in. She had been feeling at her worst that morning, was short of breath with headaches, and had also been contracting, so had finally agreed to call the paramedics to bring her in. By the time they got there, it was too late, and she was desatting and dying. We did everything we possibly could but it was just too late for her, not to mention that due to extremely high pressures and the underlying eclampsia, the uterus had probably not been getting good blood flow for who knows how long causing long lived hypoxia for the baby. We had to go into the room where her 14 yo and 18 yo kids were, along with her husband and sisters, and tell them all that their mom/wife/sister was dead. I can't even explain the depth of sorrow that I observed after that. I don't even want to go there. The husband was in shock and got up and left, so the 18yo son and brother to the baby had to sign all of the paperwork in order to air-evac the baby out to Phoenix Children's Hospital for further higher level of critical care. What a horrible job for a kid. I stayed in the room with the family for about an hour, and then the nurses pulled me away to make the calls to the medical examiner and donor networks and to sign all of the paperwork. I then went and helped 2 of the nurses clean the mom up so that the family could go in and see her one last time. I remember pulling the ET tube and washing her face, and as I brushed her hair back from her face, I just felt numb in disbelief that this young woman had died. I've coded and lost so many patients in the past two years, but never a previously healthy young woman. My heart hurt.
We all thought that the baby would probably not make it through the night and if it did, we all assumed that it would be brain dead from anoxic brain injury. That night was probably one of the hardest nights I've had- I didn't sleep much and when I did I had nightmares. The next day at work we all were in shock. I felt like we were a bunch of zombies walking around, and I felt like everything was either making me mad or making me cry, which sucked because I was trying to be the strong leader of my team. Poor Erica had still not recovered from coding our patient the day before, and was now having to deal with a whole new type of grief in having lost a young mother and likely her baby, and having to watch a family go through hell. Wendy was also in shock and said it was one of the worst situation she's ever been in. The good thing was that Marty sat us all down the morning after for a debriefing session, and helped us all talk through it and reassured us all that what we were feeling was normal.I felt like I was still walking through this gray haze for the next two weeks, and only now feel like I'm starting to come out of it, and it's because we actually got a piece of good news this past week. Lisa, my best friend, is now a peds attending at PCH, and had been following the baby's course since it was first transferred there. The baby had initially been on high vent settings and pressors. It had had an EEG which showed no brain activity, and had even had a seizure. And then, the following Monday when they were all planning to pull life support on the baby, it had a completely normal MRI of the brain, and a repeat EEG showed increasing brain activity. They extubated the baby the next day, and it continued to progress to the point where, now, they're thinking the baby is acting like a completely normal infant. The news is saying it's due to Cold Cap Therapy that they did at PCH, but we all know what really happened...100% miracle! This news was exactly what I needed and it made all of the hell that we'd all gone through seem like it was for a purpose. Here's a link to channel 3 news that did a story on the baby. The girl holding the baby was the daughter that we talked to. It was so good to see her looking so well and to see this infant moving and acting like a normal newborn!:
http://www.azfamily.com/news/health/New-high-tech-device-helps-save-newborns-life-63570707.html

I know that this situation will affect me for the rest of my career as a doctor. I think I'm slowly starting to deal and heal. It's just such a hard profession.