Sidetracked, or Doing What Matters

Resident & Staff Physician®, July/August 2007 Vol 53 No 7, Volume 0, Issue 0

Michael S. Golinko, MD, MA

Resident, Surgery Department, SUNY Downstate, Brooklyn, NY

Nights on call like these don't come around that often, and as a junior resident you pray that they don't. But when these harrowing nights do come, the pain and terror are all worth it if the patient is alive at the break of dawn. Last Friday on call was one such night.

The day had been busy enough. As the consult resident, I had already seen a dozen new consults in addition to caring for the intensive care unit (ICU) patients. The sickest guy on the service was our chairman's patient, who had just endured a 14-hour operation to remove a large mass from his colon. We put him in the ICU for observation and fluid resuscitation. There is always a dedicated ICU resident from "anesthesia" or "medicine" in the unit, so we were always in communication with that resident about patient care. Our patient was doing okay, except for his agitation and insistence on walking out of the hospital with a Foley catheter, right internal jugular vein Cordis, and freshly stapled abdominal wound. But I accepted this postanesthetic confusion, because he was hemodynamically stable. It was about 8 pm or so when I left the unit to see new consults. The frenetic pace of the day kept thumping on into the night, and I finally had a moment of peace to lie down, sometime between 1 and 2 in the morning. Then, inevitably, a beep in the night—the emergency department. I decided to stop by the unit and check out "my guy."

He was not as I had left him. I arrived at his bedside to find him tachycardic to the 150s. He had a systolic blood pressure of 100 mm Hg. He was awake and in distress. The abdominal wound looked dry. My eyes darted to his neck. Where was his Cordis? Did the ICU resident take it out? Why does the right side of his neck look a little big? The staff did not know about the Cordis, and the resident said that the patient had pulled it out earlier that evening. The surgical team had not yet been notified. Rather innocently, a 4-letter word slipped out of my mouth. I flirted with giving him adenosine. Before I did though, I called "cardiology," ordered a stat portable chest x-ray, and then called my chief resident, Dr Dronsky, a chief I will never forget.

Dr Dronsky, our oldest resident, was as robust as they come. He was Russian and a champion cyclist who competed with the Georgian National Team when he was just a teenager. Back home, he was a gynecologic oncologist. When he came to the United States, he had several nonmedical jobs, including a stint as a limo driver in San Francisco before going into general surgery residency. In contrast to most other residents who realize that their patients may die someday, Dr Dronsky always assumed that the day he was on call was that day—unless he did something about it.

I briefly explained over the phone what had happened, and Dr Dronsky said he was coming right down. The x-ray showed severe tracheal deviation—an impending airway compromise that required immediate intubation. I called anesthesia and began to draw blood for a full set of labs. Dr Dronsky arrived at the bedside and smiled. He had a "let's-rock-and-roll" look on his face. While I was sweating bullets, he was having a good time! In the wee hours between 2 am and 8 am, Dr Dronsky and I used every drop of our strength to pull this patient through. It turned out that earlier that evening our chairman's patient had ripped the 14 French Cordis out of his right internal jugular vein, and his hematocrit dropped to 23% from 35%, which is where it had been when I had checked several hours before. In a gruff Russian accent, Dr Dronsky said coolly, "Mikey, throw in a central line, arterial line, draw a full set of labs. He needs blood, fluid, platelets, fresh-frozen plasma [FFP]." I swiftly assembled what I needed: gown, drapes, central line kit, and lidocaine, and flew back to the bedside. Dr Dronsky was on the phone with the family obtaining the proper consents.

At this point, I was as tachycardic as the patient. My reserves were tested as my chief asked me to place a Cordis in the right groin, which I promptly did on the first stick—got it! Lactate ringers, full throttle. Next, the arterial line. Left hand didn't fly. Right hand—score! Now transduce. Good, a systolic pressure of 120 mm Hg. I turned around to share my expression of relief, but Dr Dronsky was not on the phone anymore. Just then, he appeared through the doors with several units of blood and said that platelets and FFP were on the way. "OK, Mikey this is how we transfuse in Russia." He set up the transfusion lines along with the nurses and began to literally squeeze the contents of the bags into the patient with his own bare hands. We watched the tachycardia resolve. We watched the patient become more edematous. But we had intubated him, and his ejection fraction was 60%. The resuscitation cocktail continued: more blood, more FFP and platelets. The lab results started to move in the right direction. After a few hours of this nightmarish pace, he was stable enough to be taken down fora computed tomography scan, and although he did not have a surgical bleed, he had a sizable hematoma in the right side of his neck.

At the end of the night, no vital signs had been taken on other patients nor notes written. There was just our patient. By the time the chairman rounded with us at 8 AM, the patient's hematocrit was 40%. Our patient was alive, intubated, and perhaps a little stunned, but alive.

In the gooey postcall glaze of the morning we both felt good after a hard, yet rewarding, night. I felt as though I was fired in a kiln—hardened and able to endure whatever came next. There are few learning experiences as a resident that "beat" working hands-on, side-by-side for hours on end with your chief resident to save someone's life. I was swept up in his fierce desire and intense caring to preserve life and avert disaster. I gained even more respect for Dr Dronsky and realized I would not want anyone else to take care of my family in the middle of the night. After morning rounds, Dr Dronsky and I were in the call room. He gave me an apple and in his robust and voluminous accent said, "No matter what they say, Mikey, we saved that guy. I am telling you, you see things here they have no place else—the patients here are really sick; you can learn a lot."

At that moment I began to believe. Despite the endless documentation and hardship of resident life, in the end, we have the privilege of doing what matters. As I was having this epiphany, I realized I still had one pending consult to see. I called down to the emergency department and told them I got a bit sidetracked, but I'd be right there.