Before we applied for this program, we were warned that if we could not handle being in the midst of hardship and frequent death, than this was not the rotation for us. This week, we have been unlucky enough to witness what they were talking about...
The week began interestingly in Sarah's ward. Both Rachel and I could hear one of her patient's breathing from our wards. Sarah had to ask a sister to start a nebulizer treatment so that the patient could breath. The lady was so distressed that when she tried to pull herself out of her bed, she yanked her IV line out. Sarah informed the nurse, who put a bandage over the bleeding wound, but did not replace the line. Less than an hour later, the patient had to be intubated for oxygen saturations in the 60%s (about 98% is normal). One new doctor and two sisters attended to the "code," and hooked the patient up to a EKG monitor and defibrillator. When the patient coded (went into arrhythmia and needed to be shocked), the sister could not find a good vein in which to administer epinephrine.
The doctor attending the call looked as though she could have been having afternoon tea. Her lackadaisical bag breaths were enough to make me and Sarah want to jump in and take over. When the pulse was lost and the CPR began, Sarah says the doctor was making such weak attempts at compressions that she knew she could've done a better job. After 6 rounds of CPR (about 2 minutes), they called time of death.
It was an unfortunate death, not only because of the seemingly apathetic code team, but also because the patient should have had a new IV line placed the moment she pulled hers out. The worst part of the whole experience was when the husband came by to see his wife shortly before CPR began. Not even knowing the patient's loved one was standing behind her, the doctor called the ICU to began a transfer. Wanting the physician to acknowledge the husband, I said "Doctor, Doctor." She did not hear me. Minutes later, the husband had been informed that his wife had passed. It was a very hard first code for myself, but more so for Sarah as she was more involved. The hardest thing was to know what could have been done, and what should have been done. It was sad to see that considered a "code blue."
Later in the week, Rachel had two dead patients when we arrived for rounds in the morning. Both of their bodies laid there for hours before being moved from the floor.
Today, the patient I have been following the closest took a turn for the worst. She is a HIV patient with severe, disseminated tuberculosis (widespread, outside the lungs) with acute liver failure. I presented her cause for my formal presentation, so I have spent many hours looking over her case. Over the past few days, I've seen her deteriorate to the point where she could not hold a bottle of water or move her legs on her own. This afternoon, I decided to check up on the patient to see what changes that doctors had made to her therapy. During the physician's examination, we realized her hands and feet were ice cold to the touch, and her nail beds and feet were blue. She could barely hold her head up and her eyes were not focusing. I suggested starting fluids, so the doctor attempted and failed to get an IV started. The patient was obviously in shock (low perfusion which can lead to multiple organ failure) and needed fluids immediately. Only one sister was qualified to place a central IV line (in the neck), but she could not be found. I asked the doctor if she could place one, and she said yes, but she was feeling a bit "hypoglycemic" and needed something to eat.
The audacity of these physicians to not take a patient like this seriously is infuriating. What's more infuriating is that fact that this patient had signs of dehydration for weeks (had a very fast heart rate, in the 140s, 150s when normal is less than 100). She should have been receiving fluids daily, but instead she had no IV line. And when a patient is in shock with ice cold extremities she is unable to mood, it is NOT an appropriate time to get a snack. To add on to everything else, she is not a candidate for the ICU because she is HIV positive and has tuberculosis (they will not admit any one HIV positive, who has active tuberculosis, or anyone over the age of 65 to the ICU; their survival is just not important enough to them to waste the resouces).
I have become quite attached to this patient. I had to leave for a meeting during this crisis, so I'm interested to see if the patient has received any fluids in the morning...or what's more realistic, is to see if she's even still alive.
