Tuesday, December 11, 2007

Young at Heart

Some patients just surprise in many ways. On call in the ICU, again. The surgeons call to ask that I admit one of their patients. The gentleman, an elderly Russian immigrant, was suffering from rapid atrial fibrillation (a chaotic rhythm where the atria beat quickly and the ventricles do what they can to keep up) that wasn't responding to treatment. He was originally admitted for an emergency operation due to a perforation of the colon, which complicated a routine colonoscopy (that's where a gastroenterologist views the inside of one's guts with a fiber-optic scope looking for polyps, tumors and the like). The odd thing was that the man was walking around with this perforation for three days before going to the ER. This must be a tough guy. I have observed that people who ate the soles of shoes in Stalingrad are not easily phased. He may have been there during that awful period in history.

Our opinion was that the rhythm disturbance was a stress response to the intrabdominal infection (which is what happens when intestinal contents leak out and slosh around freely in the abdominal cavity). So before transfer to the ICU, we requested (we meaning my boss, the ICU chief and I) that the surgeons take another look in the abdomen to make sure that there were no remnants of colonic contents still around. After the operation we received him in stable condition but with ongoing atrial fibrillation.

I started a drip of an anti-arrhythmic and asked the other doctor on call to put in a central venous line while I went up to surgery to see another patient. When I left, the patient's blood pressure was 140/70, pretty good considering.

When I returned, the blood pressure was 80/60. In response to my query, the other doctor explained that the patient began to wake up from the anesthetic, so she administered a small amount of an IV anesthetic so that he wouldn't suffer during the procedure. This caused his blood pressure to drop. I quickly injected phenylephrine to boost the blood pressure but it continued to drop. I called for the defibrillator; in the several seconds it took to reach the patient's beside, the pressure had dropped to 40/15 - this is considered incompatible with life.

But then again, life is full of surprises.

Grabbing the paddles, I give the order to set the defibrillator at 100 Joules synchronized. Shouting "clear," I administered the electrical shock to the patient's chest and the rhythm converted to normal sinus rhythm. Yes, sports fans, we have a save! Except, that the blood pressure remained low. So we infused a vasopressor to get the pressure up. A few hours later our patient was weaned from both the vasopressor and mechanical ventilation. However, he had one more surprise up his sleeve.

While the nurses were changing his position (in order to prevent pressure sores which can develop only after 2 hours of immobility), the patient complained of pain, so we gave a couple of milligrams of morphine. A few minutes later, the patient became obtunded, with slow labored breathing. The fairly small dose of morphine had depressed his respiratory center. We had to reintubate and ventilate him, again. I administered a different anesthetic this time for the intubation (putting a breathing tube into the trachea). This anesthetic is known for preserving blood pressure, yet, again, his pressure dropped.

Again we gave him a drip of a vasopressor. A couple of hours later he was fully awake and alert with a stable blood pressure and mechanically ventilated through the tube. And, get this, he was actually flirting with the nurses! He must have been a real ladies' man in his youth.

Eventually we weaned him from mechanical ventilation. He looked and acted as if he had just returned from a stroll in the park. This guy is indestructible.

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