Post 2: Tima

Post 2 (Tima):

Today we decided to spend some time in the ER.  Interestingly, there were two patients at once who came in with organophosphate poisoning.  One middle-aged man was poisoned accidentally with insecticide during his work as a farmer.  He had been in the ER for a while and didn't look that bad, except that his heart rate was 140 on the monitor.  OP poisoning here is treated with atropine bolus and drip; pralidoxime is not available.  After doing some background reading on OP poisoning, I realized he was probably over-atropinized and suggested that the ER resident either turn down or hold his atropine.  The other toxicology patient was a young woman who drank insecticide as a suicide attempt after a fight with her husband.  She really looked terrible-- scleral injection and watering, rhinorrhea, the whole story.  Both these patients had family at the bedside, but Anita pointed out the big difference in family dynamics between them.  

I came back later in the evening with Dr Gupta to do an echo on an MI patient in the ER.  We were just getting ready to start when a young woman ran in and cried "Doctors, there's an emergency!"  A few of the residents ran outside.  There was an unresponsive man in the back of a car.  One of the residents got in the car-- I think to check for a pulse.  All I saw was a lifeless hand dropping to the seat.  The resident got out of the car and called for a stretcher.  After what seemed like forever, someone brought a wheelchair.  This guy was probably dead and couldn't sit in a wheelchair, so eventually the four of us carried him into the ER.  Once he was on a bed a lot of busy commotion ensued.  They were trying to hook him up to a monitor.  I was starting to panic because by this time it had been several minutes from arrival and the patient was pulseless, but no one had started chest compressions!  I couldn't tell who was in charge of the code-- because that's what it was.  By this point I was having an internal struggle, because I didn't want to start giving orders on their patient in their ER when there were already three physicians present.  But no one was coding the patient, and time to initiation of compressions correlates with decreased survival, so that won out.  I took over and ordered them to start compressions.  I ordered a bag-mask, oxygen, defibrillator, and IV access.

Now the code was running-- but the chest compressions were about half as vigorous and fast as what I would consider adequate, and the resident ventilating didn't have a good seal to the mask-- I could hear an air leak.  By this time the patient's family had told us that he had been unresponsive for at least 20 minutes--so I knew we probably would not be able to bring him back.  But I thought, what the hell, we should still try, and I might as well use the opportunity to show these residents how to run a code.  I demonstrated proper chest compressions and got those going.  Then I showed the resident how to get a tight seal for ventilation.  The monitor showed PEA but we still didn't have IV access to give epinephrine.  No one could get a peripheral IV and I found out that the only central line kits were up in the ICU (and they don't use them in codes-- and they don't have a crash cart).   So central access was out-- but finally someone got an IV and we pushed epi.   

We ran the code for about 25 minutes before I called the time of expiration.  I briefly went over points at which we could have done better with the residents.  My first lecture is in a couple days and i had prepared a talk on ACS-- but I just decided to change it to an ACLS workshop.