This guy
Get a patient from EMS. Middle aged but not elderly woman. All I know about her history is that she has ‘cancer of some type’, didn’t have pulses for 20 minutes, and likely had high potassium cause her heart to stop. EMS did great work getting her pulses back. She’s full code, younger than my mom.
She looks like shit as she gets wheeled in. She’s got this device to give her breaths which is basically a piece of plastic that they can shove into your throat but not your airway so they can pump air in without properly intubating. It’s barely working, but her oxygen is acceptable at 91%. Her blood pressure is shit. The cardiac monitor shows that her heart is beating in a pattern that can only be described as ‘fuckery’ that’s classic for hyperkalemia. She has no neuro exam. Pupils fixed and constricted. Eyes are yellow. Glucose is 30, that’s super low, that gets fixed right away. Her abdomen is distended.
I already know exactly what’s going on already with this woman. She’s in acute renal failure which caused build up of acid and potassium in her blood. It happened because whatever cancer she has is in her liver has damaged the liver enough that the kidneys failed… because the kidneys tend to be the first thing to go. Stupid little shits always make it about them.
So I’m left with a complex set of decisions. Her breathing is entirely dependent on this plastic device that’s not working well, but properly intubating her would cause her to not breathe at all for about 30s if everything goes perfectly. This would kill her. But if I lose that piece of plastic she’ll die anyways. The better play is to hope the plastic can hold on.
So I give her a slew of medications. I give her medicines to raise her blood pressure. I give her medicine to stabilize the cardiac cells against the high potassium. I give her medicines to shift potassium from her blood into other cells. After about 10 different meds and three drips, I get her blood pressure to an acceptable level. I paralyze her, get the tube in, set the breathing machine to breathe super fast for her (this helps with the acid) and family gets here.
I talk to the family. I’m rather blunt in these kind of situations. In reality, this patient is already dead. Even not taking into account the cancer, people don’t generally survive 20 minutes of CPR, especially when not even their pupils are reacting afterwards. Add the cancer on top of that, and this is not going to end well. The only question is when. I tell this to the patient’s family member, who tells me that god will save her… I try multiple times to work around this but can’t.
I don’t talk about my faith much here, but the truth is that I have none and my atheism has stretched into ‘if there’s a god, he’s a massive asshole’ territory, so this conversation is deeply uncomfortable for me.
Blood work comes back and it’s what I expected. Her kidneys are toast. Her liver is toast. Her blood can’t clot. Her potassium is sky high. I talk to the family again. She needs dialysis, but in reality it doesn’t matter. I say we’ll do it if they want, but she will still die in the next few days. I don’t even bother with the ‘most likely’ or ‘almost certainly’ caveats anymore. I tell them that there’s a fair chance that me putting in the catheter could kill her (it could, it requires sticking a tube the size of a pencil into a huge vein who can’t make blood clots).
“Do it doctor.”
More family gets in, and finally sanity breaks out. They stop me from torturing this woman. They ask me what I would do. I tell them if it was my mother I would take her off the breathing machines and medicine, and I’d treat her pain as she died. We did that a half hour later, and she died 30 minutes after we removed all the tubes and meds surrounded by her family. She gasped a few times, and got healthy doses of meds to stop her air hunger. She died peacefully.
I spent about 2 hours in that room running that resuscitation, and at first I was just pissed. It felt like wasted time. It made me late getting home. After thinking about it more, I got the family time to get there and come to the right decision together, and she died comfortably. It’s not a win but it’s as close as I was ever going to get. Fucking shit day… but my daughter really likes screaming ‘dada’ as I get home, so it got better from there.
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Hell of a thing. Like you said, everything you did gave the family time to arrive and come to the correct decision.
I don’t know where I heard this, it might have been you for all I know, but there’s a quote I really like about surgeons: “Every surgeon carries in their heart a small private cemetery, a monument to their mistakes. In quiet moments, they return there to pray.”
This wasn’t a mistake, and she was already past saving when she arrived.
People die every single day, and sometimes the how and the why aren’t particularly relevant. The hours you spent in that resuscitation weren’t meaningless, because it gave the family a chance to go through this experience in the most compassionate way. Sometimes that’s really the job.
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And yes kidneys are definitely capricious little shits. I’m out of the ED and in dialysis now…. It’s easy to forget, because I see these patients three times a week, but they’re very sick and their continued health is balanced on a knife’s edge… almost any insult can cause real problems.
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By far, my best work on the old site was my Vegas live-blog/trip report. I’m going again tonight for 17 days, and I’m doing another trip report, this time on the OLD-old site, 2p2.
Feel free to follow along!
@commonWealth , gonna be in town? I’m there today through June 19!
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And so many conversations at the poker table. I believe most humor is rooted in truth, so I assume most Boomer men had shitty marriages that on some level made them unhappy. So I made sure to pick the right person and be patient.
I also saw numerous marriages in my extended family that were incredibly happy, so I had a good sample of, “Find someone who treats you like that,” and “Find someone who you want to treat like that,” to know what it really should look like.
I am in town! Still doing the mask thing and avoiding dining indoors, but we’ve managed to eat outdoors twice without being uncomfortable - the temperature has been pretty comfortable outside after dark. Shoot me a message!
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I needed a new ball cap so I ordered this one and just got it. I’ve been hearing increased transphobic chatter at poker tables recently (primarily prompted by the Bud Light nonsense) so maybe this will start a conversation (or fight) next time it happens.
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Need Advice: I am booking a hotel room for 4 nights with my wife and two kids for a last minute trip to Disney World because we are in the midst of an awful health scare with my wife and decided, fuck it, let’s go. I have two options, both very similar in price:
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A “value” hotel, meaning motel style, outdoor entrance, small room, thinner walls, no frills, but has two queen beds;
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A significantly nicer “deluxe” hotel, nice amenities, much larger nicer rooms, walking distance to two parks, etc. However it has two double beds, not queen beds.
Wife and I now sleep on a king at home, but had a queen for many years. I haven’t slept on a double with another person since before I was married. I can’t remember what that was like. But for the beds, the deluxe hotel blows the value hotel out of the water, but the double bed situation is giving me pause. Thoughts?
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Book the value motel with two queen beds; Or
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Book the much nicer deluxe hotel that has two double beds?
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Can you get a pull out bed or something at the nicer hotel?
I don’t think so.
What if each adult gets a queen bed and the kids can use hotel cots or an air mattress?
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Head over to the mattress store and try out a double on display imo
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How tall are you? The difference between a double and a queen is more in the length than the width.
Six Feet. I’m comfortable sleeping in a twin by myself though, so I’m not super worried about this.
I probably go with walking distance to two parks then. That is worth a lot.
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That’s what I lean towards.
How old are your kids? When my kids were little we often found the easiest thing in this situation was to split up and have one parent and one little kid in each bed. Of course now my kids are bigger than me so we just spring for two rooms.
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Nothing worse than a crappy mattress. Go for the nice digs
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7 & 4.