By Dr. Sandipan Shringi
When a 33-year-old lies unconscious in front of you, it’s never a good sign. This 33-year-old, female patient was found unresponsive by her family. Despite trying medications for possible reversible causes, she did not wake up. She turned out to be an unfortunate case of catastrophic stroke. By the time I saw her, she had fixed, dilated pupils, no reflexes, and no movements. She was brought to the ICU to do more, only to realize there was nothing more available for her. She was already on a ventilator and the maximum doses of four pressors, which were barely able to keep her BP to 40 systolic. She eventually succumbed to her disease.
When your 24-hour shift in the ICU starts with death, you make a promise to yourself: “No one else dies on my watch.” It is an admirable goal but unreasonable to sustain in reality. It is the ICU, after all—a hospital department meant for those patients who are seriously and critically ill and whose conditions may be or are life-threatening. Holding your breath doesn’t help.
When a patient dies, family members and loved ones of course feel the pain most acutely, but it is not just the family members who feel it. The entire medical team taking care of the person during their last days of life also feels that pain. It is a good idea for medical professionals to take a break of at least one minute to feel the pain, live it, move past it, and get on with your shift. I know it sounds inhumane when I put it this way, but this is the reality. A healthcare worker gets only about a minute, if lucky, to deal with this pain at all. In contrast, psychiatrists suggest that individuals in the general population may need a whole year for a grief reaction.
When my minute was up, I heard that a patient elsewhere in the ICU was having arrhythmia. I said to myself: not VT/VF…not VT, VF. It was VT.
VT is a form of ventricular rhythm that universally kills unless terminated. Everyone who has been trained in Advanced Cardiovascular Life Support (ACLS) knows that you must move fast, really fast, when it’s ventricular arrhythmia. Within seconds there was a code cart at the patient’s bedside, people ready to perform CPR, and all eyes on me awaiting my directions. Pads were placed, and his pulse checked. Interestingly, he did have a pulse. I say interestingly, because when there is no pulse, you shock. But if it is VT with a pulse, then what do you do?
My brain was blocked for a whole second. If you can’t shock and you can’t do CPR, what can you do?
You can stop the arrhythmia!
So, if the arrhythmia is not compatible with life—not compatible because it stops the flow of blood—your actions are directed towards restarting the flow and bringing the patient back to life. How do you restart flow? You do CPR or deliver an electric shock. But if the flow is already there, then your actions should be directed toward preventing that flow from stopping. You change the rhythm to one that is sustainable and compatible with life. VT with a pulse is not sustainable over time and thus needs to be changed.
I knew what to do. The patient received amiodarone, and within minutes his heartbeat converted back to a normal, sinus rhythm.
One tragedy averted. My watch suggested it was only halfway through my 24-hour shift.
I needed a break, which usually involves sitting down for a few minutes while trying to care for nutrition—my own, not the patient’s this time. Naturally, I turned my focus toward acquiring a muffin and a hot chocolate from the hospital coffee shop.
One learns to walk briskly after many such shifts like this one. I was moving through space, mentally debating with myself if I was walking or jogging, when I passed the atrium of the hospital. An atrium is a wonderful place if you can find the right spot to sit; you can feel the silence of the crowd during the day and hear the noise of the emptiness during the night.
That day, through the empty space of the atrium, I heard someone softly calling, “I need help!” I almost missed the voice and the man; in a fraction of a second, I could have passed right through that disaster space. Thankfully, I didn’t. Upon approaching the man, I asked if he was okay. He said, “I am having chest pain which feels like my previous heart attacks.” If you ever hear this sentence, it’s time to move fast. This is why you should always keep your eyes and ears open in a hospital.
I called my colleague in ICU and requested help, which came in the form of a rapid response team. The patient was shifted to ER, found to have an ongoing heart attack, and ultimately lived to see the light of the day.
I turned back to my rapidly cooling hot chocolate to calm down and plan for the rest of the night.
It was 3 a.m. I went on a stroll through the ICU, which some call making rounds, to check on existing patients and new admissions. Usually, one can figure a few things out and get the unit ready for the morning team.
There was a new admission: 40s male, fentanyl at 200, propofol at 40, levo at 30, neo at 30. He looked to be at about the same rates as when he was admitted. I confirmed with the nurse to see if there were any new developments I should know about. She responded, “Oh yeah, Doc, he has a temperature of 107 degrees Fahrenheit!” In a normal tone, without breaking my stride, I replied, “Okay.”
Then it hit me. I stopped in my tracks: “Wait! 107 degrees? WHAT?!”
I knew it was his liver. Immediate action was the theme of the night, so I started with ice packs, cold IV fluids, and a cooling blanket. None of it was going to work, though. In medicine, you cannot truly solve a problem until you know why it occurred in the first place. I sat down and thought about all possible differentials for hyperthermia. My patient was already on the usual stuff (antibiotics) for the usual stuff (infections). So, I looked back in the records for unusual clues to a diagnosis. I noticed he had received medication to calm him down and was on an anti-anxiety medication at home.
It is easy to differentiate between neuroleptic malignant syndrome and serotonin syndrome because it only requires a clinical exam, but as the patient was sedated, that exam was not going to be helpful. At 107 degrees, his brain was on fire. My heart was racing, and all eyes were on me for the next steps.
I asked if we had dantrolene. It’s not a common drug to have on hand; most have only studied it for exams, and it rarely shows up on an order history. Luckily, we not only had it but it was also approved and available for use within minutes. What was more, I had at my disposal cyproheptadine, which is the treatment for serotonin syndrome. It sounds exciting to have found a solution, but when a life is at stake, the solution doesn’t matter—everything hinges on the end results. The patient received both dantrolene and cyproheptadine, but barely responded. His temperature stayed at 107 degrees. I knew I was about to break my promise to myself.
The patient eventually succumbed to his many serious conditions happening at the same time.
My watch read 7 a.m. Time to sign out to the incoming, well-slept, fresh-as-a-daisy day team. As I prepared to sign out, flashbacks of the entire night appeared in my mind on fast-forward. I tried to pick up anything I may have missed—anyone unstable who would need immediate attention from the new team. It appeared I didn’t miss anything major, so I successfully signed out.
However, I did miss one unstable person in the ICU: Me!
After a day where I recorded 18,000 steps, I pondered how I would be able to manage a shift like this again. My reflexes were slowed, my brain was barely running, and I was drained of adenosine triphosphate (ATP), which is the source of our energy at the cellular level. What was more, I needed to now leave the hospital, cross a flowing road, make a meal, and then go to sleep. Two of those tasks are dangerous. Yet, I managed to make it into bed with no casualties.
That night, I realized that no one person can do it alone. We normally think of the resources in a hospital as medicine or machines, but it’s also the people. In fact, people are the most important resource in this setting. I could not have survived that ICU shift without the pharmacy staff who kept stocking the medications, the hospital staff who kept updating the crash cart, the nurses who kept executing my directions, the trainees who were by my side all night, and in a larger, more faraway sense, my family, who have always been there to support me. Burnout in medicine is an ongoing struggle. I suggest treating healthcare staff as the resources that they are, to be used judiciously.
My final piece of advice is when you are in ICU, don’t hold your breath. Sleep well, eat healthily, walk fast but remain vigilant, and remind yourself that it’s not over until it’s over. And it’s over only once you are safely cuddled up in bed.
This story occurred at St. Vincent Hospital in Massachusetts. I am currently in a fellowship program at Brown University in Rhode Island.
My sincere thanks to the following for their persistent support:
- My wife, Dr. Shiksha Joshi
- My residency Program Director, Dr. Susan George
- My nephrology fellowship Program Director, Dr. John O’Bell
and to the numerous colleagues for helping me survive many such shifts.