#and i dont think a lot of other staff understand the duress of that? like i am worried and stressed about these patients.

[doctorweebmd]

ok i'm going to complain about this on here since otherwise its going to come out in a drunken rant when i go to vegas in two weeks

to be fair, its ALSO probably gonna come out then. whatever.

like i'm thinking a lot about this code on Monday night and whether I did the right thing and what i could have or should have done better. I mean, the patient survived, and his brain seems to be fully intact (which, after 3 codes is... impressive. although all of them were <3 minutes at a time) like, ok. bradycardic arrest after getting am infected pacemaker out. comes back. totally fine. i walk away to check on RRT a few doors down.

as i'm checking on that person, he re-codes. same thing, bradycardic arrest into PEA. i say, ok. time to intubate. RRT nurse at the RRT a few doors down, so not with me. nurses that ARE there are clearly inexperienced. i think about 50% of them are trainees. don't know anything about the patient. tried to give meds incorrectly. don't even know what some code meds are. no one is giving me callback so i dont know what meds are going in. one of the nurses doesn't know how to work the defibrillator so they set it to 120J at 120 bpm. What.

i'm getting a little irritated, because usually codes in this hospital aren't that messy and i shouldn't have to hand-hold on BLS CPR stuff that EVERYONE in the hospital has to be certified on and should be able to do. even volunteers. in all fairness i should have been a better leader and instantly directed people and established roles rather than expecting people to know what they were doing, but thats neither here nor there.

i intubate him. start on dopamine. externally pace. pretty sure out of everything this is an electrical problem and needs an electrical solution, although i've personally never externally paced someone before. external pacer not capturing as much as it should be, but his underlying rhythm is ok at this point on dopa and his blood pressure is solid. get him to the ICU. he codes again. ok. more pressors. more calcium and mag. labs, abg, everything totally normal. stat echo. etc etc etc. call family. not sure if he's gonna make it through the night.

and see okay i think if, under duress, i HAD to put in a transvenous pacemaker i'd be able to. i've read about it and i've seen it done maybe once or twice in residency. but at my program we have an in-house cardiology service and i've never had to deal with this issue in fellowship. and also he LITERALLY just had pacemaker wires removed. what if he had new vascular/myocardial injury and I only made things worse? plus at the hands of an inexperienced person, is it worth the risk if i could fuck things up even more? but then, if its a life or death situation, shouldn't i just go for it? should i have been more insistent and told the cards folks to come in and see the patient if i personally felt underqualified to put in temp pacer wires?

and the thing is, like, i couldn't have prevented any of the three codes, the two happening on the floor and the third in the ICU when we were still trying to stabilize and get more information, so i truly do think putting in pacer wires myself would be more risk rather than benefit when i wasn't convinced that was the right move. i THINK if he coded for a fourth time i would have been more aggressive with cardiology coming in to see him, but since he stabilized out after that, i felt like it was ok until the right people got there in the morning. (this was around 2 am, people come in around 7am) including EP and thoracic surgery. like if shit does go down and he has true myocardial injury i would hate for it to literally still just be me in house and i kill him rather than waiting a few hours.

and the reassuring thing is i've checked his chart multiple times and no one changed anything i did with his management, he did get pacer wires with EP specifically in the cath lab using resources i dont have and he didn't even go until almost 18 hours AFTER this all happened so clearly cardiology didn't feel like it was emergent or maybe they wanted ID to make a comment about it prior to placing something temporary to make sure those wires didn't get infected.

like. mentally this should be a victory for me. the patient is alive and mentating normally. i secured his airway in a floor room without issue. i started externally pacing early. started dopamine early. called cardiology right away. i personally initiated CPR the third time cracking this poor mans sternum (which urgh. not my favorite. so crunchy.) placed his lines in the fem rather than IJ with consideration of potentially needing transvenous pacer. called family in. there weren't any mistakes. so why do i feel so weird and not good about that whole situation?