[NB: the following is an original article written by a batch mate in medical school. We would like to thank the author for giving us permission to post the article in this blog. ]
Maundy Thursday. April 8, 2004. 10:30 pm.
It was my first week as a junior intern in UERM. I was doing my rounds in the Medicine pay section monitoring my patients’ vital signs when I got a message from the nurse that there was a patient who was transferring from the charity wards. He was JM, a 45-year old male, who came in due to bipedal edema of several weeks duration. He was previously diagnosed with Congestive Heart Failure, a condition wherein the heart could not pump enough blood to supply the body, causing him respiratory distress.
I did not attend to him right away as I was busy recording the vital signs of the other patients I was monitoring.
Maundy Thursday. April 8, 2004. 11:00 pm.
I was in my station, 3 North 1, when Dr. Uy, the cardiologist of JM, together with Dra. Escasa, the medicine resident on duty, arrived to do their rounds. Guilty of not having seen the patient before their rounds, I was hesitant in handing them over the patient’s chart. I had no choice but to present it anyway. As they were discussing the case of the patient, I ‘slipped out’ to monitor the other patients assigned to me. However, Dr. Uy noticed that I, the junior intern assigned to his patient, was ‘missing’ and called my name. I reported right away. He asked me, “Have you seen the ECG tracing of this patient?” I answered honestly, “No, sir.” He showed me the ECG recordings and asked me to interpret it. I could not say a thing. Reading an ECG, a must know, was my Achilles’ heel. He was very kind for not humiliating me in front of everybody.
He then asked me, “Have you heard the patient’s heart sound?” I said no. He asked me to listen to his heart and come back and tell him what I heard.
I entered room 308, where the patient was confined. I saw an obese, dark-complexioned man lying on his bed. He was gasping for breath. A nasal cannula of an oxygen tank was attached to his nostrils. He was in moderate respiratory distress. He was sweating profusely and his skin was cold and clammy. His nail beds were cyanotic.
I lifted his shirt and placed the bell of my stethoscope over his chest to listen to his heart. I could not hear any heartbeat because his breath sounds were louder than the latter, thus, giving me a ‘noisy environment’. I used the diaphragm of my stethoscope but his heart sounds were overshadowed by his breath sounds. I did this for more than five minutes but I could not hear any distinct heart sounds. Then I went out of the room and reported back to Dr. Uy. I told him I could not hear anything so I could not describe his heart sounds. He accompanied me back to the patient. He auscultated the patient then he let me listen through his stethoscope. He told me to listen to the gallop sound. A normal heart sound is “lub-dub… lub-dub…” His was very rapid “lub-dub-lub-dub-lub-dub…”
Maundy Thursday. April 8, 2004. 11:50 pm.
The patient was a time bomb waiting to explode. I was beside Dr. Uy when he was explaining the condition of the patient to his relatives. Sooner or later he was going to have an arrest – he was going to die. That was the reason I have to monitor his vital signs hourly.
The relatives were faced with two choices if ever he went into cardiac and pulmonary arrest. Choice A was simple: Do Not Resuscitate. Choice B was to intubate him now so to avert a respiratory arrest and place him in the Critical Care Unit. His relatives were not sure if they would be able to afford his 100-thousand weekly hospitalization cost if ever he was placed in the CCU.
They were undecided.
Good Friday. April 9, 2004. 12:30 am.
The patient was observed to have yellowish penile discharge. Pauline, a fellow junior intern who would help monitor some of my patients whenever my load was overwhelming, and I were assigned to get the tip of the patient’s Foley catheter for gram staining and culture. We were also instructed to put on a new catheter to monitor his urine output accurately. I was kind of excited since I had not done this procedure in my first week of being a junior intern. It would be my first time.
When the materials were ready, we entered the patient’s room. She told me that I was the one who was going to do the entire procedure, as she would be there only to assist me. I put on my gloves and told the patient that the procedure would be not comfortable. We were able to get the specimen and re-insert a new Foley catheter without much difficulty.
I also pushed Furosemide 80 mg IV, a diuretic, to help the patient urinate and lose much of the fluid he had retained which was contributing to his respiratory distress and edema.
Good Friday. April 9, 2004. 1:15 am.
I checked the patient’s vital signs which had not changed much. His BP was still 120/80 mm Hg, heart rate was more than a hundred, and axillary temperature was 36.5˚C. However, he was tachypneic as his respiratory rate was already 56 cycles per minute. His urine drainage bag was empty. He was diaphoretic – his two pillows and bed sheet were wet with sweat. I told myself that Dr. Uy’s assessment was correct, this patient was about to die soon. I urgently referred his condition to Dra. Escasa, who promptly ordered another Furosemide 40 mg IV push.
Good Friday. April 9, 2004. 1:30 am.
I went to his room to check if he had urine output. There was none. “Did I insert the Foley catheter correctly?” I asked myself. Even his relatives called my attention to check if it was connected. I told them it was in place. I was sure that it was in his bladder. Pauline confirmed it. But the zero output despite the administration of two doses of diuretic agent made me wonder why he had not any urine in his drainage bag. I referred this matter to my senior intern.
Good Friday. April 9, 2004. 1:45 am.
A relative went into my station and informed me that the patient wanted to be nebulized. I checked his breath sounds but I heard no wheeze. I just explained to him that the reason he was having difficulty of breathing was not due to constriction of airways, which could be relived by nebulization. He was gasping for his breath because of pulmonary congestion. I told him that his heart could not pump blood efficiently so there was backflow of blood into the pulmonary arteries. It was causing fluid build-up, impeding proper expansion of his lungs for oxygenation of blood.
Good Friday. April 9, 2004. 1:55 am.
As I was going to leave the station to monitor JM, I saw Dra. Escasa approaching. She was now opening the door of room 308 and I immediately followed. As soon as we entered the room, the patient collapsed!
I sensed panic but I kept my presence of mind. I pulled the patient’s bed so I could go to the patient’s left side as Dra. Escasa was checking his heart and shouting instructions to the nurses, “Bring in the intubation and suction machine now! Call ECG technician now! Page Dra. Mabilangan now!”
A bloody frothy discharge came out from the patient’s mouth. She told me to do chest pumps so I immediately climbed onto the bed and knelt on his left side and performed chest compressions.
I could hear the relatives crying outside the room as the paging system announced repeatedly: “Dra. Mabilangan 3 North 1 NOW!” Dra. Mabilangan was the Chief Resident of the Department of Medicine. Announcing her name to go to 3 North 1, my station was a code that someone was being resuscitated. Seconds later she was inside the room. Some residents and senior interns were already helping Dra. Escasa in intubating the patient. A group of male junior interns were also outside waiting for their turn to do CPR.
The ECG technician also arrived and instantly placed the three electrodes to the patient. An ECG tracing showed that the heart was still contracting but failing. Epinephrine was administered while the residents and senior interns were intubating the patient. Chest pumps were resumed and after 20 or more pumps, I felt exhausted and I shouted, “Change!” Gio, the junior intern next to me, occupied my space and continued pumping. There were five of us alternating in giving him chest compressions.
A repeat ECG tracing done showed flat line – his heart was not beating anymore! Finally he was intubated but auscultation of the chest and abdomen showed the tube was in the stomach and not in the lungs. First intubation try was unsuccessful. A nasogastric tube was simultaneously being inserted to decompress his abdomen. It was now Yay, another junior intern, who was giving CPR as I pushed the sixth dose of Epinephrine.
After thirty minutes, ten doses of Epinephrine, countless chest pumps, a dozen flat ECG tracings and several intubation attempts, JM was pronounced dead by Dra. Mabilangan. All residents, senior interns and junior interns, exited one by one.
I remained inside as he was still my patient and my responsibility. He was the first person I had given chest compression, hoping that my effort would give him a new lease on life. He was the first person I had seen dying. All throughout his last moments, I was beside him. I silently prayed for his soul as I left the room to give privacy to his grieving relatives.
About the author:
Arbee Bascuna, M.D. is a graduate of the UERMMMC College of Medicine Class 2005 and is currently taking up residency training in urology at the St Luke’s Medical Center.