A grumpy old man

Ms Chen acutely worse, altered, please assist, room 522—Beth, chirped my pager. Ever increasing time pressures meant that hospitalists were supervising rounds almost daily. I had sent my resident, Beth, and the rest of the team to round separately that day, to foster their independence. It looked like we would be meeting ahead of schedule. I’d received a similar page 2 years earlier when I was a junior resident myself. From the beginning of internship, our faculty never hesitated to challenge us. I will never forget when one of the hospitalists who had just come across an unresponsive patient tapped me on the shoulder and casually asked, ‘‘Hey, you wanna run a code?’’ and will never forget my inadequacy or the specific assistance I required in those tense few minutes. He, and the ICU team that arrived, gave me every chance to lead, and supported me each time I hesitated. In similar fashion, I had sent my intern, David, to admit a patient with suspected CHF. I received his urgent update shortly after our patient arrived on the cardiology floor: Mr Johnson dropping sats, please help, room 207. I jogged to the patient’s room, where I found David, 3 nurses, 2 medical students, and in the center, Mr Johnson: lethargic, gray, cachectic, and making no effort to rise from the 40 degree incline of his hospital bed. Weak respirations fogged his nonrebreather mask about 28 times a minute. David offered a quick report: ‘‘74-year-old male, CAD, hypertension, dementia . . . CHF exacerbation . . . hypertensive to 190. I think he needs IV nitroglycerin and another 80 of lasix.’’ I was pleased to hear him commit to a diagnosis and plan, but after sitting Mr Johnson up for a quick exam, I couldn’t agree. ‘‘Are you sure? He sounds more junky than crackly. Neck veins are flat.’’ ‘‘His EF is 25% and he’s been here 3 times with CHF.’’ ‘‘Well, that won’t protect him from anything else.’’ Mr Johnson slumped forward, accessory muscles firing weakly, and only half-opened his eyes to a loud command and vigorous shake. ‘‘Well, let’s get the diagnosis later, what does he need, now?’’ ‘‘Well, the lasix and the nitro . . .’’ ‘‘Assuming this is CHF, looking at him now, will that work fast enough to prevent intubation?’’ David shook his head no. ‘‘He’s full code, right? Let’s just call a code before he gets any worse. Anyone disagree?’’ A nurse made the call, then guarded the door to turn away everyone but anesthesia and the MICU as they arrived. ‘‘So what do you think it is?’’ David asked. ‘‘This doesn’t smell like failure. He’s not anxious, he’s more obtunded than dyspneic. He looks hypercarbic. He doesn’t have COPD?’’ ‘‘Nah, just vomiting, then weaker, more confused, restless.’’ ‘‘Maybe he aspirated. We’ll see. So what do you want to have ready for anesthesia?’’ ‘‘Um, meds. An IV. Chest X-ray ready.’’ ‘‘Good . . . they bring the meds . . . he’s got an IV . . . how about we pull the bed from the wall and raise it up, get some suction ready, take the headboard off?’’ Nurses sprang into action. ‘‘If he’s hypercarbic, shouldn’t we bag him?’’ David asked. ‘‘Good point,’’ I said. David took the mask from the bag of emergency gear from the wall and started to fit it on Mr Johnson. ‘‘It’s a 2-person job, if you want to hold the mask—2 hands, good.’’ A nurse began ventilations, and I added some cricoid pressure. ‘‘Keeps us from inflating his stomach.’’ Seconds later, anesthesia arrived, and David provided a concise, organized summary. Mr Johnson was intubated and whisked without incident to the MICU, where bronchoscopy extracted several mucus plugs. He was soon extubated, and later recovered from a delirium which began with promethazine for nausea. It was the last year before the 80-hour workweek regulations, and not once in the entire process—from admission, to emergency on the ward, to initial MICU management—did I or my fellow residents think to call an attending, although I’m sure we would have learned something, as I hadn’t suspected a mucous plug. We weren’t hiding anything. We were just taking care of our patient. Two years later, it didn’t seem odd that my junior resident called me for assistance with Ms Chen—initially. In room 522, much as I found Mr Johnson, I found Ms Chen: elderly, lethargic, gray, frail, laboring to breathe, rhythmically fogging a non-rebreather mask 30 times a minute, only half-opening her eyes to *Address for correspondence and reprint requests: Ian Jenkins, Department of Medicine, University of California, San Diego Medical Center, 200 W Arbor Dr, MC 8485, San Diego, CA 92103; Tel.: 619-884-0334; E-mail: ihjenkins@ucsd.edu