Valerie Brooke, MD
Last week I said to my colleague, “It feels like it’s a full moon,” and she quickly agreed. It was a day full of chaos and emergencies, nothing flowing easily or fluidly. The day started with multiple patients having acute medical issues - before I even had a chance to do my systematic review in the computer of all my patient’s daily labs and vital signs. This usually helps me to decide who needs to be seen first. But before I could read through my list, the first rapid response of the day was called. My heart started to race, the beginning of the first flight-or-fight stress response of the day. And of course, as the doctor, my only option is to fight.
A rapid response is a way to get a small army of hospital personnel into a patient’s room as quickly as possible, at the moment when the patient is starting to decline rapidly or has a change in his/her medical status. We get these alerts first over an application on our phones, and then via an overhead page: “rapid response, room 34, rapid response, room 34, rapid response, room 34.” Yes, said three times, just in case you didn’t get the three loud phone alarms or hear the overhead page. These alerts increase the sense of urgency, as well as my own pulse. I know that this patient is mine, I know her diagnosis (hemorrhagic stroke), and so I’m already wondering what could possibly be happening, conjuring a list of possible diagnoses in my mind.
I headed out my office door, felt for my stethoscope around my neck, and quickly put on my extra PPE layers: face shield over glasses, second mask over my N95, and walked quickly to the patient’s room where there was already a nervous crowd gathering: nurses, respiratory therapist, pharmacist, with nursing students and nursing aides stepping aside. My physician colleagues were there as well, looking at me to see if I needed any assistance. The red code cart was brought into the room, and the evaluation process began. There’s a saying during medical school training that the first thing you should do when you arrive to a rapid response or a code blue, is to take your own pulse. I could feel my fast heart rate and yet had confidence that I could manage this patient emergency.
The patient was in her bed, eyes closed; nearby were her bedside nurse and a therapist at the bedside.
“What happened?” I ask.
“Well, I was working with her on her language expression,” the therapist responded, fear in her eyes, “and then she just stopped responding. Wouldn’t talk or answer me and wouldn’t move her arms or legs.”
Two nurses were taking the patient’s blood pressure via an arm cuff while another one was checking her blood sugar. I got close to the patient and said her name. Nothing. I rubbed hard on her sternum. Her eyes opened but didn’t move. I pulled out my pen light and shined it into her pupils. Reactive. My own pulse quickened.
The nurse told me her blood pressure, which was in the normal range, as well as her blood sugar. There was a charting nurse present who was writing down all the details of our assessment.
I tried again to get the patient to interact. Her eyes were open, but she was staring off into space. I took my reflex hammer, and using the handle, pressed hard on the nailbeds of a finger on each of her hands. She did not withdraw to the painful stimulus. Shit, I thought. I pressed on the nailbeds of her great toes, and to my immense relief, she did move a bit,. still reacting somewhat to the environment. That’s a positive sign, I thought.
“Call EMS, we need to send her to the hospital for a Head CT scan, she’s likely having a seizure,” I directed the staff.
By the time the ambulance arrived, the patient’s eyes were closed and now, she wouldn’t open them to any stimulus. I worried that the hemorrhage in her brain had expanded, that this was the beginning of the end of her life. I was deeply saddened by that possibility.
I called the Transfer Center, explained the patient’s status and need to go to the ED, and then gave a report to the emergency room doctor, who asked me at the end of the report, “What’s her code status?” which meant, does the patient want to be resuscitated or intubated? He was thinking the same things I was: Will this patient survive? At this point in her hospitalization, the patient was still full code, which meant do everything possible.
While the patient was on route to the hospital, I called her husband to give him an update; he didn’t answer. Minutes later, he walked down the hallway, surprised to see her room empty. My heart rate accelerated as I went over to him and explained what had happened--that she likely had a seizure, and I sent her for a Head CT to look for swelling or more bleeding. I told him that his wife would also be seen by a neurologist and would get an EEG, to look for active seizures. Externally I was composed and confident, reassuring the spouse; internally I was frightened and worried that she wouldn’t make it.
“I will keep tabs on her and bring her back to rehab once she stabilizes,” I told him, trying to quell his anxiety about what was be happening. According to the medical record, she apparently woke up in the ambulance and started talking and interacting. By the time she got to the emergency room she was even more alert, was responding and was moving all her limbs. She likely had a seizure, although not the generalized tonic-clonic type or “grand mal” that includes shaking of all her limbs, but rather a “petite mal” or small seizure that doesn’t include whole-body jerking.
The patient’s Head CT showed a mild increase in swelling, no new bleeding thankfully. She was given an EEG to check for more active seizures, of which there were none. She was admitted to the hospital, would be monitored for at least another day, and was started on seizure medication. My own fear and anxiety settled down as I realized that she would be able to return to the rehabilitation hospital, to continue her recovery from her hemorrhagic stroke.
I was only an hour into this workday. I looked down at my patient list, feeling the pressure to move on to other patients, so that this wouldn’t end up a twelve-hour workday. Instead, I returned to my office, closed the door, and took three deep breaths. Breathe in……hold at the top…..breathe out…..repeat.
I was attempting to turn off my sympathetic nervous system (fight or flight), to activate my parasympathetic (rest and relaxation), so that I could return to my work settled and present. Able to make medical decisions from a clear head space. It amazes me that there are physicians and nurses who are able to work successfully in much more stressful work environments: the emergency room, the ICU or intensive care unit, the operating room as a surgeon or anesthesiologist, on an ambulance or a medical helicopter. How do they manage their stress? Do they become immunized against the fight or flight response? Do they have better coping skills than I do? Or maybe they don’t. Maybe they have higher rates of burn out, mental health issues, or addiction issues. Maybe not. All I know for sure is that I am definitely not wired to work in those settings. I have found a place where emergencies are the exception not the norm, a place where I can best channel my intelligence and care, a place where I am looking so forward to working for many more years to come. As long as I keep deep breathing.