Sunday, November 7, 2010

The Lazarus Phenomenon

Ok, ok, I'm back.

I'm sorry that I haven't blogged, for the *ahem* handful of you out there who actually read this, but I am even more sorry to myself. This has been a great experience so far, and I am going to try harder to keep it up even when things go crazy.

To summarize my life since the last post: I survived surgery, and missed it even more when I went onto Medicine. Medicine was terribly boring and an exercise in how not to be efficient, complete with attending throw-downs, patients hitting on me (and inevitably, they were certifiably psychotic or had anti-social personality disorder), long ass rounds and long ass days. My sister came to visit around Labor Day weekend from Thailand, and I barely saw her or spent time with her. I went to the US Open Quarterfinals. I went on vacation, and spent it at home taking care of administrative stuff as well as hanging out with my cousin from London. In other words, you didn't miss much.

I'm the medicine float now, which is still boring but a bit more tolerable. We have 5 interns covering 4 floors. In the past, we would have the 5th intern help out writing notes on the busiest floor, but since that changed from day to day, continuity of care would be lost and patients would be unknown to the intern who was technically covering the floor. So instead, now we switched to a system where the Float (me) writes all the discharges for the day, and holds the pager if any intern has to be gone for any reason (ex: going to FP clinic, etc). It's a good system, and it makes everyone feel more efficient because discharges get done earlier in the day, and it lets the interns actually know all of their patients and get less bogged down with administrative paperwork.

It's efficient, for the most part, but it can lead to a few harried moments. A few days ago, I held the pager for my friend F while he served his clinic day. As I sat in the ICU writing a transfer slip for a teaching service patient, I suddenly heard, "Um, I think that's a code.." from one of the nurses. I looked around behind me, and a private patient in an adjacent bed had a heart rate of 30 with no palpable pulse. We called the code, and I initiated compressions while waiting for the code team to show up. We all took our turns performing cardiac resuscitation and pushing the rounds of epinephrine and atropine, and unfortunately the patient expired. We confirmed the death on cardiac monitor printout strips to be pasted into the patient file, listened for breath sounds and I looked for femoral and carotid pulses, and called the time of expiration. As I was the intern covering the floor while F was gone, it was my responsibility to fill out the death paperwork and write a note explaining the course of events, as well as to call the patient's private attending. Everyone else left the unit to go back to their floors and resume their work, and I left a message with the attending's service, then turned to the desk to start my work.

About 4 minutes later, the respiratory therapist, who had been standing at the patient's bedside disconnecting the tubing from the wall, suddenly said "Yeah...he's still alive. He just took a breath on his own. And, yeah, he's got a pulse. A good one." I whipped around to look at the patient, and sure enough, his heart was beating so hard that the thrill was visible on the chest wall from a foot away. His left groin, which earlier had been so still, suddenly had a bounding, impossible-to-miss pulse. The respiratory therapist scrambled to find a new bag, as she had discarded the first one, and everyone else gathered around to gawk at the suddenly-alive patient. Meanwhile, the attending called back. "Dr. B? I was calling to tell you that your patient died...but he's not dead yet. He came back! WE CALLED IT AND HE CAME BACK! GAH!!" Fortunately, Dr. B was a calm sort of guy, and reassured me that this sort of thing can happen, and that he most likely would go down very soon again anyways. As he predicted, the patient coded again 10 minutes later, and we had to go through the same round of resuscitation and medications. The patient expired (for real, this time, I triple checked and we waited like an hour just to be sure), and I went about the paperwork, still frazzled by the back-to-life experience I had just witnessed.

When I later recounted the story to a resident, she told me that the circumstances were called the Lazarus Phenomenon. The Lazarus Phenomenon refers to spontaneous return of circulation following failed cardiopulmonary resuscitation. The theory is that the cessation of chest compressions allows the chest to re-expand, re-expanding the heart and kick-starting the electrical system. Or maybe it's bad compressions, failing to circulate the epi and atropine adequately, so they arrive at the heart slowly, after compressions were stopped.

Either way, it's pretty damn freaky.

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