The Man with No Legs

About two weeks into my rotation at the state prison hospital, I admitted a patient who had no legs. He was probably around 70 years old and had lost both of his lower limbs to diabetes. Diabetics can have very bad circulation to their extremities and their immune systems are not as strong as most people's. So a simple skin infection that most of us would be able to fight off can result in gangrene and even death if not treated properly. When the infection gets advanced enough, amputation can be the only option.

That wasn't the only problem this guy was having. He had presumably had a stroke some years ago because he was basically non-verbal and only occasionally communicated by grunting. It was hard to tell if he was paralyzed because he would only occasionally obey commands. You could tell that he had been neglected in prison because his lips were so dry that they were sloughing off and he had barely any fat or muscle mass. I can just imagine him laying in bed for days on end without any attention. There was definitely no way this guy could take care of himself and somehow I doubt the prison guards fed and bathed him.

In any other situation, a patient like this would already have an advanced directive telling health care professionals not to resuscitate or intubate. It would be cruel not to, because people like that have no quality of life and no hope for recovery. You can keep people alive indefinitely on a ventilator if you really wanted to, but what's the point? You've got to draw a line somewhere. In fact physicians have the right NOT to treat someone if they think it is medically futile.

I learned that prisoners of the state do not have the right to sign their life away. This is presumably because they are serving a sentence and signing a DNR would mean cutting the sentence short. Sort of ridiculous, but I guess some silly lawyer out there had something to do with that rule (god forbid a physician should be able to decide anything in healthcare). So here he was, basically a big bag of skin and bones with absolutely nothing to live for except his life sentence.

He had actually been admitted for hyponatremia, which means low blood sodium. It's a very complicated process which actually has nothing to do with the amount of sodium that you eat. Rather, it has to do with how much water you drink and how your body handles the water in your body. You may have heard of marathoners getting water intoxication when they chug large amounts of plain water. They become hyponatremic because they drink so much water that the sodium in their body gets diluted out. That's why it's better to drink gaterade because it has about the same concentration of sodium as the body. Hyponatremia can be incredibly dangerous if not treated properly. It can lead to seizures, brain swelling, even death. But there I was, an eager intern fresh out of medical school ready to take it on.

It was day 5 of his admission and I happened to be on call that night. I was laying down in the call room, trying to get some sleep, when I got a call from one of the nurses.

"You better go see Mr. G, he's in V-tach".

V-tach (or ventricular tachycardia) is one of those buzz words in medicine that makes doctors poop in their pants. The lifespan of your heart goes something like this: you're born, your heart beats a few billion times, you go into V-Tach, and then you die. So it was strange to get a phone call like this. Yes, I better go see him--I better run my ass up to the prison ward and resuscitate him. I was half asleep when I got the call, but I instantly shot out of bed, threw my stethoscope around my neck, and sprinted up 5 flights of stairs. By then, a "code" had been called over the loudspeakers (to announce it to all 2 doctors in the hospital) and a special protocol in the prison had been enacted.

For those of you who missed my last blog, the prison ward lives behind two large jail doors which require special authorization to pass through. Ordinarily it takes a good 2 minutes to get through those doors because you have to wait for one to close before the other one opens. The protocol for codes is that all prisoners are put back in their rooms immediately and all guards stand in the hall with their shotguns at the ready. Then, both doors swing open and a guy with a machine gun stands at the entrance.

Somehow that night, the protocol didn't go quite as planned. When I arrived on the prison floor, the jail doors were still closed. I could see the guards scrambling behind the glass because they couldn't get the doors open. Meanwhile, every second that passed was another thousand brain cells that my patient was losing. It was 3 minutes before they got the door open. I sprinted down the hall like I had never sprinted before. Things were flying out of my pockets, but I ignored them because I just had to get into the room. When I finally busted into the patient's room, there was a nursing student and a full-time nurse standing above the patient with a blood pressure cuff, trying to take some vitals. It had been at least 8 minutes since I was called and all they were doing was measuring the guy's blood pressure?

I shoved them aside in a dramatic fashion and felt for a pulse. No pulse. It doesn't take a blood pressure cuff to know that that means no blood pressure.

"He's got no pulse, grab a backboard and put it under him NOW!"

Ordinarily I'm a very quiet, unassuming guy. I speak rather slowly and never shout. But I was going on pure adrenaline that night. I had never even seen a real code let alone run one, but I modeled myself after what I had seen on TV.

I knew what to do because I had recently been trained in ACLS (that's CPR for doctors).

"Starting chest compressions"

-crrrrrrack-

I had taken CPR as a high school student, and I knew that it wasn't unexpected to break ribs when giving CPR, but I hadn't expected it to be that easy or quick. It was a little bit like pushing down on a rice crispy treat.

Giving real CPR is much faster than on TV. You have to pump the chest 100 times a minute, which is almost twice per second. So it gets tiring very quickly. But I went at it, pumping as fast as I could and hoping that all of a sudden, he would grasp for air and magically come back to life. Meanwhile, I was shouting at the nurses to go grab a mask so that I could ventilate the guy. It seemed like they were just standing around watching me. Nurses are supposed to be trained at the same stuff that I was trained in. So theoretically when I had arrived in the room, the nurses should have already been doing CPR and preparing the appropriate drugs for me to order. But things were a little different there.

There was no mask in the room, so they had to go run and find one. Meanwhile, I was demanding that they draw up epinephrine and atropine into a syringe. They fumbled around with it, not able to open the medicine vial or get appropriate IV access. It was completely embarassing to be part of this effort, but it seemed like I was the only person doing anything appropriate. Ultimately, it took them 12 minutes before they pushed the first round of epinephrine (something which probably should have been done before I had even arrived).

Next step was to intubate the man. In between chest compressions, I was shouting at the nurses to get an intubation kit. They finally found one and I ordered someone else to substitute for me in giving CPR. I opened the intubation blade (which I had only played with a few times before on a dummy) and found that the light wasn't working. It had run out of batteries. Trying to intubate someone without a light is like trying to find a needle in a haystack-in the dark. But I had no choice. I had one of the nursing assistants hold a pen light over my head while I tried to intubate. I knew the motions and knew where the structures were supposed to be. But without a light, I couldn't see anything and just kind of pushed the tube in where I thought it should go. Magically, it went into the right tube and the guy had been successfully intubated.

But still no pulse.

By then it had been almost 30 minutes of CPR without any success. A moonlighting senior resident finally showed up (he hadn't been notified of the predicament I was in) and told me that I should stop. So I stopped and called it.

Strangely, I was proud of myself. I had done everything appropriately and even intubated the guy without a light. I was drenched in sweat, but all I could do was look down at the poor guy. Legless, blood dripping from his IV site, his chest deformed from the broken ribs, and eyes staring straight up at the ceiling. He was dead. I think the statistic is that 90% of codes end in death, so I didn't feel that bad. In fact in many ways it was a relief that my patient had finally been allowed to die.

I later sat down with the senior resident and went over the case. He said that I had actually done a great job and that most senior residents might not have handled it as well as I had. I guess all those years of watching ER had paid off after all.