Had another fantastic Pyrrhic victory last night. We had a call that a full arrest was coming in. Young guy--44. We all thought "Game Time!" and got ready for the maximum effort. And waited, and waited. Because of so many California ER patients don't pay their bills (and because the state doesn't) ER's are closing left and right. Which means this guy had a long ride to the ER and when your heart isn't beating that has grave consequences. Seconds really do count.
So he came in, dead and intubated, with no pulses. Idioventricular rhythm which is awfully close to flat line. We put the hammer down and pushed epi, atropine, bicaarb, mad, calcium and I'll be damned if the guys heart didn't snap back for us. Nice thudding pulse. Ah, the beauty of a healthy young heart. More meds and then fifteen minutes later his heart dropped out again, all of a sudden. We jumped on him again and brought him back. But from that point on I was amped up and on edge waiting for the next time his heart dropped out on us and trying to plan what I would do.
Spoke with his family--wonderful, loving, appreciative people. Called the ICU doc in. And waited with bated breath. No ICU beds, of course--financing and nursing ratios make those beds the most precious in the hospital. So he lay in the ED for hour after hour.
Towards the end of my shift things looked grim. His blood pressure went from very, very low to very, very high and I interpreted that (hopefully wrongly) as his injured brain swelling up like a sponge. Alas--he has a grim prognosis I fear.
It's something about this job. The furious effort to preserve life, but with the sense that the odds are stacked against us. Poor infrastructure. I guess I have the sense that Death holds all the good cards.
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It's been Biscuit-paloooza for the last few days. Now that she has been evacuated from the Arkansan's house. Very normal couple stuff that hardly warrants mention: waking up, going to work, meeting up at home at the end of the day, watching a little TV, having a little dinner and going to bed. But its all new to us. We have been dating for 9 months and never really done this sort of domestic thing. It's still new and exciting. I am kind of sad that in time these little things will become unremarkable.
I'm flying to Washington DC tomorrow. I barely remember why.
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So the Biscuit and I chose a day for our wedding. April 1, 2006. Feel free to make whatever jokes seem apprpriate--I'm just satisfied to have the date nailed down.
I think this wedding planning has been hard on the Biscuit. She's rock solid and really good with logistics so I had thought she'd be able to handle the whole rigamarole pretty well. But two weeks into it she's showing signs of wear. I think it is the combined burden of doing 99% of the wedding planning, worrying about mother/job/education issues I only partially understand, and (inexplicably!) dieting for her wedding dress try-outs. It really doesn't seem like there's that much to a wedding. Find a church, find a banquet hall, and send out invitations. All the other stuff is frills and it seems the emotional cost of addressing all these frills far outweighs whatever they add to the celebration. I mean it's going to be five hours out of our lives--its not worth the pain.
I think we're going to come in under $15k. I'm so relieved. I find expensive weddings to be in really poor taste--one of the worst manifestations of our materialistic culture. What a corruption of something that should be personal and sacred. Nevertheless it seems the 25 or 50 or $75, 000 wedding is pretty standard. Thank God that's not me and the Biscuit.
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Ran a great code today! I know it is not cool to enjoy one's work too much, but God damn I have a good job!
I was on with T tonight, the first time we've worked together since we were residents. It was great--we're both worker bees and we were each trying to outdo the other. The poor guy is on the night shift so he's still there neck deep in it while I'm home blogging.
At about 22:45 the ICU called a code to us in the ED. We run all the hospital codes at night so they just phone us instead of calling it overhead and waking all the patients up. T was with a patient so I responded to the call. I love running through the hospital hallways at night--it has the appeal of breaking taboos. I got to the bedside in a hurry--probably under a minute. Full code with compressions and bagging. I introduced myself, pro forma asked who was running the code and then announced "I'm running the code." I love that feeling, of having the ball in my hands and knowing the shot clock is running out fast. She was brady and pulseless so it was just cookbook. I ran us through the numbers and I'll be damned it it didn't work. That epi hit her heart and she snapped out of it for us. Racing heart, thudding pulse. Very satisfying. I hung Dopamine and Lido and did the paperwork. One of the nurses said "Thank you for saving her life." I was a little taken aback, but said "Sure, of course, she was lucky..." She replied "I was really worried we would lose her. Her son was so upset when we caled him." That felt great.
I have a job where I just kept some man's mother alive. I brought her back to life and he can visit her tomorrow in her hospital bed. That is a damn good job!

I just finished day 6 of a 7 day enduro-shift. Somehow my juggling of shifts at the Yard and St.D's left me with a marathon of 7 shifts in a row. This last weekend was ridiculous, all the more so because it just ended....early Tuesday morning.
After three shifts at the Yard I went in for a St. D's couplet of weekend nights. Spent Saturday afternoon dreading the pain of a 12 hour night shift and even then it was worse than I expected. The day guy had left me 5 patients to start with--so I started at 6pm already 5 down. That lazy sack of shit even had a resident with him--WHO HAD BEEN CALLED IN EARLY! I'm not so offended that the resident was called in early (to help this lazy jerk work a soft Saturday morning), so much as that meant he was sent hom early, leaving me solo from 8pm on for rough Saturday night. This old guy is one of the old guard that almost destroyed the ED--I'm just sickened by his laziness. Spent the night hungry, tired, with patients dying, and always being two or three down....just a miserable shift. But the chickenshit factor is low so I can accept the pain and just endure it. Pain I can handle. It's frustration that un-man's me.
Ended the shift and went to Stater Brothers for Newcastle Brown Ale and Baker's for burritos (beer good, burritos bad). Ate and slept in the call room and woke up at 2pm feeling decent after 6 hours of sleep. Watched football and got ready for the next night shift--it was painless. I then went to a St.D's meeting (mainly to learn from the site director who is a young savant) and drove to the Yard. I was in bed in the Yard well lighter noisy call room at 11am and up at 3 for my 4 o'clock curtain call. A little woozy to start the shift, but miraculously the PA was sick and the spot had been filled by...Pableo, the other new doc. He works like a stevedore and made for a nice night.
In a few minutes I'm going to climb into the bed I last saw 72 hours ago.
I was telling Pableo about my 7 day stretch. He pointed out that in these seven days I'll make as much money as I made in three months as a resident. It's a nice perspective to sleep on.
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Saved a woman last night. Then almost killed her. Typical for me--competence mitigated by callowness.
I was doing a little soothing of some poor lady who had to endure several hours in the ED because her doctor was too lazy to admit her directly to the hospital. A nurse called "Dr.561" and there was something in the tenor of her voice that communicated that this was not "Dr.561, you have a phone call" but more likely "Dr.561 you have a (fill in the catastrophe)." Sphicter tightened, I jogged over. Medics had brought us some poor old lady gasping, struggling, gagging, frothing at the mouth, slapping her hands on the gurney, grasping at her chest. Her eyes bulged and rolled like a frightened horse's.
"What's the story?"
"Shortness of breath." And that's all the history we're going to get. Fortunately, at this point I know that regardless of what the disease is, the treatment is 23 cm of plastic.
We move the lady to our bed, keep her upright, start breaking the intubation kit open, and try to get her on some oxygen. She drops out on us all of a sudden. From 60 breaths a minute to 2 in the span of a heartbeat. Her face starts to purple. I keep her upright (on the theory that....whatever) and then flop her down for the intubation. The resident is going to do it. What The Fuck?! Totally inappropriate! But I don't have enough confidence as an attending to tell him to back off so I let him give it a shot. He blows it, and I give him a second shot that he blows. Fuck this--I step in, crank that throat open and jam a 6.5 tube into her trachea. The problem was she had a narrow diameter, anterior lying airway with some edema around it. Also, she was awake and not paralyzed so her vocal chords were clapping open and shut adding another layer of difficulty. Good lord.
What a sense of relief when I got that tube in place! Ahhhh.....a little breathing room. Time to think about the next step. And that's when things went wrong. Doing shit? I'm pretty good at the doing part of the job. But Thinking? Not soo much. I'm the anti-Hamlet of the ER.
Because her BP was 263/100 and her heartrate was 160 and she was old I thought "Maybe this is an MI causing this sudden CHF, and we got to get that blood pressure down. Maybe just a touch, a whiff, of beta blockers....." And 10 of labetalol and forty seconds later her pressure was 1234/68! Perfect! And twenty seconds later her BP was 62/34--much, much, much less perfect. Shit, shit, shit, shit, shit. I put her on Levophed and feel really stupid. I go back to my hovel and dread her imminent death and having to explain this stupid decision of mine to her family, the ICU doc, and a jury of my peers.
And at the point the Beautiful Biscuit shows up. Out of no where! It was so wondeful I had the odd sense I was hallucinating. She's miles from home, middle of the night, and she shows up at work with a burger and fries for me. It's 9:30 at night and I haven't eaten since 12 and if there's anything I was in the mood for more than some loving moral support it was a double cheeseburger. She was, as always, beautiful and happy and wonderful. She came by just to see me and bring me dinner. I wanted to go home with her right then. It was like water in a desert. She's phenomenal.
Proposing to this girl is the best decision of my life. I don't know how I stumbled into a girl like this, but its miraculous.

The woman pulled through, the Levophed came off, the ICU doc and cardiologist and I had a nice collegial discussion of it all. And I got out an hour late and went home to the wonderful Biscuit. It's a good, good life.
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Engaged. I wrote a long and clever bit on my engagement, but lost it to the viscitudes of digital fate.
The ring was hit. The Biscuit was great. The mother-in-law is wacky. The wedding is in April.





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Oh, I forgot. Worked a night shift at Saint D's. First night shift is always hard because you can never force yourself into the night schedule before going in and it always ends up as a long, long day. The medics brought in a full arrest. Heres' the story. Woman and her boyfriend are drinking. Heavily. She goes to the bathroom. About 45 minutes later he goes to the bathroom also. And finds her collapsed on the ground. Unresponsive. Not breathing. So he calls 911. And waits. The medics arrive to find him drinking beer and watching TV. He then escorts them to the bathroom where this woman is still lying on the ground slowly approaching room temperature. The medics start CPR and bring her to me.
Just to be clear, the report I receive when they bring her in is that the patient has been down for about one hour and fifteen minutes. 75 freaking minutes of being dead! I run the protocol, but my main thought is "Are you fucking kidding me? What do you expect me to do?" We pushed some meds, did compressions for two minutes and called it. In the "Impression" section of my chart I wrote "Dead". And then I circled it.
75 minutes down. Are you kidding me?
Also, interestingly, a metaphor for my relationship with the Arkansan.
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Okay, I just came from asking the Biscuit's mom for her hand in marriage. And if anything deserves careful journalistic documentation, this does.
I showed up unannounced and was invited in. The Biscuit was at work. I could almost smell the fear and uncertainty in her mom as I make casual small talk about the new microwave she bought from Wal-Mart. Then I invited her to sit down, took a seat well outside of slapping range, and got to work.
I made my case and wrapped it up with "...I want to ask you for your daughter's hand in marriage."
She responded, laconically, "No." and then elaborated "You can't have it."
I detected an attempt at Arkansas humor in their somewhere (somewhere well hidden) and said if money was an issue I could run to the car and get my wallet.
"You can't have her hand. You're gonna have to take all of her." Ah--so it was humor. Great. How wonderful that she's enjoying herself.
"Alright, you've got a deal." I said.
Then things got odd. Awkward stilting Arkansas backwater odd.
She proceeeded to warn me that the Biscuit was raised Pentecostal and would soon tire of my drinking, and she flat out told me that was the one/main thing she (the Arkansan) did not like about me. Well, I had suspected as much, but it was nice to have the confirmation. The obvious rejoinder was to inform the Arkansan that her daughter was a damn fine drinker, that, in fact, my friends praised me on finding a beautiful woman who loved Newcastle Bown Ale as much as I do, and that, by the way, she fucks like a tiger when she's a little tipsy. But, Dear Reader, I chose decorous silence as my contribution to this part of the conversation instead.
She then warned me that the Biscuit was a "spendthrift" and particularly liked to spend money on shoes and clothes. This is not entirely fair, but I happily sold the Biscuit out in the name of good relations with her mom. The Arkansan and I bonded over archly bemoaning the Biscuit's wayward spending habits.
Then the Arkansan asked me if I thought that the Biscuit should stay living at home (with the Grand Inquisitor Arkansan sleeping eight feet away from her bedroom and providing 24 hour surveillance on her life) to save money for the marriage. I was torn: option one was to kiss up to the prospective mother-in-law who despises me for my intemperate ways, and option two was to say "No, I think it's probably a good idea for her to move out." I chose option two. And, for the record, I'm drinking a beer (Medocino Brewing Company "Eye of the Hawk": good flavor, nice body) while i write this. The Arkansan pointed out the Biscuit would have more money to bring to the marriage and I rather immodestly said--"Arkansan--yeah, that's not going to be an issue." We debated for a moment over the (sparse) pros and (manifest) cons of the Biscuit living at home for the next eight months until marrying before I ingloriously bailed out of the conversation with some meaningless aside.
The Arkansan then went into one of her patented monologues. In an effort to suck up I tried to feign interest, but mere comprhension was so far beyond me that I did no better for myself than to maintain a dumb cowlike gaze and briefly utter some inane comments when the opportunity presented itself. We were passing from awkward and strained to embarrassing, so I ejected. I hugged the Arkansan (our first hug), promised to take care of her daughter, and fled the building. Ah, what a relief to have that ordeal done with!
There was one highlight--in the Arkansan's rambling solioquy she touched upon the topic of the Biscuit's ex-husband. Compared to this jobless, adulturous, prostitute-screwing winner I felt I came off looking pretty good. Moraly and spiritually crippled by my five beer a week drinking habit, sure, but still good by comparison to the first Mr. Biscuit. I relished this part of the Arkansan's dissertation and was sad when it segued into a discussion of furniture upholstery.

I came home and tossed my Del Taco comfort/celebration food in the microwave to reheat. The aluminum foil wrapper on my Carne Asada Taco sparked and snapped and by the time i realized what the hell was happening and rushed to shut off the machine the more than ample handful of napkins shoved into the bag had ignited. I yanked the blazing bag from the microwave, burned my fingers, tossed it into the sink and tried to blow the flames out. Thereby fanning them to greater heights. Lord--it all seemed like a metaphor for my conference with the Arkansan. Thank God the Biscuit is a firefighter.