Rapid Reduction

Can’t hardly a day go by without learning something new! As long as your patient’s are sick, that is. Tonight I was on call and admitted a patient with an aortic disection to the service. Aortic disection is a scary, scary word. Many don’t survive to make it to the hospital. Of those that do, many never leave the hospital, and many more have neurologic impairment due to damage to the arteries that supply the brain or spinal cord. From what I read in the news, John Ritter died of an aortic disection. The consequences can be devastating as the blood vessle wall tears in half and allows blood to track into a “false passage”. (Imagine mice in the walls of your house, creating a “false” living space.) If the tear in the vessel crosses over the origins of the larger arteries that supply your arms, your brain, or even the heart itself…disaster, stroke, limb loss, paralysis and death can result.

The more I learn, the more I realize that now (residency) is the time to jump in to every situation possible. Even though this patient was sick, sick, sick, I had right at my side (well, down the hall in the radiology viewing room) a cardiologist, a cardio-thoracic surgeon, and the cardiology fellow, not to mention the ED nursing staff, attending and resident who had seen the patient. I was agressive with my blood pressure management, and eventually made the call to start an arterial line and a second IV drug to continue lowering blood pressure, knowing that I had two attendings to bail me out if disaster occured. I felt totally comfortable, well, a little bit squirmy, in how I was treating the patient in regard to administering powerful intravenous cardiovascular medicines.

WE got up to the CCU and I continued aggressive management until his goal blood pressure was met. The intern was unfortunately finishing a previous admission and missed out on most of the acute management. I felt bad about that, but there was nothing I could do about it. He lamented, “I’ll never get the patient alone,” in order to finish his History because the patient had constant nursing care while we worked on his pressures. Meanwhile, I realized how far I’d come in a year’s time. Last year, as the intern on cardiology, I would have been terrified to try and manage this type of my patient without the help of someone else making decisions and going over every single order I wrote. But today, once I understood the plan, I just continued on the right course of action. I felt good, I consulted all my resources including pharmacy and online reference material. The nurses understood my main goal and helped him get rapid and aggressive treatment. When patients are really, really sick, it’s great to see all the team members come together.

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