Stories From Med School: Hyperthermia

As a fourth-year medical student, you’re supposed to know enough about what’s going on in a patient’s treatment to be able to follow along with the rest of your team, and even to contribute a few aspects to the patient’s care. As a result, a fourth-year student at my med school is often distinguished from a third-year student by the title of “Sub-Intern”, or “Sub-I”.

I did my Sub-I in internal medicine at the county hospital, and then I requested a rotation in Intensive Care in the same hospital, with one of the toughest old-guard docs the hospital had. I figured I’d learn a lot. And I did.

Anyway, this story is from my ICU month.

—–

One Tuesday at four in the morning, when I was on call with my team, a patient came onto our service in really, really bad shape. He was a young guy (younger than me, which still gives me a touch of existential crisis when it happens), in his teens.

He had been running away from the cops with a stash of cocaine, about eight ounces in a plastic bag. He realized that he was going to get caught, so he decided to get rid of the evidence.

By swallowing it.

And eight ounces of cocaine entered his system. He was unconscious within minutes.

Here’s what cocaine does to you. It cranks up the thermostat in every system in your body. Your heart rate goes through the roof (which is why you can get heart attacks from cocaine use), your blood pressure goes through the roof, your breathing ramps up, et cetera. Your temperature also skyrockets.

When we assessed our friend, his temperature had reached 106 degrees. That’s well into brain-damage territory. If we didn’t bring his temperature down, and fast, he’d die. And if he didn’t die, he’d likely come out of this in a permanent coma.

I’ve never seen my team move so fast.

So, we started an IV of refrigerated saline, and set the drips as fast as they would go. We packed him in ice, and covered him with a cooling blanket that would draw even more heat from him.

If you need to cool someone down, the best places to put the cooling sources are in superficial (close to the skin) areas with high blood flow. In practical terms, that means neck, armpits, and groin.

But that apparently wasn’t even enough. The cocaine was still raging through his system, telling it to RAMP UP! RAMP UP! RAMP UP!

We had to bring his temperature down even faster , and it had to happen SOON! The only other thing we could do was to blow cool air on him in addition to the other measures.

Which meant we needed a floor fan. And as the junior member of the team, it was up to me to obtain one.

In retrospect, the team might have just needed me out of the way; the fan wouldn’t help THAT much. But I didn’t realize it at the time. At the time, it seemed like the most important task in the UNIVERSE!

—–

Let me tell you something about the county hospital. It’s a huge old building with maybe ten floor fans in total. They are all located at the nursing stations.

In August in that part of the country, floor fans become a desperately sought-after commodity, and are fiercely guarded by the nurses. Understandably. That hospital is not the friendliest working environment, temperature-wise, and nurses spend their entire day running around.

But if you need a floor fan in August…especially if you’re a medical student…you need to either run across a really, really understanding nurse…or you need to risk pissing one off.

I did not have time to find a really, really understanding nurse. There was a kid dying in the ICU. And a floor fan would help.

Cue Mission: Impossible music.

I ran through each ward on each floor of the hospital at top speed, taking stairs between floors two at a time. Patients and nurses eyed me curiously as I flew past. A doctor running in a hospital usually means an emergency. But a med student running at four in the morning? Who knew what that meant!

Finally, I located a precious fan on the fourth floor, cooling off the momentarily empty 4 East nursing station.

I then called an elevator.

And made a mad dash.

Three things happened at once.

1) I unplugged the fan and hefted it against my shoulder.
2) The night nurse appeared from a patient’s room.
3) The elevator dinged down the hall.

We both started to run. And we both started to yell.

“Where are you taking that! Come back here! What are you doing?” She didn’t know why I was taking the fan. She just knew that the nursing station would be practically unliveable for the rest of the night without it. Like I said, who can blame her?

“I’m the Sub-I on the ICU team!” Oh, there was no way I was stopping! Patient care trumps nursing comfort, and Sub-I safety! “My pager number is 123-4567! This is for a patient! I’ll bring it back! I promise!”

The elevator doors started to close. The night nurse was right behind me.

I dashed in, just in time for the doors to close behind me and right before the nurse could catch the elevator. I punched the button for the ICU floor so the nurse would not be able to call back the elevator.

I’d made it.

I ran back to the ICU as fast as I could, and we set up the fan. And we worked. And we worked.

—–

The kid was in the ICU until the end of my rotation. On the last day of the rotation, he woke up a bit.

“Hello,” we said.

“Hello,” he carefully said back.

“How are you?”

“Fine.”

Success! We had saved enough of his brain function that he had at least retained enough processing power for a simple conversation! We grinned at each other like idiots.

I left the ICU service the next day, so I have no idea how much function he recovered. But he survived to see his family again. So I call that a win.

And the floor fan was there, helping him stay cool, until I left the service.

—–

On the last day, I took the fan back up to the nurses’ station on 4 East, and plugged it back in.

The nurses all exchanged looks. They knew who I was. And I was all alone, the baby gazelle on the Serengeti of the county hospital wards.

And I slunk out of there as fast as I could.

—–

Bonus round! Which branch of the autonomic nervous system predominated in every single person in that story? Especially the teen?

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Stories From Med School: Impetigo

Caution: yucky picture below.

I went to Honduras during my Last Summer Vacation EVER, between my first and second year of med school. We worked for a month in an emergency room in a small coastal town called Trujillo. It was a fantastic experience.

As I was heading home on the plane, I got a sore throat. Probably picked it up in the ER right before I left.

A day or so later, I developed a rash across the bottom half of my face. It looked like I had grown a beard made of strawberry ice cream.

It itched like crazy.

Of course, it turned out to be impetigo, a manifestation of either a staphylococcus or a streptococcus infection. (In this form, I read at that time, they are clinically indistinguishable.)

It looked a little like this. Over the entire bottom half of my face.

Quiz time!

After I was diagnosed, was my first reaction:

A. Crap! If I didn’t get the chance to treat this in time, it could have progressed into necrotizing fasciitis and disfigured me for life if it didn’t kill me!

B. Wait till my med school buddies see this! They’ll love it! I gotta do a call-around!

I’ll give you a hint. I made sure I had some exam gloves, in case people wanted to poke at it.

You are welcome to draw any conclusions you like about my mental health.

Published in: on June 15, 2010 at 1:18 am  Comments (15)  
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