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Residency, Year 1: Day 346

I'm nearly two weeks into my MICU rotation and it's draining me. I've always been the type to need 8 hours of sleep every night, and MICU is just NOT compatible with that.

Anyway.

This might be a little morbid, but three of my patients so far have died. Two of them passed when I was there, the other one happened one night when I was not on call. Unfortunately, all three of them coded, though I can't say that two of them were completely unexpected.

The first was Mr. R. He was originally transferred from an outside hospital to the heme/onc service for elevated white count. To about 500,000 (normal is around 7,000). He was undergoing leukopheresis (procedure to remove his white cells) when he was found to be unresponsive. He was intubated and sent to MICU. Over the next couple of days, he developed renal failure. He received multiple rounds of leukopheresis, but his white count would increase in between sessions. Despite being off all sedation medications, he continued to be unresponsive. Our consult heme/onc doc spoke with the family, but they were not ready to give up yet. And then he coded. One of my co-interns was on call that night, and CPR for performed after he went into arrhythmias.

The next was Mrs. D. She was transferred from another outside hospital after she was found unresponsive at home and a head CT showed multiple infarcts. She had metastatic bladder cancer and was undergoing chemotherapy. She was originally admitted under the medicine service, but was transferred to the MICU after an arterial clot was found in her right leg and she went to the OR to get it removed. She came to us because she could not be extubated and was on pressors post-op. Her workup showed vegetations on her mitral valve as well as a mass in her right atrium. Despite the risks of intracranial hemorrhage, the family decided to place her on a heparin drip. She remained unresponsive and intubated for several days. One day, during rounds, she was found in her room without a pulse. She was coded twice, lasting for over 90 minutes. By the end of the code, her face had turned blue and she was cold to touch.

The very last of the three was Mrs. S. She coded this morning about half an hour after I got in. She was transferred from an outside hospital for new-onset cirrhosis and acute renal failure. She was not making a lot of urine, but otherwise wasn't too sick. A few days ago, she underwent liver biopsy, which eventually showed fatty liver and some cirrhosis. She was started on dialysis yesterday, but her blood pressure didn't tolerate any volume removal. In fact, she required a small dose of pressor after dialysis. Over the course of yesterday, her clinical condition was otherwise unchanged. Sometime last night, she became unresponsive and required intubation. About half an hour after that, her pupils were dilated and unresponsive, and she was placed on three other pressors. This morning, we coded her for about 30 minutes when she was found without a pulse. This was totally unexpected. We knew she had cirrhosis, but we didn't know why. She previously had a normal liver, as far as we know, just two months prior. She was sick, but she wasn't in critical condition. She made a turn for the worse so dramatically, and it's not clear why. We suspect that because of her liver failure, she wasn't producing her clotting factors and bled into her brain.

I'm not even two weeks into this month and this is the record I have. Hopefully the next couple of weeks will go a bit smoother. But I'm not holding my breath.

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