Thread by @TheRealDoctorT

The sickening realization hits me with all the force of a punch to my gut.

Suddenly light-headed, I try to breathe deeply, feeling my heart race and my mouth go dry.

My patient is going to die tonight, because of me...

But this isn’t where the story begins. 1/

It’s early Winter, in the small town of Brockton, Massachusetts.

The sky is overcast, and getting darker.

Snow’s in the forecast.

The little town is known as the “City of Champions” because of its famous native sons, Rocky Marciano and Marvin Hagler, legendary boxers. 2/

The “City of Champions” makes you picture Asgard or Atlantis, but Brockton isn’t quite like that.

It’s a gritty place, like the fighters who come from it.

It’s 30 minutes outside Boston, and it’s where I’m coming, as a senior resident, to run an ICU in a small hospital. 3/

As part of our residency program, senior residents rotate out to Brockton to take call in their ICU.

It’s a small ICU, only 8 beds, but it terrifies us for one simple reason:

Being on call at Brockton, is being on call alone. 4/

Granted, we aren’t entirely alone. An anesthesiologist/intensivist attending is our backup, but he can be unavailable if there’s emergency surgery overnight.

What that means is we often run all codes, admit to the ICU, and manage all ICU patients overnight - by ourselves. 5/

Being a senior medical resident is reaching a sweet spot in your competency.

You know enough to be able to handle the majority of what you’ll see in a hospital, and you’ve got a pretty good grasp on your limits.

Covering an ICU solo is pushing the limits. 6/

The charge nurse in the Brockton ICU on this particular night is a Texan, named Sharon.

Everyone makes fun of her accent, but she’s a steely-eyed veteran with that greatest of gifts: foresight.

She is never unprepared, and can sense danger.

Tonight she will save a life. 7/

For whatever reason, Brockton doesn’t use a regular pager system. Instead we wear two-way radios that crackle to life with static and the terrifyingly loud voice of an operator.

This adds to the mystique, and provides an additional level of bowel-loosening terror. 8/

I’m sitting in the cafeteria eating my depressing dinner of chicken strips and soggy fries when the pager booms to life with the first call of the night.

Sepsis, in the ER awaiting ICU resident eval.

I leave my (sad) meal and head to the ER.

Outside, snow begins to fall. 9/

Several hours later, it’s almost midnight. I’ve admitted two patients and run one code blue. I’m lying in bed, the call room lit by the sickly glow of the TV.

I can never sleep in Brockton.

Outside the snow falls heavily now, large flakes that clump together.

I wait. 10/

The next page crackles through shortly after 1AM. It’s Sharon. She doesn’t have a good feeling about one of my admits.

I know better than to question her.

If she’s worried, I’m worried.

I grab my stethoscope and jog out of the call room and down the hall to the unit. 11/

The patient is a young man with pancreatitis. I admitted him to the ICU out of an abundance of caution.

I’ve learned the hard way over the years that pancreatitis is one of those conditions that can go really bad, really fast.

Sharon is worried, and I can see why. 12/

His blood pressure is dropping despite high dose fluids, and he’s spiking fevers. More ominously, his oxygen saturation levels are dipping as his respiratory rate climbs.

Severe pancreatitis can be associated with respiratory failure.

His skin is pale, shiny with sweat. 13/

I make the decision to intubate him and mechanically ventilate. Sharon calls my attending, but he’s in an emergent surgery. He says to call the ER.

The ER attending comes up to intubate while I step outside to talk to the patient’s wife.

She’s understandably worried. 14/

The patient is intubated and I feel a little better. At least I can manage oxygenation now.

But one look at the patient’s bloodwork shatters any optimism I have.

Sharon is seeing the same labs that I am. She looks at me from across the room, and I see her eyes widen. 15/

We live on the edge of a knife.

Our bodies are kept in a beautiful equilibrium, a complex and self-adjusting homeostasis.

But these intricate systems depend on each other. One critical failure can doom the rest.

I am seeing a shocking cascade of failures in the bloodwork. 16/

“We need to transfer him,” Sharon says, matter-of-factly, and she’s right.

I’ve started intravenous bicarbonate, vasopressor support, he’s already on antibiotics. But this is just buying time.

His organs are failing.

I call a local GI specialist who says “transfer him.” 17/

He hangs up before I can get any more guidance. I feel a surge of anger but I’m just a resident, and he’s an attending.

I call my backup attending for help transferring the patient into Boston, but he’s still in the OR and unavailable.

I have to figure this out on my own. 18/

I start calling city hospitals one by one and asking to speak to their ICU fellows. Mass General, Beth Israel, Boston City, and Tufts are all full. Brigham has an open bed but four patients are vying for it.

“Hold on,” says the Brigham fellow, “yours might be the sickest.” 19/

Brigham accepts my patient. I’m elated, but how do I transfer them?

It’s a snowstorm out there. Area roads are going to be closed.

“MedFlight him,” Sharon says. She starts digging through a drawer and produces a slip of paper with a 1-800 number.

I call it. 20/

The MedFlight operator asks me if my hospital has a heli-pad. I... really don’t know. Sharon shakes her head. No. Dammit.

It’s okay, says the operator, there’s an adjacent school. We’ll land there.

But with this weather, they aren’t sure if they can make it soon. 21/

The patient is more hypotensive. I’ve placed a call to a nephrologist for dialysis but she isn’t sure when she can make it in.

Ventilator requirements are climbing.

I realize that he’s going to die here.

Because I didn’t move him sooner.

Because I couldn’t get him help. 22/

I move to the patient’s bedside, sitting down, sick with the feeling of impending doom. I’m not a deeply religious man, but I start to pray.

Minutes feel like hours...

And then...

I hear it!

The unmistakable sound of a helicopter in the distance.

I dare to hope. 23/

The MedFlight team arrives, all expertise and professionalism. I’m practically crying with relief.

They take a report from Sharon and ask me to sign some paperwork.

And then, as briskly and professionally as they arrived, they take the patient with them, into the blizzard. 24/

Sharon and I sit together in the empty room for a few long moments. We sit in silence. Reflecting.

And then I thank her.

She hugs me, and all my tension leaves.

My co-residents arrive as the sun rises, and ask me how the night went.

I tell them there was a storm.

(Afterword: Thanks to the excellence and expertise of the critical care team and specialists at Brigham and Women’s Hospital, the patient survives and recovers.

Pancreatitis remains one of those illnesses that makes me nervous.

Be grateful for your nurses, and listen to them.)