What I have learned

Have completed the last of my shifts on PICU. The second to last night was completely crazy, starting with a child going onto ECMO; a week-old  baby post-op from an arterial switch operation dropping his blood pressure, an ex-premature baby with RSV blocking off his ET tube and needing an emergency intubation just as a different baby with RSV was admitted from the ward and looked like he was going to need intubation as well. The unit was full, so we were constantly pressured to discharge patients – 2 were discharged to the wards overnight, and 5 were readied for the next morning. One of my patients – a one-year old with polycystic kidneys and hypoplastic lungs, sepsis and ARDS (on triple inotropes and HFOV) was overventilated but swinging her blood pressure with changes in blood pH whenever I adjusted her ventilation, so I was stuck. Another who has been trying to die for the past 3 weeks lost his arterial line and I was tied up trying to re-wire it when the ECMO bed suddenly collapsed. This could have (but didn’t thanks to a nurse with quick reflexes) resulted in the patient bleeding out and dying in a rather dramatic fashion. And at the end of the night we got griped at by the day shift charge nurse for not completing the drug charts for the patients who were being discharged. The consultants seemed pretty appreciative of our work though. The whole thing was a bit like a sequence from the introduction to some medical drama (where all the ‘action’ clips get spliced together), except it was for real, and lasted for 12 hours. It was strangely satisfying though. Not that I would ever do it again.

So at the end of 6 months, I think I’ve learned a few things:

1. Some patients will die no matter what you do [i.e. the ‘critical’ in critical care refers to the condition of the patient on arrival, not to the treatment given on ITU, however much intensivists wish to flatter themselves]

2. If there is a discrepancy between monitored physiological parameters, the least sophisticated one is usually correct

3. If it looks precarious it probably is

4. If the cardiac surgeon hangs about pensively after the handover of the post-operative patient, then there is something they aren’t telling you in the op note [to quote a friendly surgeon, “the op note describes the operation you wish you had done”]

5. You can guess the age of an anaesthetist by his preferred induction agent

6. If the picture doesn’t fit, go back to the beginning [with reference to a boy with low sats who turned out to have methaemoglobinaemia, clearly evident but ignored on his first blood gas]

7. The greatest bravery is in deciding when to stop

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