Me: hello dr. Smith. I'm calling you this evening because your patient is in compensated metabolic acidosis. Her ph is 7.34 but she is over breathing the vent and her base excess is -13. I'm concerned that if we don't give her some sodium bicarb, she will decompensate and become severely acidotic. Her calcium is also critically low.
Dr. Smith: why are you calling me?
Me: because you are listed as her primary MD.
Dr. Smith: yes, but she is intubated. Call pulmonary.
Me: but she is in metabolic acidosis. The pulmonologist doesn't want to fix non-respiratory problems. Can I give her some sodium bicarb and another dose of calcium gluconate.
Dr. Smith: the day shift nurse already gave three doses of calcium.
Me: but her calcium is still critically low.
Dr smith: no. It's 2300. Call in-house with any further problems.
One hour later
Me: good evening dr. Jones. Sorry to bother you. I have a patient of yours who has metabolic acidosis, is on several different pressers and an insulin drip and is intubated. She's in SVT with heart rate in the 150's. She's on an amiodarone drip but if I increase the rate her pressure will drop even more and I will have to go up on the pressors. I think she would respond well to some sodium bicarb. Right now her acidosis is preventing the pressors from working.
Dr. Jones: this isn't my patient, I'm just on call. Increase the amiodarone drip until 7 am
and then dr. Moore will take over.
One hour after that
Me: good morning dr. Brown. Sorry to bother you at 1 o'clock in the morning, but I just got a gas on my patient and she is now severely decompensated with a ph of 7.18. Her base excess is now -21. Her heart rate is in the 140's and her pressure is 84/46 on maximum drips. I feel she needs some bicarb.
Dr. Brown: that's not that bad.
Me: I just notified organ procurement due to the fact that she is non- responsive to painful stimuli with no gag reflex. I assure you, it IS that bad. Can I give her some bicarb?
Dr. Brown: she was admitted with DKA wasn't she?
Me: yes. She is on an insulin drip and her sugars are in the 400's despite hourly boluses of iv insulin.
dr. Smith: your doing everything you can. Insulin will fix her.
two hours later
Me: dr chance? Sorry to bother you. I know it's only 3 o'clock in the ,owning and this patient isn't actually in renal failure (in fact, her kidneysnare the only thing that are still miraculously functioning) but I've called every doctor on the case and I don't know what else to do.
Dr. Chance: what's the problem?
Me: my patient's last blood gas was 7.18 and that was two hours ago. I'm afraid to get another one.
Dr. Chance: well, she needs bicarb!
Me: thank you. I agree. Do you want me to give her a bicarb drip?
Dr. Chance: yes! How quick can pharmacy get that to you?
Me: I will call and offer them my first born child. She is two and very cute.
Dr. Chance: better grab a few amps from the accudose and give them as a push. Give 4. Start the sodium bicarb drip at 250 and call me back in 2 hours so we can see if that's doing the trick.
Me: I have a beautiful diamond that my husband gave me. It's yours if you want it.
Two hours later:
Me: dr. Chance? I gave 4 amps bicarb iv push. I started the bicarb drip. The patients blood pressure is 114/66. She is off all pressors. Her heart rate is 115 and her blood sugar is down to 196. Her blood gas is greatly improved and she appears to be waking up.
Dr. Chance: great job. Why didn't you give the bicarb sooner?
This was a fictional account. Nothing like that has ever actually happened to me, any doctors or any patients. I would never offer up my first born or my diamond ring to a colleague. I have never spent the entire night waking random doctors up until I finally find one who will give me the one little thing that I know will help the patient...