First of all, I want to state that I don't know if this will be interesting or not. Let's give it a shot.

You are an overnight pharmacist at a well-regarded tertiary care hospital. It's about 0030 and you're posting on 2p2 between orders. Suddenly, your code pager goes off! You grab the code cart and race to the scene, a surgical recovery floor, and arrive about the same time as the rest of the code team.

The patient appears to be ~60 years old and is an obese male. He already has an ECG on it shows a HR of 70 with a normal rhythm the best you can tell (remember, you're a pharmacist. You're sure it's not Torsades). He has a pulse which makes this an unusual code right away. The floor nurses are giving him oxygen with a bag and facemask. His eyes are open and staring straight up at the ceiling. He appears unresponsive. His wife is there, apparently sleeping over. She looks scared but not overwhelmed.

Your job is to bring the cart, draw up medications, anticipate, and give occasional suggestions. You will speak rarely and when you do you'll speak like a pharmacist (you'll see what this means).

So, where should the team begin?

is patient having a seizure?

I guess I'll start with the obvious:

MD (code leader): What happened?

Floor nurse: His alarm started going off and I came in and he was desat'ed in the 50s and totally unresponsive like this

was the patient previously responsive postop?

Well, for sure he's not having a tonic-clonic seizure. He's not moving at all.

okie dokie. The MD should establish an airway if there isn't one already and possibly intubate. We should be ready to draw up the drugs for rapid sequence intubation.. what all is the code team up to at this moment?

Well, we don't know that answer exactly. The resident covering the surgical service has shown up to give us some background.

Resident: 63 year old male with renal cell carcimona, had a left nephrectomy (had his left kidney removed) yesterday. He required 4 units of blood postop.

MD: Yesterday like just this past day? (just after midnight is fun!)

Resident: No, the day before yesterday. Recovery has been going well. Hemoglobin was 9.8 today (low but not terrible). His serum creatinine was 2.0 (high, but he just had his kidney removed remember).

finger stick?
o2 sat?
12 lead?
abc's?

A code nurse has hooked him up to a BP machine. His BP is 100/60.

He is saturated at 100% now. The code leader removes the face mask and tries to get a response by calling his name and with pain (a sternal rub). No response.

He asks you for 20mg of etomidate. They are going to intubate.

if airway isnt compromised, (spontaneous respirations,sating fine) i wonder if intubation is the first thing to do? also, if he is not moving/responsive..why RSI? just stick a tube in.

how are his pupils? symmetric? pin point? if he is breathing, has a heart rate and is nonresponsive, sating OK, i would do a finger stick and glance at his pupils and see if they are reactive.. as well as try to elicit any type of stimuli/reflexes? any chance of a CVA? maybe the PCA pump is set incorrectly or he is schlogged from too large of a dose of pain meds or sedatives (was he agitated earlier and got some vitamin H?) Is he a diabetic? did he recently get insulin (maybe the wrong dose?)

how advanced is his RCC?

also, what is the relationship between the wife and the husband? why is she not more freaked out?

The intubation seems to be a bit of a challenge. He's an obese guy with an apparently difficult airway.

Since you're pretty sure they're not about to scream at you for epinephrine you wonder away from the cart to look at the meds hanging on the IV pole. IV #1 is furosemide, probably nothing but worth noting. IV #2 is insulin!!

Here's something! Time to talk like a pharmacist. Instead of ordering a blood sugar and stopping the insulin you set up the MD like a volleyball setter.

RPh: Is this insulin drip still running?

Leader: Stop that insulin and get me an RMG stat!

The nurse informs you that both drips have been stopped. Lab has been called but isn't here yet. The RN goes and grabs the glucometer. RMG is 127. Darn, a deadend.

well we would intubate if we thought there was some type of neurologic thing going on here, or if airway patency couldn't be maintained for whatever reason (injury, aspiration etc.).. not sure if any of those things apply here anymore since he's sat'ing 100%

so patient has sortof a lowish but not catastrophic blood pressure, good sats with non-rebreather on supplemental oxygen, and is unresponsive.



edit: i am slow

Well he definitely has risk factors for a stroke, surgical patient, cancer patient, obese, advanced age. The MD has looked in his eyes but hasn't remarked about what he saw. Code leader asks how much pain medicine he's had (this actually was asked right away). He hasn't had any since the morning.

The wife hasn't left the room, she's watching from the back. It turns out she's handling things non-hysterically because she's a nurse. She's very concerned.

The code leader asks her what they were doing before this happened.

Wife: We were just talking and then I guess we dozed off. It was only a few minutes before this happened.

I guess that tells us at least whatever is going on hasn't been happening for hours.

Meanwhile, it looks like the intubation has been postponed after some difficulty. They're back to bag and mask.
Lab's here. Anything we want?

Assessing for spousal murder is rather toward the end of the flow diagram

didnt realize it was even on it :P how about a cmp, cbc, and UA

how bout a stat venous panel (at our institution, it has venous gases, bmp, crit, lactate).. specifically.. i'd like to know his bicarb, lactate, lytes, hgb

also, any chance we have a 12 lead.. or what does hte monitor show roughly on his pattern? (not that anything i can think of cardiac wise that can really cause this.. besides afib-->clot, unless he was hypotensive prior and was ischemic (thus the need for lactate)

haha, yea that spousal thing was WAY WAY down there.. just might introduce an element of tox or other meds/zebras onboard that might come into play down the line.. if you are posting this case, im assuming there is something intersting here.. anyway.. the fact she is a nurse and relatively calm with her husband coding doesnt make me feel any better if im going go down this line of reasoning.

..but the relatively acute onset for this presentation does point towards a neurological event

Lab has a cool gizmo that gives you a bedside readout in a couple minutes. You get maybe a chem 7 or something. Not much has changed. Serum creatinine is still bad at 2.2. Potassium is pretty high at 5.7 but not high enough we'd expect problems.

Blood may have been drawn and sent away but we'll have to we'll wait for it.

I forgot a big detail. His bicarb is 12 (normal 22-26).

It's been 4-5 minutes now. HR is still around 70. BP slipped a bit ~95/55. I don't see any unusual rhythm and nobody more knowledgable has started screaming yet. Status seems about the same

barring a lactate, can we get an anion gap?
in lieu of a stat crit, if i have an ultrasound handy, i'd FAST his abdomen.. make sure hes not bleeding into his belly (tho i dont know much about neprhectomies.. do they go anterior? posterior? FAST would miss anything in the retroperitoneum) tho if he is bleeding, i'd expect him to be tachy.. unless he was on any type of beta blockers..

Lab represents a bit of a challenge for me here. There's lots of reasonable things you can ask for, but as they weren't drawn I don't know what to tell you.

You guys are basically all over this so...

An arterial blood gas was drawn. It showed:

pH: 7.05 (!!!! normal 7.34-7.46)
PaO2: 304 (i think we broke the machine, he's on oxygen)
PaCO2: 62 (normal 35-45)
Bicarb: 12 (normal 22-26)
Anion gap: 14 (normal 8-12ish)

We give the guy a couple amps (150mEq) of bicarb and the situation resolves. The code part is over (not that the guy can walk out the door).

Knowing that you took an 800 level elective class in pharmacy school on fluids and electrolytes, an invisible little boy asks you the real question: What happened?

Think about everything going on here.

Could have a combo of metabolic and respiratory acidosis here, guy goes sleep apnea and can't breathe much or something, and kidneys obv not at full function.

Not to derail this... but are there normally pharmacists on code teams?

What is the typical makeup of code teams?

ER/Anesthesia attending, couple interns, nurses, a pharmacist?