Tonight was a great night to be an ER doctor. It was a perfect storm; Monday, after a long holiday weekend, evening shift--all the stars were aligned for a brutal, brutal shift in the ED. Me and Pableo have noticed the pick up in the traffic since early November: the virus season is taking its toll on the very old and very young and we are caring for a lot of sick babies and sick old folks who require a high level of vigilance. Today was going to be especially bad. The waiting room looked like a zoo. Just a madhouse. What a lunatic way to provide emergency medical care to a population, but so be it. Back in Trauma I was doing a fairly decent job keeping on top of my patients and charts, when suddenly things turned ugly. Ugly, ugly, ugly. Medics brought in an old guy with rectal bleeding. Severely demented. I went to check a quick rectal and (DANGER-MATURE CONTENT WARNING!) found a diaper filled with thick gelatinous red blood. Uh-oh, this is not a little cosmetic internal hemmorhoids bleeding, this is something muy muy malo. The guy is on Coumadin-a fairly large dose-and his last INR was checked.....last year. Oh, shit. Low blood pressure, but not tachy. But he's on "heart medicines" which may include a beta blocker so...procede with caution. I decide on the full court press--the "presumption of acuity" I call it. Order two units of red blood cells, a unit of fresh frozen plasma, all the labs, place a central line, start bolusing fluids (but he has a history of renal insufficiency and CHF so, double underscore, procede with caution). Call his primary and wait for the hemoglobin. Then the medics bring in a woman found down at home. Unresponsive, eyes deviated to the left. Snorting and gurgling through her clenched teeth. She is freezing! We can't get a pulse ox. Mercifully she has a narrow complex rhythm that is producing a pulse. I order the STAT CT Head, tell them to prep for intubation, order labs....and then the nurses tell me her rectal temperature. Guess what this woman's body temperature is? Guess. It's....84 degrees Farenheit. That's--what?--29 degrees Celsius! Holy shit! Doing a residency in California didn't really prepare me for managing a whole lot of hypothermia (I've seen a grand total of one mildly chilled patient in my career), but my Board preparation did cover this material. And this woman is sick, sick, sick, sick, sick. Whoah--I must be delicate with the intubation, as it has been shown to possibly precipitate VFib in hypothermia. Pre-load with lidocaine and relax her with Etomidate and Sux. A tube in and....still in sinus brady. Good. Then I worry about whether this woman who has been laying on the ground presumably all night long has rhabdo and an elevated K+. Geez--I cover for hyperkalemia and get her bundled for a STAT CT Head. And then the hemoglobin comes back on my bleeder--3.3! Whoah! I have a acute heady sense of tense heightened awareness. Suddenly we are in it deep. And then my hypothermic lady arrests. VFib that swiftly drops into Asystole. Total unambiguous Asystole. No pulses. Okay--I yell some orders for the bleeder and send the med student to chase down some STAT O negative and jump on our frozen lady. ACLS protocol is going nowhere. She's just too damn cold. We kick our warming measures up a notch and I commit myself to a long, long flog on her. She will not be dead until she is warm and dead. And then they show me the EKG on the little Asian lady with chest pain who is in the gurney next to the bleeder. Acute MI. Huge 4-5 mm ST segment elevations in all the inferior leads. A quick check on the history--yes, yes, she is having some chest pain--and I pull the trigger on the Cath lab. Call Cards, call in the nurses and techs and start the lady on a little Aspirin, a little Beta Blocker (very little, she was bordeline on her BP) and a soupcon of Heparin. My frozen lady, thirty minutes into our code and well into the bag of pharmeceutical tricks, develops a rythm. Irregular, narrow complex, rate of 18. But by God she has a thudding pulse (occasionally) in her carotids. We nurse it up to a rate of 48. The nurses had been obliquely suggesting we call the code, but I had persisted in the face of reason and statistics and here she was, cold but perfusing! She was hypothermic and relatively young and we knew she had a myocardium capable of conducting and contracting so I had pushed it deep into Code Blue no man's land. Whew! I called the intensivist in and she promptly told me that there was no hope for meaningful life and the certainty of catastrophic brain injury--well, be that as it mayy, I'm damn happy to have gotten her back. Her son arrives....about my age. Poor guy. My bleeder is doing okay. Turns out his Coumadin levels were about four times what they should have been. Still, we have the blood and the plasma running and his pressure looks decent. And the myocardial infarction is off to the Cath lab--nice work team! Got off work two hours late and because of the severely ill patients that took up all of my time my statistics or the shift will look bad--we get paid more for seeing a lot of healthy patients then for managing one sick patient in the same amount of time. I've let the partners down in terms of billing and raising money for the group. Still, satisfying day, and hopefully the money and billing side of things will work out in the next few days. Before I sign off I need to say the nurses were fantastic! So, so strong! When it's a madhouse like that the nurses bear a heaviest burden and the teams yesterday were incredible. Took the overload with total grace and professionalism. I really enjoyed working with them. Can't wait to go back. U-561