About 3 years ago, I began a unique position as a cardiac critical care PA at the esteemed Piedmont Hospital, a rapidly growing tertiary care facility in Atlanta, Georgia. My PA teammates and I practice at the hospital with a high degree of autonomy, especially after hours. On a daily basis, we manage critically ill patients, perform procedures at the bedside, and provide a central line service for the entire hospital. Besides caring for cardiology patients in the ICUs, the other PAs and I also help to manage patients in the cardiothoracic, vascular, and thoracic surgery departments.
6:55 PM
I arrive at the hospital to begin the critical care night shift. My day shift counterparts give me sign out on our ICU patients, and my phone starts ringing before the shift begins. Already, I can tell it will be a busy night. We are short-staffed, so I will be working alone tonight. The nurse on the phone describes a problem with a coronary care unit (CCU) patient and requests a prn medication. Midway through our conversation, call waiting interrupts and I switch over. It's the emergency department (ED) reminding us to admit a patient for chest pain. After finishing sign out and wrapping up the CCU nurse's request, I admit the chest pain patient. Luckily, this admission is straightforward, and I submit orders and finish dictating the history and physical examination before the next call comes in.
7:40 PM
The phone rings three times in a row. I have a patient to see in the CCU, a cardiology consult for bradycardia in the oncology unit, and a central line to put in for a patient in the ED. I go first to the patient who needs a central line. I discuss the procedure with him and assess the ideal position for placing the line. This particular patient is septic, has stage IV chronic kidney disease, and is on warfarin for atrial fibrillation (AF) with an international normalized ratio (INR) of 3. I decide to go in through the left internal jugular vein with direct ultrasound guidance. The line goes in smoothly, and I order a chest x-ray to confirm proper placement. While awaiting the images, I get a call that the patient awaiting a cardiology consult in the oncology unit has heart block.
8:20 PM
I run up to the oncology unit and review the telemetry strips. The patient has progressed from Mobitz type II to intermittent complete heart block. His labs are normal and he is not receiving any negative chronotropes, but he is borderline hypotensive with a mean arterial pressure of 60 mm Hg. I notify my attending cardiologist and the admitting oncologist that I will be transferring the patient to the cardiac intermediate unit and that a temporary pacemaker may be needed tonight. After IV isoproterenol (Isuprel) fails, I have a nurse bring pacing supplies. Meanwhile, I confirm placement of the central line in my previous patient's x-ray, then immediately begin to place a temporary transvenous pacemaker in my current patient. I choose a right internal jugular vein approach to preserve the subclavians for a possible permanent device. Once the bipolar pacing probe is in the right ventricle, I determine the capture thresholds and program the external pulse generator. I update my attending physician, write a progress note, and dictate the consult.
9:45 PM
The oncology patient is paced at 60 beats per minute and is resting comfortably. I follow up on the CCU patient with rapid AF, then head back to the ED for another chest pain admission.
12:15 AM
During a quick break, I hear a call for code blue in telemetry and arrive at the same time as the rapid response team. We find a nurse already performing chest compressions on a patient who is not breathing. The respiratory therapist "bags" the patient while another prepares for intubation. I ask the nurse to hold compressions briefly while I check for a pulse. The patient, a 60-year-old male with an ejection fraction of 20% admitted 2 days ago with a mild heart failure exacerbation, is pulseless, and his rhythm shows ventricular fibrillation. I order the first shock to be given. After a prolonged resuscitation with several shocks and administration of multiple advanced cardiac life support medications, the patient finally has a perfusing rhythm. We transfer him to the ICU. He remains unresponsive and, after a brief phone call to update my attending, I proceed with the induced hypothermia protocol. In hopes of a good neurologic recovery, I place a cooling catheter via the femoral vein. Then I place an arterial line in the femoral artery for close blood pressure monitoring. It is clear that this patient is now in florid heart failure and needs careful hemodynamic monitoring. I insert a Swan-Ganz catheter via a right subclavian approach. His cardiac index measures 1.5, and wedge pressure is 30. I order diuretics and an inotrope while discussing ventilator settings with the respiratory therapist before finishing my progress note.