Here's a good idea:

If you have a patient without IV access and with a blood glucose of twelve, who is having a prolonged seizure because of that hypoglycemia, do not call casually down to the NCCU and ask me to mosey on up "when I have a minute" and put in an IV for you.

Call the response team instead.

I arrived to find a patient who'd been burned over about 40% of her body when her meth lab took a wrong turn, with a nurse and doctor standing at the bedside like calves at a new gate. The doctor was beseeching the patient to breathe slowly and deeply as her eyes rolled back in her head and she seized. The nurse was doing something, I don't recall what, but it wasn't what needed to be done.

So I grabbed a start kit off the cart and found the only place I could without fresh grafts: her left ankle. Her daughter started protesting that she'd "had tumors in that leg" and trying to stop me from inserting the IV. The daughter got told to get out of my way. As I found one decent vein and stuck it, I asked, "What's her CBG?"

"Uh....low" said the doc.

"How low?" I pressed.


I looked up from the blood flash I'd gotten and turned to the nurse. "Call the response team" I said, low and forcefully.

"What?" she said.

"Call the fucking response team. Dial ninety-nine and tell them you need a response team stat."

Back to the IV. I heard the call go out. The catheter hit something and wouldn't budge any more, so I tried floating it in. No go, and I lost blood return. I eased the catheter out about a quarter inch (about half of the length it was actually in) and got blood.

"Give me the D50" I said.

The nurse fumbled around for a minute and managed to give me an amp of D50 with the needle guard removed. At that point, thank God, the response team showed up and included a nurse I'll call Stoya because, well, she looks like Stoya. She got the needle guard back on the dextrose and managed to push the amp through a 22-gauge that was only about an eighth of an inch in the vein. It blew as she finished off the amp.

The response team chief was looking at the doctor, expecting some sort of explanation and perhaps a brief history of what was going on. Doctor Moo stared back, speechless. "Forty-five-year-old female, brittle type I," I said to the chief, "who was given 125 units of NPH this morning and hasn't eaten since. CBG of twelve, no access. Why the hell doesn't this patient have a central line?" That last was to the doc.

Meanwhile, somebody showed up with Glucagon, and that got into a muscle somehow, and Stoya handed me a 20g to start another IV. A couple of CCU nurses were working on the other leg, but nobody was getting anything. After several minutes of this (it felt longer), Stoya said, "Oh, fuck yeah" under her breath and turned the woman's leg to the side.

A huge vein had popped up out of nowhere on her ankle. I slid my right hand under Stoya's arm and, with her stabilizing the vein for me with one thumb, watched the entire universe collapse down to this one scene: right hand with a needle, blood on my ungloved left hand (I'd taken off the glove to try to feel something; don't tell me you don't do that too), a single vein popping out of a bony ankle. Stick, flash, fumble for a flush, yank the cap off the flush with my teeth. Get the access flushed and taped. Push another amp of D50.

The patient's blood sugar had come up by this time to the point that she was no longer seizing, but instead was actively fighting. She took a swing at one of the nurses and began to scream. Her daughter, at the head of the bed, started screaming back. "Get her out of here" I said to the biggest respiratory tech we have, and he did. A patient care aide who weighs somewhere around 220 laid down across the patient to keep her from coming out of the bed.

"I need a milligram of Ativan, stat" I said, to one of the dozen people clustered around the door. "Uh...I don't know if we have that on the floor..." she started to reply. "Then get it out of the code cart. A milligram of Ativan. MOVE!"

Working with those nurses was like working with a group of sedated turtles in Jell-O. I'm proud that the only time I raised my voice was when I said "move" to the nurse who was impersonating one of the more languid varieties of rock.

Through the whole response (twenty minutes, total) the doctor at the bedside never said a damn word. He simply had no clue at all what to do. The nurse was new, so I'll excuse her for not knowing: knowing what to do in the classroom and doing it automatically in a crisis are worlds apart.

The pharmacist came to visit me the next day. "I liked the way you handled that response the other day" he told me. "Nice work."