5 posts tagged “death”

Interesting tidbit, but did you know that if your loved one dies in a hospital you don't need to sign the release of remains off to a funeral home? You can take the body home with you if you like, instead.

Today, starting at about 7:15am, 21 31 33 college students at Virginia Tech were the victims of a shooting rampage. Some of the students that were killed were housed in Ambler Johnston West (one of Tech's largest dormitories, if not the largest -- my own cousin stayed there during her first year of college). The shootings were continued in Norris Hall (one of the buildings in the Engineering quad next to Buruss Hall) until the killer either killed himself or was killed by police.

I feel really sad for Virginia Tech's loss -- I spent some of the best years of my youth at Tech and I can't imagine that those buildings (especially Norris where I had classes once) are now tainted with death.

It always surprises me, that in a world where there's already so much death, that people choose to promulgate it by taking the lives of others. Aren't there enough diseases and wars to do that already? Why add to the mess? In this killer's case, it was downright selfish and unreasonable and I have little sympathy for him in whatever afterlife exists for a soul like his.

My heart goes out to the hokies.

Quick anatomy crash course before our entry begins. Kidneys are located towards the back of your abdomen (retroperitoneal) and to give you a rough idea of where they are you can place your hands with your fingertips pointing at the top most arch of your hips and then rotate them backwards towards your back. Feel those babies? Those are filtering toxins and electrolytes.

Back to our scheduled program... Renal (or kidney) failure comes in multiple forms and each can be problematic for  the kidneys in different ways: Pre-renal (or before the kidneys), intrarenal (within the kidneys), and post-renal (after the kidneys). There is also acute versus chronic, but for my purposes I won't get into that... Anyway, with damage being dealt to the kidneys they are unable to perform their most important task which is filtration of toxins (and of course removal of serum electrolytes or water and even production of certain hormones). Dangerous accumulations of these cause death.

In the adult intensive care setting, we manage renal failure several ways: 1) transplantation 2) hemodialysis/peritoneal dialysis  or 3) continuous renal replacement therapy.

Kidney transplants are one of the most frequently (if not the most) done solid organ transplants in the United States. The cost of a kidney transplant between the individual involved, the donor, the hospital, and the maintenance is exorbitant. Possible donors are evaluated by a group called LifeNet and the list of possible recipients is kept by UNOS. Transplantation is the last resort.

Hemodialysis is usually an option for many people with kidney disease (renal failure) and people that usually need this get dialyzed three times a week. Patients who need this have some kind of dialysis access placed in their bodies (like a permacath, or fistula -- see here for more details) through which they're able to be hooked to a machine that filters their blood for them. It's tasky, tiring, and very time consuming and of course has a myriad of complications associated with it. Peritoneal dialysis can be done at home by the patient by letting different types of dialysates rest in the abdominal cavity (via a port to infuse it by) and then draining them. It's usually done twice a day, every day, and is probably as equally time consuming as the HD with just as many complications. The only upside to PD is that it seems to be less stressful than HD.

The last way I mentioned to manage kidney disease is continuous renal replacement therapy. Generally, the only time this is even done is in an inpatient intensive care setting (ICU) and it's a process that needs to be done by a trained ICU nurse. The device is similar to a hemodialysis machine, but one that pulls and replaces fluid much slower causing less of a disturbance to the patient's body. This is ideal for very sick unstable patients who can't handle the drops in blood pressure associated with hemodialysis. This type of device can also remove fluid in different ways (slow continuous ultrafiltration, continuous veno-venous hemofiltration, continous veno-venous hemo dialysis and, continuous veno-venous di-filtration). It's exactly as it's namesake describes -- continuous, and people can be on it anywhere from a few days to weeks depending on the severity of their kidney damage and other present co-morbidities. The process of managing the device is really complicated, very time consuming (for both patient and nurse), and ridiculously expensive.

The first time I had to do CRRT as a nurse was when I was caring for an individual that had been admitted after having a heart attack related to some marijuana they had smoked which was laced with "a little something special." Needless to say, that special something landed them in our care and on CVVH. The patient had been causing trouble in our ICU asking for a new nurse every shift, and giving each and every single person a hell of a time demanding one absurd thing after the other. The patient later on, against medical advice, decided to check out of our ICU and died several days later because of his non-compliance with his treatment.

Since that patient, I've had several others that needed CRRT and where there once was excitement with managing it, there is now sadness. There's nothing more annoying than another device that alarms every five minutes needing attention. Anyway, I still get a little kick out of managing the device and I'm even happier when it has some kind of malfunction (nothing against the patient or anything... it's not funny business really when the device fails) because it usually means I have to call the company we outsource to fix the machines. That means calling my favorite DaVita guy, Chris who also just happened to teach the in-service Elaine and I went to last night about the Prisma device. Nothing like business and pleasure mixed together.

Of course, I still wouldn't want renal failure just to get a visit from the DaVita guy. Honestly.

My advice to people when dictating their advanced directives to medical staff is to accept the option of doing chest compressions. What good is giving chemical resuscitation if you've got no way of circulating the drugs? Sometimes it's better just to go all-or-none with DNR status.

Last night, I ran into a room with a crash cart and a backboard all gung-ho and ready to start some ACLS, when I was stopped with a concerned "no" head movement. The expression on my face was, "You mean we're not going to pump and thump?"

It was understood that this man was definitely not going to survive our life saving efforts regardless of how much support we would give. He was in multisystem organ failure (hepatic, renal, and respiratory), he was old (and I do mean genuinely old -- in your golden years old), and was hooked to so many chemicals that would've been toxic in most anyone with normal kidney function. Still, his family wanted full chemical and pulmonary resuscitation (but like I said, the drugs don't do much if you aren't circulating them). Needless to say, the man died 10 minutes later, after a long two month battle in our ICU.

About an hour later as a nurse was just foreshadowing that her patient just looked like death he suddenly brady-ed and flatlined into asystole. Our jaws dropped as we had just rushed into the room and he was already dead (usually we have at least a FEW seconds). Just as she was calling to let the family know he had died (about a minute in) his heart suddenly began beating again only to flat line. It was slightly spooky and my jaw dropped yet again. He was a full DNR, so we just watched and bid him farewell and good luck on his next journey out of our care and ICU.

Within the next 20 minutes we got both rooms cleaned and both patients device and line-free and ready to be viewed by the families. Ten minutes after both families had left we had finished wrapping up the bodies and bagging them, and about fifteen minutes after the bodies were gone we had another two admissions to fill the spots that were left open from people expiring.

It's scary how quickly life moves on in an ICU. That's my two cents for the day.

PS: On an unrelated note, I found the description on this picture disturbing.

So I've decided to do a running set of entries about heart problems you don't want. These are, of course, in no particular order.

Today's entry focuses on aortic dissections.

First off, let's start with a little crash course in the anatomy of your heart. Your heart is part of a major organ system that supplies blood to your entire body. The aorta is the largest blood vessel which carries oxygenated blood from your heart to the rest of your vital organ systems.

Think of it as the main pipe in a series of ones that run under a city. To keep it simple, this particular pipe has three layers of 'metal' that make it up (kind of like how the earth's crust is made up of different layers with different properties). In an actual dissection, blood seeps into the middle of the three layers of the aorta and creates a stagnant pocket of blood that creates pressure in that layer causing it to further tear the lining of the vessel. Similar to further packing cars into a cul-de-sac; eventually cars spill out onto the street because there isn't any more room. The explosion of said aneurysm causes massive bleeding and almost instantaneous death.

Some individuals with abdominal aortic aneurysms (where the ballooning occurs in the lower portion of the aorta) can have surgical repairs to prevent further progression. People that can't undergo surgery can opt with medical management to control their blood pressures instead.

There aren't any definite causes as to why aortic dissections occur. We can point to the usual suspects like high plaque build up on the walls of blood vessels from eating foods high in fats/cholesterol (which causes subsequent hardening of the vessels -- aka atherosclerosis), or high blood pressure. Surgical complications can also cause aortic dissections (very rarely), and/or a lot of trauma to your entire body (like in some type of massive motor vehicle accident).

That concludes the first, friendly public service announcement. Stay tuned for the next freakish heart condition!