4 posts tagged “medicine”

My unit (in comparison to the previous one I worked in at a smaller hospital) receives a massive amount of post-arrest patients. The difference with our service is that our unit is probably the one most familiar with initiating what's called the hypothermia protocol.

The hypothermia protocol is a treatment plan that's initiated after someone has been resuscitated from an 'arrest state' (induced by either ventricular fibrillation, ventricular tachycardia, or pulseless electrical activity). During hypothermia protocol, a patient is chilled (down to 32 degrees celsius) for a period of 24 hours and then slowly rewarmed back to a normothermic body temperature. The reasoning behind hypothermia protocol is that if you can chill a patient (whose body has just sustained a large amount of damage and is in a 'hypermetabolic' state) down, you can slow the rate at which the cells are being destroyed and minimize damage to the body and, in theory, preserve some of it's function. All of this winds down to hypothesizing that patients who have been through hypothermia and rewarming have better outcomes than patients who receive no such treatment at all (if they didn't -- why would we bother going through the therapy at all?).

Of course there are also other factors that need to be taken into account before saying that the survivability is greater after hypothermia... Co-morbidities like shock states (cardiogenic, septic, etc.), disseminated intravascular coagulation (DIC), previous damage from other heart attacks/arrests also play into how good of a chance a person is going to have in surviving the arrest itself in addition to how well they will recover from the hypothermia therapy.

Lately, perhaps because we're in the midst of a hot summer, the ICU acuity at our medical center has been through the roof with patients requiring the hypothermia therapy. I'm interested in knowing how many medical centers actually implement a supportive therapy of this type and whether it improves their mortality rates or not.

The last place I worked was a large academic medical center in the middle of the city which has both the reputation of being both very good and very bad. It's understandable that everyone will have a different opinion of it, but personally, I loved it there (and is the main reason I'm heading back now). It was in that hospital's different units and corridors that I learned the most valuable nursing lessons -- and where I also gained my love for health care in general. It was also the place that I saw a lot of my "firsts" in nursing.

While I was still a student, I had the opportunity to work in several of the ICUs (and step-down units). My favorite of them was the Coronary/Coronary Medical ICU, my home unit. It was there that I first watched a patient die, and there that I also first watched patients be 'brought back from the dead.' Between there and where I work now, there is a serious difference in the culture (and I don't mean this in a derisive manner) in the way individuals with advanced directives are treated.

The very first patient that I watched die had gone into a full cardiac arrest (asystolic for 20+ minutes) at a nearby prison and was revived en route to our hospital where they underwent a cardiac catheterization to have an intervention. Prior to his arrest, he had an infection in his newly placed dialysis access port, and was stabbed in it causing a massive blood loss. Add to that the delay before intubation and the problems associated with a full arrest and you've got a cocktail that is incompatible with life. On arrival to the unit -- he was septic, had a pH of 6.9, and was coated in blood; the only things keeping him alive (and just barely, at that) were chemical pressors, constant transfusions of blood products, a mechanical ventilator, continuous veno-venous hemodialysis, and several doses of emergency drugs to control irregularities with his heart rhythm. In addition to that, we were seeing a lot of bleeding coming from every one of his orifices -- nose, eyes, ears, penis, rectum. That night, the gastroenterology team on-call came to 'scope' him and were unable to localize the source of his bleeding because of the sheer volume of blood that was just pouring out of him. It was clear however, that this man was a goner -- his belly growing larger by the hour, and his blood pressure and heart rate fading as well. His family was asked to come in that evening to make decisions regarding his medical care, and whether or not to continue to aggressively treat him. It was, with heavy but benevolent hearts, that the family made the choice to allow him to be a DNR (do not resuscitate). They wanted to continue with the medications he was already on, but to let him die without any additional life-prolonging measures like CPR or defibrillation. The nurse that took care of that patient for the rest of the night was swamped with the backlogged charting and medications that needed to continually be given to keep the patient comfortable.

Around 6am, the man slowly passed away into an agonal pulseless electrical rhythm. I watched as his family cried until their faces were red, and they could no longer breathe from the suffocation of the grief. They'd made the right decision -- I couldn't imagine prolonging their misery, or the patient's. The nurse that was assigned to him, asked the resident on-call (Seth) whether he should just unplug the ventilator and let him 'go'. Seth responded with, "he'll go in his own time, you don't need to expedite it any further." At which point the resident looked at me and said, "Don't you ever become that kind of nurse."

It was around the time that I'd first watched that patient fade into death, that my own grandfather's illness began to take over. He was a very sick man in his 90's -- he had been a smoker for an amount of years longer than my own mother's life (she was 55 at the time) and had only quit when my youngest cousin was born. My family, being the kind of people who can't live with guilty consciences chose to keep prolonging his life with this procedure and that; stuffing tubes every which way, until my grandpa could no longer take it and was attempting to remove the tubes himself. My family couldn't live with the idea that they shouldn't do everything they could to keep him alive. The man had esophageal tumors large enough to obstruct his ability to swallow and was receiving tube feedings through a nasogastric tube that was large and uncomfortable. The mental torture of being unable to eat also got to him, and eventually he pulled the tube out himself and attempted to feed his weakening body. He died sometime in the night, sleeping.

This fall, as I took my first critical care course as a nurse, the issue of having an advanced directive was addressed. It was the general belief of the people that took that course, that individuals who had designated themselves as DNRs should not be 'treated.' I was slightly saddened and dismayed that everyone seemed to think that being labeled a DNR meant giving up treatment altogether -- which wasn't what I had so painstakingly learned in the previous hospital setting I was in. I still remember everyone in the classroom staring at me and saying, "what's the point of continuing to treat someone like that?"

Maybe I'm too fond of life, but I take a DNR to mean that in the event of an emergency (and by this I mean anything preciptating asysole), a person would want to just be left to pass away in their own right. There are DNRs in every different shape and form -- and not everyone is like the first patient I saw die. Some are cancer patients that want to live out what life they have left, and even though they have terminal illnesses still undergo some form of treatment to give them a bearable quality of life. Others are healthy individuals that just don't want to go 'out' in such a manner as a coding patient does -- does that mean that you wouldn't continue to treat their other illnesses if they were (and I quote) "...just a DNR anyway,"?

Perhaps I'm too passionate about saving lives, but the attitude of those nurses disgusted me to the core. I understand the need for DNRs and the belief of benevolence involved with implementing them (in fact, I myself have my own advanced directives), but I don't think that because of them you should just be given up on altogether. Healthy DNRs walk into a hospital to be treated, and if they didn't want to be they wouldn't have appeared at all -- or would've signed out AMA.

My last statement opens up another can of worms altogether, but my point is that I've slowly realized that most of the nurses I work with are all of the same fabric -- that a DNR meant you 'do not care'. While there were individuals at my old hospital (like the nurse that had the first patient I watch die) that had pieces of that fabric sewn into them, it was the amalgamation of other nurses and members of the house staff of doctors that taught me that DNR didn't mean a 'death wish.' When I think back to what Seth had said to me, I realized that these nurses I had been so disappointed in were precisely the ones he spoke of.

I don't know what made me think of it today, but I'm both glad and thankful I remembered the philosophy of what he and others had worked to instill in me.

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!

So I walk into work tonight thinking I'm just going to breeze through my lovely princess shift (7pm-11pm).

I get report on two patients; both male, one who was on the coronary ICU service, the other on vascular surgery service. Both were very pleasant people. Man #1 (the cardiac guy) was nauseated most of the day, and decided that in addition to being neurotic and anxious he would be nauseous this evening too. Other than occasionally having to go in there to put cold compresses on his head; he wasn't that tasky.

So here's the skinny on Man #2 -- Man #2, like many of our patients, has a history of high blood pressure (hypertension), atrial fibrillation (for which he had previously refused to take coumadin), elevated cholesterol (hyperlipidemia), gastric reflux disease, esophageal strictures (tight portions of muscle that have really small openings -- that don't allow much to pass through them), and a liver transplant. Yesterday he felt a little tingly while sitting in his computer chair at home. He went to lay down on his couch when he felt like the feeling just suddenly turned into complete numbness in his legs. Man #2 dialed 911 and was rushed to the hospital. Upon arrival a CT was done and the findings showed he had thrown a clot to the bifurcation in his descending aorta. Today, he went for an aortic embolectomy with angiography (to suck the clot out), in addition to having two failed TEE's (transesophageal echocardiograms), PVR with ABIs, and a transthoracic echocardiogram (because the TEE was unable to be obtained -- why they didn't try a transthoracic one first is beyond me...).

Anyway. Through the day the nurses had been documenting that they were able to feel a pulse in the right foot. The left foot had been ok; I tried using a doppler to listen to the signals in both feet; got all three of the ones in the left, but absolutely nothing on the right. I heard maybe (and I mean MAYBE) a signal in the dorsalis pedis area on the right foot.

Sweat, sweat, sweat.

I felt the foot and it was definitely colder than the left one. The patient wasn't in any pain in the right leg, and he was able to move it. I looked through the flowsheets for the last time they had looked at this guy's foot -- 4pm. The last nurse said she could even TOUCH the pulse. I'd gotten nothing.

Sweat, sweat, sweat.

I'd decided, after talking to a few of the other nurses, to go ahead and page the surgeon.

Her: "。。。

[Note: The rest of this entry had been deleted when Vox recompiled my entry after I had replaced my name with Japanese characters. I tried my best, but it wasn't restored... Sorry!]