Wednesday, July 17, 2013

the maybe-ECMO patient gets lungs!

Maybe-ECMO patient is now Lung Transplant patient, after a day and a half of having ECMO (while I was off), he was called to the OR to receive his new lungs at 2am. We are following the board, watching for him to return to TICU.

Interesting facts about lung transplants:
Survival rate after 5 years: 50%
Survival rate at 10 years: 28%
Transplanted lungs typically begin to fail after 5 years, and typically fail completely at 10 years.

A single lung transplantation takes 6-8 hours, a double lung transplant can take up to 12 hours.

The single most common reason (27%) for lung transplantation is emphysema. IPF (such as what this patient has) is the reason for a transplant 16% of the time.

Patients, even vented or ECMO patients, are required to continue to do physical therapy. They cannot have received blood transfusions in the recent past, have no signs or symptoms of any kind of infection, and must be non-smoking, non-drinking, non-drug using, and willing and able to comply with medical instructions.They must fit a psychological profile, have no other chronic disorders of major organs, cannot have hepatitis or HIV, be within the required age range, and have a good social support system.

Here's to hoping Mr. Lung Transplant gets his lungs and everything goes off without a hitch!

patient funnies

Me holding up phone to confused patient's ear: "This is your son. Here you go. Say hi."

Patient, looking straight at me and ignoring the phone: "Hi!"

Me to patient: "No no... on the phone."

Patient, smiling at me: "On the phone."



Same patient after phone call...

Me to patient: "That was your son, he just wanted to hear your voice."
Patient: "Oh... [pause] Did he hear it?

Me: "Um, yes. He heard it."

Patient: "Good."


Attending to patient: "Who do you live with at home sir?"

Patient: "Yes... we live together."

Attending: "Who is we? Your wife?"

Patient: "Yes... [pointing at senior, male resident] her and I!"

Heh heh.

Sunday, July 14, 2013

mini-live blogging on the maybe-ECMO patient

1200: We thought we had a green light for ECMO. They changed their minds. They want us to oxygenate him with 100% FiO2, then turn the paralytics off and try again. If (when) he tanks, I'll bolus him with vec, the paralytic du jour, and restart the drip. Hopefully, he'll recover. This will prove (at least to ECMO, no one else needs convincing) that he absolutely must get cannulated for ECMO. Then that will happen tomorrow.

If he doesn't improve when I restart the paralytic?

I don't like playing games like this. I am pushing buttons right now only after clear confirmation from the ICU attending and no one else. I'm not sure the resident and intern feel like this is even their patient.

1300: FiO2 is increased to 100%, will pre-oxygenate him for 30 minutes until turning off the paralytic, which will take up to 30 minutes to wear off. Group huddle with family. I encouraged his wife and daughter to walk around and stretch before the paralytic wears off.

1330: Paralytic off.

1400: Paralytic should be out of his system. Train of Four is 4:4 (four out of four).

1440: ICU Fellow tells us to continue routine care (bath, ET tube tape changes, turns, etc) per usual, if not with an extra degree of caution.

1445: Couging attack begins. I bolus versed and fentanyl. His sats drift into the 80s, he comes back up. I bolus more, repeat. His wife tells him over and over he's ok. Her mantra works. He recovers to the 90s and we don't have to start the vec. I swab the back of his throat with lidocaine and pour lidocaine down his ET tube. We got through this one somehow.

1545: Patient's heartrate suddenly increases to 138 with loss of blood pressure, appears to be afib. Rate then decreases to low 100s, irregular, EKG arrives. Patient in and out of afib/sinus/frequent PACs with intermittent need for pressors.

1645: Patient's secretions are causing him to have low tidal volumes and coughing. We take him off the vent and bag him with a PEEP valve, suctioning intermittently, to remove large amounts of tenacious secretions. Patient desats to 60s, but recovers to 90s within one minute. Victory!

1730: Patient is bathed and ET tube tapes changed without coughing or desatting.

1900: We can't believe we made it to the end of the shift without incident! I leave him with pressors off, satting well, off paralytics. I hug his wife goodbye. I know I'll spend the next few days wondering if he's still alive, and hoping that he gets his lungs.

hours of boredom, minutes of terror

The title refers to the way anesthesiologists describe their job. 

They said yes to ECMO.

It's been two days of exultant highs, white-knuckled lows. You float peacefully along the riverbed we carved out for you, like the dreamers that we are, until you catch, you snag, you tear. You break.

We patch up the hole, we sew the pieces back on. We mend you with tight lips and grim faces. Every victory snatched away from us too soon.

We bolus you over and over to stop your coughing. We watch your pulse ox saturation nose dive and sit at a breath-taking low, the seconds ticking by ever-so-slowly.

Fuck it, I say, I'm restarting paralytics. I reach for the line. Almost as if responding, your sats jump up into the 70s. My finger pauses on the button. The attending appears, and gives me the go ahead. We paralyze you. We pump up your blood pressure with pressors, trying to repair the damage we've done with our other drugs. Your head lolls, rag-doll-like. Behind us, the photos of your life (jet-skis, graduations, and sunny days) seem to call out in sudden pain.

No options, we say to the family. No options, we say to ourselves.

What will happen to you? Can you survive every odd, can you hang on through ECMO, physical therapy, waiting for lungs, and a high-risk surgery?

I want to hope, but somehow... I just don't think so.

Monday, July 8, 2013

follow-up to "Making mistakes in the ICU..."

A friend mentioned that it would be beneficial (at least to perfectionists like me) if nurses got together with management once in a while to discuss mistakes that are being made (anonymously, of course) so we could all feel a little better about ourselves when we DO make them.

I doubt this is going to happen, but I am going to email our former supervisor for some perspective. How many of us do make mistakes, what kind, and how often? Am I alone in this? Am I alone in thinking I'm alone? That much I seriously doubt.

making mistakes in the ICU

*This is a shared post with my other blog, as being an ICU nurse affects my whole self and life*
I made an error at work yesterday, a small push of a button (that I forgot to push) and everything got all screwed up for a while. The nurse following me was very kind about it, even defending me while writing a risk report… but just knowing that managers/quality indicator people/other nurses are looking at me like I’m a dummy, it bruises my ego big-time. I freely admit that I DO care about what my co-workers and superiors think of me. When I make a mistake, even one that doesn’t hurt a patient, my stomach twists into knots and I can’t eat. I am so harsh with myself that I feel I should probably leave the ICU and go somewhere where I’ll make fewer mistakes, or at least my mistakes won’t have the potential to really hurt someone. I never hear of mistakes being made by other nurses, they never talk about them, certainly, nor does anyone mention mistakes that have been made anonymously. Making an error as a nurse translates into shame, and the shame I feel each time it happens cripples me.
I am feeling the need to really look at this aspect of myself. My extreme perfectionism, which some might argue makes me the ideal ICU nurse, also works to damage my self-esteem and lead to self-loathing when I make a human mistake. Yet, I am told time and time again, that I am NOT supposed to make mistakes at work. I am supposed to do 100 tasks in an hour, anticipating needs and thinking critically at the same time, and never press the wrong button, miss a number, or forget something. If I do, I am cornered and made to feel inadequate and unworthy of working in the ICU. The environment is a pressure cooker, and I’d be lying if I didn’t say that in the mornings right before my shift, I am terrified that I will do something wrong or forget something important. At the end of the day, I drive home white knuckled, going over every detail of the day in my mind, looking for an error. I have nightmares of doing something wrong, forgetting to chart something, not wasting a narcotic, etc etc.
It’s not as intense at home, but it happens here, too. I see a diaper rash or a bit of cradle cap on the baby, and I immediately feel like a failure as a parent, and worry that she will be taken from me for it. I berate myself for not using more cream, noticing it sooner, etc. I look critically at my house, at my body, and at my own past poor decisions in relationships. But making a mistake at work is usually the trigger for my anxiety about everything else.
I want to find ways to address this anxiety, and to accept myself as human and not perfect. I want to find peace with “doing my best”. Right now, I wonder if this is possible in the environment I work in, if the expectations there are simply too high, and if I’m the only there who feels this way.
As usual, this has begun a cascade of negative emotions for me, so now I am feeling quite low about a number of things. I am going out to float in the water for a moment, and try to give my ball anxiety to the waves. Hopefully I will return with a sense of peace and contentment with things as they are, the world as it is, my self as I am.

Friday, July 5, 2013

a nurse's dreams

My dream last night:

Something had happened to the Earth's atmosphere, and some of us had swelling airways. Mine starting to swell and I was struggling to breathe. A doctor was running around, deciding who needed to be intubated. He told me I was "fine". I begged him to tube me, so he finally did. The moment the ET tube was in place, I could breathe again. It wasn't too bad going in either (but of course, what is worse than feeling that you're suffocating?). I laid there, in a bed, on a vent, signaling to a nurse that I needed a pulse ox on my finger, I wanted to see my sats.

I don't know what happened to the Earth. I don't know if I was smushed against a pillow and starting to suffocate, and then turned over and could breathe better, and this was how my nurse's brain interpreted it. I have dreamed many times that I am in VT and getting shocked, but this is my first intubation dream.

Tuesday, July 2, 2013

Gift of Life: the new bullies in town

When a person has a very poor prognosis, but the condition of their body is still such that they have viable organs, we have an organization called Gift of Life who handles possible or prospective organ donation. We are required to call them when the death of a patient is imminent or on the horizon, or after a quick or unexpected death.

Yesterday, the Gift of Life team was sitting on my side of the unit, keeping track of a patient who was going to be an organ donor. They did a chart review on the patient we had whose brain had herniated, and whose husband would be withdrawing support from, and decided she was a potential donor. In the meantime, the resident approached the husband and asked if he would like an autopsy to be performed following her passing (this affects the way we do postmortem care, but I still prefer to ask the family AFTER their loved one has passed). He then asked the husband if his wife had ever expressed interest in being an organ donor, or did he think that was something she would have wanted. The husband said no, neither she nor he was interested in her becoming an organ donor.

I told Gift of Life that he was not interested, and the lady immediately got up on her high horse and made a grand speech about the policy in the hospital and state being that THEY (Gift of Life reps) are the only ones qualified to approach family members about organ donation. Ok, fine, the resident broke with policy. Whatever. Either way, the husband had been asked, and had no further questions, and was firm in his decision. As the patient's nurse and advocate, and therefore her husband's advocate, I did not wish for her to continue to pester him about organ donation. She insisted that she had to be the one to ask. Why? Is it not redundant? Are you not laying it on thick at this point? And yes, I did say that to her, in those words. I told her that it is my job to protect this family, and at this point asking about organ donation AGAIN becomes a form of pressure and intimidation and I DO NOT LIKE THAT.

You know what? She went in there anyway. And the poor man was very irritated with her (and us) because he had already very clearly stated his wishes. And she (and as far as he knew, we as a hospital) was coming across like a vulture circling the body of his not-yet-deceased wife in his hour of greatest pain.

I really, really did not like that.

She left the room with a red face, and the intern told me how awful it was in the room when she was asking. He said not only did the husband repeat his wishes in a very agitated tone of voice, but the lady continued her spiel even after he spoke up. NOT ACCEPTABLE.

I will be going to my manager about this situation. Organ donation is a wonderful, beautiful thing, but it cannot and should not be pushed upon family members. It should be perfectly acceptable for a physician or nurse who already has rapport with the patient and their loved ones to inquire about interest in organ donation. If the family says they would be interested in learning about the options, we can get the Gift of Life rep in ASAP. Nothing like this should EVER happen.

I'm still so pissed.

when death follows you

I've written about being a midwife in reverse, when it comes to the dying. Sometimes it seems that death chooses one nurse in particular to do his work for a period of time, and these last three weeks, that person has been me. We often notice that one nurse or another will have a 'black cloud' that will last weeks to months, a time period where she has an unusual number of patients who either code and don't survive or are transitioned to comfort care before passing. The last three weeks, six out of 12 patients I've taken care of have died, expectedly or unexpectedly, and one co-worker on the job.

My extern is getting pretty good at post-mortem care, people.

Yesterday alone, we lost two patients in one day. The first, a man in his 60s with multiple episodes of severe bacteremia and septic shock, which came from his legs and all of the wounds they had, a result of his advanced peripheral vascular disease. For the last two days, we tried to make his distraught wife understand that he was MAXED on pressors, and the only way to stop the sepsis was to amputate both legs, which we could not do in his condition. Even maxed on pressors, his MAPs were in the 40s. She finally let him go, and he died within ten minutes of turning off pressors, and five minutes of extubation.

After we had done his postmortem care, we picked up another patient who was on innercool following a witnessed cardiac arrest, a middle-aged woman with no significant past medical history. She had just returned from a CT scan which showed severe swelling of the brain, and herniation. We had to stand by as the husband was told, by the neurology team, the resident, and finally the fellow and attending, that her chances of surviving in any way, meaningful or not, were ZERO. We watched this man cry and hold her hand and stroke her face, as we had watched the previous patient's wife do the same with her husband only hours before.

Man, it's been a tough month, and this Midwife in Reverse could use a little break from death.