August, 2006 Archive

August 24, 2006, 11:14 am

A Typical Shift In An ICU, A Devastating Loss for A Family

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Sustained ventricular tachycardia.

Never a good sign.

That night, for Steve’s patient, it was the beginning of the end.

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Steve had never taken care of this particular patient before, although she had been in the intensive care unit for two weeks. He received report:

She had gone into surgery believing she had pancreatic cancer. She came out of surgery to the wonderful news that while a Whipple procedure had been necessary, the mass in her pancreas was benign.

The sigh of relief from her family was audible.

But there was the probability that she had a small heart attack. One doc said yes, one doc said no. They drained a small pericardial effusion. They drained a pleural effusion from the left lung one day and the right lung the next day.

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The patient rarely slept.

She was a bit confused, although she could hold an entire conversation.

She gave her husband a verbal recipe for chocolate mousse and made her sister swear that he put it in the refrigerator. She offered one sister a candy bar, one of many that she “kept” under her sheet. One shift, she kept summoning her nurse to get the “beverage” she ordered.

She wanted her tubes out. She would find the tube and follow it to its source to figure out what it was.She would connive to get her daughters to turn their backs so she could “work” on her abdominal sutures.

A problem solver from the beginning, the patient actually managed to pull out a PICC line! On purpose! In a wide open ICU, in soft wrist restraints while her daughter slept two feet away.

Where there’s a will, there is a way.

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A post-op abdominal CT revealed something unexpected: a clot in the left femoral vein. Heparin and Coumadin were started. The patient began bleeding, source unknown.

Anti-coagulants were stopped.

Six units of blood were given.

Kidney function began to decrease. They couldn’t find the source of bleeding without contrast and contrast was contraindicated because of the patient’s elevated creatinine.

The patients abdomen was becoming distended, she was able to take oral contrast and the repeat CT showed no retroperitoneal bleeding. The surgeons said that she may have a small leak at the surgery site, and an operations was scheduled for 0800 the next day to find, and repair, the leak.

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The patient was intubated as she was now working too hard to breathe, and her continuous pulse rate of 120 had become 145.

Before surgery, it was felt that a filter should be placed to stop the femoral vein clot from dislodging bits and pieces to the patient’s lungs. Yes, they would need to use contrast, but the smallest amount possible. The bigger risk to the patient was the potential for the pulmonary embolism.

Her niece arrived while the filter was being inserted. Up until the patient was placed on a respirator, she had not visited the patient as the ICU was quite strict in allowing visitors other than immediate family.

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The patient developed a pulmonary embolus during the insertion of the filter. Her kidneys shut down.

A Swan-Ganz catheter was placed for fluid management. A Quinton catheter was placed in her left jugular for dialysis.

Except they couldn’t dialyze the patient. Her blood pressure was too low, and she was on Neosynephrine, Levophed, Vasopressin and Dobutamine to keep it up.

“Up” meant 80-90 systolic.

They couldn’t sedate the patient very well, for the very same reason.

They tried a very new type of bedside, continuous dialysis but after six hours the machine broke and the family was told they didn’t have another one and they couldn’t get the rep in until the next day.

The biggest Health Maintainence Organization in the world. At least six or seven hospitals in the Bay Area alone. No one else had the machine.

The niece didn’t get in to see the patient that night, although she kept vigil with the rest of the family in the waiting room all night.

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Multi-organ system failure.

That’s what they called it by the next morning. Said the patient was terminal.

Her husband, a fire-fighter, knew exactly what a full resuscitation meant and made the patient a DNR (do not resuscitate).

Now any family was allowed in. And it took some assertiveness on the part of the family to get that approved. It actually took the form of a doctor’s order.

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Steve took over the patient’s care at 7 pm on that night, around the time the niece returned after sleeping all day.

The niece was sitting at the bedside, holding her aunt’s unresponsive, mottled, vaso-constricted hand and marveling how if she talked, the blood pressure came up.

She kidded her aunt about being her “fifth” drip.

And then came the ventricular tachycardia.

The niece told Steve. Steve made a phone call and about 15 minutes later gave an amp of bicarb. Immediate switch back to Sinus Tachycardia.

The niece marveled that bicarb isn’t usually a first line v-tach drug. Steve looked the niece straight in the eye and said he wasn’t going to place any wager on it being the reason for the conversion.

Twenty minutes later, the patient went back into a ventricular tachycardia and stayed there. Her kids and husband were at the bedside, exhausted and near collapse from no sleep and the impending loss of their wife, mother.

One hour passed, then two hours. Three hours. Four.

Steve stayed around the periphery, available immediately when needed. He worked around up to seven family members at one point. The niece asked if he would set up a Yankauer suction as the patient seemed to be dripping bile from her mouth, and she would be happy to handle any suctioning.

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Eventually the niece was turning off monitor alarms that could not be over-ridden. The patient’s breathing had dropped from 40 to 30 and even with the ventilator it was obvious they were irregular. She watched Steve from the room. He was obviously working behind the scenes. A doctor had come into the unit and Steve spoke with the doctor in hushed tones.

The tachycardia had turned into a sustained ventricular rhythm that would vary in speed. The cuff still marked the occasional BP (the arterial line never functioned), but the cardiac index dropped, slowly, from a high of over 2 to 0.8.

It was pretty obvious that the only thing keeping the patient going were the vasopressors. This could go on for hours….

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The doctor did a neuro check. Pupils fixed. No response to pain. A small, soft-spoken woman, she had actually cried with the family earlier that day when the family was given the terminal diagnosis. She now, very gently, went over, again, what the husband wanted kept up or withdrawn. Antibiotics, nutrition….

The last thing the doctor asked about were pressors. With tears in his eyes, the husband looked at his niece who said, “it’s the only reason she’s still here”.

The patient’s husband asked to stop the vasopressors. The son was enroute back to the hosptial, having left just an hour before. Could we wait until he came back?

Of course.

But the patient had other ideas.

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The minute the decision had been made to withdraw the pressors, the patient, after sustaining a ventricular rhythm for over four hours, slowed her rate to 35 and went into a PEA. Any spontaneous respirations ceased.

It was almost as if she was given permission to leave, as her husband acknowledged his acceptance of the situation.

The ventilator and drips were maintained for an additional 10 minutes, allowing the son to arrive. They were then stopped.

The grieving family gathered the cards, hand-drawn pictures and photos and left the hospital.

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The patient was my aunt and we lost her on August 23, 2006 at 0300.

She was 15 when I was born and my first two years were spent in the same house she lived in, Mom being only 17 and Dad in the Navy.

She called me Pee-Pot, a moniker which I, thankfully, outgrew.

She leaves behind a husband, a brother, a sister, three children, eight grandchildren, two foster-grandchildren, seven nieces and nephews and her 90-year-old father, my last remaining grandparent.

She is the third relative in six years that I’ve lost who has been under the age of 65. My dad, my uncle and now my aunt.

The only thing that makes this loss even remotely tolerable is that she is finally reunited with her mother, lost to cancer when she was nine-years-old. She always told me she had never stopped mourning the death of her mother.

They have a lot of catching up to do.

As for me, I’m just numb.

And the irony of it all is that she didn’t have cancer.

God certainly has his own timing. I pray that one day I’ll understand it.

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August 23, 2006, 8:21 pm

Change of Shift – Volume One, Number Five

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Welcome once again to Change of Shift: A Nursing Blog Carnival, the bi-weekly conpendium of nursing-related postings from around the medical blogosphere.

Modeled after the blogfather of all things medical, Grand Rounds, and shamelessly copied from Nick of Blogborygmi, Change of Shift is nursing related, but written from the perspective of all participants in the world of health care.

A big thanks to Intelinurse2b at It’s A Nursing Thing, for hosting our last edition..

And now, the fifth edition of Change of Shift.

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Ever pray you don’t miss an important finding during your patient assessment? Rural RN, from her blog Rural ED puts it quite succinctly in Symptoms of Significance.

Susan, mother to a child dealing fighting cancer, describes a very personal encounter with one of his nurses in the heartwarming post Baby You Can Drive My Car, found at How Can I Keep From Singing?.

Men are treated as equals in the nursing profession, yes? Hold your opinion until you have read Bumped and Bruised but Breathing, written by Too Fat For Ponies, SN followed by Gender Based Vocation. You’ll find them both posted at Too Fat for Ponies. Hmmm…I thought it was the 21st century. Some of our colleagues need a reminder.

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Deb Serani presents The Rich Rewards of Pro Bono Work posted at her well known blog, Dr. Deborah Serani. Interestingly enough, there is a clinic in a local city looking for volunteeers to staff a clinic for those who need health care but have no means. I am actually considering volunteering a few hours a week. Rather fortuitous timing of this submission!

Mother Jones, RN at Nurse Rached’s Place sends in a heartwrenching post of loss and gain in “Help Me Say Goodbye“. No synopsis will do it justice. Get your kleenex handy…..

I recently posted a missive here on Emergiblog with my ideas about How To Talk To Doctors. I knew I had read a post addressing the same issue, but could not remember when or by whom.

In response to my post, my “inspiration” re-posted her original topic and submitted it to Change of Shift, thereby saving my sanity by helping me remember where I had seen it!

And so, with no further introduction needed, NPs Save Lives presents An Important Note Regarding Communication Between Healthcare Providers posted at The Nurse Practitioner’s Place. And on her sister blog, Nurse Practitioner’s News a warning regarding antibiotic resistance in Nurse Practitioner News – MRSA is on the rise – BlogCharm

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Student Nurse Prisca at “N is for… Nurse” gives us all a reminder of that memorable first clinical experience in The Nerves. It was five years before I quit getting acute abdominal cramping (to put it delicately) after a code, so I can totally relate.

Gail Rae Hudson is not a nurse, but she practices nursing everyday of her life as her mother’s caretaker. Her post, a practical take on a the old idea of “being in the moment” is actually a wonderful guide on how to prevent burnout. Read How To Be Where You Are, one of many essays found at The Mom and Me Journals.

No matter what the topic, Ron Hudson writes from the heart. As a 21-year survivor with HIV, Ron gives nursing a big “thanks” in 2sides2ron: Homage to Nurses posted at 2sides2ron.

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And finally, our favorite ER Chaplain, Susan Palwick, not only discusses how weaknesses can be strengths in the ER environment, but describes a few of the personalities encountered along the way in PITA for Christ at Rickety Contrivances of Doing Good.
(And she isn’t talking about bread…)

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Thanks for checking out this week’s Change of Shift.  Our next edition will be in two weeks and hosted here at Emergiblog.  Send in your submissions via blog carnival or email me directly at “kmcallister911 at yahoo dot com”.

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6:04 am

100 Posts of Grand Rounds on the Web, 100 Posts of Grand Rounds…

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This is how I pictured Dr. Charles after he finished the fifty-seven post extravaganza known as The 100the Edition of Grand Rounds.!

I have to say he definitely did justice to the “grand” occasion, and if you have not paid a visit to this week’s post, You must go now!

You will find an unbelievably good selection of topics from blogs both well steeped in the Grand Rounds tradition and newcomers who are just discovering the fun.

Even better, offer to host an edition!

Check out Nick’s Blogborygmi for details on how to join the “Host Club”!

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About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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