NHS Doc does a spot on job of hosting Grand Rounds this week and what's probably the best explaination of cricket I've come across so far (eat your heart out, Bill Bryson).
In other news, GeekNurse is no more. Hell, we hardly knew ye....the paediatric RN from New Zealand did an awesome job of teaching hard-core critical care nursing with love and compassion. You'll be missed. (and that's why I blog from a small, unchartered fishing boat off the coast of Ghana.)
Tuesday, March 28, 2006
Sunday, March 26, 2006
No time like the present, no present like time
It has been a very stressful month for TC. Not work, no, no, work is fine. A bit slow, actually. But real life has been kicking me in the bum. Enough to make TC very, very cranky. Enough to make TC talk in the third person, like the queen. My apologies. TC will have a longer, more coherent post soon and in the mean time, if my head explodes, you know what to do with my organs. Cheers!
Sunday, March 19, 2006
Donor Management
Lest you think my job is all Kleenex and hugs, it does have a clinical side. When we start to take over donor management varies with hospital, circumstance and personel involved. Tonight, for instance, I'm in an ICU that we work with pretty frequently. The doctor has already done the first clinical exam for brain death and the family understands that she is not going to survive. The intensivist told me to do whatever I want to manage the patient and she will sign the orders.
This is very nice for me. The earlier we manage the patient clinically, the more likely we'll have healthy organs to recover. For instance, this patient had been given Mannitol to keep the ICP down and was going into DI, so she was peeing like crazy and her BUN and creatinine were going up. The hospital had already discontinued the Mannitol, but her urine output was over 300cc/hour. Also her blood pressure was low(80-90/50), she was tachycardic and she was on 15mcg/kg/min of Dopamine. So, I did a few things: first, a liter bolus of normal saline followed by a rate of 125cc/hr. Then I gave a bolus of T4(synthroid) followed by a continuous drip. After brain death, hormone production is impaired including TSH and a rapid decline in free triiodothyronine occurs. Replacing with T4 helps maintain cardiac stability. I also had them start a pitressin drip at 0.5 units/hour, figuring that it will stem the DI and raise the BP.
She still was hypotensive for a while, so we gave more fluid boluses and increased the T4. After about 2 hours, her heart rate started to come down and her BP was up to 100/60. Her urine output was now about 75cc/hour. We were starting to come down on the dopamine ever so slowly. Also, her BUN and creatinine were trending down to normal.
If the hospital didn't let us manage her this way, she could easily have gone into kidney failure. The low BP would have caused decreased perfusion of the organs. High doses of pressors will do that also. Managing the brain dead patient is like standing in the middle of a see saw and trying to find the right balance. It's a challenge to the staff as well. They have been caring for the brain injured patient-keeping fluid input low, not turning the patient. Then I come along and want to pour fluids into the patient and do frequent turning and suctioning. It's a 180 degree turn around. A lot of staff challenge our right to be on the unit. ICU nurses are especially protective of their patients-I should know, I used to be one. Some hospitals won't let us do anything. The patient could be declared brain dead and consented for donation and they still don't want to let us do anything.
Once a patient is brain dead and consented, we pick up the all the costs (except for funeral arrangements). We'll order echocardiograms, cardiac cath's, bronchoscopies, CXR's, EKG's and labs, labs, labs. It's nice to have a triple lumen for CVP and A-line in too. We pay for the consults and the anesthesiologist when we get to the OR(but that's for another day). We'll start hormone replacement therapy: T4(if not already up), pitressin, insulin. We send blood for serologies and typing. We'll start giving Solumedrol, 15mg/kg every 8 hours to try and stem the catecholamine cascade. We'll work with respiratory therapy to maintain maximum oxygenation-vent changes, chest PT, suctioning. And correct anything else that comes up, electrolyte imbalances, infection, etc. And try to support the family and share the organs and arrange for the teams to come in and fight the OR for a time slot....it keeps me busy.
This is very nice for me. The earlier we manage the patient clinically, the more likely we'll have healthy organs to recover. For instance, this patient had been given Mannitol to keep the ICP down and was going into DI, so she was peeing like crazy and her BUN and creatinine were going up. The hospital had already discontinued the Mannitol, but her urine output was over 300cc/hour. Also her blood pressure was low(80-90/50), she was tachycardic and she was on 15mcg/kg/min of Dopamine. So, I did a few things: first, a liter bolus of normal saline followed by a rate of 125cc/hr. Then I gave a bolus of T4(synthroid) followed by a continuous drip. After brain death, hormone production is impaired including TSH and a rapid decline in free triiodothyronine occurs. Replacing with T4 helps maintain cardiac stability. I also had them start a pitressin drip at 0.5 units/hour, figuring that it will stem the DI and raise the BP.
She still was hypotensive for a while, so we gave more fluid boluses and increased the T4. After about 2 hours, her heart rate started to come down and her BP was up to 100/60. Her urine output was now about 75cc/hour. We were starting to come down on the dopamine ever so slowly. Also, her BUN and creatinine were trending down to normal.
If the hospital didn't let us manage her this way, she could easily have gone into kidney failure. The low BP would have caused decreased perfusion of the organs. High doses of pressors will do that also. Managing the brain dead patient is like standing in the middle of a see saw and trying to find the right balance. It's a challenge to the staff as well. They have been caring for the brain injured patient-keeping fluid input low, not turning the patient. Then I come along and want to pour fluids into the patient and do frequent turning and suctioning. It's a 180 degree turn around. A lot of staff challenge our right to be on the unit. ICU nurses are especially protective of their patients-I should know, I used to be one. Some hospitals won't let us do anything. The patient could be declared brain dead and consented for donation and they still don't want to let us do anything.
Once a patient is brain dead and consented, we pick up the all the costs (except for funeral arrangements). We'll order echocardiograms, cardiac cath's, bronchoscopies, CXR's, EKG's and labs, labs, labs. It's nice to have a triple lumen for CVP and A-line in too. We pay for the consults and the anesthesiologist when we get to the OR(but that's for another day). We'll start hormone replacement therapy: T4(if not already up), pitressin, insulin. We send blood for serologies and typing. We'll start giving Solumedrol, 15mg/kg every 8 hours to try and stem the catecholamine cascade. We'll work with respiratory therapy to maintain maximum oxygenation-vent changes, chest PT, suctioning. And correct anything else that comes up, electrolyte imbalances, infection, etc. And try to support the family and share the organs and arrange for the teams to come in and fight the OR for a time slot....it keeps me busy.
Tuesday, March 14, 2006
Grand Rounds 2:25
Head on over to GeekNurse for Grand Rounds, Kiwi-style. The PICU nurse from New Zealand does a fine job. He says doing the post took him 4 hours....me, it would probably take me 4 days, but that's why he's GeekNurse and I'm not. See ya there.
Wednesday, March 08, 2006
Fill 'er up
You gotta fill her up with light!
You gotta fill her up with spirit!
You've gotta fill her up with faith You gotta fill her up with heaven!
You've got the rest of life to face ...
You've got to fill her up with love!
-Sting
The first time I saw Baby Mia, she was more tubes and wires than baby. At 6 months old, she weighed barely 6 kilos. The very first thing you noticed was her enormous, brown belly. She looked like a python that swallowed a pig. Her arms and legs were little, dry twigs. She lay motionless, a tiny speck in a hospital bed, intubated and sedated.
I was still on orientation to the PICU when I met her. It was the first time I had taken care of anyone so small and so sick. In the beginning, it was all I could do to manage her lines and tubes. She had a broviac catheter in her chest, an A-line and endotracheal and naso-gastric tubes plus several IV's and a foley catheter. Following her surgery, she had a draining T-tube. You see, Mia was born with several disadvantages, some medical and some social. Her mother was a drug addict who never received prenatal care. Mia was born addicted and placed in foster care shortly thereafter.
At a few months old, she became increasingly ill and jaundiced. She was diagnosed with Biliary Atresia, a condition where bile flow from the liver to the duodenum in obstructed. Bile accumulates in the liver causing scarring and liver damage. Without surgery a child will die. In addition, half of all these patients will need a liver transplant by age 2 and 70% will need a transplant by age 20. Mia had had her surgery and was now bombarded with complications: pneumonia and infection. When I met her, she was at her sickest.
Fate, luck or angels had given her one break, and she was named Teresa. Teresa was an older, married woman who had already raised her kids and was now a grandmother. For years she had been taking in medically fragile foster children who were hard to place. Nurses with more experience told me how several of her foster kids had died from AIDS. Now she had 2 children she had adopted, both with developmental delays and multiple medical problems. She sat at Mia's bedside day and night. I remember her as always calm. She was in the middle of embroidering a complicated baby blanket for Mia. In the middle was Noah's ark and the border was made up of all the animal pairs. I can see her now, just sitting in the window seat, pushing her needle through the fabric. She'd look up and when we came in and ask about Mia's progress.
I hadn't taken care of Mia for a few weeks when I was assigned to her again. By this time she was extubated and awake. The change was profound. The minute I walked in the room I was greeted with the biggest smile I had ever seen on a baby. She still had a million things in her or on her and her belly was still the size of Rhode Island, but she was happy. Slowly, as the days progressed, we saw less lines and more Mia. One night my preceptor said she needed a bath. She was still so tiny that we just filled up a wash basin with an inch of water and sat her in it. She loved it. Teresa would help out, go home to her family for a few hours and come back for the night. By now she could hold her and give her snuggles and Mia always had a smile. Sometimes, her siblings would come for visits. She adored them and they couldn't get enough of her.
I couldn't get over it. It made me think about all the little complaints I'd have in a day-my feet hurt or I didn't get a dinner break or whatever. Here was a baby who had only known hospitals and surgery, fevers, being intubated and stuck with needles-I don't know if I'd even want to go on after all that, but here was little Mia smiling through it all. Eventually came the day for her to get transferred to the regular floor. She was listed for a liver transplant, but would be stable enough to go home. She was about 9 months old and still couldn't sit up or crawl and she didn't really make any sounds but she could light up a room with that smile. I didn't know if I'd ever see her again.
Eventually, I left the PICU to become a transplant coordinator, a job I had wanted since nursing school. One day I went back to the hospital to pick up some things. I ran into Teresa, Mia and the whole brood on the elevator. Mia was then 6 weeks post transplant. Someone's gift had given Mia a new life. She looked like a new baby. She was chubby in all the right spots and her huge belly was gone. She was sitting up and reaching for things and cooing. And she still had that radiant smile.
There are days my glass is half full and days it's half empty. There are even days when I think my glass is dried up and I remember Mia, whose glass is always overflowing.
You gotta fill her up with spirit!
You've gotta fill her up with faith You gotta fill her up with heaven!
You've got the rest of life to face ...
You've got to fill her up with love!
-Sting
The first time I saw Baby Mia, she was more tubes and wires than baby. At 6 months old, she weighed barely 6 kilos. The very first thing you noticed was her enormous, brown belly. She looked like a python that swallowed a pig. Her arms and legs were little, dry twigs. She lay motionless, a tiny speck in a hospital bed, intubated and sedated.
I was still on orientation to the PICU when I met her. It was the first time I had taken care of anyone so small and so sick. In the beginning, it was all I could do to manage her lines and tubes. She had a broviac catheter in her chest, an A-line and endotracheal and naso-gastric tubes plus several IV's and a foley catheter. Following her surgery, she had a draining T-tube. You see, Mia was born with several disadvantages, some medical and some social. Her mother was a drug addict who never received prenatal care. Mia was born addicted and placed in foster care shortly thereafter.
At a few months old, she became increasingly ill and jaundiced. She was diagnosed with Biliary Atresia, a condition where bile flow from the liver to the duodenum in obstructed. Bile accumulates in the liver causing scarring and liver damage. Without surgery a child will die. In addition, half of all these patients will need a liver transplant by age 2 and 70% will need a transplant by age 20. Mia had had her surgery and was now bombarded with complications: pneumonia and infection. When I met her, she was at her sickest.
Fate, luck or angels had given her one break, and she was named Teresa. Teresa was an older, married woman who had already raised her kids and was now a grandmother. For years she had been taking in medically fragile foster children who were hard to place. Nurses with more experience told me how several of her foster kids had died from AIDS. Now she had 2 children she had adopted, both with developmental delays and multiple medical problems. She sat at Mia's bedside day and night. I remember her as always calm. She was in the middle of embroidering a complicated baby blanket for Mia. In the middle was Noah's ark and the border was made up of all the animal pairs. I can see her now, just sitting in the window seat, pushing her needle through the fabric. She'd look up and when we came in and ask about Mia's progress.
I hadn't taken care of Mia for a few weeks when I was assigned to her again. By this time she was extubated and awake. The change was profound. The minute I walked in the room I was greeted with the biggest smile I had ever seen on a baby. She still had a million things in her or on her and her belly was still the size of Rhode Island, but she was happy. Slowly, as the days progressed, we saw less lines and more Mia. One night my preceptor said she needed a bath. She was still so tiny that we just filled up a wash basin with an inch of water and sat her in it. She loved it. Teresa would help out, go home to her family for a few hours and come back for the night. By now she could hold her and give her snuggles and Mia always had a smile. Sometimes, her siblings would come for visits. She adored them and they couldn't get enough of her.
I couldn't get over it. It made me think about all the little complaints I'd have in a day-my feet hurt or I didn't get a dinner break or whatever. Here was a baby who had only known hospitals and surgery, fevers, being intubated and stuck with needles-I don't know if I'd even want to go on after all that, but here was little Mia smiling through it all. Eventually came the day for her to get transferred to the regular floor. She was listed for a liver transplant, but would be stable enough to go home. She was about 9 months old and still couldn't sit up or crawl and she didn't really make any sounds but she could light up a room with that smile. I didn't know if I'd ever see her again.
Eventually, I left the PICU to become a transplant coordinator, a job I had wanted since nursing school. One day I went back to the hospital to pick up some things. I ran into Teresa, Mia and the whole brood on the elevator. Mia was then 6 weeks post transplant. Someone's gift had given Mia a new life. She looked like a new baby. She was chubby in all the right spots and her huge belly was gone. She was sitting up and reaching for things and cooing. And she still had that radiant smile.
There are days my glass is half full and days it's half empty. There are even days when I think my glass is dried up and I remember Mia, whose glass is always overflowing.
Tuesday, March 07, 2006
Arts & Crafts at donorcycle
For those of you who are crafty (and you know who you are), check out these stitch holders for knitting shaped like little organs (awwww, how cute). And for those of you who just like to drink a lot (and you know who YOU are), they also make great wine glass charms. Cheers!
Grand Rounds, ER style
This week Kim at Emergiblog does a fine job of triaging this weeks medical blogs. See ya' there. (Excuse me, nurse, I've been waiting 3 hours to get my ingrown toe-nail looked at. Is it going to be much longer?)
Sunday, March 05, 2006
At the Oscars
Tonight at the Academy Awards, Robert Altman, director of such films as M*A*S*H, The Player and Gosford Park, was awarded an Oscar for lifetime achievement. The last thing he said in his acceptance speech was that several years ago he received a heart transplant. He said that he thought his heart came from a young woman in her 30's, so perhaps they gave him the lifetime achievement award too early, as he expects to have another 40 years or so with his new heart. Well, Mr. Altman, you also get the green ribbon award:
-
for bringing organ donation to the attention of a world-wide audience of bazillions. Thank you.
Also, tomorrow night, Monday, March 6th, ABC will air its premier of Miracle Workers, a medical reality series. As per the ABC website, the first episode will feature two medical treatments utilizing donated human tissue – spinal fusion using donated bone and eyesight restoration using donated eye tissue. For more info, go to:
http://www.abc.go.com/primetime/miracleworkers/index.html
http://www.abc.go.com/primetime/miracleworkers/index.html
See you at Grand Rounds!
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