Monday, May 15, 2006
The Real 24
All right, listen up. This is a seriously long post. So go to the bathroom, grab a snack, take the phone off the hook and tell the kids to be quiet. Don't say I didn't warn you.
Keifer Sutherland can kiss my butt. Last night I did a real 24, and I didn’t get to film it over a bazillion episodes, either. Here’s how it went: I got called out at 0615 to evaluate a potential donor who was unstable. 24 hours later I was leaving the hospital having completed a successful organ recovery. So what did I do in that time? Well, I don’t have fancy split-screen technology and multiple camera angles, but I think you’ll get the idea.
0615 Triage calls me to go see this patient. I have an hour to get on site, so I jump in the shower and get ready, only to find at
0700 My car won’t start. I left the lights on (Doh!!). I call triage back and let them know. Fortunately, another coworker is already en route to the hospital to help me out, so she’ll arrive first. I call the hospital and check on the patient’s condition. The nurse allows that he’ll keep the patient from coding ‘til I arrive.
0830 Finally arrive in Shoot’em Up City Medical Center. My patient has his brain injury the old-fashioned way, from a spontaneous bleed in the brain, but that’s rare in these parts. My coworker is already in the unit, watching the attending chew out a resident for not calling him in the middle of the night with a bad ABG result. This continues for some minutes. When the dust settles, we huddle and decide what the course of events is going to be the morning and how we’re going to manage the patient. I’m impressed with the doc right away-he really wants to help us keep organ function viable in this brain dead patient and do whatever he can to help us get consent. Ahhhh, when they don’t fight you at every turn. It makes my heart happy. Neurosurgery was in already and started the first brain death clinical
0915 Doc takes the family into the conference room to talk. When they can’t talk at the bedside, it’s usually bad. He comes back several minutes later and says that he told them the prognosis was brain death. They want to make the patient a DNR and remove the vent. If I’m going to ask them to make him an organ donor, it has to be now. Coworker and I head to the family room. They have already declined a priest or a counselor, so it will be just the two of us.
Conference Room-I introduce myself to the family as a nurse who works with families of patients with devastating head injuries. Sometimes I’ll have the doctor or nurse introduce me as part of the health care team, but today I just walk in for no other reason than my spidey senses tell me to. His parents are not English speaking, but a family member translates. I tell them that I know the doctor has given them some bad news and that I’m here to see if there’s anything they need and to help them make some end-of-life decisions. Mom says she knows he’s gone. They talk about having to make funeral arrangements and taking his body “home” (he’s From out of state). This is important. You can’t ask for organ donation is they think the patient is going to recover and walk out of the hospital some day. You can’t ask them the second you tell them about brain death-they need to absorb that information first and really process it and understand what it really means. If they’re saying, “well, the doctor says he has a one percent chance of making it,” or “will he be like that person on TV and be a vegetable for 15 years,” they’re not really understanding brain death and you need to do more teaching before you ask for organs. I mean, come on, it’s not brain surgery, and yet I’ve seen more than one brain surgeon say the stupidest things to family members. The family keeps talking back and forth in Spanish. All I pick up is “Corazon, something, something, corazon”. Finally, they say yes. They want other people to live, not that he’s gone. They just want the recovery done by tomorrow because they want the funeral arrangements made and to bring him home.
1030 I go over the consent with the family and the family member who speaks English does the medical-social history with me. It takes about 20-30 minutes, depending on how much history the person has. I like to tell people that it’s like the questionnaire you fill out when you donate blood. Some questions are very general, some are very intimate. I ask every family these questions, whether the donor was 5 or 95. So please don’t be offended. I’ll reiterate that right before we get to the question that asks if Grandpa ever had gay sex for money or drugs. Please don’t be offended. In more cases than you think, it’s actually an ice-breaker. People start laughing, “Oh, God, if he was only here, he’d be so mad!” or something like that.
1100 Everything’s being done at once. I draw blood for serologies and HLA testing. This takes about 8 hours to process, so we do it as soon as we can. I call triage, I call the office. Triage goes nuts because I promised this family that we’d do this by tonight. Never make a promise you can’t deliver. I’m not worried. We’ll get the second clinical at 1500-it’s already set up with the doctor who’s going to do it(the same one who was yelling at the residents, bless him). We’ll have serologies this evening and then go to the OR. I may even be home by 2am. That would be nice. I call home and tell LM the good news (or bad news, that I’ll be out all day). I’ll call later when I get a better idea what’s going on. LM wishes me luck. Coworker and I start working to get an echocardiogram done. Lungs will be out-he smoked 2 packs per day for 25 years and his PO2 is 75 on 100% FiO2. So, no good. Also, he’s starting to go into renal failure for no reason I immediately think of. His BUN/creatinine was 49 & 2.2 this morning. Now they’re 50 and 3.5. So I’ve got to try and reverse this. Or at least halt it.
1130-1430 I get the hospital to start a synthroid drip. The patient is on levophed and dopamine to keep his blood pressure up. The synthroid will make him more hemodynamically stable and hopefully we can come down off the other pressors and maybe save his kidneys. Meantime, the echo is done and lo and behold, a cardiac transplant surgeon is in this hospital seeing patients and reads it. Bad news, his hearts a mess. Left ventricular hypertrophy, pulmonary hypertension, right ventricular enlargement and an aortic valve stenosis. Finally, he has a small, pericardial effusion. Even I can tell his heart looks bad on the echo and I usually don’t see anything on a sonogram. We had the cath lab on standby but we call them and tell them it won’t be necessary. So, now we’re looking at recovering liver, pancreas, kidneys and tissue. He’s way ahead on fluid, so boluses aren’t really going to help. I ask them to give 5% albumin, 40mg lasix and another albumin to see if that helps his urine output. 2 hours later, still no pee.
1532 Patient is pronounced legally dead. The doctor goes out to tell the family in the waiting room. A large group of family comes in with their own priest and prays. Someone asks when they are going to take him off the machine. I had gone over this with the immediate family, telling them that he’ll be on the ventilator until we go to the OR, but now I’m wondering if maybe it got lost in the translation. So I get someone on staff to translate. They say they know, they’re just waiting for more family to arrive then they’re all going home. Meanwhile, I’m keeping up on my charting. We’ve called the OR to tell them we’ll be doing the recovery sometime tonight. The nurse manager stops by to see if we need anything. The attending comes over with the residents and tells me that if I need anything to just tell them. Then he tells them to listen to me. I like this guy.
1800 I’m making calls to transplant centers to share the organs. Serologies are back and they’re negative. Liver gets accepted right away by a local program. I keep making calls to find a backup in case they get to the OR and don’t like the way it looks. Someone actually is interested in the kidneys, despite the BUN/creatinine. OR says we can go at midnight, my recovering surgeon agrees. Woo hooo! I’m excited by the “early” OR. Usually we’re going at 0400. I start calling the tissue banks but because this guy had a history of drug use, no one wants his tissue-so no bones, heart valves, eyes, ligaments, skin.
2000 His urine output is still almost zero, despite my attempts to turn it around. I’ve talked to my medical director. We’re out of ideas. We’ll draw labs at 2100 and see what happens. I’m getting myself together, all the paperwork I’ll need for the OR. The recovery specialist has been called and will be here to help with the OR. My coworker goes home. I meet the night shift nurse and go over everything with him. So far, so good.
2130 Recovery surgeon calls. They have to move the OR back to 0200. Damn! OR says that’s fine with them. The anesthesiologist comes over and I give her our info sheet on what we need from her in the OR. I also have a pick list for the OR staff so they know what we need.
2215 Labs are back. BUN 52. Creatinine 4.5. Kidneys are out.
2330 I make sure everything is ready. My charting is done and ready to be copied and put in packs that go with the organs (organ, in this case). I grab something to eat. I ate once, earlier, about 1330, but I’m starving again. I try to not imbibe too much caffeine, it only backfires and makes me frazzled, so I’ve only had one cup of tea since this am. Do chocolates count? Cause I’ve had a few of those, too.
0030 Oh, the hour I should have been in the OR. I try and lay my head down and nap but I keep getting phone calls and pages.
0130 I run over to the OR to make sure they’re ready. They have a fresh pot of coffee, so I give in and have some. The nurse starts packing up the patient and we call respiratory for the ride over.
0230 Incision. The circulating nurse is, I actually believe, nuts. She’s certainly driving the scrub tech crazy. She asks a million questions, which is not so bad, but always at the wrong time. Then when I need her, she’s gone. My surgeon is cranky and so am I, having been up since 6am. We get the solutions set up for flushing and storing the liver.
0323 Cross clamp. This is always hairy. They cannulate the aorta to flush the organs with a special solution we use that preserves the cells. I open up the lines to start flushing. The surgeon fills the chest and abdomen with ice. It’s eerie to see the monitor go flatline, even when you know they’re dead.
0430 Liver is packed, paperwork is done. The surgeon is just finishing. I’m sitting on a cooler and nodding off. The OR nurse is STILL TALKING. God in heaven.
0600 I’ve helped the staff do post mortem care, cleaning the body and putting it in the body bag. Tags on. I grab my bags, thank everyone and leave. I stop at Burger King on the way home and have the grossest breakfast.
0700 I pass out. Ahhhh, sweet bed. Why do I do it? Because it feels so good when it’s over.