Monday, June 05, 2006

What to do when your patient's not dead

So here's my weekend. 72 hours on call and really, I shouldn't complain. I wasn't even out for a total of 12 hours. Friday, I went to a hospital close by, found out another coordinator was already there, so we both talked to a few people, got a few things done. We still hadn't actually seen the patient, cause there was a ton a family and we weren't ready to announce our presence. The neurologist had seen the patient and done the first clinical. So far, things going smoothly. Then we see the door open and a tech walk out. We look in at the patient... and she's moving. We sigh. Call that neurologist back, her patient's still alive(barely, but still).

Saturday, no calls. I slept like a cat. 8 hours of sleep, 1 hour for stretching, eating and using the litter box(eh hem). Then back to sleep. The family, bless them, left me alone.

Sunday, I'm back out to a hospital an hour away for a potential donor who "had nothing" ie they had no reflexes:no cough, no gag, no pupil response, no pain response and not breathing on their own. I get there and fortunately for me the respiratory therapist had put the patient on CPAP for a few minutes and she did indeed breathe on her own. Then I went into the room and noticed she was shivering. The nurse(who was very overworked, I admit) said, "her fever must be coming down too fast." Except, and here's the thing, dead people don't shiver. Not even brain dead as compared to your dead dead. Shivering, still alive. It's a fact. Look it up.

Just when I think my my weekend call is over, just when I said, "hey, this weekend wasn't so bad." What was I thinking? I get phoned at 1:30 in la manana to see another patient who's "got nothing, maybe a little breathing on her own, but not much". I head on out, luckily not terribly far away. I get there just as the patient is going up to the ICU from the ER. She's being bagged by respiratory. "Sure she's breathing on her own, see." and he stops bagging for a second. Deep inhale. They get her onto the bed and I take a look at her. Pupils equal, one sluggishly responsive, one brisk. I ask the doc to get a set of liver enzymes and call me in the morning. Well, later in the morning. And go back to bed.

So why do we go on site so early. Sometimes I feel like that scene from Monty Python's The Meaning of Life:

"I've come for your liver."
"But I'm still using it!"

I don't know about where you live, but in my neck of the woods the hospital staff(nurse or doc) are supposed to call when the patient meets certain criteria:
  1. Neurologically devestated-anoxic or an injury(bleed or trauma)
  2. GCS of 5 or less
  3. Loss of 2 or more cranial nerve reflexes

The idea being that the earlier we get on site, the better the outcome will be. Many times, like in the above scenarios, we just wait and see. If they get better, good for them(unlikely, though, as the prognosis for someone with a GCS >5 is pretty dismal. I mean, you get 3 points just for lying there). If they're not medically suitable ie multi-organ failure, HIV, cancer, then we say thank you for the referral and walk away. If they are medically suitable and brain death is imminent, we formulate a plan with the hospital staff about talking to the family, management and when, how and who is going to start the brain death protocol. So, yeah, I do feel like a vulture sometimes.

So nurses, (or docs) if you call us with a referral, here are some handy tips. Please give me about 5 minutes of your time. If you're too busy(and you frequently are) let me know when I can call you back. I need to know your assessment of the patient, their vital signs, their medical/social history, what drips they're on, their urine output and recent labs. If you don't know something, just say you don't know, you haven't gotten to it yet, whatever. I'll let you know when I'll be there and if there's anything that would help us, like maybe the doc will order LFT's or some other blood work to see if they're worth pursuing as a donor. It's a team effort.


Judy said...

Maryland law requires that we notify the donor folks for ALL deaths.

I work in a neonatal ICU. The vast majority of our deaths ar <25 weeks, generally <23, less than 700 grams, also tend to be overwhelmingly septic.

We tend to ignore the law, presuming that they're not really donor material.

OTOH, this habit makes us not think too much about calling the donor folks in certain other instances - like anencephalic infants who might actually be potential donors. They're not dead yet either, but they aren't going to live long. Definitely need to re-think this.

TC said...

It's hard with the wee should call only so that you know it's ruled out, which at their age they would be. Anencephaly has its own problems. Infants usually must be a week old before they can be declared brain dead, but what parent wants to suffer like that for a week and who would want to inflict that on them? And there's always the chance that some little brain tissue will kick in and then they live like that...neither's a really palatable choice. Thanks for posting.

Robin said...

While not to detract from the serious nature of the post itself... which I found as interesting and thought-provoking as always... but your post title reminds me of a joke.

Two hunters are out in the woods. One hunter clutches his chest and falls to the ground.

Other hunter calls 911 on his cell phone. "Help! Help! I think my buddy has had a heart attack. I'm afraid he's dead!"

The 911 person tells him, "It's ok. I can help you. First thing, we need to make sure your friend's dead."



Then the hunter says, "Ok, now what?"

Judy said...

A week before they can be declared brain dead? I didn't realize that. I definitely wouldn't want to put parents through THAT - and very likely we couldn't keep the organs perfused and healthy that long.

TC said...

Judy, that's the legal requirement in MY state, it might be different in yours.

Thanks Robin, that's funny.

I am a Milliner's Dream, a woman of many "hats"... said...

No joke: I thought of you when I saw that Monty Python scene awhile back and meant to tell you.

You wrote:
I slept like a cat. 8 hours of sleep, 1 hour for stretching, eating and using the litter box(eh hem). Then back to sleep. The family, bless them, left me alone.

You CRACK me up.

Keith, RN said...

I think your job must be so very challenging. Thank you for doing work that most of us could never do.

You are also a great writer with a sense of humor. Great combo!

Tresa said...

I want to thank you for this blog. I am currently trying to be a live Kidney Donor for a friend and I love reading about your work.

Flygal said...

Your work is very important and it's good to know that such people like you do this job. Thank you for your working.