3 cheers for PICU!!!

I would like to extol the virtues of the Pediatric ICU and all who staff them. Why? Because in PICU, your patients aren't combative, they're cranky. Because in PICU, turning and positioning requires 2 hands, not a team of people. Because body fluids are kind of cute when they come out of little behinds, or noses, or whereever.

I've been in this PICU for, hmmm, let us see, 18.25 hours now. My patient is a teen who made the bad mistake of mixing booze, driving and bad weather to her permanent and everlasting sorrow. And the sorrow of her mom, siblings, cousin and young baby. It's been a slog, and I'm emotionally drained. I felt so bad for her mom, then when I found out she had a little baby-home, crying for Mama, I thought I was going to lose it. They chose to donate so that someday, this little one will at least know that his Mama saved 7 other lives. That all sounds so trite to me right now, because I'm exhausted and all I can think about is my little, wee one growing up without me. We(by we I mean the nurses) were sitting around, catching our breath for a few minutes and we started telling each other about "our worst" stories-the worst dead child story, etc. It was getting to be the wee hours and I was too creeped out for that shit. Finally, somebody told a story about her son's toilet training adventures and we were laughing again and THAT is why I like PICU-because nothing will get you out of your own shit like a good poop story.

About Face

As some of you may know, France did the first successful partial face transplant last year. Now, an English surgeon has received the go-ahead from the NHS. The ever thorough BBC has everything you need to know and more about face transplants here, including a link that shows what the journalist would look like with the surgeon's face, if you're really interested.

I was thinking that donating my face would be very, well, icky. Believe me, I'd donate any part of me after death(except my eggs, but that's another matter). But when I read the article and thought about having to go through life with terrible facial burns, or no nose or lips, I changed my mind. Let me know what you think.


Grand Rounds 3.5 is up at Health Care Law Blog. And if you have to catch up on your reading, like I do, Grand Rounds 3.4, check out Emergiblog. Happy Reading!

This just in...

So, I was talking to this nurse today over the phone, trying to get some information on a patient we're following. So I ask her, "Is he on any pressors?"

She answers, "Well, he's on lopressor." And she's serious.

If you think that's funny, you may have been a nurse too long.

Play this!

UK Transplant has this great game about allocating organs. It's addictive. I so need to practice...because, uh, my patients didn't do very well. Also, NATCO, The North American Tranplant Coordinators Organization, has a patient simulation for various professionals: transplant coordinator, hospital development, etc. which is very useful, educational and fun, if you're into that sort of thing. I am.

Better Late, If Ever...

And who reads ANYTHING on a Tuesday? Oh, guess what, Grand Rounds v3.3 is up at Unbounded Medicine, which is a funky site. Go there today and see a neat pic of someone who has there arm, well....just go and check it out. In the spirit of full disclosure, and because I'm a selfish Bee-otch, I only bring up the GR because I'm in it. And I'm listed under the Physician Stories...so please, it's Dr. TC from now on, thank you.

You think you can handle this?

Sometimes, this is my job:

"We do more before breakfast than most people do all day."

And sometimes, it feels like this:

"Faster than a speeding bullet, more powerful than a locomotive, able to leap tall buildings in a single bound. Look, up in the sky, it's...

Yet other times, it feels like this:

Recently, though, it feels like this:

"The hell you will. He's got a two day head start on you, which is more than he needs. Brody's got friends in every town and village from here to the Sudan, he speaks a dozen languages, knows every local custom, he'll blend in, disappear, you'll never see him again. With any luck, he's got the grail already. "

But in reality, I often feel like this:

"Hello?...Hello?...Does anyone here speak English?"

Recently, someone in the comments section asked me what it takes to be a transplant coordinator. Of course, I didn't read my comments, or surf the web at all, for like a month. So, I thought I make it into a post. Sometimes, it does seem like an army of one. Depending what hospital you're at, you're either surrounded my friendlies or behind enemy lines, but I'll take that analogy no further. Sometimes you do feel like Superman, you hit your groove, you haven't slept for 24 hours and you're going on pure adrenalin. And yes, occassionally I DO feel like the Grim Reaper, waiting around the bedside of a dying person. Although I want to be more like Indiana Jones (I even majored in Archaeology, a long, long, time ago), I usually feel more like bumbling Marcus Brody.

I don't want to be too snarky. It is a good job with a good purpose and I still like it. I will say this-my co-workers and I are an eclectic bunch. We're all idiosyncratic. We spend many hours alone in hospitals where we don't know the staff, don't know the doctors and don't know how the system works and yet, within a short period of time, we've got to get the system working and differing parties collaborating toward a single goal.

An ability to stay awake for long hours helps. It's very common to get a call at 5 or 6am saying that you have to be at a certain hospital in an hour. I've arrived onsite to find that the clinicals are already in progress and sometimes the family is ready to be approached. You spend the day managing the patient clinically, sharing the organs, coordinating the teams to come in. Inevitably, the OR is never at a sane hour. So by the time you get in the OR at 3am, you're fried and wondering if maybe a job in food service is the way to go.

Strong clinical skills are a definite requirement. Every donor is different. Some are hemodynamically unstable from the get go. Think a gun shot wound to the head or some other massive head trauma. They're in DIC, or DI. They're hypotensive from blood loss. Other donors are brain dead from anoxia, like a status post cardiac arrest. They may take a week to become brain dead and then you have all the problems of someone who's been immobile and on a vent for a week. Pneumonia, electrolyte imbalances, blood clots. Another challenge is the 180 degree turn in clinical objectives: from a head injury to an organ donor. With a neuro patient, you're trying to keep the ICP down, so you're minimizing fluids and maybe using 3% saline. You're clustering care and not moving the patient so much. After brain death, the patient becomes hypotensive from vasodilation and you're pouring fluids into them. To keep the Na low, or to lower it if it's already high, they're put on 1/2 NS. Suddenly you're asking for chest PT and frequent turning and suctioning. Inevitably, someone will ask, "why are we doing all this on a dead guy?" The best answer I've heard is that when you're taking care of an organ donor, you no longer have one patient, you have up to 8-one for every recipient who's going to benefit from these organs.

And that leads to the important skill:tact. You have to be a diplomat. Some hospitals do one donor a year, maybe. Some hospitals call you every week. Some now what they're doing, some don't have a clue. Some are very excited when they get a donor and are eager to work with you and some...well, not so much. In any event, you can't really go in their like gang busters and start telling everybody what to do. Well, you can. And some have. But it won't make you very popular and you'll make the next transplant coordinator's job that much harder the next time. Not that I'm bitter or anything, I'm just saying.

Add a large dose of compassion. And a good sense of humor. And don't take things personally. So, are you ready to see new places, experience new things and meet new people? And then take their organs? This job's for you.