Tuesday, April 17, 2007

The List

I started my day yesterday(Monday? I need to reorient myself) at a hospital to evaluate a guy who had drowned in a flood. He was found pulseless, had coded 3 more times in the ER and then coded again a few minutes before I got to the hospital. While in the middle of evaluating the chart, he brady'd down to the 30's, then went asystole. I helped code him. My husband thinks I'm crazy to do this...ethics or some such, but when you're at a small place and there's only 3 people in the room, what am I going to do? Stand there with my hands in my pockets? So I did compressions, which I hadn't done in ages. He didn't make it. I felt for his family, one day he's fine and the next he's dead from a freak accident. He was ruled out for tissue too, because of the foulness of the flood water giving him a nasty pneumonia, so we didn't get involved with the family at all. Fortunately, the hospital had good family support people to help them. That was all before noon.

I go home, nap, and get called out again around dinner time. My fellow TC has a potential 8 organ donor and she's swamped with stuff. I drive up to the middle of nowhere to this tiny hospital. She just recently got off orientation(One of my orientees-well, the one who stayed, anyway-Hi G!)

Anyway, she was swamped between supporting this poor guy's wife and trying to manage the donor and get him to the cath lab so his heart could be evaluated. When we got back from the cath lab we made a few changes to his treatment. His blood sugar had been going up since noon, when he was started on a dextrose solution and also on solumedrol, which makes blood sugar go up. His normal BS was now over 300 and he was on an insulin drip because of it. No one would want that pancreas, so we put him on 1/2 normal saline and switched from solumedrol to solucortef, which doesn't have the hyperglycemic side effects. And we started sharing.

I think seeing the list was the coolest and weirdest part of the job when I started. Pages and pages of names, starting with the sickest. We used to have paper lists faxed to us onsite after their blood type and HLA was confirmed back at the lab. We'd call a center for each name on the list and they'd have an hour to decide if they wanted an organ for that potential recipient or not. If they don't decide within an hour, or if they're not interested, you move on down the list. I've had centers refuse for a variety of reasons. A lot of time size is an issue-you can't put an adult heart into a little kid. Sometimes the recipient is too sick and they're worried he or she won't survive surgery. Now, everything is done on computer and it saves some time, despite a few bugs. But it doesn't seem to have the same impact as a long list of names, every one hoping for a miracle.

A lot of centers decline due to what they call "donor quality", meaning there's something in the history or donor's condition they don't like. With our donor, we went through the intestine list pretty quick because he was on levophed, a potent vasopressor that will shut down blood flow through the mesentary and cause clotting. Transplant surgeons do not like clots. Clots=poor organ function. So we exhausted the intestine list and moved on. We knew his heart was good and there was a local, status 1A patient on the list. Status 1A's are the sickest and will die soon if they don't get an organ. We also knew that his liver numbers were good and we have a pretty aggressive local center that will usually accept a liver that other centers will decline. "Well, it won't win any beauty contests, but it's working" is what I hear from one of the surgeons about a not so great liver. But this donor's liver should be fine. So the heart and liver are shared.

In the mean time, his wife is spending her last minutes with him. Up to now she's been pretty composed, but now she looks troubled. She asks me how to get a funeral home. She's never had to think about this before. I call a guy I know and get a recommendation for a funeral home in the area. I call for her and explain the situation to the director, then I put her on the phone and she starts making arrangements. Afterwards, she asks for a half hour alone with her husband. She dims the lights and puts on some soft music. We close the door and put a sign on the outside telling people to see the nurse before entering. She slips out the door before we even know she's gone.

We are having trouble sharing the pancreas. The nurse is doing hourly blood sugar sticks and slowly the BS comes down to normal. In the middle of everything else, we work on recruiting the lungs. The respiratory therapist is doing q2 hour chest PT and turning and suctioning the donor. He's also getting respiratory treatments. We do put his PEEP up to 30 for 30 seconds and then back down to 8. His Po2 is 399 on an FiO2 of 100%, but it looks like he might have a right sided pneumonia and most centers are declining. Finally, one center, waaaaay down on the list says they might be interested. They ask us to increase his tidal volume to 850, repeat the 30 of PEEP and do another O2 challenge. His PO2 comes back 560. We high five each other and call the center back. They'll accept the left lung.

His creatinine had crept up to 1.3. We give albumin(his is 2.9) and follow with lasix. He's still getting 1/2 NS @150cc/hr. 6 hours later, his creatinine is 0.9. We breathe a little easier. His blood sugar is 110. A center accepts the pancreas. Now we're all set for the OR. It looks like he'll be able to donate 6 organs. Six more people off the list.

I leave her around 4am, tidying up a few details and getting ready for the OR. I get home around 5am and collapse into bed. I sleep for a few hours and at 5pm I get called out again. That's the life of a TC.


Raveen said...

Been reading your blog for a little bit now and figured it was about time I commented. Just wanted to say as a first year med student what you do is really amazing. I never bothered to think about the people behind organ donating. I mean I know it happens and it saves a ton of lives that would otherwise be lost, but the thought about the people that make it possible was an avenue that never crossed my mind.

Thanks for sharing and opening up my eyes a little bit more to the world of medicine.

Kat said...

Great Job! The feeling you get by knocking a good number off the list isn't easily duplicated anywhere else.

PJ Geraghty said...

Nice work! We're finding it harder and harder to find centers that will accept a single lung; there just aren't that many out here in the west. Plus, the road trip for a cath has killed many a lung in my experience. We're starting to be a little more aggressive about insulin use in a donor who is hyperglycemic (even if for known reasons) and placing more pancreata as a result.

Six organs is nothing to sneeze at! I like to point out to ICU staff/docs/etc. that while that's six lives saved, each of those six people has countless family & friends who will also be touched by the donation. We forget sometimes how many different connections we have individually; imagine how many people you know and/or love, and remember that recipients have the same types of connections. The "donation ripples" go quite a distance.

geena said...

Fascinating. I've always wanted to try being a coordinator, but the families in those situations scare me. It's irrational in a way, but I could see myself drowning in their grief.

Plenty of people die in my unit (well that sounded good), and rarely one's an organ donor, but we don't do traumas... the overwhelming majority of our deaths are elderly. Still sad, but not usually drown-worthy.

Lisa said...

Thank you for doing this job! I have worked with so many of you through the years and am always amazed. I work with kids so so many of you are a little intimidated but thank you so much again!