Thursday, May 31, 2007

Change of Shift

Change of Shift is up at Emergiblog! And the next addition will be it's one year anniversary, so send Kim your submissions now.

Tuesday, May 29, 2007

BYO punchline

All I can say is, read this:

Apparently a terminally ill dutch woman is going to appear on a game show to find a recipient for her organs. The article didn't mention what her illness is, I'm thinking she's vent dependant and is going to have herself taken off the vent to die? I guess I should be more offended, but this passes ludicrous and is on to surreal. The shows creators say it's going to highlight the need for organ donors. Mmmm, ok.

Well, I guess reality TV has used up all the sex angles, so they've moved on to death.

GR, et al

Grand Rounds is up over at From Med Skool. I like the picture on his banner-does putting a stethoscope to your head really work?

Check out the NJO Blog, too. New posts this week including yours truly. I'm working on a DCD post, but the more I research, the more I find. Maybe one of these weeks I'll actually write about something.

And, because better late if ever is my motto: Change of Shift(from May 17th) at Nurse Ratched's Place.

Now, where's my coffee?

Sunday, May 27, 2007

All Death is Brain Death

Let that sink in for a moment. When the brain doesn't get oxygen, via the blood, for more than 5-10 minutes, the brain cells die en masse and then necrose. I once read an autopsy report for a person who was an organ donor. (Spoiler alert:this may be considered gross by people who aren't me) By the time the autopsy was started, a few hours after donation took place, the brain was already liquifying. See, it's not a theory. Your brain really dies. It's just that in most cases, the heart stops first, then the brain dies. Brain death, were blood flow to the brain stops due to cerebral edema following trauma or other brain injury, occurs in less than 1% o all deaths.

The heart can be restarted. Think open heart surgery-they actually stop your heart. But without blood flow to the brain, you're toast. Except in rare cases, like cold water drowning, where the brain metabolism is brought almost to a stop.

Remember history class? During the French Revolution when everyone was losing their heads, sometimes the executioner would hold the head up and the eyes or lips would still be moving.

The new debate about the machine began soon after the first few executions. One of the more recognized incidents involved Charlotte Corday. Charged with the death of revolutionary leader Jean-Paul Marat, Corday faced the guillotine on 17 July 1793. After being beheaded, the executioner’s assistant held up her head by the hair, showed it to the crowd, and slapped it across the face. The cheek turned red out of the indignity of the act or so the spectators thought. The scandalous moment upset the crowd and thus gave reason to investigate the matter further. (The Guillotine: A Look into the Machine Built for a Humanitarian Death by Jonas L. Bulman)

Gross. This is why when someone goes into cardiac arrest, you do CPR. Not to keep blood pumping to their heart, but to keep oxygen moving to their brain. Duh, right? If I had a quarter for every doctor who's told me, "But I can't sign the death certificate. Their heart's still beating." Well, I'd have enough to buy a grande latte. Because, of course when someone is going to be an organ donor, they are kept on a ventilator and given various medications to keep the heart pumping and the organs perfused. But their brain flow scan, if they had one, will look like the one above. White=blood flow.

So maybe we need to rethink the whole term "Brain Death". It certainly seems to confuse many, even medical professionals, into thinking it's different from "Real Death". Maybe we should just say they're dead.

Thursday, May 24, 2007

Calling all healthcare bloggers!

Labornurse wants to create a discussion about the issues of healthcare blogging. Any of you who have a submission, comment or thoughts on the pros and cons of being a healthcare blogger should email her at:

Should be an interesting discussion, I'm sure

Wednesday, May 23, 2007

Enough about the job, already

I can't wait to read this week's Grand Rounds, over at ImpactEDNurse. We're looking at the best of the best. And no, I didn't submit. Because my life is call, call, endless call. Yes, I'm on call again for 2 days. But I just got OFF 3 days of call. Well, if it was easy we'd all be TC's.


I also can't wait to get home. The baby is in rare form these days. She's adding to her verbal repertoire everyday. So far she can say dog dog, ditty(kitty), duck, cheese and fish. And Dada, of course. She only says Mummum if she's hurt. If she's hungry, she lifts my shirt up. I try and keep her well fed BEFORE we venture into public. But the funniest thing(to me, anyway) is that she went from saying "hello" to saying "HI!" and it's always "HI!" not "Hi". She wakes up in the manana, pops her head up like a gopher and yells, "Hi!" She also is stringing it together with Dada, so she wacks him in the head while he's sleeping and says, "Hi, Dada!"

I'm leaving for a conference in 3 weeks and will be away from this awesome cuteness for 4 whole days. I don't know how I'll stand it. She will be fine, I'm sure, except for missing her nummies, because her daddy and her share a special bond. I only carried her for 9 months you know.

Seriously, after 3 days of call I swear she was bigger and more smarter ("more smarter?" You know what I mean. Listen, I'm tired). She's amazingly intelligent, it's the genes dontcha know. I love her meeces to pieces. There's nothing like coming home after being out for a zillion hours and having her face light up when I walk through the door. Not even the dog loves me this much.

Well maybe I'd love you if you walked me once in a while-T. Dog

Sunday, May 20, 2007

The Waiting

Have I mentioned how much of my job involves WAITING for things to happen? I was out all day yesterday for a woman who wasn't quite brain dead. But the hospital was an hour away and I knew once I got home I'd be called out again. So I waited. Then I had respiratory check on her respiratory drive every once in awhile. Not breathing over the vent. Call the doctor. Wait for him to call back. Try and convince him that just because the monitor says she overbreathing the vent, doesn't mean she really is...honest. Take her off the vent and see, no breathing. Then I waited for them to do the first brain death clinical. Doctor finally shows up to do it. "But she's breathing over the vent, see the monitor?"

Finally he does the clinical exam. No apnea test. He wants to do the apnea test with the second clinical. I'm still waiting for family to arrive from out of state. Some peripheral family comes in...maybe the legal next of kin is coming in, maybe not. So we wait some more.

I call Neuro to say we've done the first clinical. He's says he's rounding and he'll be by soon. 2 hours later he shows up. "Hey, she's still breathing over the vent. Did you look at the monitor." I patiently explain that if you look at the patient and not the monitor, you'll see she's not breathing on her own. He wants an apnea test now, to be sure. Then he leaves with no further instructions. We page the medical resident and tell him neuro wants an apnea test. He says he'll be over, "in a bit." I go to the lounge, which has a huge window. I try not to walk out on the ledge and jump.

A couple more hours and no resident. We call him again. This time he tells me he's not qualified to do an apnea. I assure him that he is indeed qualified to see if a persons chest is rising and falling or not. He refuses. I call neuro back and tell him the resident won't do it. He curses some then says, "well, we'll do it in the morning." Like we originally planned to do. Aaarrgghh!!!!!

I have been out all day, woken at 04:59 and now it's now 23:00. I disengage for the night, someone will come onsite in the morning to talk with the family. The most frustrating thing is that I feel like I did NOTHING all day.

Today, I get called out to another hospital. I won't go into all the details...but I will say that the family said they be back at 21:00. And the time stamp of this post is.....

Saturday, May 19, 2007

Dora, the Explorer

Have I mentioned how much I can’t do this job with my husband. Yesterday, I went to one hospital. Patient wasn’t brain dead but the nurse had brought up donation, so I spoke with the family. They said they were going to see how he did in the next 24 hrs before they made any decisions. I left there and triage told me to head up to another hospital, 40 minutes away. Half way there, triage calls me. How far away are you? She said that pt is medically ruled out, but I may have to go to one of 2 other hospitals, both in the other direction. “Just turn around and I’ll let you know where you’re going to in a few.” I stop at the office for supplies and she calls and tells me to go to the nearer hospital. I get there, pt is not even close to brain dead. I chart a few labs, etc. I help another nurse help a Jewish family figure out how they can be contacted about their father during Shavu’os next week. And then I leave. Now it’s rush hour. I slog through the traffic. Five miles from home, triage calls yet again. Can I go back to the very first hospital. Family decided NOT to wait 24 hrs, they want to extubate right now.

Confused? Me, too. It’s amazing I found my way home that night and didn’t just keep driving in circles until dawn. In the middle of all these trips, I'd call my husband and say, "Can't come home yet, I've got to go to...." He start to protest, "but, but," and then he'd just sigh and say, "Ok, I love you honey. See you later."

When I first speak with the family, I introduce myself like this:

“Hi, I’m Susan and I’m a nurse who works with families of patients with severe brain injury.” This is not lying. But it is a mental leap I had to make, and my preceptees had to make. Walking in first thing and saying, “Hi, I’m here from the organ procurement organization!” is likely to get an immediate NO from the family. They are thinking about how their loved one is going to survive and recover no matter how bad the doctors say it is. They want to know that the hospital is doing everything possible to save them. They need some time to let the bad news sink in. Sometimes, I just completely stay out of the picture until it’s time to ask, especially if the hospital has a good family support system in place. In other hospitals, they don’t have the resources, I step in and try to be that support, whether they donate or not.

So, back to my first family. There were a lot of them. When I returned, there had to be 30-40 people around. He wasn’t brain dead and they wanted to extubate now. They didn’t want to donate. And the hospital had no family support, pastoral care or social workers on a Friday night. So I told them I’d stay to help support the family and help with the crowd control. Someday I’ll go into the whole story but it’s a little too fresh right now. Suffice to say, they needed someone and our family support person was still en route. My coworker calls it “doing the Lord’s work”, when we stay and help the family after they’ve said no. I even offered to help with the post mortem care, because these nurses were swamped and overwhelmed by the number of family.

Because no matter how much I want that 7 organ donor or that next successful DCD, I really am concerned about more than just your organs.
**If I'm Dora, guess which one of youse is the monkey! Ha!

Tuesday, May 08, 2007

Happy Nurses Week!

My new column is up at! Please check it out-I'm very proud to be included with Emergiblog, Nurse Ratched and Labor Nurse.

Kim will be doing Nursing History every Monday
Moi will be writing about Nursing Ethics qTuesdays
Kim's back on Wednesdays with Nursing Research
Nurse Ratched will be blogging about Nursing Leaders on Thursdays
and Labor Nurse has Fridays to bring you a compendium of Nursing Links

See you there!

Sunday, May 06, 2007

Is it over yet?

Busy weekend. I've been on call since 7am Friday and I still have 8 hours to go. Thursday we had 5 consented cases going at the same time(that's a lot) and it spilled over into Friday so I knew I was going to get called out. And we had one team member on vacation. We work in teams of 6, one person does phone triage and the rest of us respond to referrals around the state.

I got called at 6:30 am to go to the hospital furthest South for our area, an hour and 15 minutes away for me, more with rush hour traffic. And I was the last person called out. I spent the day there, everything went perfect, the staff did a great job of treating the patient and supporting the family, the doctors were respectful and kept them informed of everything. Pastoral care was there. And the family was just as nice as could be, given the devastating circumstances they were dealing with. And they said no. For whatever reason, they didn't want to donate this young person's organs. I was pretty bummed. Could you imagine having to make such an important decision hours after receiving the news that your child was going to die? I can't. Unfortunately, if your wishes aren't already known, we have to ask your family around the time of your death if they want to donate your tissue or organs. I'm always floored by the amount of people who take time from their grieving to think of saving another's life.

Saturday I got called at 5:30am to relieve another TC who was out all night and do the OR, which was scheduled for 8am. Of course we didn't get to the OR until almost 9:30. Then we found evidence of possible TB and rounds of phone calls ensued, but in the end the organs got shared(it was old TB and treated). I got home around 5pm and tried to nap but was still receiving phone calls about the kidneys, so no nap for me, sigh. Sunday was blissfully quiet.

Donorcycle is included in Pediatric Grand Rounds over at one of my favorite blogs, The Wait and the Wonder. Moreena somehow takes time out from her busy life to do PGR this month-I've been there sister. I won't be volunteering to host a blog carnival again anytime soon, curse you blogger! And your broken links!

Thursday, May 03, 2007

I'm Coming Out!

Now that I have your attention. I came out at work today. No, not like THAT! I told my boss about the blog. Some of you(all 5 of you that read this blog, not including myself) may remember that I wrote an essay for Karen Quinn's Wife in the fast lane about being a working mom. I told 5 people at work about it-all of them my team members. 2 days later my boss calls me in to his office to say that "someone" showed him the essay and should he be concerned.

Anyhoo, NOW I am going to be writing a weekly article(YES! WEEKLY! Cause I'm insane and don't have enough to do) for! I can't quite believe it, they want me to write for them. They like me, they really like me-shades of Sally Fields at the Oscars, if you're old enough to remember such things. Then, yesterday, one of my coworkers calls to ask me if I have a blog. I sense my anonymity is coming to an end. To after days of anguish...well, one day, I went and had a talk with the boss man. We've had a few talks, I think he twitches when he sees me coming. BUT, now he knows and if he's not thrilled beyond belief at least he's not stopping me after giving me some advice and a few warnings about what might constitute bossial concern on his part.

SO-check out this Monday, May 7th! For my amazing new column on nursing ethics. When I'm old and famous you can say you knew me when.


Check out the latest Change of Shift at Emergiblog.

I was catching up on Grand Rounds, albeit a few weeks late, and found out that Transplant Headquarters linked to my post on DCD. Thanks and thanks for writing such a comprehensive post on Donation after Cardiac Death. Please read the comments, there is a lovely one from a mom whose son was a DCD donor that you shouldn't miss.

Tuesday, May 01, 2007

Matching Kidneys

I was searching teh internets for something to write about and I came across this cool game about living kidney donors from Liberty Science Center. Receiving an organ from a living donor has an 84% success rate, compared to a 54% success rate from deceased donors.

Finding a kidney recipient is a little different then with the other organs. Because the person who needs a kidney can be maintained on dialysis, kidneys are matched not only by blood type but also with with tissue markers, similiar to the way people are matched for bone marrow transplants. This applies to pancreata as well-don't mean to exclude you pancreas people, I'm just trying to keep things simple.

See, if you need a heart, chances are you need one really soon or you're going to die. So you transplant surgeon is going to be looking at the donor's blood type, height and weight. You can't put a linebacker's heart into a petite woman, for example. There are other considerations, obviously, like risk factors and heart function, but if your patient has only days to live, blood type, height and weight are the big three.

Because of dialysis(or insulin therapy for the pancreas), a patient can be maintained until a "perfect" organ becomes available. Actually, there is no "perfect" kidney match. According to my lab director, there are HLA markers that haven't even been discovered yet, they just know they're out there. So, there are six markers that are looked at in matching kidneys and pancreata. If the recipient and the donor share all six, it's called a "zero mismatch". That means they all match, hence NO mismatches. Why don't they just say it's a "six match". Because the HLA never perfectly matches up, due to all the subgroups or something. Dammit Jim, I'm a transplant coordinator, not a biochemist.

Why is this so important? Because an organ with a zero mismatch will last longer and work better. Extending the life of an organ means less chance or rejection, less chance of needing to be retransplanted and less people back on the waiting list. This is why using a living donor is prefered for kidneys. Obviously, only with kidneys, unless you live in China. But that's another post. The easiest way is to find a family member that is compatible. Since you get half your markers from you mom and half from your dad, it is most likely that a sibling will have the same markers as you. 25% chance or matching from a sibling, unless you're identical twins-which is how the first successful kidney transplant was done. But what if you don't have a sibling, let alone an identical twin. What if no one in you're family is a match?

One solution is using a paired donor exchange. Say my daughter needs a kidney but I don't match her. Then say another person needs a kidney and their brother doesn't match him. But his brother matches my daughter and I match with him. We would then donate our kidneys to each other. These programs are usually done at transplant centers and they're being studied, not only for their success rates for also for ethical considerations. Just a few things to think about. Maybe sometime I'll write about the evils of black market kidneys.