Tuesday, July 31, 2007
Sunday, July 29, 2007
I've been offered a per diem position, which I may take 'cause God knows one job has never been enough for me. Not to mention that little "mommy thing" I do on my days off. I'll also be working at a transplant center, seeing donation from the other side as it were. PICU gets the occasional kidney transplant and we also see a lot of cardiac and liver kids, but so far they get sent out to NY or CHOP for transplants. I'm going to ride my bike to work-how nice is that? I'm going to get reacquainted with the family. I'm going back to school. 3 twelve hour shifts and the blackberry is getting tossed down the toilet(only kidding, IT guy).
I am interested in hearing from other TC's....people from all walks of life seem to read this blog, but WHERE are the TC's. Busy working, of course. Who has time to surf when you keep a schedule like this? So, if you have a good TC story, please email it to me at the address above. Please keep it all HIPAA happy, thanks.
So, there I was at 0315 Sunday morning. I was awakened at 0615 Saturday morning evaluate this patient. I got consent around 1800. Two and 1/2 years ago I asked another mom for consent all by myself for the first time. I was nervous as hell. I was waiting for a TC who spoke Spanish to arrive and help me out. Before she could get there, the surgeon told the family, "You can donate or we're taking her off the vent." I nearly crapped my pants. I did the consent and med/soc with a family member to translate. Between my Triage Spanish and her Spanglish we got it figured out. Why did they consent? Because they had a cousin who needed a kidney. Similiar family dynamics today, except I can't go into details because they'd be too telling. I will say that for the first time in 3 years I had a real ethical and moral dilemma. We convened the hospital ethics committee but I was still funky weird about it. Then I spoke with the hospital priest, who is awesome. Sometimes, the right person you need to talk to comes along at the right time.
Anyway, it's after 3am, my circadian rhythm is at an ebb and my scrubs could stand by themselves, I've been wearing them so long. Dinner was a bag of Cheetos and a peach Snapple. Ymmmm. Oh, yeah, and a donut for dessert. Also, my partner in crime came out to help me and brought me an enormous iced decaf. I know what you're thinking. Decaf? At 3am? Trust me on this: if you give up caffeine that little 5 mg in the decaf really perks you up.
The OR isn't going to be until morning, so I'll get relieved at 0700. Immediately following consent, it's very exciting. I mean, it's sad, because you're dealing with the family but you're also like, "Yes! I got consent!" Then, there are a million things to do right after you get consent. Phone calls to make, paperwork to fill out and fax. Orders to write, huddling with the staff to go over the best treatments to maximize organ perfusion and function. It's like you've been sitting on your butt a lot of the day waiting for things to happen and then you spring into action mode. That was me at 1800. Now my butt is dragging and my teeth feel fuzzy and I left my little toiletry bag back home. Uck.
I spent a lot of the night working on lung recruitment. She had some atelectasis on the right, maybe aspirated. The nurses were amazingly helpful. I'm lucky to be on this unit, they practically don't even need me. So we got respiratory treatments on board, started Solucortef, Gave albumin and lasix. A repeat CXR, repeat ABG's. We did the "30 second PEEP", putting the PEEP up to 30 for 30 seconds, then down to it's original setting for 30 seconds, then repeat the whole thing 2 or 3 times. Do another O2 challenge and repeat the ABG. Both lungs wound up being recovered, along with heart, liver, panc and kidneys. I know what I said last week, and I stand by it, but it feels good to know you made a difference to seven people and all the people they'll touch in their lives. Feels good.
My coworker left around 5 and I spent the last 2 hours trying to figure out how to get everyone to the OR at the same time, with help from triage and inhouse. Ever try coordinating 4 surgeons, their assists, their perfusionists and all the people who are driving or flying them to the hospital. It's a little like trying to rustle cats. Thankfully, I only got a few minor scratches. Have you ever had one of those mornings where you literally want to kiss the calzuros of the incoming nurse? It was that kind of night.
Friday, July 27, 2007
Thursday, July 26, 2007
I've written a couple times in the past few weeks about trying to get consent and recover organs from less than marginal donors. "Extended criteria" is what we call them in my business. Now, extended criteria means(if I don't get it exactly right, I'm sure I'll be corrected) a donor who:is older than 50 with a history of hypertension or stroke, someone with a history of Hep B or C, or someone who's admission creatinine is >1.5. Apparently, NJ is the extended donor capital of the world, or something. When we go onsite, though, sometimes we are evaluating people who are far worse than just having hepatitis or a high creatinine.
Often I will get a doctor or nurse who tells me a patient is not eligible to be a donor because of x,y, or z. Sometimes it's something simple like pneumonia. As long as they're getting antibiotic treatment, they may be a lung donor, but they could donate other organs. People with brain tumors can donate-depends on the type of tumor and whether or not it's been resected. Bacterial meningitis also is not an absolute rule out. If they've been treated and have negative cultures, we'll pursue it.
There's not many absolute rule outs besides most cancers and HIV. Although some programs are recovering from HIV+ donors to transplant into HIV+ recipients, but I believe that's still considered experimental and would need a consent for research. Recently, we had a family consent but there was a strong suspicion of viral encephalopathy, maybe West Nile Virus. We wound up walking away. WNV is lethal to recipients.
Back to last weekend. I can't go into details but we had couple of referrals that just made you go, "ick." Several times I, as triage, had to listen to some bitching about why we were going onsite. (you know who you are!) I can't go into details, but the patient was what we would call a "train wreck." The family wanted everything done, even though it appeared she had been brain dead for a long time. Neurology wouldn't do brain death. Everything pointed to this being a no consent and, at best, we were looking at "liver only." Maybe. So why are we putting all these resources into it? Hanging out at that hospital, sending labs, supporting the family, etc. This isn't going to go anywhere, right?
Yesterday, the patient became a liver donor. The family consented, we were able to offer them the opportunity to donate and, AND, someone's life was saved. Someone got another chance at life. That's why we do it.
Wednesday, July 25, 2007
I'm on call this weekend, the last call for a while. It's bound to be a doozy.
Among the hills, when you sit in the cool shade of the white poplars, sharing the peace and serenity of distant fields and meadows-then let your heart say in silence, "God rests in reason."
And when the storm comes, and the mighty wind shakes the forest, and thunder and lightning proclaim the majesty of the sky,-then let your heart say in awe, "God moves in passion."
And since you are a breath in God's sphere, and a leaf in God's forest, you too should rest in reason and move in passion.
Tuesday, July 24, 2007
Monday, July 23, 2007
Friday started out ok. I only sent out one person for a few hours. Friday into Saturday, I get woken up at 0130. I went back to sleep at 0700 for 2 hours. Saturday, I went to bed at Midnight and had, really, the most delicious sleep. For 4 hours. Up all day, back to bed Sunday at Midnight. Woke up at 0400 again, tried to sleep for an hour, no luck. I was up and stayed up until 0930 Monday morning. Blessedly, I gave report at 0700, stayed up for another 2 hours catching up on my charting while the baby watched A LOT of television. BTW, has anyone else noticed that TellyTubbies and Boohbah are really indoctrination films from our alien overlords? No? Well, maybe it was the lack of sleep catching up with me.
Baby and I went back to sleep at 0930 Monday morning and slept til 1430. Nice. I feel human again. Also, it's a dreary day and raining steadily, so perfect for sleeping and snuggling a warm baby. I highly recommend it.
We had a couple situations where it was pretty iffy if the person was medically suitable for donation, for various medical reasons. The hospitals basically weren't doing any more care for the patients due to their grim prognosis and I had to ask coordinators to approach the family. That way, if they said yes, we could push the hospital for more management. Nobody was really comfortable with this. I said to the one coordinator, be up front with them. Don't paint this rosy picture that their going to save 7 lives when we'll be lucky if they can donate a liver. Just tell them it's a possibility and see if they're interested. They weren't. It gets very frustrating. You have to tell yourself, it's not a liver, it's someone's life. It's worth a shot. But you can see why we get called vultures.
Calling all geeks. I am looking to embed a playlist on the blog. Any advice, either on a good playlist to use, a good place to find tunes(it has to be extensive, I like classical as well as top 40) and how the hell do I embed it?
And Tuesday...Grand Rounds is up at Laurie's blog, A Chronic Dose. Check it out. Now if you'll excuse me, I have to go pull an NJO blog post out of my butt before tomorrow.
Thursday, July 19, 2007
Tuesday, July 17, 2007
Do You Deserve an Organ?
Occasionally, I come across commenters who say they don't believe in organ donation. Curious, I think, because unlike Tinkerbell one doesn't need to close their eyes and clap their hands to know that organ donation saves lives. Also, on occasion, such comments make me irate.
I've been going to Ask Sister Mary Martha, because a Google alert showed she had a post on organ donation. Sister states correctly that the Catholic Church is in favor of donation. She argues that people's fear of donating is a lack of faith. However, many of her commenters think otherwise. Can people really not believe in brain death? I ran into similiar opinions at this site. I won't go into my whole argument again, you can read my comments at her blog or read this. Through the marvels of modern medicine, we can keep a body going long after nature would have called it quits. Yet for some people, "pulling the plug" at this point is against God's will. Unfortunately, I don't have a cozy enough relationship with the Big Guy to pretend to know his will. I speculate that keeping a body going, not alive-just going, is man's will, not God's. At least Sister's readers aren't hypocrites. Most of them said they wouldn't accept an organ either.
What about that? What about people who wouldn't donate, but would accept an organ if they needed one. You might think that once a person has had an organ transplant, they would agree to donate. You'd be wrong. I have asked families of patients who, following their transplant, developed complications and became brain dead. Some have said no. If I get past my annoyance, I can understand, I think, their response. Perhaps they're mad that the transplant didn't work. You don't know what kind of relationship they had with the doctor or the hospital. This is not a time for people to be logical or selfless and it's hard to analyze why a person makes the decision they do in the small window of time we have with them.
Should someone who's against donation get an organ? Organs and organ donors are rare, I think we can all agree on that. Less than 1% of all deaths are brain deaths and medically suitable to be donors. In NJ, there are currently over 3000 people on the waiting list. Last year we had about 300 potential organ donors. A little more than 2/3 consented. That's why the waiting list keeps growing. Into this mix are people, patients and institutions who are trying to come up with solutions, sometimes controversial ones.
Dave Undis from LifeSharers wrote an op/ed piece in the Baltimore Sun last week in which he says that organ donors are "getting the shaft".
registered organ donors who need transplants are treated no better than
people who have declined to donate their organs when they die. As a result,
every year, thousands of registered organ donors die waiting for transplants
when the organs that could have saved their lives are given to nondonors.
He's very persuasive. Why should people who won't donate receive an organ?His argument takes a creative leap, however. More accurately would be to say that every year organs go to people whose beliefs regarding donation are unknown. There are many requirements for getting onto a transplant list. Your feelings about being a donor yourself is not one of them. He goes on to say,
But shouldn't organs be given first to the people who need them the most? Not if these people aren't willing to donate their own organs. If people are unwilling to save their neighbors' lives, should we really elevate their needs above everyone else's?
In other words, if you join LifeSharers, you agree to donate your organs, if you are brain dead and medically suitable, to other LifeSharers members. That in itself is a big "if", given the small likelihood that you will be a donor. This falls under the "direct donation" stipulation, that families are able to direct who will get the organs and bypass the national list. If you see a cute kid on TV or know someone at church who needs an organ, you can direct an organ to them, as long as it's a medical match and the recipient's surgeon ok's it. What Mr. Undis is saying is that, even if a person on the waiting list is a status 1A, they shouldn't receive an organ if they won't agree to be a donor. But what if that person has never heard of LifeSharers? How would you know what their wishes are? If I'm a LifeSharers member and I become an organ donor, my organs will go to other LifeSharers members, even if there are people ahead of them on the waiting list. Even if some of those people(the status 1A's) will die if not transplanted immediately. Tough Nooggies, is his response.
LifeSharers is at least free. MatchingDonors has a fee of several hundred dollars to be listed for a living donor transplant. Go to his site and you'll see requests, "help my dad lead a nrml life" or "desperately need kidney, blood type A+". What's wrong with this? It brings to mind, my mind at least, women who go to a sperm bank looking for the perfect donor. Ooh! Pick this one-he's Norwegian and he speaks three languages! And he's a doctor!" There's nothing wrong with paired kidney exchange programs when there is oversight. The two biggest problems with these online programs are 1. they are not accessible to all and 2. they aren't accountable to anyone. The day people can advertise for a kidney donor is the day that money will exchange hands and the day that some people will be considered "not worthy" of an organ.
It's easy to say that people who won't donate shouldn't receive an organ. I have said it myself. Then a respected colleague and friend reminded me that putting restrictions on who can get a certain treatment could lead to restrictions for other illnesses. A person who had unsafe sex wouldn't get HIV treatment, for example. If nothing else, your insurance company would love to find some more reasons to deny your claims. Fat people receive treatment for heart blockages, smokers get help for their COPD and alcoholics sometimes get new livers. If you don't think that's fair, ask yourself if you've always gotten what you've deserved. I haven't, and that's a good thing.
Monday, July 16, 2007
Also, new posts everyday at the NJO Blog. Kim wrote a good piece yesterday about the history of nurse practitioners. My new Penlight post is finally up. Friday, Labor Nurse put up some links from a NY Times article that I can't wait to read in my free(?) time. Terri is taking a little break, but she's still writing at Nurse Ratched's Place. Over the weekend I saw part of "One Flew Over the Cuckoo's Nest". Not only did I never realize what a great actress Louise Fletcher is, her Nurse Ratched was a PATIENT ADVOCATE! After Jack steals the boat and takes the boys fishing, she petitions the medical board to keep him in the hospital rather than return to prison. Imagine that.
Oh, and if you'd like to see what TC really looks like, there's a new picture up with my bio on the NJO blog. Try not to be blinded by my beauty.
Saturday, July 14, 2007
This week we had a case where nothing was recovered. The patient had various infectious diseases, but his family really wanted to donate. We went to the OR thinking we were going to recover liver and kidneys. Then, literally as we were pulling in the door, I got word that no one wanted the kidneys. God, there are so many people waiting for kidneys, I couldn't believe it. Plus, kidneys can be put on pumps for a few days to improve their function AND they can get shipped just about anywhere. Once, I had a box o' kidney go to Hawaii. I offered to take it there personally, but my boss didn't go for it.
So, the liver team proceeded with the case but, unfortunately, the liver turned out to be severely cirrhotic. Case aborted. I was with another coordinator, the one who had gotten consent, so she told the family. I can only imagine it must be heart breaking, when organ donation is the only silver lining in a horrible situation and then it doesn't happen.
It happens. I always tell families that it's a possibility. You open the donor up and find a large tumor or a necrotic bowel. I've had a couple experiences, both with little babies, where they had a rare blood type and there was no one their size on the list. In those cases, the lists are usually small to begin with and I went through them quickly. I think it's especially heart breaking when something goes wrong with pediatric donors. Losing a child is the loss of hope, and organ donation can be the only hope they have left-that a part of their child will live on. It's so hard to have to tell these families that the donation can't happen.
Sometimes, you find out a patient is HIV+. Legally, as part of the consent, we tell the patient's doctor, the funeral home and the legal next of kin. Imagine calling an elderly widow and telling her that the donation didn't happen because her husband was HIV+. Or a husband that his dead wife had hepatitis B or C. At that point we've already done the medical/social history with them, so we know if they didn't know about it. Again, it's a possibility I try to prepare people for, but at that point, most people are just going, "yeah, yeah, ok" They have a lot more on their minds at that point than theoretical possibilities.
With DCD, there's always a chance that the patient won't expire in the 60 minute window. This is something we discuss with the hospital staff beforehand. The patient would then go to a predetermined spot-back to the ICU or a medical floor. There, end of life care will continue as before until the patient dies. I always think with DCD that you are really asking the family to take a journey of faith with you. The act of dying is so personal and private, but these families are so commited to organ donation that they're willing to open that moment up to you, so that someone else can live.
Saying yes to donation is an act of faith. It's a seed of hope for a tree you might not ever see bloom. Sometimes even I question why we're putting so much effort into a marginal donor, or a "liver only". Except that it isn't just about the liver or the kidneys, it's about John, the 48 year old who's been on dialysis for 4 years or Amy, the 17 year old who won't live to graduate high school without a new liver. I'm constantly amazed by the families who could understandably think only of their own grief, but instead think of the good that can be done for others.
Don't forget Wednesday the 18th is Blogging for Donation day! Hmmm, what to write about?
Thursday, July 12, 2007
Wednesday, July 11, 2007
"Tut, tut. Doctor knows best. Now lie still, this won't hurt me a bit."**
p.s. I also now know that many of you are enjoying the "Name Your Girl Parts" link. Naughtly readers!
Tuesday, July 10, 2007
Anyway, Grand Rounds is up at Aetiology. And don't forget to check out the NJO Blog, with some of the best nursing writing on teh internets.
Saturday, July 07, 2007
1. If, and only if, you get tagged, write a post with links to 5 blogs that make you think,
Friday, July 06, 2007
Anyway, regardless of what you think this doctor did or didn't do-read the comments. I can't believe, in regards to organ donation or anything else for that matter, that people are so ignorant. I read things like this and I think that if you don't believe in organ donation, you shouldn't get an organ. It's that simple. It's like members of PETA, who can believe whatever they want, but don't come to the hospital and expect to get any treatments that involved animal experiments. That may leave you with only bandaids and ice packs, but I wouldn't want your principles to be compromised just because your dying.
Am I alone in thinking it's a miracle that ANYONE gets an organ?
BTW, I got a great reader comment in the last post and I posted a rather lengthy reply. Just thought you might be interested and also I'd be interested in other points of view on the same.
Thursday, July 05, 2007
Tell all your friends, yes, even your imaginary, internet friends, that JULY 18th is Blogging for Organ Donation day. This is being sponsored by BlogCatalog with the hopes of raising organ donation awareness and getting folks to sign up to be organ donors. What can YOU do?
1. Link to organdonor.gov and/or UNOS. (In the effort of full disclosure, you can also link to matching donors dot com. I will not, as I do not support their efforts). If you live outside the US, link to your country's organ donation site, if you have one. The British Organ Donor Society (BODY-the Y is really an psi, you clever Brits!) has a site with links to organ & tissue donation websites around the world.
2. On July 18th, On Wednesday, July 18, write a blog post asking all your readers to sign up as organ donors. Your blog post should:
• Have the title “BlogCatalog Community Organ Donation Awareness Campaign” (or some variation)
• Explain the importance of organ donation and how it is a gift of life.
• Link to one (or all three) of the sites above or the most suitable site for your country.
• And add a link to our BlogCatalog Community Organ Donation Awareness Campaign page so we can give you and your blog credit for being part of it. (you have to sign up in order to do this.)
If you have any questions, email firstname.lastname@example.org