But a month of Tuesdays would be GREAT!

....Because it's Grand Rounds! Head over to Polite Dissent for your weekly reading. Who knew there are so many medical references in the comics? Zoinks!

A month of Mondays

It's Sunday night. Tomorrow I will be on call and I anticipate getting called out early. Call me cynical, but I've worked many a weekend on the unit and through the fault of understaffing or weekend apathy, many a braindead patient has gone unnoticed(Sorry 'bout the run on sentence). Monday morning and the head nurses will burst onto the scene, take a census report and demand to know what's going to happen with the grim, head-injured patient in 20 or the stroke in 14. Then I'll be called in to evaluate them. Last month was a little slow, so I guess I shouldn't complain, but I hate Mondays.

What's wrong with Auntie?

I pondered for a few days about what to write for Blogging Against Disablism Day. As a nurse, I've taken care of many people with disabilites, from children with chromosome abnormalities to elders who've had strokes. I couldn't think of anything. So I asked Love Monkey. No help there. Finally, Dear Kid said, "What about Auntie?" How dense could I be? I'd forgotten my own family member and her struggles being differently-abled, which only shows how marginalized people like her are.

I was probably 7 or 8 when I realized Auntie was "different". I might have noticed a little earlier, but she didn't live close by, and really you could know her for a while and not realize it or just think she was a little "off". Finally, one day I asked my older sister, "What's the matter with Auntie?" "She's retarded!" Just the way my sister replied made me feel like it was shameful to even ask.

Those who qualify such things say she is "high functioning." I know that she writes her letters neatly in the blanks of the crossword but they don't spell anything. She looks through the paper but doesn't read it. When my grandfather drives, she tells him what street to turn down and she remembers everyone's name-even people she hasn't seen in a long time. She was born in the early 1940's, the only one of her siblings born in a hospital. Something happened during birth and she was deprived of oxygen and had brain damage. So she doesn't "look retarded." If she was born today, she'd probably be in special education classes and maybe mainstreamed. She might even hold a job and live independantly or semi-independantly. But she was the product of another time and a dysfunctional family. She was advanced through Catholic school for several years and then just stayed home. Nobody talked about it.

I probably wouldn't even think about it much except that Auntie came to live with us when I was 19. At the time I was horrified. Something in those two words my sister said years before shattered my child's love and made me ashamed of her. My teenaged selfishness thought it was a terrible imposition, even though it really didn't change my life at all. I left home that year and again, it wasn't something that really registered on my radar except for visits home. Then, all I could think about was how she bugged me. Like the weird way she had of moving her mouth when she listened to you and how she was always twitching and moving. Nobody then realized she had Tourette's Syndrome. Then I would leave and not really think of her again until the next visit. My parent's were having difficulty adjusting to Auntie in their home, but that was their problem, not mine.

Somewhere in my 20's I started to change. Somewhere between having a child, becoming a nurse and going through several difficult years as a single parent I started to have more compassion in general and more feeling for Auntie's situation. Maybe it was when Dear Kid asked me the same question I had asked my sister years before, "What's wrong with Auntie?" Being less blunt I explained a little bit about how and why she was the way she was. Dear Kid loved her. One of my favorite pictures is of Dear Kid and Auntie walking away from the camera down a path framed with Autumn trees turning gold. DK never felt shame about her Auntie and I learned that if you teach a child with truth and compassion they respond with nonchalance. Auntie was different from DK in the same way that some people have different skin or hair color. Interesting, but it didn't change their love for each other.

By now, the stress of taking care of Auntie was taking a toll on my parents. My mother in particular would snap at her for little or no reason. Auntie was like having a perpetual 9 year old on your hands. You always needed to remind her to wash or brush her teeth or put on clean undies. Mom either couldn't or wouldn't remember that or maybe she was just mad that she had raised us all and now was raising one who would never grow up and leave home. Fortunately, they were put in touch with someone from Social Services and found out about a day program. Auntie, after some initial fear, really seemed to like it. They also had overnight programs, where they went to the movies and stayed in a hotel and went swimming and such. My parents are also entititled to three weeks a year of caregiver respite. Sometimes these go fine, but one time Auntie came home crying. They had roomed her with someone who wasn't "high functioning," someone, in fact, who needed help with feeding and their diapers changed. It really scared her, I think because she knew this could have been her. For the first time I really, truly understood that Auntie was a person, not just my "different" aunt. Not just a brain damaged, Tourette's twitching diagnosis but a person. Not the shameful, family secret but a person and my aunt.

She is responsible for my seeing patients in a different way. For not having conversations about who's sleeping with who over the confused patient during the bedbath. For not talking loudly to the blind person or condescendingly to the old. For not assuming anything about the differently-abled. I started having conversations with Auntie, asking her about things. I'm embarrassed even to tell you that it took me this long. She's never asked for anything. She's spent her life dependant on others to look after her. If she outlives my parents, my sister and I will be her guardians. She loves babies and chocolates. Despite her small stature, she gives bone-crushing hugs. She still bings around from place to place with her crazy, frantic energy. And there's nothing wrong with her.

What do we owe?

"The single most important thing to know about Americans -- the attitude which truly distinguishes them from the British, and explains much superficially odd behavior -- is that Americans believe that death is optional."
Jane Walmsley

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Some of you may have been following the comments from this post. I made a reply, but I still had something Sailorman said on my mind (I'm not picking on you, Sailorman, I swear). He said that the dead owe nothing to the living. Which got me thinking about personal responsibility. What do we owe other people:our families, our children, strangers, other residents of our nation or the world. Do we intervene when we see someone getting beat up? Do we stop at an accident? Do we intervene if we think the neighbors are molesting their kids? Do we keep the world clean for future generations even if it means we drive less or give up something we really like(I don't know, pick something)?

I feel like I'm rambling. Do the dead owe the living anything? The thought has brought out the existentialist in me. The Talmud says, "he who saves one life, saves the world entire." When a family has to make a decision to donate, do they owe the potential recipient anything? I'm not talking about laws or presumed consent. I'm talking about morally. When it comes to donation, though, I don't think it's about what the dead owe the living, but about what the living owe the living. If given the opportunity to save someone's life, would you do so? What if it was conditionally? One commenter said she would only donate for a family memberif she could know who the recipient was, that it was her right and if the recipient didn't go for it, they didn't have to accept the organ. But when a house is on fire, do you say to the people trapped inside, well, I'll rescue you if you promise to come clean my house. They're in no position to say no. One guy I know recently found out he had received a new heart after being in a coma. He couldn't agree to anything. People waiting for organs are desperate and sometimes have only days or hours to live. So is it morally right to place a restriction on the gift of life?

This whole line of thinking led me to think about dead people. Now I have personally done post-mortem care on dozens of people. I've cleaned blood and various other body fluids from them, redressed them in clean gowns and generally made them presentable to be seen by their families. One of the big concerns families have is having their family member "cut up". But when you've actually touched a dead person, you see that this is just the shell we live in. Our bodies are just a suit of clothes that we wear and when we die, no matter what you believe happens next, we take off that suit and move on. It's fitting to act with respect and reverence, but it's still just your shell. I think everyone should do post-mortem care at least once. Like it used to be done(and still is, in some parts of the world), when a dead person was layed out in the parlor for the wake.

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On Monday, I'll be participating in Blogging Against Disablism Day.

Check out the above link for more info.

Grand Rounds!!

Head on over to this week's Grand Rounds at the Health Business Blog. And check out the comments in my last post. I hope to get a lively discussion going.

Organ Donor Awareness Month

April is Organ Donor Awareness Month. You critical care nurses out there may have already seen this month's Critical Care Nurse magazine, but if you haven't, it's devoted to organ donation and it's very, very good. Check it out.

One of the discussions I've had recently is how to increase donation rates(well, not just me but the whole HRSA Collaborative.) Our neighbors to the north(Canada, for those of you who are geographically-challenged), are considering the possibility of presumed consent. This is where an individual would have to "opt-out" of being a donor on a national list or else, in the event of brain death, would be presumed to be a donor. Spain, which has the highest organ donation rate in the world uses a system of hospital-based transplant coordinators. Here in the U.S., consent must be obtained from the next of kin-who have to make this decision while their loved one is still on a ventilator, at or near brain death. Not an ideal time for a well thought out, informed consent. Many states have enacted laws for first-person consent. This means that if you document that you want to be an organ donor-on you driver's license or on a registry-it is considered informed consent and your next of kin's permission is not needed. Where I come from this has not been challenged. Most families want to honor the deceased's wishes and will agree to donation when they realize that's what they want.

Another, more controversial idea is that only people who sign up to be organ donors should get organs. I'm interested in hearing opinions on this. Should someone who wouldn't donate their organs receive one? What if they changed their minds? Something needs to change. Waiting lists are growing as technology keeps potential recipients alive. Today, 18 people will die waiting for an organ. It's an uneasy thing to consider theoretically. Now think about how you would feel if it was your spouse, your child, your parent who was brain dead. Would you donate? Recently I asked a mother of a teenager who died suddenly if she would donate her daughter's organs. She said she knew it was a good thing and she wanted to help other parents who were waiting for an organ to save their kids lives-but she couldn't see her baby "cut up". Who can blame her? This is the last decision she will ever make for her.

I personally don't care what you do with me when I die. Cut me up and bury the rest by the pound. I won't need it anymore. Let my eyes help someone see their children or a sunset. Let my skin be used for grafts for burn patients. Let my heart, lungs and liver go to someone who doesn't know from one day to the next if it's their last or their first-with a life saving organ. My kidneys, pancreas and intestines can go to someone with a debilitating disease. Take every bit of it. If you feel that way too, tell your family, write it in your living will, put it on your driver's license and tell your family again. Over 90,000 people are counting on you.

I haven't posted since March!?

I'm tired. Very, very tired. It's been a busy month. Ended by a long week at work-I had a donor who was a baby, killed in house fire with mom. I DO NOT want to talk about it.

I will say this, though. You should never jump to conclusions. The intensivist told me afterwards that she was taken aback by how heartless the recovering surgeon was. She wanted to hate him. I told her that she didn't see him in the OR when he asked me what the baby's name was as he made the first incision. I told him and he said "S____, I'm so sorry. I so, so sorry." He has kids, too, and he didn't want to do this but we had no one else.

There are two things about this job. One good thing is, it makes me so grateful for the things I have-my health, my family. I try to live every day like I may never see them again. The one bad thing is-I live like I may never see them again. It scares the bejesus out of me. I think of all the bad things that could happen to my Laughing Baby or my older, Dear Kid. It drives me nuts. I want to encase them in bubble wrap whenever they go out of the house.

I remember a bad week I had many years ago when I did trauma. In one week I took care of a teenager who hanged himself, a young girl killed in a head-on collision and a new father who had pulled over to the shoulder when his car broke down and was rear-ended by another driver who had passed out from being sick at 70 mph. He had taken off his seatbelt while he was waiting for the tow truck and killed. I had to talk to his wife, the mother of his 4 month old baby. Then I had to return to the ER where the driver that killed him was being treated.

That was it for me...I did something I had never done before. I sought out the priest from pastoral care. Father was a great guy. I told him how upset all this had made me and then how I was worried I'd run into the guy that did it as my next patient. He said, "I understand. I spent a long time with the family of the man who died and it was very draining on me too. Then I wanted to know if I'd have to minister to the other man as well, but I looked him up in the computer, and thank God, he's Protestant!" *

Which leads me to the third thing about this job:you need a wicked sense of humor.

* I cross-my-heart-and-hope-to-die swear that that is exactly what he said! I loved that priest.

Good Lord, It's Grand Rounds

NHS Doc does a spot on job of hosting Grand Rounds this week and what's probably the best explaination of cricket I've come across so far (eat your heart out, Bill Bryson).

In other news, GeekNurse is no more. Hell, we hardly knew ye....the paediatric RN from New Zealand did an awesome job of teaching hard-core critical care nursing with love and compassion. You'll be missed. (and that's why I blog from a small, unchartered fishing boat off the coast of Ghana.)

No time like the present, no present like time

It has been a very stressful month for TC. Not work, no, no, work is fine. A bit slow, actually. But real life has been kicking me in the bum. Enough to make TC very, very cranky. Enough to make TC talk in the third person, like the queen. My apologies. TC will have a longer, more coherent post soon and in the mean time, if my head explodes, you know what to do with my organs. Cheers!

Donor Management

Lest you think my job is all Kleenex and hugs, it does have a clinical side. When we start to take over donor management varies with hospital, circumstance and personel involved. Tonight, for instance, I'm in an ICU that we work with pretty frequently. The doctor has already done the first clinical exam for brain death and the family understands that she is not going to survive. The intensivist told me to do whatever I want to manage the patient and she will sign the orders.

This is very nice for me. The earlier we manage the patient clinically, the more likely we'll have healthy organs to recover. For instance, this patient had been given Mannitol to keep the ICP down and was going into DI, so she was peeing like crazy and her BUN and creatinine were going up. The hospital had already discontinued the Mannitol, but her urine output was over 300cc/hour. Also her blood pressure was low(80-90/50), she was tachycardic and she was on 15mcg/kg/min of Dopamine. So, I did a few things: first, a liter bolus of normal saline followed by a rate of 125cc/hr. Then I gave a bolus of T4(synthroid) followed by a continuous drip. After brain death, hormone production is impaired including TSH and a rapid decline in free triiodothyronine occurs. Replacing with T4 helps maintain cardiac stability. I also had them start a pitressin drip at 0.5 units/hour, figuring that it will stem the DI and raise the BP.

She still was hypotensive for a while, so we gave more fluid boluses and increased the T4. After about 2 hours, her heart rate started to come down and her BP was up to 100/60. Her urine output was now about 75cc/hour. We were starting to come down on the dopamine ever so slowly. Also, her BUN and creatinine were trending down to normal.

If the hospital didn't let us manage her this way, she could easily have gone into kidney failure. The low BP would have caused decreased perfusion of the organs. High doses of pressors will do that also. Managing the brain dead patient is like standing in the middle of a see saw and trying to find the right balance. It's a challenge to the staff as well. They have been caring for the brain injured patient-keeping fluid input low, not turning the patient. Then I come along and want to pour fluids into the patient and do frequent turning and suctioning. It's a 180 degree turn around. A lot of staff challenge our right to be on the unit. ICU nurses are especially protective of their patients-I should know, I used to be one. Some hospitals won't let us do anything. The patient could be declared brain dead and consented for donation and they still don't want to let us do anything.

Once a patient is brain dead and consented, we pick up the all the costs (except for funeral arrangements). We'll order echocardiograms, cardiac cath's, bronchoscopies, CXR's, EKG's and labs, labs, labs. It's nice to have a triple lumen for CVP and A-line in too. We pay for the consults and the anesthesiologist when we get to the OR(but that's for another day). We'll start hormone replacement therapy: T4(if not already up), pitressin, insulin. We send blood for serologies and typing. We'll start giving Solumedrol, 15mg/kg every 8 hours to try and stem the catecholamine cascade. We'll work with respiratory therapy to maintain maximum oxygenation-vent changes, chest PT, suctioning. And correct anything else that comes up, electrolyte imbalances, infection, etc. And try to support the family and share the organs and arrange for the teams to come in and fight the OR for a time slot....it keeps me busy.

Grand Rounds 2:25

Head on over to GeekNurse for Grand Rounds, Kiwi-style. The PICU nurse from New Zealand does a fine job. He says doing the post took him 4 hours....me, it would probably take me 4 days, but that's why he's GeekNurse and I'm not. See ya there.

Fill 'er up

You gotta fill her up with light!
You gotta fill her up with spirit!
You've gotta fill her up with faith You gotta fill her up with heaven!
You've got the rest of life to face ...
You've got to fill her up with love!
-Sting


The first time I saw Baby Mia, she was more tubes and wires than baby. At 6 months old, she weighed barely 6 kilos. The very first thing you noticed was her enormous, brown belly. She looked like a python that swallowed a pig. Her arms and legs were little, dry twigs. She lay motionless, a tiny speck in a hospital bed, intubated and sedated.

I was still on orientation to the PICU when I met her. It was the first time I had taken care of anyone so small and so sick. In the beginning, it was all I could do to manage her lines and tubes. She had a broviac catheter in her chest, an A-line and endotracheal and naso-gastric tubes plus several IV's and a foley catheter. Following her surgery, she had a draining T-tube. You see, Mia was born with several disadvantages, some medical and some social. Her mother was a drug addict who never received prenatal care. Mia was born addicted and placed in foster care shortly thereafter.

At a few months old, she became increasingly ill and jaundiced. She was diagnosed with Biliary Atresia, a condition where bile flow from the liver to the duodenum in obstructed. Bile accumulates in the liver causing scarring and liver damage. Without surgery a child will die. In addition, half of all these patients will need a liver transplant by age 2 and 70% will need a transplant by age 20. Mia had had her surgery and was now bombarded with complications: pneumonia and infection. When I met her, she was at her sickest.

Fate, luck or angels had given her one break, and she was named Teresa. Teresa was an older, married woman who had already raised her kids and was now a grandmother. For years she had been taking in medically fragile foster children who were hard to place. Nurses with more experience told me how several of her foster kids had died from AIDS. Now she had 2 children she had adopted, both with developmental delays and multiple medical problems. She sat at Mia's bedside day and night. I remember her as always calm. She was in the middle of embroidering a complicated baby blanket for Mia. In the middle was Noah's ark and the border was made up of all the animal pairs. I can see her now, just sitting in the window seat, pushing her needle through the fabric. She'd look up and when we came in and ask about Mia's progress.

I hadn't taken care of Mia for a few weeks when I was assigned to her again. By this time she was extubated and awake. The change was profound. The minute I walked in the room I was greeted with the biggest smile I had ever seen on a baby. She still had a million things in her or on her and her belly was still the size of Rhode Island, but she was happy. Slowly, as the days progressed, we saw less lines and more Mia. One night my preceptor said she needed a bath. She was still so tiny that we just filled up a wash basin with an inch of water and sat her in it. She loved it. Teresa would help out, go home to her family for a few hours and come back for the night. By now she could hold her and give her snuggles and Mia always had a smile. Sometimes, her siblings would come for visits. She adored them and they couldn't get enough of her.

I couldn't get over it. It made me think about all the little complaints I'd have in a day-my feet hurt or I didn't get a dinner break or whatever. Here was a baby who had only known hospitals and surgery, fevers, being intubated and stuck with needles-I don't know if I'd even want to go on after all that, but here was little Mia smiling through it all. Eventually came the day for her to get transferred to the regular floor. She was listed for a liver transplant, but would be stable enough to go home. She was about 9 months old and still couldn't sit up or crawl and she didn't really make any sounds but she could light up a room with that smile. I didn't know if I'd ever see her again.

Eventually, I left the PICU to become a transplant coordinator, a job I had wanted since nursing school. One day I went back to the hospital to pick up some things. I ran into Teresa, Mia and the whole brood on the elevator. Mia was then 6 weeks post transplant. Someone's gift had given Mia a new life. She looked like a new baby. She was chubby in all the right spots and her huge belly was gone. She was sitting up and reaching for things and cooing. And she still had that radiant smile.

There are days my glass is half full and days it's half empty. There are even days when I think my glass is dried up and I remember Mia, whose glass is always overflowing.

Arts & Crafts at donorcycle

For those of you who are crafty (and you know who you are), check out these stitch holders for knitting shaped like little organs (awwww, how cute). And for those of you who just like to drink a lot (and you know who YOU are), they also make great wine glass charms. Cheers!

Grand Rounds, ER style

This week Kim at Emergiblog does a fine job of triaging this weeks medical blogs. See ya' there. (Excuse me, nurse, I've been waiting 3 hours to get my ingrown toe-nail looked at. Is it going to be much longer?)

At the Oscars

Tonight at the Academy Awards, Robert Altman, director of such films as M*A*S*H, The Player and Gosford Park, was awarded an Oscar for lifetime achievement. The last thing he said in his acceptance speech was that several years ago he received a heart transplant. He said that he thought his heart came from a young woman in her 30's, so perhaps they gave him the lifetime achievement award too early, as he expects to have another 40 years or so with his new heart. Well, Mr. Altman, you also get the green ribbon award:

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for bringing organ donation to the attention of a world-wide audience of bazillions. Thank you.

Also, tomorrow night, Monday, March 6th, ABC will air its premier of Miracle Workers, a medical reality series. As per the ABC website, the first episode will feature two medical treatments utilizing donated human tissue – spinal fusion using donated bone and eyesight restoration using donated eye tissue. For more info, go to:

http://www.abc.go.com/primetime/miracleworkers/index.html

See you at Grand Rounds!

There's no good time

I never cease to be amazed at people who ask about organ donation when their family member is brain dead. If I were given that terrible news I don't think my first, or even my second or third, thoughts would be about helping someone else. I think that most people could, in time, see that donation is a positive thing, but to get the grim news, "He's not going to make it," and say, "Can he be an organ donor?" astonishes me. Yet that is exactly what my patient's family did today. He was not yet brain dead, but the prognosis was not good. His wife told me, "I am still holding on to that last shred of hope. But if he does become brain dead, I definetely want him to be an organ donor." She felt that it would bring some meaning to this senseless trajedy. He had beautiful eyes, and a good heart, and she wanted them to live on in someone else.

Knowing that the family had initiated discussion of donation, it was still hard to make that first contact. What do you say? When is a good time? It's even harder when the family doesn't expect you. I have to juggle my compassion for the family and when I think they're ready to hear what I have to say, with the needs of the recipients. The sooner we recover after brain death, the better the organ function. Many people think that a brain dead person can stay on that vent indefinetely, but within a few days, depending on the cause of death and their baseline health status, they'll go into multi-organ failure and then cardiac arrest. Brain dead patients can be very unstable.

That is why I have to ask families to make this decision in the middle of their grief. I'd like to wait, let them process it, but there's not much time. As it is, we decouple the approach. Let the hospital staff tell them the patient is brain dead and start the clinical process. Then, I'll meet with the family, assess what they understand so far and see if they know what the person's wishes are; did he have a living will, an organ donor card, etc. You'd be surprised(or not) at how many doctors have said, "He's brain dead. You wanna donate the organs?" It's not nice, it's not compassionate. People need to let it sink in. Especially when their loved one still looks alive:they're warm and pink, their chest still rises and falls. Many times I have to go over what brain death is, and why they won't recover. Some people surprise you, so you can never think, "Oh, they'll never go for it." The least likely people have said yes. Families that were in denial, families mad at the hospital and threatening lawsuits have said yes. Then, sometimes, people I swore would want to donate say no. It's a very personal decision.

Most people want to know if my job is sad. The short answer is yes. It's difficult to put into words why I feel called to do this. When I worked in the ER, I was the one nurse who didn't shy away from grieving families. Sometimes,(not often) you'd have one of those docs who'd tell the family the patient died and then run away and I'd be left consoling them and answering their questions. I guess the only way to describe it is to say that I feel blessed to be around grieving people. I want to help them to navigate their way through those confusing first moments. I don't feel like I'm a particularly consoling person. I'm not very touchy-feely. I don't have a lot of meaningful phrases that I use or anything. Instead, sometimes, I feel like a death-midwife, helping this family transition to the next phase. I couldn't do this if I didn't feel like I was doing good for the families. I know ultimately I'm doing this for the recipients, but when a family makes a decision to donate, it really seems to help them. Like the wife of the above patient, it brings some consolation and a hope that a little piece of them lives on.

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I don't usually take my work home. I used to get very anxious when I worked in a trauma center, worrying about bad things happening to me and my family. Now I'm a little more calm about dying-when your times up, it's up. It has made me appreciate my family and my life more than ever. So while it's always on my mind, I don't usually worry about it. But today was different. I got called back to the hospital tonight and as I was getting ready I was convinced that something was going to happen to me. Maybe it was the talk I had with the wife earlier, now a widow. Maybe it was the blog I read (I can't now remember which one, I know I had a link somewhere) about a woman whose husband died of cancer when their baby was 4 months old. I started thinking about what my family would do if something happened to me. What would I do if something happened to them? How would I go on? Like I said, this stuff doesn't usually hit me, but when it does, it hammers me. Really, I was practically in tears. So I gave Love Monkey and Dear Kid extra hugs and I whispered into Laughing Baby's ear, "I love you." That's all I can do.

If it's Tuesday.....

It must be GRAND ROUNDS! Interesting reading over at A Chance to Cut is a Chance to Cure.
Peruse it while I whip up my next post.

What do I do?

I'm on call about 10 days a month, for 24 hours at a time, usually 2 or 3 days together, then off for a few days. I'll get a call that goes something like this:"I need you to go to Springfield Medical Center(made up name, think Simpsons). The ICU called with a 24 year old male, gun shot wound to the head. He has no history. BP is 100/50. He's on multiple pressors. Urine output is 500cc an hour. Family's at the hospital. He's got a fiance, mom and dad are divorced and a big crowd of cousins, etc. 1st clinical's done. Call back when you get there and let me know what's going on."

Off I spring into action. Well, spring's a bit of a euphamism. Okay, so I haul my old bones off the couch. I have to be there within 90 minutes and the area I cover is rather large. Already packed is my bag, with laptop, organ donation literature, paperwork, calculator, pen light, snack, personal care items like toothpaste(never know how long I'll be out, could be all night)and other, assorted junk I might need. Some stuff I keep in my trunk, like memory boxes and a gauge for reading NIF's(for DCD referrals).

When I get to the unit, I introduce myself to the staff. I usually get one of two reactions:Hey! the transplant coordinator's here! or Ugh, the transplant coordinator's here. I've been called a vulture too many times to count. But I digress. I'll read through the chart and see if there's any reason this person CAN'T be a donor-HIV, cancer, multi-organ failure. There's not too many absolute rule outs anymore. Yes, we will recover organs from people with hepatitis, particularly for recipients with hepatitis. Brain tumors are okay, generally, as long as there's no metz and no VP shunt.

The reason for this, and the reason we always ask staff NOT to mention donation is this:many families want to donate....If you bring up donation and then find out that the person can't donate because of some medical condition, it's like a second heartbreak for the family. First, they have to deal with their loved one's death, but donation was a silver lining, a way to keep that person alive in someone else. So we look through the chart. If they're not medically suitable, I pack up my bag and go home.

If they can be a donor, I've got two very different jobs to do. One, talk with the hospital staff about what's going to happen next. In an ideal situation, we all "huddle"-doctors, nurses, nurse manager, chaplain, case manager, respiratory therapist-whoever's on the case and can provide insight into what needs to happen. In a bad situation, the patient's been dead on a vent for three days with docs who don't want to start brain death protocols and a family that has no idea how bad it is and keeps hoping that "he'll pull through".

The second job is to support the family. Yes, I have to keep the recipients in mind, but when you see this grieving family in front of you, you really want to do everything you can for them-out of humanity, not because "you want the organs". I try to see what the family needs-a chaplain, a room for privacy, info from the hospital. If the doctor has told them that the patient's brain dead, I'll assess them to see if they really understand. A lot of people think that brain dead means coma, that the person will be Terry Schiavo, living in a nursing home for years. But a brain dead person can't breath on their own. If the vent's shut off, they'll go into cardiac arrest. Even on the vent they'll go into multi organ failure within a few days and eventually cardiac arrest as well.

I tell people that when the brain gets injured, it swells, just like if you twist your ankle. Only the head is a closed container-a little swelling isn't too bad, but too much and the brain has no place to go, it runs out of room. Docs will try to keep this from happening with medication or sometimes surgery, even going so far as to remove a piece of the skull. Nurses keep the ICP(intercranial pressure) down by keeping stimuli to a minimum, keeping the head of the bed up at 30 degrees, etc. Sometimes this works, sometimes it doesn't. When the pressure gets too great, the only way left to go is down, through the little opening where the spinal cord, arteries and veins run. The pressure clamps down on the vessels leading to and from the brain and within minutes the brain is deprived of oxygen. Within 10 minutes, brain cells die en masse and once they're dead, that's it, there's no coming back.

Look at a nuclear brain flow and you'll see exactly what I mean. It's like the patient is wearing a black cap, except that that black space is where there is no blood flow. It's pretty dramatic.

See what I mean. Maybe someday I'll write on why I hate EEG's. The picture really says it all.

At some point I'll take the family aside. I'll ask them if the patient had ever talked about his wishes, if he had a living will. I'll ask them what he or she was like. What is it like, to ask a family if they want to donate the person's organs? It ain't easy, but I think I'll have to leave that for another day.

I remember a family of a brain dead patient that I was involved with. I spent two days with them, helping them to understand brain death, making sure that they were getting the correct information from the hospital and giving them emotional support. I hadn't yet asked them about donation. Sometime during the second day I took the daughter aside and asked her what she thought and if she thought her dad would agree to it. They had been married 54 years. The daughter thought organ donation was a great idea. Finally, the time came to bring the family together and ask the patient's husband if he would donate her organs. He really wanted to, he said, but she had been through so many operations already, he couldn't put her through one more. He understood brain death, he knew she was gone, but he couldn't do it. Let someone else donate, he told me.

I've also listened to the pleas of a mom whose 11 year old daughter died waiting for a lung transplant. Why won't they say yes? she told an audience of transplant professionals.

When I first started this blog(a whole 8 posts ago), first I thought it would just be a way for me to blow off steam. My job's pretty stressful at times. At best, I thought a few other transplant coordinators might read it and chime in. Now I see that there's this whole, big blogosphere out there. I realize I need to be a little more responsible in what I write. Holy moly, I just found a link for Dr. Andy's Grand Rounds on Medscape. Yikes! And I remembered that to a lot of people, medical professionals and lay people alike, don't really know what goes into making transplants happen. I realize a few posts might sound callous. It's hard to get frustrated in the world of medicine and I'm a very impatient person to boot. So for the next couple of posts I think I'm going to write on just what it is I do and why it's so important to make donation happen.

Did I miss it?

Jeez! Grand Rounds were Tuesday! I was out allnight on a case and then slept all day Wednesday......so this must be Thursday, right? Anyway, here's the link: Grand Rounds 2:22
(and guess who made the top 10? Hmmmm? Need a hint?) Now, back to writing a longer post, as soon as I have some coffee.