Got your prozac handy?

After my last post I hate to do another write up of a depressing event, but I can't let this one go by without saying something about it.

Saturday night we got a transfer from our sister hospital, a 57 year old man who'd collapsed while dancing at his son's wedding. There were two EMTs and a nurse at the wedding and they began CPR almost immediately, in addition to delivering 3 shocks from an AED (automated external defibrillator). The medics arrived and transported him to the hospital, but he decomponsated on the way and had to be shocked twice in the ambulance. He arrived at the ER in asystole (flat line) and was given several rounds of cardiac drugs in addittion to TNK (a thrombolytic designed to break up clots causing heart attacks). They eventually re-established a normal hearth rhythym and transferred the patient to us (our hospital handles the cardiac patients for the area). His wife and brother came with him from the other hospital and that night they were both very optimistic that he would come through everything and leave the hospital as good as new. They said that even though he was 57 he was in excellent physical shape and had in fact been preparing to try out for a semi-pro football team in his home state of Texas. They said he had no history of cardiac trouble save for mild hypertension that was well controlled with medication. I don't know if I thought that he would be playing football once he got out of the hopsital, but I was optimistic that he would indeed leave eventually as was the physician who admitted him.

I came in the next day and talked with his nurse about him. Between the time I left at 3:30am Sunday and the time I came back at 7pm that same day, he had gone into acute renal failure, had developed rhabdomyolysis, had stopped breathing over his ventillator, and had lost any sign of cerebral activity. His pupils were fixed and dilated and he didn't respond to any sort of stimuli, including cold water injected into his ear (called a cold caloric test). The family didn't want to give up, but by thursday (after an EEG and MRI which showed virtually no brain activity) they finally agreed with what his doctors were telling them, and resigned themselves to the fact that he would not be waking up. A cerebral perfusion scan was scheduled for the next day, and if that established brain death then they would consent to organ donation.

On Thursday I was working as a monitor tech (we keep track of all the patients on telemetry and communicate any problems with their heart rhythym or vital signs to the appropriate nursing units) and he was not doing well. His blood pressure was getting dangerously low and we were only keeping it up by running 22mcgs of dopamine (a pressor that increases blood pressue). The trouble with using that much dopamine is it tends to cause tachycardia and arrhythmias. That night he went into a rapid Afib with a rate of nearly 150, but we managed to get him out of it with amiodarone. Nevertheless, we knew he probably wouldn't hang on for too much longer. When I came in to work on Friday at 7pm I again spoke with the nurse taking care of him. She said that the tech had read the cerebral study and that there was zero flow, but she couldn't call in the organ procurement folks until she got the official report from the radiologist. While she was giving report to the night shift nurse, the family was in the room saying goodbye for the last time. As they left the unit to go to the waiting room they thanked us for everything and said they were glad that some good was going to come from his death.

We finally got word from the radiologist around 9 and called the transplant organization to come in. The transplant coordinator arrived at about 10:30 and her staff began to filter in (they had to come from all over the state to get to our place). Around 2am they started drawing large amounts of blood for the various lab tests they needed to run. Around 2:30 I went into the room to tell the nurse that his heart had skipped a beat and then his p-waves had inverted (p waves are the first part of a heart beat on an EKG, and they represent the electrical activity of the atrium). While I was still in the room he went into Aflutter (an atrial arrhythmia similar to Afib) and his rate began to decrease. He eventually suffered a brady-asystolic arrest. We began CPR (on a brain dead man) and managed to get him back with two amps of Epinephrine. I asked the transplant folks after his vitals stablizied if they thought he'd make it to surgery tommorrow. They said they figured he would but that they would probably only be able to use his liver. My shift ended at 3:30am and I left hoping that they were right.

I just got back from the hospital (I had to pick up my schedule but really I wanted to see what had happened). He died this morning at 7:30am, before they could harvest his organs.

A while ago on SA there was a thread about unexpectedly depressing moments at work. I posted a story from this summer, and now you get to read it (I say you like anyone has ever been to this site). Enjoy.

Last week I was working the night shift as a nurse tech in the CCU/PCU at St. Elizabeth's Hospital. The nursing supervisor for the night called up to let us know that we were about to receive an admission from the ER. Our patient was an 83 year old lady with a GI bleed and a hemoglobin of 4 (that's incredibly low, indicating very severe bleeding). We prepared 2102-2 for her admission and the ER folks rolled her up a few minutes later. Mac was the nurse who was going to be taking care of her for the night and I went in to help get the patient situated. Her husband came up with her from the ER, he was also 83 years old and dressed the part. He was wearing corduroy pants and a button up sweater, walked with a slight hunch and had thinning gray hair. His wife looked extremely sick; she was pale and very thin with easily visible veins and a slow heart rate. She didn't have any problems with speech or memory, but she was very fatigued because of the bleeding and had trouble answering our questions without pausing for long periods of time. We got most of the history from her husband; he was a fastidious record keeper and had a small piece of paper in his wallet that detailed all of his wife’s conditions, medications and doctors. "I'd forget otherwise" he told us lightheartedly, trying to break the obvious tension in the room. As we were getting the information from him, he told us that his wife had recently been diagnosed with Parkinson's disease, was diagnosed with lung cancer a year ago (though she was not receiving treatment for it), and had a bevy of other problems from cardiac to gynecologic. She had a do not resuscitate order at home but they hadn't brought it with them, so we asked her what she wanted us to do in case she stopped breathing or her heart stopped beating. She and her husband both answered that they didn't want any heroic measures taken should that happen and thankfully there was no disagreement between them on that issue.

We continued our usual admission procedures, and while the nurse was collecting vital signs I asked the husband how long they had been married. It was his reaction to this question that made this case so difficult and is the reason I'll never forget it. He looked right at me, and his face lit up as he said, "65 wonderful years on July fourth. She just celebrated her 83rd birthday." In that instant that he looked at me and said those words, I could tell that there was so much more that he wanted to say, that my question had brought those 65 years of memories flooding back. Their wedding, their first house, their children, their old jobs, their vacations, their grandchildren, everything they had ever done together was written on his face, just below the surface. Instead of relating everything to me, he just looked back at his wife, and took her hand in his. The nurse finished up her assessment and we left the room. He went home late that night to get some sleep, but he was back before I came in at seven the next morning. I took his wife's vital signs at eight and asked if there was anything I could do for him. He smiled and told me that he was fine, thanking me for asking. He never took his eyes off his wife, and I think he knew that she likely wouldn't live to see their anniversary.

Several days later I came into work and learned that she had died the night before. Usually with a death like hers that's more or less expected, it's sort of routine to hear that the patient has passed away and no one really gives it much thought. However, when Mac told me that she was dead, it wasn't in the usual casual manner, and both of us looked at the ground and couldn't really think of anything to say. All I could think of was the image of her husband holding her hand, and of his face when he told me how long they'd been married.

First post am I rite lol!

So in order to post a comment on someone elses blog I had to reg an account here, and now I have my own blog. I've noticed that every group of friends has certain types of people which include the smart guy, the gay guy, the conservative (or liberal) guy, and the medical guy. I'm the medical guy, medicine has really become a big part of my life and I have plenty of wacky experiences to relate to the occasional isomniac who floats through here, so be prepared to be assaulted by the random and esoteric experiences of my young working life.

No blog post would be complete without linking to another blog, so check out my friends blog Duty, Honor, Country. He just got his commission in the US Army and has alot of interesting stories from his training.